Quality Report 2014/15 - James Paget Hospital · Healthwatch Norfolk Healthwatch Suffolk Council of Governors Health Overview and Scrutiny Committee The annexes also include a glossary

Quality Report 2014/15

James Paget University HospitalsNHS Foundation Trust

PatientSafety

Clinical Effectiveness

Staff, Carer andPatient Experience

Where you come first

James Paget University Hospitals NHS Foundation Trust Quality Report 2014/15

Contents

FOREWORD ...................................................................................................................... What is a Quality Report? ................................................................................................... Scope and structure of the Quality Report .......................................................................... Organisational Structure for Quality Performance ...............................................................

Part 1 Statement on Quality from the Chief Executive ................................................. 1 Part 2 Priorities for Improvement and Statements of Assurance from the Board ........ 2

2.1 Priorities for improvement 2015/16 ........................................................................ 3 Patient Safety ............................................................................................................. 4 Clinical Effectiveness .................................................................................................. 8 Patient and Staff Experience ..................................................................................... 12

2.2 Statements of Assurance from the Board: ............................................................ 15 Clinical Audits and National Confidential Enquiries ................................................... 16 National Confidential Enquiries ................................................................................. 20 Participation in Clinical Research .............................................................................. 21 The Commissioning for Quality and Innovation (CQUIN) Framework ........................ 21 The Care Quality Commission (CQC) ....................................................................... 22 Secondary Uses Service ........................................................................................... 23 Information Governance ............................................................................................ 23 Payment by Results .................................................................................................. 24

2.3 Reporting against core indicators ......................................................................... 25 Summary hospital-level mortality indicator (SHMI) .................................................... 25 Patient Reported Outcome Measures (PROMs) ....................................................... 26 Hospital re-admissions .............................................................................................. 27 Responsiveness to the personal needs of patients ................................................... 27 Venous Thromboembolism (VTE) risk assessments ................................................. 28 Clostridium difficile (C.difficile) .................................................................................. 30 Patient Safety Incidents ............................................................................................ 32 Friends and Family Test – Patient ............................................................................. 34 Friends and Family Test – NHS Staff Survey 2014 ................................................... 34 NHS Staff Survey ...................................................................................................... 35

Part 3 Review of Quality 2014/15 ................................................................................ 38 Summary of Achievement of Quality Priorities 2014/15 .................................................. 39

Patient Safety ........................................................................................................... 40 Clinical Effectiveness ................................................................................................ 43 Patient and Staff Experience ..................................................................................... 45

A Listening Organisation ................................................................................................ 49 Learning from complaints .......................................................................................... 50 Patient Advice and Liaison Service (PALS) ............................................................... 51 Compliments ............................................................................................................. 52 Patient experience measurement tools ..................................................................... 53 Family carers ............................................................................................................ 54 Patient surveys ......................................................................................................... 54 Cancer Patient Experience Survey - 2014 ................................................................ 54 National A&E Survey 2014 ........................................................................................ 55

A Responsive Organisation ............................................................................................ 56 Serious Incidents ...................................................................................................... 56 Never Events ............................................................................................................ 56 Inquests .................................................................................................................... 56 Mortality Reviews ...................................................................................................... 56 Savile Enquiry ........................................................................................................... 57

External inspections ....................................................................................................... 59 Medicines and Healthcare Products Regulatory Agency (MHRA) ............................. 59


Clinical Pathology Accreditation (UK) Ltd. (CPA) ...................................................... 60 PLACE – Patient Led Assessments of the Care Environment ................................... 61 Environmental Health ................................................................................................ 61 General Pharmaceutical Council (GPhC) .................................................................. 62 Norfolk Fire and Rescue Service ............................................................................... 63 NHS Protect .............................................................................................................. 64 Royal College of Obstetricians and Gynaecologists (RCOG) .................................... 64

Delayed Transfers of Care (DTOC) ................................................................................ 65 Monitor’s Governance Indicators .................................................................................... 67

Annex 1 Statements from stakeholders .......................................................................... 68 Great Yarmouth and Waveney Clinical Commissioning Group ....................................... 69 Council of Governors ...................................................................................................... 71 Healthwatch Norfolk ....................................................................................................... 72 Healthwatch Suffolk ........................................................................................................ 72 Health Overview and Scrutiny Committee ...................................................................... 73

Annex 2 Statement of Directors’ responsibilities for the quality report ............................ 74 Glossary of terms and abbreviations .................................................................................. 74 Monitor mandated indicator definitions ............................................................................... 74


FOREWORD

What is a Quality Report?

All providers of NHS services in England have a statutory duty to produce an annual report to the public about the quality of services they deliver. This is called the Quality Report and includes the requirements of the NHS (Quality Accounts) Regulations 2010 as amended by the NHS (Quality Accounts) Amendments Regulations 2011 and the NHS (Quality Accounts) Amendments Regulations 2012. Quality Accounts (and hence this report) aim to increase public accountability and drive quality improvement within NHS organisations. They do this by getting organisations to review their performance over the previous year, identify areas for improvement, and publish that information, along with a commitment to you about how those improvements will be made and monitored over the next year.

Quality consists of three areas which are essential to the delivery of high quality services: • Patient safety • How well the care provided works (clinical effectiveness) • How patients experience the care they receive (patient experience) Some of the information in this Quality Report is mandatory – this report contains all of Monitor’s detailed requirements for quality reports – but most is decided by patients and carers, Foundation Trust Governors, staff, commissioners, regulators, and our partner organisations, collectively known as our stakeholders.

Scope and structure of the Quality Report

This report summarises how well the James Paget University Hospitals NHS Foundation Trust (‘the Trust’) did against the quality priorities and goals we set ourselves for 2014/15. It also sets out those we have agreed for 2015/16 and how we intend to achieve them.

This report is divided into three Parts, the first of which includes a statement from the Chief Executive and looks at our performance in 2014/15 against the priorities and goals we set for patient safety, clinical effectiveness and patient experience.

Part 2 sets out the quality priorities and goals for 2015/16 for the same categories and explains how we decided on them, how we intend to meet them, and how we will track our progress.

Part 2 also includes statements of assurance relating to the quality of services and describes how we review them, including information and data quality. It also includes a description of audits we have undertaken and our research work. We have also looked at how our staff contribute to quality.

Part 3 sets out how we identify our own priorities for improvement and gives examples of how we have improved services for patients. It also includes performance against national priorities and our local indicators.

The annexes at the end of the report include the comments of our external stakeholders including:

NHS England

Great Yarmouth and Waveney Clinical Commissioning Group

Healthwatch Norfolk

Healthwatch Suffolk

Council of Governors

Health Overview and Scrutiny Committee

The annexes also include a glossary of terms used.

If you or someone you know needs help understanding this report, or would like the information in another format, such as large print, easy read, audio or Braille, or in another language, please contact our Associate Director of Governance, Safety and Compliance by calling 01493 452887 or emailing [email protected].

Any text shown in blue boxes is a compulsory requirement to be included in the Quality Report

as mandated within Monitor’s Annual Quality Accounts Regulations.

mailto:[email protected]


Organisational Structure for Quality Performance

Safety and Quality

Governance Committee

Chair: NED

Audit Committee

Chair: NED

Patient Safety &

Effectiveness (Monthly)

Chair: DON

Executive Nomination & Remuneration

Committee Chair: Trust Chairman

Charitable Fund

Committee

Chair: NED

Carer and Patient

Experience (Bi-monthly)

Chair: DON

Information Governance (Bi-monthly)

Chair: MD

Hospital Infection Control

Chair: DiPC

Finance, Performance and Strategic

Planning

Chair: NED

Health, Safety & Staff Welfare

(Bi-monthly)

Chair: DON

BOARD OF DIRECTORS (monthly) COUNCIL OF GOVERNORS

(6 times per year)

Key: NED Non-Executive Director DoW Director of Workforce and Corporate Affairs DON Director of Nursing, Quality and Patient Experience MD Medical Director DiPC Director of Infection Prevention and Control

Workforce, Education & Wellbeing

Chair: DoW


Part 1 Statement on Quality from the Chief Executive

James Paget University Hospitals NHS Foundation ?rust aims to provide sale and elfective care at alltimes. This means:hat patien: safety and quality are at the hean of everything we da. Our staff arecentral to detivering the care standards that we expect every patient to receive.

2814{15 has eertainly been a year of significant change, with lots of developmen:s taking place toensure that our services are fit for the future, I a.n extremely proud ol what we have developed duringthe lasl year to funher improve dre quality and safety af our serviees. I am delighted:o have thespportunity:o share with you some of our achievements in this Quality Repo* and to let you know offte plans we have:o continue to improve our services.

Our Trast Priorilies tar 2O15116 have been developed !o ensure that we ernbed qualify changes intooar daily praciice. As patient talls remain one of our highest reported incident:ype we will review howwe assess patients for lheir tsk cf falling and will look at prevention of f*lls proactively.

Our bigges: change through 2014/13 and inta the new financial year has been how we engage wi:hour patients and their rela?iveslcarers. We recognise that in order to create a*u,y patient-centredorganisalion and to deliver the best possible care;there needs to be genuine and meaningfulengagement and involvernent with patienls, carers and lhe public at every opportuniry of seruiceirnprovement, design and delivery. The Trust is comraitted to listen, capture and use feedback fromindividuals, group$ a*d organisa:ians io intluence and effect positive change. We have develogedsur Palient Experience and Engagement Stra?egy described within our Quali:y $tra:egy and our Headof Pa:ien? Experience and Engagemen: joined the Trust in March. We will be holding numerousevents throrghaut the next year including Patient Engagement Focus Groups. These events wlll helpus to enrich the breadth ol feedback we get irom our patients especially ihose groups of people wiomay find it difficult lo access seryiees e.g. the lravelling community, people wilh learning disabilities orour older population.

We, along w?th o:her healthcare providers acress the eeuntry, lelt fte pressure of additional demandon our services throughout the year and continuing into the new tinancial year, Nevertheless, ourstaffs dedication to safe and effective patient care continues to make a huge difference. A greatexample of this is the successful pilot of the ambulaiory emergency care pathway project in ourEmergency Assessrnent and Discharge Unh {EADU), which has already saved 59 bed days byallewing s?aff to quickly diagnose and :reat patienb $/i:h acute medical conditisns who shsuld no?require an overnight hospital say. The Care Quality Comr*ission {COC) published the repor: on itsfindings during an unannounced inspection at the hospital in $eptember. The report was very positiveand shows that the Trus: has taken action to en€ure all oubtanding issues in patient records andmedicines managetrents have been resolved. Tha inspec*ors had remarked at the time that th€ staffthey came into contact with were supportive and helpful, which was also reflected in feedback frompatient$ and rela?ives

?A14115 has also been another year wilh zero cases of MR$A bacteraemla which is an outstandingachievemen: and a conlinuing testameni to our staff a*d patients for suppo*ing our stringent infectioncontrol measures

Our emergency training exercise received high praise from examiners; the catering service wasrefened to as a 'benchmark' in &e industry, and the Trust was named one ef the 'top 100 best placesto work in the NHS' as voted by our stafi.

I wsuld like to take this oppoftunhy:o:hank our etaff, without thei. hard work and comxitment wewould not have achieved :he successes we have set ou: in this Quality Repe*.

Quality and saiety rennain our priority and as we move into 2015116, we look forward to anather yearof continued tocus on irnprovemen:s in the quali:y of care and experience for our patients.

To lhe best of my knowledge, the inforrnation in this document is accurate.

Christine Allen

( aur.. chief €xecutiveJames 7age2 University Hospitals NH$ Foundation Trust

James Paget Universily Hospitals NHS Foundation TrustQualtty Beport 201 4l't 5

James Paget University Hospitals NHS Foundation Trust Quality Report 2014/15 2

Part 2

Priorities for Improvement and Statements of Assurance from the Board

Page

2.1 Priorities for Improvement 2015/16 3

- Patient Safety 4

- Clinical Effectiveness 8

- Patient and Staff Experience 12

Page

2.2 Statements of Assurance from the Board 15

- Clinical Audits and National Confidential Enquiries 16

- Participation in Clinical Research 21

- The Commissioning for Quality and Innovation (CQUIN) Framework 21

- The Care Quality Commission 22

- Secondary Uses Service 23

- Information Governance 23

- Payment by Results 24

Page

2.3 Reporting against core indicators 25

- Summary hospital-level mortality indicator (SHMI) 25

- Patient Reported Outcome Measures (PROMs) 26

- Hospital re-admissions 27

- Responsiveness to the personal needs of patients (CQUIN) 27

- Venous Thromboembolism (VTE) risk assessments 28

- Clostridium difficile (C.difficile) 30

- Patient Safety Incidents 32

- Friends and Family Test – Patient 34

- Friends and Family Test – NHS Staff Survey 2014 34

- NHS Staff Survey 35

In this section we describe our priority areas for quality improvement for 2015/16. We explain how we have

chosen our priorities, what we set out to do, what we have done in previous years and how we will monitor our

progress with the priorities throughout the year

IN this section we have included all of the mandatory statements of assurance as required under the NHS (Quality Account) Regulations 2009 and associated amendments 2011 and 2012

In this section we have included our performance against a core set of indicators. For each indicator we have included the data for the last two reporting periods and, where available and/or applicable, have included the national average for the same and those NHS Trusts with the highest and lowest for the same


32.1 Priorities for improvement 2015/16 The Board of Directors has agreed the following key priorities under the three domains of quality for 2015/16. These have been identified from and/or aligned to:

Trust Quality Strategy 2014-17

The Care Quality Commission (CQC) five Key Lines of Enquiry (KLOE) - Safe - Effective - Caring - Responsive - Well-led

The Trust’s ‘Sign Up to Safety’ pledges

Governors/Trust Members/local population feedback via questionnaire

Quality Report priorities 2014/15

Quality Improvement Fellow 2014/15 project ‘Setting the Trust standard for falls assessment’

Issues identified from the CQC assurance process

Priorities identified by NHS England The public and patients are involved in identifying risk and bringing this to the attention of the Foundation Trust in a variety of ways:

Healthwatch;

The Council of Governors has been involved in setting the priorities within the Quality Report;

Involvement of patient representatives in the assessment of compliance with CQC outcomes at ward level;

Priorities Questionnaire sent via media and Trust website;

The Trust Board of Directors has continued to include a patient story at each monthly meeting to help identify, manage and mitigate key risks;

Patients and relatives are involved in addressing issues identified through complaints, claims, Patient Advice and Liaison (PALS) and incidents via involvement in action planning;

Patient Satisfaction Surveys. Public Stakeholders are involved in managing risk which impacts on them, for example:

There are Foundation Trust meetings at all levels with members of the Clinical Commissioning Group at which risk is assessed;

Health Overview and Scrutiny Committees;

Partnership working with Social Services; and

Joint working with other Trusts i.e. Norfolk & Norwich University Hospitals NHS Foundation Trust, East of England Ambulance Service NHS Trust, Norfolk and Suffolk NHS Foundation Trust, and East Coast Community Health Community Interest Company.


Patient Safety a) Medical negligence claims

What we set out to do (Priority):

To develop and embed a process for identifying the learning from medical negligence claims similar to that employed for complaints and Serious Incidents

Why we chose this (Rationale):

This priority has been aligned to the Trust’s Sign up to Safety pledges

Claims result in a large financial cost for the Trust both in pay-outs to claimants and from the resulting increase in NHS Litigation Authority (NHSLA) premiums

What we intend to achieve (Goal):

A robust process for identifying learning from actual and potential claims at the earliest opportunity and development of improvement actions by the clinical and operational teams.

How we will deliver and monitor progress:

- The Trust is working to identify a resource to work with Trust Solicitors and clinical and operational teams.

Responsible Person:

Medical Director

Baseline data This is a new piece of work and, as such, there is no baseline data for this Priority. Actions To identify resource and recruit to a role whose remit will be to develop this process in liaison with the Trust Solicitors and the clinical and operational teams.


b) Inpatient falls


To set the Trust standard for falls assessment to ensure our patients receive a comprehensive assessment and to reduce incidence of avoidable inpatient falls.


Patient slips, trips and falls are consistently one of the highest reported adverse incidents at the Trust (n=849 for 2014).

Patient slips, trips and falls are also one of the highest reported harm events for the Trust (n=299 Minor Harm or above for 2014).


A reduction in the absolute numbers of inpatient falls


- The baseline for this measure will be the number of patient falls reported each week for an initial 26 week period (to give a statistically significant set of figures) plotted onto a run chart.

- Ongoing measurements: Weekly figures will be collected from the point at which the revised Falls Policy and/or falls assessment are launched. If these two points are different, a note will be made on the run chart to show where each element was launched.

- This will be monitored via reporting to the Patient Safety and Effectiveness Committee.

Responsible Person:

Director of Nursing, Patient Safety and Experience

Baseline data

There was an 8% reduction in the number of inpatient falls in 2014/15 and incidence of falls is the lowest it has been in the last three years. Inpatient falls are, however, one of the Trust’s highest reported type of incident.

Inpatient falls 2012/13 to 2014/15


Inpatient falls with harm The number of falls with harm graded as Minor (Non-permanent) Harm or higher has also shown a decrease of 18% for 2014/15.

Actions

Review and update the Trust Falls Policy to include recommendations from NICE Clinical Guideline 161: Falls: assessment and prevention of falls in older people

Review existing falls assessment referencing against the FallSafe programme to see if anything can be utilised from there.

Launch revised Falls Policy

Launch revised Falls Risk Assessment


c) Hospital-associated thrombosis


To develop and embed a process for investigating and learning from incidences of hospital-associated venous thromboembolism (HAT). To improve reporting, review, root cause analysis processes and learning from HAT.


HAT is a high harm incident

There is not the same level of robust process in place as for other harm events such as Serious Incidents


All HAT will be managed in a way that is aligned to Serious Incident processes to ensure that full and robust investigations are completed.


- Progress with the development of the process will be monitored at the Hospital Thrombosis Committee with assurance reporting to the Patient Safety and Effectiveness Committee.

- All HAT root cause analysis reports will be ratified at the Hospital Thrombosis Committee and reviewed by the Strategic Risk Group.

Responsible Person:

Clinical Director of Quality, Safety and Care

Baseline data During 2014, a review was undertaken of all Hospital Acquired Thrombosis (HAT) reported during the previous two years. This review showed a requirement for improved governance processes to be developed. Actions Processes in place for the management and investigation of hospital acquired thrombosis are currently under review. Discussions are currently underway with the Divisions and Clinical leads to agree the process which will be co-ordinated by the Risk and Governance Department.

Align the process for managing HAT to the processes already in place at the Trust for managing Serious Incidents (SIs) thus ensuring that full and robust investigations are completed.

Develop new pathways and Root Cause Analysis (RCA) templates.


Clinical Effectiveness a) NICE Quality Standards


To implement NICE Quality Standards to be achieved within 2015/16 agreed from the 2014/15 priority


This is the second phase of the 2014/15 Quality Report priority ‘To review all NICE Quality Standards and demonstrate planning of service delivery around the ability to achieve these aspirational standards. With the goal ‘To agree those which will be implemented and identify robust plans to achieve compliance.’


Positive development of Trust services using NICE Quality Standards as one of the markers for quality.


- The template Service Development Plans all include a section on Quality Standards and compliance with associated NICE Clinical Guidelines

- The proposed projects and business development within the Transformation Programme will be managed on a day to day basis through a mix of individual project and programme governance, joint project frameworks with the Clinical Commissioning Group and other partners, and divisional management.

- The overall monitoring and management of the Transformation Programme will be managed through the transformation governance framework with ultimate responsibility at the Finance, Performance and Strategic Planning Committee. This will not only provide monitoring and escalation, but will also enable a clearer focus on performance, accountability and business decisions.

Responsible Person:

Medical Director

Baseline data Service Development Plans exist for 34 services currently with the following having NICE Quality Standards relevant to the service:

Breast Care

Community Paediatrics

General Surgery

Obstetrics & Gynaecology

Ophthalmology

Orthopaedics

Paediatrics

Urology

Emergency Department (A&E)

Oncology

Diabetes

Renal medicine

Cardiology

Respiratory

Gastroenterology


Neurology

Rheumatology

Dermatology Actions

Implement and embed the Service Development Plans which includes moving towards and achieving the relevant NICE Quality Standards and achieving compliance with the associated NICE Clinical Guidelines.

b) Clinical guidelines


Develop and embed a robust process for review and ratification of Trust Clinical Guidelines


Currently going through a process of amalgamating clinical guidelines across three Trusts (James Paget University Hospitals NHS Foundation Trust (JPUH), Norwich and Norfolk University Hospitals NHS Foundation Trust (NNUH) and The Queen Elizabeth Hospital, Kings Lynn (QEHKL)

There is not an existing robust process of review and ratification currently for all clinical guidelines

There is a need to bring the internal clinical guidelines process more into alignment with the robust process in place for Trust Policies and Procedures.


A standard ratification process for producing, reviewing and ratifying Trust Clinical Guidelines which are published on the Trust Intranet.


- The Clinical Audit and Effectiveness Group (newly-formed) will be the ratifying body for Trust Clinical Guidelines.

- Ultimate responsibility will be with the Patient Safety and Effectiveness Committee.

Responsible Person:

Trust Clinical Audit Lead

Baseline data There is no current final ratification process for Trust Clinical Guidelines. The existing process requires Divisional sign-off as the end point. Actions

Develop and agree Terms of Reference for the Clinical Audit and Effectiveness Group.

Develop and agree the process for developing new Clinical Guidelines considering the joint process with the NNUH/QEHKL.

Develop, agree and publish the process for reviewing Trust Clinical Guidelines.


Agree and publish the ratification process for Trust Clinical Guidelines and ensure this is

embedded within the Terms of Reference for the Clinical Audit and Effectiveness Group. c) 7 day services


Continue to work towards implementing 7 day services around the identified clinical standards


The Great Yarmouth and Waveney Clinical Commissioning Group and the Trust were announced as participants in the NHS Improving Quality, Cohort one ‘Early Adopters’ Delivering NHS Seven Days a Week’s “Seven Day Services Transformational Improvement Programme” (SDSTIP). Through the application process to be an early adopter the health economy partners have committed to “One shared vision to deliver the same high quality and safe services, seven days a week and we have one, overarching commitment and determination to make sustainable whole system change a reality”.


The CCG and the Trust have committed to work as a system to improve weekend discharges. Through its participation, the Trust’s implementation team has identified key themes for early assessment and consideration:-

Increasing weekend discharges

Senior clinical involvement at weekends

Access to diagnostic services

AHP (Allied Health Professionals) involvement and enhanced service provision

Increasing non-medical support at weekends.


- A working group chaired by the Medical Director, with representation from Medical, Nursing, Allied Health Professionals, Pharmacy and Human Resources, has been convened to drive forward this work.

Responsible Person:

Medical Director

Background The aim of seven day services is to ensure every community in England is able to access routine, urgent and emergency care services and their supporting diagnostic services every day of the week. This includes collaboration between different sectors of the health and social care system. National evidence has shown that standards of care (and therefore patient outcomes) can vary depending on the time of day and when in the week we need to access health and social care services. The need to address this has been a national focus. The work to develop seven day services within JPUH and the wider health system is gathering pace. The national review chaired by Sir Bruce Keogh identified ten clinical standards, which evidence suggests make the biggest difference to securing good outcomes for patients and therefore should be provided seven days a week. Examples include


timescales for consultant clinical assessment, provision of information and patient, family and carer access to appropriate health and social care professionals, access to key diagnostic services 24/7 and timescales to access psychiatric liaison where a mental health need is identified. Importantly, it is about delivering the right 24/7 services – it is not about replicating our Monday to Friday services, seven days a week or seven day working (although it will inevitably mean a change to some of our patterns of work). Our seven day service focus is on preventing admission where patients can be better cared for in the community, diagnostics and discharge. For this to be effective it must be a whole system approach. We are working closely with primary care, social care, community and ambulance providers to look at our combined roles. Teams across the organisation have been involved in assessing our current practices within the ten clinical standards and are now developing proposals for change needed to enhance our seven day service provision. Actions Identified key actions which correspond to the ten national clinical standards as listed below.

1. Patient Experience 2. Time to first consultant review 3. Multi-disciplinary review 4. Shift handovers 5. Diagnostics 6. Intervention/key services 7. Mental health 8. Ongoing consultant review 9. Transfer to community, primary care and social 10. Quality improvement

Ten clinical standards have been reviewed and disseminated within two subgroups, to include the Seven Day Services Transformation Improvement Programme (SDSTIP). Sub group 1 primarily focuses on: - Clinical Consultant review within 14 hours of admission - Clarifying Senior Decision Makers - Weekend Handovers - Pharmacy 7 days a week Sub group 2 primarily focuses on:

Point of Care testing (POCT)

Diagnostic testing, to include endoscopy

Human Resources

Administration processes and support


Patient and Staff Experience a) Noise at night


To reduce patient movements out-of-hours with a view to improving patient experience and reducing complaints of noise at night


Feedback from various sources e.g. complaints and the Friends and Family Test (FFT) identified noise at night as an issue leading to poor patient experience


Improved compliance to the Trust Patient Discharge Policy to avoid moving patients between the hours of 9pm and 7am.


- This will be monitored through the milestones of the Flo Project.

Responsible Person:

Director of Nursing, Patient Safety and Experience/Director of Operations

Baseline data - 5.7% of ‘requires improvement’ comments from January 2015 FFT - Verbal feedback from Governors’ Ward visits Actions Flo Project: The Flo Project is named after Flo. Flo is not a real patient, her persona is our typical patient. Flo (and all of our patients) should receive the right care, in the right place, at the right time. The Flo Project will:

- Enable Flo (our patients) to be cared for in the right place at the right time (reduce outliers or patients receiving care on the wrong ward)

- Help staff to give Flo (our patients) a safe and timely discharge (reduced length of stay for patients who are medically stable for discharge)

- Release capacity so that we can cope with increasing admissions and begin ward refurbishment to improve the environment for both patients and staff

Monitor movements of patients out of hours – all occurrences of this should be reported as an adverse event on the Trust’s incident reporting system.

Divisions have been tasked to act on the information discussed at the Carer and Patient Experience Committee (CAPE) meeting in March 2015 with a report on actions back to CAPE in May 2015.

Actions in place in Emergency Division: lights out and noise reduction by 11pm


b) Raising concerns


To enable our staff to feel comfortable and confident in reporting concerns.


Feedback from the annual staff survey for Key Finding 15. ‘Percentage of staff agreeing that they would feel secure raising concerns about unsafe clinical practice’ identifies the Trust as below the national average for staff feeling comfortable in raising concerns

Response to ‘Freedom to speak up’ report by Robert Francis QC


An organisation where staff feel able and confident to raise concerns without fear of judgement or reprisal.


- Improvement in responses received from NHS Staff Survey, Staff Friends and Family Test and evidence from Board to Ward visits monthly.

Responsible Person:

Interim Director of Workforce & Corporate Affairs

Baseline data The Freedom to Speak Up Review makes clear that the report is about a fundamental reform in NHS culture. Since the Francis Hard Truths report the Trust has:

Developed a Quality Strategy monitored by the Board of Directors

Carried out extensive work to develop and embed our values and behaviours

Increased the Board of Directors’ line of sight on patient safety

Re-established Board to Ward visits

Implemented monthly nursing staffing levels reports to the Board of Directors

Established a confidential employee assistance programme via Occupational Health

Circulated a pocket-sized card to all staff with the February 2015 payslip on raising concerns and how to ‘speak up’

– Staff have access to advice and support from an external organisation (whistleblowing helpline) promoted on the pocket card and in the policy.

Set up a confidential email address for all staff accessible only by the Chief Executive Officer and Director of Workforce.

Members of the executive team are currently attending as many existing forums as possible for example team meetings, Grand Round, student forums, clinical leaders, to talk about the importance of raising concerns and also to ask what would help them feel safe in doing so. Actions

Health and wellbeing initiatives planning underway

Management and clinical leadership development programmes

‘Remarkable’ branding throughout currently being refreshed


Review of Raising Concerns policy

A programme of executive-led sessions across all staff groups to support Freedom to Speak Up

A publicity campaign will also follow specifically on raising concerns to include posters, screensavers and use of social media.

c) Improve information provided to patients on discharge


Improve information provided to patients on discharge


Feedback from national in-patient survey, complaints and Friends and Family test.


Improved satisfaction with discharge information provided to patients and carers.


- Action plan to be developed once the result of the Inpatient Survey are published May 2015. This will be monitored for progress at the Carer and Patient Experience Committee

Responsible Person:

Medical Director

Baseline data Feedback from previous surveys and complaints shows that patients feel that they are not provided with sufficient information on discharge from hospital. Actions

Once the results of the National Inpatient Survey 2014 are published (end of May 2015) actions will be identified and entered onto an action plan that will be monitored through the Carer and Patient Experience Committee

Update Patient Discharge Policy to define what information should be provided, who to and when.


2.2 Statements of Assurance from the Board:

Specialties and services:

Em

erg

en

cy

Accident and Emergency (A&E) Gastroenterology

Bereavement Services General Medicine

Cardiology Genitourinary Medicine

Care of the Elderly Haematology

Clinical Measurement Hyperbaric services

Coronary Care Intensive Care Services

Dermatology Medical illustration

Diabetes Nephrology and renal dialysis

Diabetic Liaison Oncology

Diagnostic Imaging: Pharmaceutical services

- X-ray services Rehabilitation

- Specialist Imaging Respiratory Medicine

- Ultrasound services Rheumatology

- Mammography services Sandra Chapman Centre

- MRI & CT services Stroke Services

Endocrinology Therapies e.g. physiotherapy

Endoscopy

Ele

cti

ve

Anaesthetics Haematology

Antenatal screening Maternity services

Audiology Neonatology

Blood Transfusion Obstetrics

Breast Surgery Ophthalmology

Children’s Centre Oral Surgery

Community Dental Services Paediatric Surgery

Community midwifery Paediatrics

Community Paediatric Service Pain Management

Continence and Stoma Care Palliative Care

Dental and Orthodontics Parentcraft

Ear, Nose and Throat Safeguarding children

Fertility services School Nursing (Great Yarmouth)

Gastro-intestinal Surgery Trauma and Orthopaedics

General Surgery Urology

Gynaecology Vascular Surgery

During 2014/15 the James Paget University Hospitals NHS Foundation Trust provided and/or subcontracted 64 relevant health services, [listed in the table below]. The James Paget University Hospitals NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these relevant services The income generated by the relevant health services reviewed in 2014/15 represents 100% of the total income generated from the provision of relevant health services by the James Paget University Hospitals NHS Foundation Trust for 2014/15


Clinical Audits and National Confidential Enquiries

Audit Title Relevant to

JPUH Services?

Trust participation

Case Ascertainment

Elective Surgery (National PROMS Programme)

Yes Yes Data collection ongoing.

Medical and surgical clinical outcome review programme: National confidential enquiry into patient outcome and death

Yes Yes See Confidential Enquiries section below.

Head and neck oncology (DAHNO) Yes Yes Data collection ongoing. Co-ordinated by Norfolk & Norwich University Hospitals Foundation Trust

Bowel cancer (NBOCAP) Yes Yes >95%

National emergency laparotomy audit (NELA)

Yes Yes 100%

Case Mix Programme (CMP) Yes Yes Data collection ongoing

Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK)

Yes Yes Data collection ongoing

National Joint Registry (NJR) Yes Yes Data collection ongoing

Diabetes (Paediatric) (NPDA) Yes Yes 100%

Epilepsy 12 audit (Childhood Epilepsy)

Yes Yes Awaiting information

National intensive and special care (NNAP)

Yes Yes 100%

Prostate Cancer Yes Yes Data collection ongoing

During 2014/15 34 national clinical audits and 2 national confidential enquiries covered relevant health services that the James Paget University Hospitals NHS Foundation Trust provides. During that period the James Paget University Hospitals NHS Foundation Trust participated in 76% (26/34) national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that the James Paget University Hospitals NHS Foundation Trust was eligible to participate in during 2014/15 are [shown in the table below]: The national clinical audits and national confidential enquiries that the James Paget University Hospitals NHS Foundation Trust participated in during 2014/15 are [shown in the tables below]: The national clinical audits and national confidential enquiries that the James Paget University Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2014/15, are [shown in the table 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 [where available].



JPUH Services?

Trust participation

Case Ascertainment

Fitting child (care in emergency departments)

Yes Yes 100%

Mental health (care in emergency departments)

Yes Yes 100%

Older people (care in emergency departments)

Yes No Participation was arranged but not in time to meet the data collection deadline (31/01/15)

Severe trauma (Trauma Audit & Research Network, TARN)

Yes Yes

Jan – Dec 2014 58.7% data completeness 93.7% data accreditation (quality of data) -

National Comparative Audit off Blood Transfusion programme (2 audit workstreams for 2014/15)

Partial – 1 of 2 workstreams

No

National Heart Failure Audit Yes Yes

Not all cases were entered, but a case ascertainment percentage could not be accurately reported due to coding issues.

Pulmonary hypertension Yes No

Diabetes (Adult) ND(A) (3 audit workstreams for 2014/15)

Yes Partial (2 of 3 workstreams)

1) NDA (National Diabetes Audit) workstream: participation status currently under review. 2) NPID (National Pregnancy in Diabetes) workstream: participated, case ascertainment 100%. 3) NDFA (National Diabetes Footcare Audit): participated, data collection ongoing.

Inflammatory bowel disease (IBD) Yes Unknown

Oesophago-gastric cancer (NAOGC) Yes Yes >90%

Adherence to British Society for Clinical Neurophysiology (BSCN) and Association of Neurophysiological Scientists (ANS) Standards for Ulnar Neuropathy at Elbow (UNE) testing

Awaiting information

Awaiting information

Falls and Fragility Fractures Audit Programme (FFFAP)

Yes Yes 100%

Renal replacement therapy (Renal Registry)

Yes Yes 100%

Adult community acquired pneumonia

Yes Yes Data entry ongoing

Lung cancer (NLCA) Yes Yes 100%

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme (2 audit workstreams for 2014/15)

Yes Yes

1) Secondary Care workstream: Awaiting information 2) Pulmonary hypertension workstream: Data collection ongoing

Pleural procedures Yes No

National Cardiac Arrest Audit (NCAA) Yes Yes 100% Data collection ongoing



JPUH Services?

Trust participation

Case Ascertainment

Rheumatoid and early inflammatory arthritis

Yes Yes 100%

Acute coronary syndrome or Acute myocardial infarction (MINAP)

Yes Yes 99%

Sentinel Stroke National Audit Programme (SSNAP)

Yes Yes

October – December 2014: - Band A (90%+) Case

Ascertainment - 89.1% Audit Compliance (data

quality) -

National Audit of Intermediate Care

Commissioner-led; no

participation from

commissioner.

No

Mental health clinical outcome review programme: National confidential enquiry into patient outcome and death

No N/A

Prescribing Observatory for Mental Health (POMH)

No N/A

Congenital heart disease (Paediatric cardiac surgery)

No N/A

Paediatric intensive care (PICANet) No N/A

National Vascular Registry No N/A

Cardiac Rhythm Management (CRM) No N/A

Coronary angioplasty No N/A

National Acute Cardiac Surgery Audit No N/A

Chronic kidney disease in primary care

No N/A

Some actions from national clinical audits:

Dementia Carers Audit as part of the national dementia CQUIN: - Establish Training Project Group to review training plan and work up a plan for the next 3 years. - Meet training requirement in CQUIN targets. - Meet CQUIN targets for emergency patients over 75 years. - Set up CQUIN Project Group to review progress and plan for future requirements including

supporting key carer and evaluating carer satisfaction. - Review how mental health is currently assessed on admission, especially for patients over 65

years; ensure there is guideline/policy to support this.

British Thoracic Society National Asthma Audit: Making improvements: - Protocols: The use of assessment-driven algorithm and an integrated care pathway (detailing

bronchodilator usage, clinical assessment, and specific criteria for safe criteria) has been shown to reduce hospital stay without substantial increases in treatment costs

Barriers to change:

The reports of 38 national clinical audits were reviewed by the provider in 2014/15 and the James Paget University Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:


- Adherence to an asthma-management program involves a number of areas: medication, appointment-keeping, prevention, and applying an emergency plan of action. Barriers to adherence may exist in one or all four of these areas, leading to ineffective control of asthma. Recommendations are made for improving the patient-physician partnership to improve adherence.

Training: - A nurse-led asthma home management training programme administered during a hospital

admission can significantly reduce subsequent admissions to hospital for asthma. Acute hospitalisation may be a particularly effective time to deliver home management training.

- Re-auditing: Re-audit yearly Priorities for 2015: - Documentation - use of stickers (incorporating documenting written Asthma Plan) - Written management plans

Royal College of Radiologists (RCR) Standards for safety in radiological interventions: Raise awareness of WHO safety checklist for any radiological intervention to all staff directly involved in these types of procedures Use of intervention procedure checklist, consent form, IV contrast form, biopsy sheet and nursing notes for maintaining high standards of patient safety

Some actions from local clinical audits:

Age-related Macular Degeneration (ARMD) referral to treat time audit (wet/neovascular/ exudative): - Contact community referral sources

(optometrists, GPs) with audit findings - Recommendations, advice, and guidance

regarding usage of wet ARMD Rapid Access Referral Forms

- Information regarding training and guidance sessions available for wet ARMD

- Provision of community referral sources with more Rapid Access Referral Forms

Paediatric Urinary Tract Infections are we following best practice?: - Culture appropriate samples. - Robust follow-up of culture results. - Appropriate interpretation of results -

microbiology input if unsure. - Ensure appropriate imaging is organised - as

per NICE guidelines. - Clarification during handover - specific

page/checklist in admission notes. - Produce local clinical guideline. - Re-audit.

Sepsis Six Care Bundle: - Encourage use of Sepsis Proforma - Hospital

wide education programme - Repeat Sepsis 6 Care Bundle Audit -

Snapshot audit of patient diagnosed with sepsis /severe sepsis in December 2014.

- Representation From Elective Division - e-Mail Divisional Director requesting name of member to represent Elective Division at Sepsis team.

- Patient Group Direction (PGD) for Antibiotics

Intravenous (IV) Fluids on Medical Wards: - Presentation of audit finding to highlight

areas where we underperform. - Formulate hospital guidelines for IV fluids

policy (including recommended fluid choice for day 1).

- Regular training and formal assessment for doctors involved in fluid prescription and nurses involved in administration.

- Re-audit.

The reports of 84 local clinical audits were reviewed by the provider in 2014/15 and James Paget University Hospitals NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:


Consent Form 1 Audit: - Results to be shared - Emergency Divisional

Director to take to Divisional Clinical Governance Meetings

- Review juniors practice – Divisional Directors to speak to doctors in training

- Letter to Consultants - Corporate letter by Elective Divisional Director

Movement of Patients with Alert Organisms 2014:

Infection Prevention Team will continue to work with clinical staff to monitor patients with alert organisms. Ensuring wherever possible these patients are identified promptly, receive correct topical treatment if appropriate and are not transferred between clinical areas unless clinically necessary.

Audit of compliance to NICE guidance on the initial management of self-harm in A&E: - Available SAD score posters and proforma in

A&E - Ensure proformas are available and well signposted.

- SAD Score poster in A&E - SAD score awareness increased - Teaching

sessions to juniors - Consultants to promote SAD score - See & Greet nurse to ask about relevant

topics on admission - poster in see & greet room.

Compliance with documentation of urethral catheterisation re-audit: - Presentation of audit results at doctors in

training induction in August to highlight re-audit has demonstrated an improvement in compliance with documentation criteria.

- Catheter sticker template has significantly better compliance with documentation when compared with non sticker use - further feedback from Multi-disciplinary team on input to sticker template

- Trust wide re-audit.

National Confidential Enquiries

Title Aim Relevant to JPUH Services

Trust participation

Percentage of Cases

Submitted

Gastrointestinal Haemorrhage study

To identify the remediable factors in the quality of care provided to patients who are diagnosed with an upper or lower Gastrointestinal Haemorrhage.

Yes Yes

80% 1 (n=3 submitted

and 1 exclusion)

Sepsis study

To identify and explore avoidable and remediable factors in the process of care for patients with known or suspected sepsis.

Yes Yes

100% (n=5 submitted

with 2 exclusions)

1 One set of audit notes not completed within timescales

NCEPOD - What is it?

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an independent charitable organisation that reviews medical and surgical clinical practice and makes recommendations to improve the quality of the delivery of care for the benefit of the public. They do this by undertaking confidential surveys and research covering many different aspects of care and making recommendations for clinicians and management to implement. The Trust has a dedicated lead for NCEPOD who provides regular reports regarding the Trust’s progress with implementing the recommendations from the published reports. Self-assessments have been carried out using the NCEPOD tools and action plans are in place to ensure implementation of the recommendations.


Participation in Clinical Research The Research and Development (R&D) team comprises eighteen dedicated research nurses and research management/ support staff. The research nurse team worked on fifty eight studies across sixteen specialities. Twenty four doctors acted as principal investigators for multi-centre research studies sponsored by other organisations, supported by other clinicians acting as co-investigators. There are approximately seventy studies currently running across the Trust. Studies in oncology are supported by the Clinical Trials Practitioners from Clinical Research Network Eastern.

Staff held a research awareness programme to coincide with International Clinical Trials Day in May 2014; this aimed to inform both staff and patients of our research and what we do. The R&D Department launched its Twitter account, @JPUHResearch, in May 2014 and ended the year by starting the #whywedoresearch campaign which has attracted national and international followers. The Trust joined forces with the Stroke Research Unit in York to produce a video advertising the campaign which is available to view/download on YouTube: https://www.youtube.com/watch?v=cjkrBzeluNo. So far the campaign has generated nearly 3000 tweets and the video has been viewed over 600 times. The Commissioning for Quality and Innovation (CQUIN) Framework

The number of patients receiving relevant health services provided or sub-contracted by the James Paget University Hospitals NHS Foundation Trust in 2014/15 that were recruited during that period to participate in research approved by a research ethics

committee was 820.

A proportion of the James Paget University Hospitals NHS Foundation Trust’s income in 2014/15 was conditional upon achieving quality improvement and innovation goals agreed between the James Paget University Hospitals NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of relevant health services, through the Commissioning for Quality and Innovation payment framework. Further details on the agreed goals for 2015/16 and for the following 12 month period are available electronically at: http://www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf The amount of income in 2014/15 conditional upon achieving quality improvement and innovation goals is: £3,411,307

The amount of income received for the associated payment in 2013/14 was: £3,283,495

CQUIN - What is it?

CQUIN means Commissioning for Quality and Innovation. This is a system introduced in 2009 to make a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care. This means that a proportion of our income depends on achieving quality improvement and innovation goals agreed between the Trust and its commissioners.

https://www.youtube.com/watch?v=cjkrBzeluNo

http://www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf


The Care Quality Commission (CQC)

A Care Quality Commission themed review took place from 20th October 2014 to 24th October 2014 and was conducted under Section 48 of the Health and Social Care Act 2008 which permits the CQC to review the provision of healthcare and the exercise of functions of NHS England and Clinical Commissioning Groups.

The review explored the effectiveness of health services for looked after children and the effectiveness of safeguarding arrangements within health for all children.

The focus was on the experiences of looked after children and children and their families who receive safeguarding services.

They looked at:

the role of healthcare providers and commissioners.

the role of healthcare organisations in understanding risk factors, identifying needs, communicating effectively with children and families, liaising with other agencies, assessing needs and responding to those needs and contributing to multi-agency assessments and reviews.

the contribution of health services in promoting and improving the health and wellbeing of looked after children including carrying out health assessments and providing appropriate services.

They also checked whether healthcare organisations were working in accordance with their responsibilities under Section 11 of the Children Act 2004. This includes the statutory guidance, Working Together to Safeguard Children 2013.

The James Paget University Hospitals NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is registered to carry out the following legally registered services: • Treatment of disease, disorder or injury; • Surgical procedures; • Diagnostic and screening procedures; • Maternity and midwifery services; • Termination of pregnancies; and • Family planning services. • Assessment or medical treatment for persons detained under the 1983 Act (The

Mental Health Act 1983)*

The Care Quality Commission has not taken enforcement action against the James Paget University Hospitals NHS Foundation Trust during 2014/15

The James Paget University Hospitals NHS Foundation Trust has participated in one special review or investigation by the Care Quality Commission during the reporting period. *Applied for, awaiting confirmation April 2015

CQC - What is it? The CQC make sure hospitals, care homes, dental and GP surgeries and all other care services in England provide people with safe, effective, compassionate and high-quality care, and encourage them to make improvements. They do this by inspecting services and publishing the results on their website to help people make better decisions about the care they receive.


The Trust is awaiting the final report and will address the conclusions and requirements within once available. The final report for this themed review was not available by the 31st March 2015, hence we cannot report on progress within this Quality Report. Secondary Uses Service

Information Governance

Information Governance - What is it?

Information Governance (IG) is the way in which the NHS handles all information and in particular the personal and sensitive information of patients and staff. Following strict IG guidelines enables the Trust to ensure that personal information is dealt with legally, securely, efficiently and effectively, in order to deliver the best possible care to our patients.

The James Paget University Hospitals NHS Foundation Trust submitted records during 2014/15 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: - Which included the patient’s valid NHS number

• 99.6% for admitted patient care • 99.8% for outpatient care and • 98.9% for accident and emergency care

- Which included the patient’s valid General Medical Practice Code was: • 100% for admitted patient care • 100% for outpatient care and • 99.1% for accident and emergency care

Secondary Uses Service - What is it?

The Secondary Uses Service is designed to provide anonymous patient-based data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, clinical audit and governance, benchmarking, performance improvement, medical research and national policy development.

The James Paget University Hospitals NHS Foundation Trust will be taking the following actions to improve data quality [in relation to Secondary Uses Service]:

Data is reviewed locally and monitored against the Information Governance Toolkit’s Data Completeness and Validity scoring system

The James Paget University Hospitals NHS Foundation Trust intends to take the following action to address the conclusions or requirements reported by the CQC.

The James Paget University Hospitals NHS Foundation Trust has made the following progress by 31st March 2015 in taking such action.


The table below shows this year’s position against previous year’s results.

The ‘Unsatisfactory’ rating for 2013/14 was because the Trust scored a Level 1 achievement for Requirement 112 (Staff Training). The Trust was unable to provide evidence from Information Governance mandatory training reports to demonstrate achievement of the required 95% staff trained at the submission date. The percentage of staff trained in 2013/14 was 85.18%. To achieve a ‘Satisfactory’ rating, the Trust would have to achieve Level 2 for each of the Requirements. For 2014/15 the Trust achieved the Level 2 requirement with 95.4% of staff trained, hence the ‘Satisfactory’ rating despite the 2% lower overall result.

An Improvement Plan for the 2014/15 IG Toolkit will be developed during May 2015, looking to strengthen the evidence available to the Trust in support of version 12. Payment by Results

Year 2012 Result

(IGT version 9) 2013 Result

(IGT version 10) 2014 Result

(IGT version11) 2015 Result

(IGT version 12)

Overall Result

71% (Satisfactory)

(45 out of 45 answered)

72% (Satisfactory)

(45 out of 45 answered

72% (Unsatisfactory)


70% (Satisfactory)


The James Paget University Hospitals NHS Foundation Trust Information Governance Assessment Report overall score for 2014/15 was 70% and was graded GREEN

The James Paget University Hospitals NHS Foundation Trust will be taking the following actions to improve data quality [in relation to Information Governance]:

Payment by Results - What is it?

Payment by Results (PbR) is the rules-based payment system in England under which commissioners pay healthcare providers for each patient seen or treated, taking into account the complexity of the patient’s healthcare needs. PbR currently covers the majority of acute healthcare in hospitals, with national tariffs for admitted patient care, outpatient attendances, accident and emergency (A&E), and some outpatient procedures.

The James Paget University Hospitals NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission.

The James Paget University Hospitals NHS Foundation Trust will be taking the following actions to improve data quality [in relation to Payment by Results]:

Not applicable in this year


2.3 Reporting against core indicators Summary hospital-level mortality indicator (SHMI)

JPUH

2012/13 JPUH 2013/14

2

JPUH 2014/15

National Average 2014/15

Highest SHMI for

Foundation Trusts

Lowest SHMI for

Foundation Trusts

(a) Value and (banding) of the SHMI for the Trust

84.64% 92.34% (As Expected)

108.53% 100.13% 119.82% 78.84%

(b) % of patient deaths with palliative care coded at either diagnosis or specialty level

21.09% 16.47% 22.35% 21.40% 47.16% 6.43%

NB: Palliative care figure included as a contextual indicator to the SHMI indicator response.

2 2013/14 data is measured on a rolling 12 month basis, at time of report data available to the end of June 2013

Summary hospital-level mortality indicator - What is it? The SHMI shows whether the number of deaths linked to a particular hospital is more or less than expected, and whether that difference is statistically significant. It covers all English acute non-specialist providers. The dataset used to calculate the SHMI includes all deaths in hospital, plus those deaths occurring within 30 days after discharge from hospital. The expected number of deaths is calculated from a risk-adjustment model developed for each diagnosis grouping that accounts for age, gender, admission method and comorbidity (any other illnesses or conditions). The lower the SHMI figure, the better the outcome for patients.

The James Paget University Hospitals NHS Foundation Trust considers that this data is as described for the following reasons:

Data is taken from Dr Foster Intelligence which uses Secondary Users Service (SUS) Hospital Episode Statistics (HES) data which is audited on an annual basis by external auditors.

The James Paget University Hospitals NHS Foundation Trust intends to take/has taken the following actions to improve the indicator and percentage in (a) and (b) above, and so the quality of its services, by:

The Trust has implemented a Unified Mortality Review (UMR) process, the process identifies patients for review on a monthly basis for diagnosis codes where the mortality rates were above the expected range as classified by Dr Foster Intelligence.


Patient Reported Outcome Measures (PROMs)

PROMs participation rates

JPUH 2012/13 JPUH 2013/14 JPUH 2014/153

Provisional 2014

participation (England)

Groin hernia surgery 71.00% 72.90% 57.90% 58.30%

Varicose vein surgery 62.50% 65.70% 56.80% 42.40%

Hip replacement surgery 79.60% 76.20% 68.10% 86.10%

Knee replacement surgery 85.00% 97.90% 81.70% 96.60%

All procedures 76.70% 81.50% 68.40% 76.70%

3 April 2014 to September 2014 as this is the current data available

PROMs - What is it?

Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering four clinical procedures, PROMs calculate the health gains after surgical treatment using pre- and post-operative surveys. The four procedures are

i. groin hernia surgery ii. varicose vein surgery iii. hip replacement surgery iv. knee replacement surgery

PROMs have been collected by all providers of NHS-funded care since April 2009. PROMs measure a patient's health status or health-related quality of life at a single point in time, and are collected through short, self-completed questionnaires. This health status information is collected from patients through PROMs questionnaires before and after a procedure and provides an indication of the outcomes or quality of care delivered to NHS patients.

The James Paget University Hospitals NHS Foundation Trust intends to take/has taken the following actions to improve these outcome scores, and so the quality of its services, by:

Outcome scores are voluntary and it is recognised that it is difficult to influence patients’ participation.

The James Paget University Hospitals NHS Foundation Trust considers that the outcome scores are as described for the following reasons:

• Cannot be determined until full-year data available


Hospital re-admissions

JPUH

2012/13 JPUH

2013/14 JPUH

2014/154


Highest score for Foundation

Trusts

Lowest score for Foundation

Trusts

Patients aged 0-15 years

8.40% 8.40% 7.9% 8.53% 13.66% 4.38%

Patients aged 16 or over

10.60% 10.80% 5.83% 7.66% 9.47% 5.61%

Responsiveness to the personal needs of patients

4 October 2013 to September 2014 as this is the current data available

What is the standard?

This indicator is based on data from the National Inpatient Survey and forms part of the NHS Outcome Framework (Domain 4 - Indicator 4.2) ‘Ensuring People Have a Positive Experience of Care’ Indicator 4.2 is based on questions from the inpatient survey under the domains:

Access and waiting

Safe, high quality, coordinated care

Better information, more choice

Building closer relationships

Clean, comfortable, friendly place to be The scores are out of 100. A higher score indicates better performance: if patients reported all aspects of their care as "very good" we would expect a score of about 80, a score around 60 indicates "good" patient experience. The domain score is the average of the question scores within that domain; the overall score is the average of the domain scores.

Hospital re-admissions - What is it? Includes patients readmitted to a hospital within 28 days of discharge from that same hospital or from a hospital which forms part of the same Trust.

The James Paget University Hospitals NHS Foundation Trust considers that these percentages are as described for the following reasons:

Data is taken from Dr Foster Intelligence which uses SUS/HES data which is audited on an annual basis by external auditors

The James Paget University Hospitals NHS Foundation Trust intends to take the following actions to improve these percentages, and so the quality of its services by:

Continuing to work with our local commissioners to ensure readmissions are kept to a minimum.


Domain Adjusted 2013/14

2014/15

Access and waiting 58.9 63.4

Safe, high quality, coordinated care 76.4 74.8

Better information, more choice 75.4 73.0

Building closer relationships 82.0 81.1

Clean, comfortable, friendly place to be 80.7 83.4

Overall 74.7 75.1

Venous Thromboembolism (VTE) risk assessments

VTE - What is it? A clot within a blood vessel is called a thrombus and the process by which it forms is known as thrombosis. It can be damaging as it might block the flow of blood. Also, part of the clot might break away and block a blood vessel further along, cutting off the blood supply to important organs. Deep vein thrombosis (DVT) is the formation of a blood clot in one of the deep veins within the body, such as in the leg or pelvis. This kind of thrombosis can occur after surgery and may cause redness, pain and swelling. Pulmonary embolism (PE) is a serious condition in which the arteries leading from the heart to the lungs becomes blocked. It can occur when a blood clot breaks away from its original location and travels to the lungs. Symptoms may include sharp chest pain, shortness of breath and coughing up blood. The process by which blood clots occur and travel through the veins is known as venous thromboembolism (VTE), the collective term for DVT and PE.

The James Paget University Hospitals NHS Foundation Trust considers that this data is as described for the following reasons:

This data is published via the CQC website

The James Paget University Hospitals NHS Foundation Trust intends to take/has taken the following actions to improve this data, and so the quality of its services by:

The Trust intends to continue its current processes and to maintain performance against this indicator


What is the standard required

(a) Percentage of all adult inpatients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool. The final indicator value for this is 97%.

Month Target Trust Actual Variation

April 2014 97% 98.13% +1.13%

May 2014 97% 98.41% +1.41%

June 2014 97% 98.32% +1.31%

July 2014 97% 99.14% +2.14%

August 2014 97% 97.31% +0.31%

September 2014 97% 98.69% +1.69%

October 2014 97% 97.70% +0.70%

November 2014 97% 98.40% +1.40%

December 2014 97% 97.96% +0.96%

January 2015 97% 98.45% +1.45%

February 2015 97% 97.75% +0.75%

March 2015 97% 98.2% +1.2%

We have a robust and sustained process embedded in clinical practice to ensure VTE admission risk assessments are completed.

A multidisciplinary approach is used to manage and implement VTE prevention interventions.

The root cause analysis process is not embedded in practice hence the development of this into a Quality Priority for 2015/16 – see Part 2, page 7.

The James Paget University Hospitals NHS Foundation Trust considers that these percentages are as described for the following reasons:

The James Paget University Hospitals NHS Foundation Trust intends to take the following actions to improve these percentages, and so the quality of its services by:


Clostridium difficile (C.difficile)

JPUH

2012/13 JPUH

2013/14 JPUH

2014/15


5


Trusts


Trusts

Rate per 100,000 bed days C.diff infection

8.67 12.96 14.5 Data not available

Number of cases of C.diff infection

13 19 22 26 99 0

The rate of hospital acquired C Difficile is demonstrated in the table above, 22 against a target of 17. However, following appeal 10 cases have been deemed unavoidable and two further cases are currently within the external appeals process.

Continuing the strong focus on prevention as well as control.

Since we have had dual screening in place for C.difficile, we now isolate symptomatic carriers so are proactive in controlling the risk.

Encouraging prudent use of antibiotics through: - Updating all antibiotics policies. - Encouraging use of narrow spectrum antibiotics - Limiting the duration of usage of antibiotics - Encouraging IV to oral switch

5 April 2014 to February 2015 as this is the current data available

C.difficile - What is it?

C.difficile is a type of bacteria (germ) that can cause infection of the digestive system resulting in diarrhoea. C.difficile infections are usually caused by antibiotics; hence the majority of cases happen in a healthcare environment, such as a hospital or care home. Older people are most at risk from infection - people aged over 65 account for three quarters of all cases. In recent years, the number of C.difficile infections has fallen rapidly. There were 14,687 reported cases in England during 2012/13 compared to 52,988 in 2007.

What is the standard?

This measure shows the rate per 100,000 bed days of cases of C.difficile infection that have occurred within the Trust amongst patients aged two years or over during the reporting period.

The lower the figure, the lower the number of C.difficile cases.

The James Paget University Hospitals NHS Foundation Trust considers that this rate is as described for the following reasons:

The James Paget University Hospitals NHS Foundation Trust intends to take/has taken the following actions to improve this rate, and so the quality of its services by:


Continuing to educate all staff and keep the organisational culture that Infection Control is everyone’s business.

The infection Prevention and Control team have also introduced a sticker which is attached to the antibiotic page of the drug chart for all patients identified as C.difficile toxin positive and/or Glutamate dehydrogenase (GDH) positive. This should remind staff to carefully consider antibiotic prescribing for these at risk patients. It has been recognised regionally as good practice and suggested other hospitals should adapt it.

Antibiotic audits have been completed for all clinical areas every three months throughout 2014/15 measuring: correct antibiotic for condition, duration, stop dates, change from intravenous to oral, and indication documented. Results have improved throughout the year.

NHS England has published the C.difficile infection (CDI) objectives for NHS organisations for 2015/16. The objectives in terms of rate and actual number of cases have been calculated based upon previous performance. All organisations with a current CDI rate for the year to November 2014 below (better than) their cohort median for the same period, have a CDI objective for 2015/16 set as their current number of CDI cases reported during the year to November 2014 minus one. This maintains the principle of the NHS delivering continuous improvement in patient safety but reflects that those performing better than average may be approaching the irreducible minimum of cases. All organisations with a current CDI rate for the year to November 2014 above (worse than) their cohort median for the same period have a CDI objective set as their CDI rate for the year to November 2014 minus the percentage reduction in median CDI rate seen for their cohort between the preceding year and the current year. The graph below illustrates how this is reflected in the CDI objectives for local trusts. This Trust’s objective for 2015/16 remains unchanged from 2014/15 at 17 cases.

C.difficile Infections Objectives 2015/16


Patient Safety Incidents

JPUH

2012/13 JPUH

2013/14 JPUH

2014/15

Highest score for Medium Acute

Trusts (Apr 14 to Sep 14)

6

Lowest score for Medium Acute

Trusts (Apr 14 to Sep 14)

Number of patient safety incidents

4922 5926 4954 12020 35

JPUH (Apr 14 to Sep 14) 2641

Rate per 1000 bed days 32.8 40.4 32.6 74.96 0.24

JPUH (Apr 14 to Sep 14) 38.48

Percentage of incidents resulting in Major Harm

0.5% (n=27)

0.1% (n=7)

0.3% (n=13)

74.3% 0.0%


Percentage of incidents resulting in Death

0.1% (n=5)

0.1% (n=5)

0.1% (n=4)

8.6% 0.0%


6 This date range has been selected as this is the most current data available from the National Reporting and

Learning Service.

Patient Safety Incident - What is it? A Patient Safety Incident (PSI) is any untoward incident that happens involving a patient whilst they are on Trust premises or in Trust care e.g. a patient fall.

Harm Definitions The Trust uses the nationally recognised definitions of harm as described by the National Patient Safety Agency (NPSA)

No Harm - An incident has occurred but with no harm as a result

Minor Harm - Minor injury or illness requiring minor intervention (treatment)

Moderate Harm

- Moderate injury requiring professional intervention

- Increase in length of hospital stay by 4–15 days

Major Harm - Major injury leading to long-term incapacity or disability

- Increase in length of hospital stay by more than 15 days

- Mismanagement of patient care with long term effects

Death - Incident leading to death

The James Paget University Hospitals NHS Foundation Trust considers that this number and rate is as described for the following reasons:


Patient Safety Incidents 2012/13 to 2014/15

Incident reporting as a whole has decreased by 8% in 2014/15 compared to 2013/14 (a 16% increase was seen in 13/14 compared to 12/13).

We have maintained our good position on reporting PSIs to the National Patient Safety Agency within this period. We sit the higher end of the middle 50% of reporters among our peer group (acute (non-specialist) trusts). Organisations that report more incidents usually have a better and more effective safety culture. You can't learn and improve if you don't know what the problems are.

The NPSA say: ‘We encourage high reporting. Scrupulous reporting and analysis of safety related incidents, particularly incidents resulting in no or low harm, provides an opportunity to reduce the risk of future incidents. Research shows that organisations which report more usually have a stronger learning culture where patient safety is a high priority. Through high reporting the whole of the NHS can learn from the experiences of individual organisations’.

Awareness has been raised as to what constitutes a PSI through training and communications

Monthly monitoring of what has or, more importantly, has not been submitted as a PSI

The James Paget University Hospitals NHS Foundation Trust intends to take/has taken the following actions to improve this number and rate, and so the quality of its services by:


Incident reporting rates are discussed at Divisional governance meetings and at the Patient Safety and Effectiveness Committee. The importance of incident reporting is to be reiterated alongside the launch of the revised NHS England Serious Incident Framework and the revised Never Events Policy and Framework

Continuing to increase awareness around categorising harm when reporting incidents.

Uploads to the National Reporting and Learning Service (NRLS) and quality checking of Patient Safety Incidents will continue. Uploads to the NRLS are carried out at least weekly.

Incident reporting and learning is discussed at Divisional governance meetings monthly with trends and themes analysed and cascaded to wider teams. This will be continued through 2015/16

Friends and Family Test – Patient

Trust Score March 2015

7

Trust response

rate March 2015

NHS England Score February 2015

8

NHS England response

rate February

2015 Area

% recommended

% not recommended

% recommended

% not recommended

A&E 93% 2% 25.99% 88% 6% 21.2%

Inpatients 96% 2% 45.63% 95% 2% 40.1%

Maternity (combined)

98% 0 22.81% 95% 1% -

Trust Summary 95% 2% 30.79%

Friends and Family Test – NHS Staff Survey 2014

7 Benchmarked data is no longer available based on the FFT Score as this is a redundant measure

but data is released nationally based on the percentage of respondents who recommend our Trust and those who do not recommend our Trust, as shown in the table. 8 March data due for release early May

What is it?

The Friends and Family Test (FFT) is a single question survey which asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. It is initially for providers of NHS funded acute services for inpatients (including independent sector organisations that provide acute NHS services) and patients discharged from A&E (type 1 & 2) from April 2013. As of 1st October 2013 the survey was extended to include all women of any age who use NHS funded maternity services.

What is the standard? Percentage of staff surveyed who strongly agree/agree with the question. 'If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation'


JPUH 2012

JPUH 2013

JPUH 2014

National Average

2014


Trusts


Trusts

Question 12d - Staff 59% 67% 65% 65% 97% 54%

The graph below how James Paget University Hospitals NHS Foundation Trust compares with other acute trusts on an overall indicator of staff engagement. Possible scores range from 1 to 5, with 1 indicating that staff are poorly engaged (with their work, their team and their trust) and 5 indicating that staff are highly engaged. The trust's score of 3.81 was above (better than average) when compared with trusts of a similar type. Overall staff engagement

The final JPUH response rate was 47% (373 usable responses from a final sample of 797) which was up 11% on 2013; a notable achievement. We believe this is mainly due to the survey being circulated in hard copy form rather than electronically as it was in 2013. NHS Staff Survey Statement of approach to staff engagement

In line with the NHS Constitution pledge ‘to engage staff in decisions that affect them and the services they provide …. All staff will be empowered to put forward ways to deliver better and safer services for patients and their families’. The James Paget University Hospitals approach to staff engagement is to fulfil the NHS Constitution pledge to engage staff with the services they provide as there is plenty of evidence to suggest that more engaged clinicians and staff achieve safer and better outcomes and experiences for the patients they serve.

The James Paget University Hospitals NHS Foundation Trust considers that this

percentage is as described for the following reasons:

The James Paget University Hospitals NHS Foundation Trust intends to take/has taken the following actions to improve this percentage, and so the quality of its services by:


Our engagement strategy is as follows

a package of health and wellbeing initiatives

surveys

staff listening events

quality appraisal

Leadership and team briefing sessions

Board to Ward walk rounds

Senior leaders attend regular update sessions across the Trust where they receive feedback from staff – medical staff

Regular trade union representative meetings

Providing leadership and management development

Behavioural Champions

Staff recognition schemes This is a core part of the Trust’s Organisational Development Strategy. Summary of Performance for NHS Staff Survey

1) Response rate

2012 2013 2014 Trust Improvement

or Deterioration

JPUH National Average



Response rate 49% 50% 36% 49% 47% 42% +11%

2) Top 4 ranking scores


or Deterioration Top 4 ranking scores 2014 JPUH

National Average



KF1, Percentage of staff feeling satisfied with the quality of work and patient care they are able to deliver.

81% 77% 82% 77% 85% 77% 3%

improvement Higher score = better

KF2. Percentage of staff agreeing their role makes a difference to patients

89% 89% 91% 90% 93% 91% 2%

improvement Higher score = better

KF7. Percentage of staff appraised in last 12 months

79% 83% 97% 84% 92% 85% 5%

deterioration Higher score = better

KF25. Staff motivation at work. 3.78 3.82 3.92 3.85 3.96 3.86

+0.4 improvement

Higher score = better


3) Bottom 4 ranking scores


or Deterioration

Bottom 4 ranking scores 2014 JPUH National Average



KF16. Percentage of staff experiencing physical violence from patients, relatives or the public in last 12 months

20% 15% 15% 15% 19% 14% 4%

deterioration Lower score = better

KF13. Percentage of staff reporting errors, near misses or incidents witnessed in the last month

88% 90% 96% 90% 88% 90% 8%


KF6. Percentage of staff receiving job-relevant training, learning or development in last 12 months.

83% 81% 84% 81% 78% 81% 6%


KF28. Percentage of staff experiencing discrimination at work in last 12 months.

12% 12% 8% 11% 14% 11% 6%

deterioration Lower score = better

Action plans to address areas of concern

The survey highlights a number of areas for attention, which is where our focus of work will be. This will be incorporated within the refresh of the Organisational Development Strategy, rather than have separate action plans for each area. Future Priorities and Targets

Details of the revised Strategy is due to be presented to the April Board of Directors meeting (24th April 2015).


Part 3

Review of Quality 2014/15

Page

Summary of Achievement of Quality Priorities 2014/15 39

1. Patient Safety 40

2. Clinical Effectiveness 43

3. Patient and Staff Experience 45

Page

A Listening Organisation 49

- Learning from complaints 50

- Patient Advice and Liaison Service (PALS) 51

- Compliments 52

- Patient experience measurement tools 53

- Family carers 54

- Patient surveys 54

A Responsive Organisation 56

- Serious Incidents 56

- Never Events 56

- Inquests 56

- Mortality Reviews 56

- Savile Enquiry 57

Page

External Inspections 59

- Medicines and Healthcare Products Regulatory Agency (MHRA) 59

- Clinical Pathology Accreditation (CPA) 60

- Patient Led Assessments of the Care Environment (PLACE) 61

- Environmental Health 61

- General Pharmaceutical Council (GPhC) 62

- Norfolk Fire and rescue Service 63

- NHS Protect 64

- Royal College of Obstetricians and Gynaecologists (RCOG) 64

Page

Delayed Transfers of Care 65

Monitor’s Governance indicators 67

This section details how we have done against the targets we set for 2014/15 in our 2013/14 Quality Report. Where relevant we have included what we said within the 2013/14 Quality Report as an easy reference for the data included. Where possible we have included historical performance and where available we have included national benchmarks.

This section includes other information relevant to the quality of the services we have provided over 2014/15

This section shows how we have done when external inspectors/regulators have visited the Trust. The details include any remedial action that has been identified following these visits/inspections.

This section shows our performance against the relevant indicators and thresholds set out in Monitor’s Risk Assessment Framework e.g. 18 week referral to treatment targets


Summary of Achievement of Quality Priorities 2014/15

1. Patient Safety

a

Never Events - To increase staff education and training around Never Events and ensure systems and processes are in place to reduce the risk of occurrence

Achieved

b

Medicines Management - Improve controls assurance by implementing robust, effective, sustainable systems for safe and secure handling of medicines.

Achieved

c Documentation - To reduce the incidence of omissions in patient documentation so as to achieve complete and accurate records of care.

Achieved

2. Clinical Effectiveness

a

NICE Quality Standards - To review all NICE Quality Standards and demonstrate planning of service delivery around the ability to achieve these aspirational standards.

Achieved

b

Clinical Audit Prioritisation - Prioritise clinical audits, conducting those which are linked to Never Events, Serious Incidents, major litigation, complaints and other national and local priorities and risks

Achieved

c Clinical Audit Forward Plan - Deliver our Clinical Audit Forward Plan in-year.

Partially achieved – 88% started in-year

3. Patient and Staff Experience

a Patient Experience Information - Complete review and development of strategy for how we seek and review patient experience information

Achieved

b

Communication - Improve communications with patients, relatives and carers e.g. Do Not Attempt Resuscitation orders, end of life care, admission, discharge

Achieved

c

Responses to Complaints - Shape our responses to complainants to meet their specific needs, including earlier meetings at times and places convenient to them, involvement of complainants in developing improvement plans and audits to ensure changes have been embedded

Achieved


Patient Safety

(a) Never Events - To increase staff education and training around Never Events and ensure systems and processes are in place to reduce the risk of occurrence

The Trust reported one Never Event in 2014/15 which was categorised as follows:

Reported date Never Event Category

July 2014 Air embolism

The Trust carried out a full root cause analysis (RCA) investigation into this incident and a number of actions were identified and have been completed.

ID Action taken

1 Staff Competency

1a All staff caring for patients with arterial lines had review of competency and this will subsequently be carried out annually

2 Elimination of air from arterial monitoring and administration set

2a Local Guideline has been amended to include the mandatory flushing of the arterial monitoring and administration set under pressure for a minimum of ten seconds

2b Local Guideline also amended to include that staff carrying out and assisting in the changing of the arterial monitoring and administration set must have received training in the procedure and their competence assessed to be commensurate with the role they are undertaking

Never Event – What is it? Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Incidents are considered to be never events if: - There is evidence that the never event has occurred in the past and is a known

source of risk (for example, through reports to the National Reporting and Learning System or other serious incident reporting system).

- There is existing national guidance or safety recommendations, which if followed, would have prevented this type of never event from occurring (for example, for ‘Retained foreign object post procedure’ the referenced national guidance is related to the peri-operative counting and checking processes that would be expected to occur at the time of the procedure, including suturing after a vaginal birth).

- Occurrence of the never event can be easily identified, defined and measured on an ongoing basis.

The 2014/15 list details 25 incidents that are considered to be Never Events. The full list can be accessed here: http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf.

http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf


ID Action taken

3 Learning from the RCA and investigation

3a RCA findings and learning from the incident shared at key forums: - ICU/HDU Morbidity and Mortality Meeting - East Anglian Critical Care Network Meeting - E mail to all ICU/HDU staff and theatre staff who care for patients with arterial lines - Divisional Clinical Governance meeting - E mail to all Anaesthetic Consultants for cascade to junior anaesthetists - Anaesthetic tutorial meeting - ICU/HDU nurse training day

3b A system and process review has been undertaken

(b) Medicines Management - Improve controls assurance by implementing

robust, effective, sustainable systems for safe and secure handling of medicines.

The outcome of the CQC inspection held in November 2013 identified that improvements were required against the Outcome ‘People should be given the medicines they need when they need them, and in a safe way (outcome 9)’. The CQC re-inspected in September 2014 to check that action had been taken to meet the Standard and the decision was that the provider (Trust) was meeting the Standard. Findings

There were clear policy and procedures for the prescription and administration of as required (PRN) medicines.

Medicine charts included a section for additional notes between pharmacy, nursing and medical staff to enable good communication about prescribing orders and administration.

There had been education with a focus on PRN medicines following the previous CQC inspection.

There was new medicines guidance attached to medicine trolleys which outlined the process for ensuring that nursing staff administering medicines were aware which PRN medicines to give and in which order.

There were clear responsibilities for ensuring medicines to take home (TTOs) were available for patients on discharge, including doctors prescribing medicines, discharge letters for GPs identifying what had been prescribed, pharmacy involvement and medicines being made available for patients on discharge.


(c) Documentation - To reduce the incidence of omissions in patient documentation so as to achieve complete and accurate records of care.

The outcome of the CQC inspection held in November 2013 identified that improvements were required against the Outcome ‘People's personal records, including medical records, should be accurate and kept safe and confidential (outcome 21)’. The CQC re-inspected in September 2014 to check that action had been taken to meet the Standard and the decision was that the provider (Trust) was meeting the Standard. Findings

Records were completed appropriately.

Medication charts examined were appropriately completed.

Prescribing and pharmacy staff had made clear entries and advice for staff respectively.

Staff administering the medications made clear entries to show the treatment had been given.

Risk assessments had been appropriately completed in the care records examined.

Staff had recorded the assessment of risk and the patient's needs with respect to safety of bed rails, falls risk, skin integrity for pressure sores, and the moving and handling needs of patients.

Staff had completed regular observations including early warning scores to identify if patient's health was deteriorating.


Clinical Effectiveness (a) NICE Quality Standards - To review all NICE Quality Standards and

demonstrate planning of service delivery around the ability to achieve these aspirational standards.

Throughout 2014/15 the Divisions developed Service Development Plans for their key services. The template Service Development Plans all include a section on NICE Quality Standards and compliance with associated NICE Clinical Guidelines. These Service Development Plans will be reviewed and implemented throughout 2015/16, please see Part 2, Page 8 for details of the 2015/16 Quality Priority in relation to the NICE Quality Standards. (b) Clinical Audit Prioritisation - Prioritise clinical audits, conducting those

which are linked to Never Events, Serious Incidents, major litigation, complaints and other national and local priorities and risks

The Trust has a four-point priority rating system for clinical audit – Serious Incident and Never Event audits are categorised as Priority 2 – Internal must-do. NB: Priority 1 is External must-do i.e. compulsory national audits, CQUIN audits etc. The 2014/15 Clinical Audit Forward plan was developed to include auditable elements of Serious Incidents and Never Events. The Forward Plan is a living document and was updated throughout the year with audits that were undertaken as a result of a Serious Incident. Divisional reports to the Patient Safety and Effectiveness Committee now contain details of the Divisions’ performance against the high priority audits as identified on the Forward Plan. (c) Clinical Audit Forward Plan - Deliver our Clinical Audit Forward Plan in-

year.

For the period of 2014/15 there were 25 audits which had been prioritised as ‘must-do’ on the Forward Plan. 22 of these (88%) were started in this time. This is up from 82% (83/101) of ‘Must-do’ Forward plan items started in-year in 2013/14 (Note: the big difference in the quantity of audits from 13/14 to 14/15 is partly due to the CNST Maternity project, involving around 50 audits in 2013/14). The graph overleaf shows the number of audits from the 2014/15 Forward Plan which were due and not started in 2014/15. The figures are divided by the priority ratings assigned by the Audit Leads on the Forward Plans.


2014/15 Forward Plan Audits Overdue for Start

The 2014/15 Clinical Audit Forward Plan was developed to only include audits (and re-audits) that were achievable in the one year timeframe. The expectation was that all priority one and two audits will be complete in the year. It was recognised, however, that some of the lower priority audits on the Forward Plan would still not be completed within the year as the Forward Plan is a living document and other high priority audits came to bear in-year.


Patient and Staff Experience (a) Patient Experience Information - Complete review and development of

strategy for how we seek and review patient experience information

During 2014/15 we have devised and approved a Patient Experience and Engagement Strategy (2015 -2018) which details progress to date in terms of engaging and involving patients and service users and our strategic vision and direction for the next three years. The Patient Experience and Engagement Strategy, whilst is the responsibility of all staff, will be monitored by the Executive Lead for Patient Experience with progress updates to the Carer and Patient Experience Committee. Any risks to the delivery of this strategy will be highlighted to the Board of Directors and the Trust stakeholders via the Board Assurance Framework. There are several activities already in place within the Trust which support the Patient Experience and Engagement strategy. The Corporate Team provide on-going support to the Divisions to fully embed the principles of Patient and Public involvement through discussions at Divisional Governance and Board meetings. The Divisions report to the Carer and Patient Experience Committee to provide assurance that all sources of feedback are explored and shared, that themes and trends are identified and analysed, and service improvements are implemented, where applicable. The impact of the change improvements is also measured in order to close the loop or, if necessary, to discuss and refocus the direction of travel. Other achievements during 2014/2015

PACE (Patient Experience and Carer Committee) has been reviewed, restructured and renamed to CAPE (Carer and Patient Experience Committee) with new terms of reference to deliver the Trust’s Quality Strategy and strategic objectives in relation to improving carer and patient experience of our services.

Head of Patient Experience and Engagement appointed; responsible for developing systems and processes for delivery of the Trust’s Quality Strategy in relation to Patient Experience and ensuring alignment with the Patient Safety, Clinical Effectiveness and Transformation agendas.

Divisions have appointed identified Patient Experience Leads (Nursing and Medical Staff) to campaign for patient experience at every opportunity ensuring that it remains central to all aspects of business planning and care delivery.

Feedback from FFT, National Surveys, PALS and complaints, NHS Choices and Trust Governors are discussed as part of reporting to CAPE to identify themes and key priorities for action at that committee

Staff education and raising awareness has taken place across the Trust related to Patient Experience and Engagement to refocus priorities ensuring the patient experience is considered in all aspects of service design and delivery.


(b) Communication - Improve communications with patients, relatives and carers e.g. Do Not Attempt Resuscitation orders, end of life care, admission, discharge

During 2014/15 we have reviewed and updated our Do not attempt Cardiopulmonary Resuscitation (DNACPR) Policy following revised guidance from the Resuscitation Council (UK) and as a result of a recommendation following an inquest. This includes a flowchart which details the expectations and decision making process when considering a DNACPR order.

A Grand Round on DNACPR decisions was held in September 2014 led by the Medical Director. An email communication has been undertaken to raise awareness of importance that all available information is used to support patient assessments on admission. The Trust has introduced a Patient Discharge Logger on the background of increased admissions, patient safety concerns across the Trust and escalation beds being in use. This is available across the Trust and the expectation is that is the focal communication tool during board rounds, with a review of the previous day’s actions, followed by a discussion of what actions need to take place today. The focus is on patients who are medically safe for discharge and safe discharges.


The Trust is introducing the Advanced Care Planning: What on earth do I say? initiative to further improve information to patients around end of life matters. Incorporating discussions, group work and interactive exercises, What on earth do I say? aims to give staff a ‘toolbox’ of skills to enable them to:

Identify barriers to effective communication and end of life conversations

Describe behaviours known to block communication with patients and the skills to enhance it

Describe skills required to build rapport and initiate conversations

Demonstrate familiarity and understanding of strategies required for breaking bad news, handling difficult questions, denial and collusion

The programme has been locally developed by Norfolk Community Health and Care NHS Trust (NCH&C), NHS Norfolk & Waveney, HealthEast and the University of East Anglia in the context of the Mental Capacity Act, national guidance and local policy. (c) Responses to Complaints - Shape our responses to complainants to meet

their specific needs, including earlier meetings at times and places convenient to them, involvement of complainants in developing improvement plans and audits to ensure changes have been embedded

Complaints Responses - Acknowledgement The Trust continues to aim for a 100% standard to acknowledge all formal complaints within three working days. This has been achieved in 99% of cases during 2014/2015. The table below details this further. A telephone call from the Complaints Investigator is the initial method of contact to discuss and agree how the complainant wishes the complaint to be handled; for example they may wish to go directly to a meeting with the relevant staff involved in the care delivery, or prefer a written response after a full investigation has taken place. In all cases, a telephone conversation will be followed up with a written acknowledgement.

Days to Acknowledge

2012/13 2013/14 2014/15

0 2 3 0

1 233 222 235

2 100 23 14

3 40 12 2

4 12 3 2

5 15 1 0

6 7 1 0

7 1 0 0

8 0 0 0

9 2 0 0

10 0 0 0

11 0 0 0

12 1 0 0

13 2 0 0

Total 415 265 253


Formal Response Letters to Complaints

Timeliness of response letters is very important to complainants. From the complainant’s perspective, the Trust appreciates that each complainant has taken the time to write in to complain about an aspect of care or service delivery that was not to their satisfaction. This is also a learning opportunity for the Trust. We therefore aim to agree investigation period with the complainant at the beginning of the process, at the point of the initial telephone contact.

A complaint may involve several clinical areas including facilities, diagnostics and support services. The impact of investigating concerns across services and departments can result in response delays. The complainant is kept updated and timescales are re-negotiated where necessary should delays occur.

The following chart demonstrates a deterioration in the number of complaints responded to within 45 days during the latter part of 2014/15. This is due to a number of factors including offering more meetings with staff prior to sending a closing response, enhanced investigations taking place by the clinical and operational teams, the commissioning of external independent reviews and in some cases difficulties with the availability of staff to respond and capacity to develop the complex responses in a timely way. In order to support the timeliness of formal responses the process of appointing an Interim Complaints Officer is underway.

Response within 45 days

Improving the Quality of Responses

Whilst the majority of the complaint responses appear to satisfactorily resolve the concerns raised, there are an increasing number of complainants who return to the Trust with additional concerns, follow up questions or areas which need further clarification.

In 2014/2015 the Trust received 14 re-action letters from complainants; this equated to 5% of all response letters not completely resolving the issues and concerns that the complainant had raised. This mirrors the 2013/2014 data (5%, n=14). It should be noted that however, that a full and detailed response can raise further questions from the complainant and therefore does not mean that the complainant is dissatisfied; but merely requesting further information following a formal response. The Trust always offers to meet complainants at the start of the complaints process (and throughout) and if there appears to be additional issues that remain either in dispute or have not been resolved to their satisfaction a resolution meeting is normally the best way to finally settle the issues.

Summary

The Trust’s processes for managing and responding to complaints has been greatly improved and is, in the most part, reflected in the timely way in which we respond to complaints and the letters of thanks we have received from complainants following conclusion of the process. Work will continue to ensure that timescales are met and that learning is shared across the organisation not just from complaints but from all aspects of patient feedback.

%


A Listening Organisation

We continue to respond to all comments made about our care on NHS Choices. Our Head of Communications and Corporate Affairs will add a Trust comment and if concerns are raised, provide the direct contact information to our PALS Service. In year, Suffolk HealthWatch requested a formal response on a range of comments from their members and the public, which the Trust responded to within the required timeframe.

A new Trust website has been set up with a more effective patient experience and feedback section to ensure we are more responsive than we may have been previously. We have set up Twitter and Facebook accounts that public and staff can access to make comments via social media.

Listening to patients so that we understand what matters to them, what works well and what we need to do to get better is very important to the Trust. We believe that improving patient experience is a continuous journey and use a number of measures to monitor our performance:

Compliments and complaints figures and learning

Patient Advice and Liaison Service contacts

National Surveys including:

- Cancer Patient Experience Survey (CPES)

- National Inpatient Survey (report due 21st May 2015)

- National A&E Survey

Patient experience measurement tools including:

- Friends and Family test

Listening Events

A customer care ‘In Your Shoes’ event will be taking place commencing April 2015 and run through until July to engage patients and facilitate a listening opportunity for our internal ‘customers’ to explore how we can enhance our customer care experiences and service delivery going forward. The initiative will be supported by the Head of Facilities Management and the Assistant Director of Learning and Organisational Development. An update will be provided at the May CAPE regarding feedback progress. The PALS team will be supporting the coordination of patients/service users interested in taking part in the event and will be monitoring the ‘In Your Shoes’ email address where potential participants can log their interest in attending the event. The event will be advertised via posters and also on the Trust website.

Patient Participation Groups (PPGs)

Trust Public Governors have a responsibility within the Great Yarmouth and Waveney area to be representative at the GP surgery based Patient Participation Groups (PPG). This allows the Trust to gain further feedback related to NHS services. Feedback from the PPGs is also disseminated at the Patient and Public Experience Forum which is set up to make sure that the patient voice is involved in and can influence the planning, commissioning and review of high quality integrated care, making sure it meets the needs of patients across Great Yarmouth and Waveney. The Head of Patient Experience attends the PPEG to ensure the Trust is represented, to comment on feedback received and identify actions taken as a result where necessary.

Feedback gained via the PPEG regarding Trust services and care delivery is fed back into the Trust via the Carer and Patient Experience Committee for consideration alongside other feedback received.


Learning from complaints

Complaints 2012/13 to 2014/15

Some actions taken following complaints

Student physiotherapy supervision has been improved, new training package for physiotherapy supervisors

Barcode to be attached to urology form to facilitate scanning of the form into the correct place in electronic Health Records

Healthcare Assistant permanently based in Cohort on ward 16 to ensure patients do not feel isolated

A&E EDIS (Emergency Department Information System) updated with next of kin (NOK) details

Where it is deemed inappropriate, patients will not be transported home after 19:00h. However, staff will continue to take into account patients’ wishes and the transport service will still be available until 22:30h.

eHR and iPM updated with allergy alerts and new addresses


Patient Advice and Liaison Service (PALS) The NHS expects all members of staff to listen and respond to patients, their relatives and carers to the best of their ability. The Patient Advice and Liaison Service (PALS) ensures that the NHS listens to patients, their relatives, carers and friends, and answers their questions and resolves their concerns as quickly as possible. PALS also helps the NHS to improve services by listening to what matters to patients, their relatives and carers and making changes, when appropriate. In particular, PALS:

Provide patients with information about the NHS and help with any other health-related enquiry

Help resolve concerns or problems relating to care given by the Trust

Provide information about the Trust complaints procedure and how to get independent help if needed

Provide information and help introduce patients to agencies and support groups outside the NHS

Inform patients about how to get more involved in their own healthcare and the NHS locally

Improve the NHS by listening to patients’ concerns, suggestions and experiences and ensuring that people who design and manage services are aware of the issues raised

Provide an early warning system for the Trust and monitoring bodies by identifying problems or gaps in services and reporting them. PALS enquiries 2014/15


PALS enquiries by category 2014/15

Compliments

We have received many positive comments and compliments from users of our services via thank you cards, letters, emails and correspondence on the NHS Choices website and through the Trust Patient Advice and Liaison Service (PALS):

‘From reception to triage, porters, health assistants to nurses, doctors and consultants – our experience at the James Paget was wholly positive.’

‘I can wholeheartedly say that all of your staff consistently make me feel as if I am the only one who matters to them. Even when walking the corridors perhaps looking lost, a member of staff always asks if you need help.

‘I felt that the staff were accessible and friendly, needs were met very promptly by medical practitioners from my point of view and intimidating experience was made less fearful’

‘The staff nurses were pleasant and competent and when necessary did not hesitate to sympathetically inform us of a serious deterioration even in the middle of the night’

‘The staff pre theatre and involved in my immediate recovery were great at their jobs

and I would like you to pass on my thanks.’


Patient experience measurement tools

Friends & Family Test Key Performance Indicator

Friends & Family Score 2014/15

Friends and Family Test (FFT) data capture forms part of the NHS Standard Contract as of April 1st 2015. Part of this is the mandatory requirement for FFT data capture to be rolled out to all outpatient departments and day care units. The Trust implemented the data capture for FFT into many outpatient departments prior to the mandatory requirements being in force and continued efforts are being taken to ensure the achievement of this is maintained.

The Friends and Family Test - What is it?

Friends and Family test is a simple experience measure which asks patients at discharge a simple question: how likely are you to recommend us, and why? Patients respond on a 6 statement rating scale as follows:

• Promoters (extremely likely) are loyal enthusiasts who have had a positive and memorable experience

• Passives (likely) are satisfied but unenthusiastic – their experience was nothing more than acceptable

• Detractors (Neither likely nor unlikely; unlikely; extremely unlikely) are unhappy customers who can damage reputation through negative word-of-mouth

• Don’t know A score is calculated by taking the percentage of patients who are promoters and subtracting the % of patients who are detractors, i.e. the proportion of patients who would strongly recommend minus those who would not recommend, or who are indifferent. The higher the score the better, the more satisfied patients are with their experience of the hospital. In addition locally we have added a further question asking if there is anything we can improve.


What we have done

The Divisions are working with the Patient Experience Team to ensure that continued compliance with this is achieved and analysis reporting of the same is presented at the Trust’s monthly Carer and Patient Experience Committee. Patients will be asked, as part of the data capture process, whether they would be willing to have their feedback comments publicised, see example feedback card below. In addition, further information regarding any disability entered will be gathered as part of the demographic information.

The Trust has recruited several Patient Experience volunteers to support the wards and departments to achieve the required data capture

The Patient Experience Team will review responses on a daily basis and target low response areas providing increased support to achieve the necessary requirements.

Improvement actions are being implemented to ensure that the FFT data capture is represented within the ward/department performance dashboards to provide on-going monitoring and assurance of achievement

Family carers

There are numerous services provided for family carers by Suffolk Family Carers and Norfolk Carers Support. These include:

Carers Information Centre – takes place in the foyer of the hospital every Thursday

Family carer Champion training – a training package put together by the professional trainer from Suffolk Family Carers. To date 51 people have undergone training: 42 of which are staff from various wards around the hospital, volunteers from the Louise Hamilton Centre, a Trust Public Governor and a Trust social worker.

Dementia Café – working in partnership with the Alzheimer’s Society, the Dementia Café has been running now for 18 months.

The Carer Lead is invited to attend the Carer and Patient Experience Committee twice each year to ensure continued partnership working and as a further source of feedback for the Trust

Patient surveys

Feedback from National Surveys are reported to the Carer and Patient Experience Committee (CAPE) and the themes identified are looked at with other feedback data received into the Trust. During 2014/15 the National Surveys which took place are shown below. Divisions are required to look at the findings and formulate action plans to address key issues identified. The national Inpatient Survey is due for publication in May 2015 and the Children and Young Persons survey findings are expected to be published in June 2015. Cancer Patient Experience Survey - 2014

The annual Cancer Patient Experience Survey (CPES) has proven valuable to the Trust. The responses from cancer patients who use the in-patient/day-case facilities at the Trust have identified issues which the Trust can resolve to further improve the experience of future patients.

Overall the results from the survey have been positive with 20 responses in the highest 20% of Trusts in England. 10 responses fell within the lowest 20% of Trusts. When data is


reviewed, none of these lower responses fell close to or outside the lower 95% confidence interval.

It is particularly rewarding to note that some very positive responses have mirrored initiatives undertaken by the Trust to improve patient care and experience. Examples include:

easy access to their Cancer Nurse Specialist

definitely listened carefully the last time spoken to

get understandable answers to important questions all/most of the time

patient had confidence and trust in all ward nurses

nurses did not talk in front of patient as if they were not there

always given enough privacy when discussing condition/treatment

always treated with respect and dignity by staff

patient’s rating of care ‘excellent’/‘very good’ National A&E Survey 2014

During 2014, a questionnaire was sent to 850 people who had attended an NHS accident and emergency department (A&E) during January, February or March 2014.

Responses were received from 308 patients at James Paget University Hospitals NHS Foundation Trust.

The survey compares the Trust for 2012 and 2014 and against the national average.

Trust score 2012

Trust score 2014

Position against National Average

Waiting times

Patients waiting more than one hour to speak to clinical staff 30% 22% 10% higher

Patients waiting more than one hour to be examined 18% 18% 4% higher

Patients not being informed of how long they would have to wait 52% 55% 4% higher

Repeat attenders

Patients attending A&E in previous month with same issue 9% 12% 3% higher

Privacy and Dignity, Compassion and Care

Patients with privacy of information/confidentiality at reception 48% 52% 3% below

Patients reporting not having enough privacy when examined 3% 4% 2% above

Patients could not attract medical/nursing staff if needed 7% 9% 2% above

Patients not reassured by staff if distressed N/A 28% 6% higher

Diagnostics

Patients receiving test results before discharge 81% 83% 5%higher

Medicines Management

Patients not receiving pain relief when requested N/A 45% 4% higher

Patients having medications explained prior to discharge 85% 90% 4% higher

Patients not receiving an explanation regarding side effects of medication

42% 62% 22% higher

Discharge planning

Patients not advised when they can return to normal duties 33% 43% 7% higher

Patients with family/home situation considered as part of discharge plan

35% 49% 9% higher

Patients not being given information regarding danger signals to be aware of

34% 37% 5% higher

Patients not being given follow up contact information 26% 29% 4% higher


A Responsive Organisation Serious Incidents The Serious Incident (SI) Register contains formal SIs, which must follow the agreed reporting process to the Clinical Commissioning Group (CCG). The SI process has been followed in terms of providing 3 day updates and root cause analyses within the required timescales to the CCG (or via prior agreement), throughout 2014/15.

Never Events The Trust has reported one Never Event in 2014/15. Please see page 40 for further detail. Inquests In 2014/15 there were 39 inquests heard for which the Trust was an ‘interested person’. There were two ‘preventing future deaths’ reports issued for which we have developed and implemented action plans following each of these. Inquest conclusions included 13 accidental deaths, 1 industrial disease, 1 suicide and 11 natural causes. All others received a narrative verdict by the coroner. Mortality Reviews Part of the process for Trust assurance on mortality is to review mortality cases identified via Dr Foster Intelligence as statistically significant. Each month a rolling 12 month period is reviewed through the Dr Foster Intelligence HSMR reporting tool. Where an area is identified as being statistically significant these cases are reviewed at patient level to identify whether any lessons can be learnt from the individual case. The table opposite highlights the number of deaths within the hospital, and of these deaths how many have been identified for review by senior consultants.


Mortality Cases Identified for Review via Statistically Significant Relative Risk in HSMR

Period Deaths within

hospital

Identified for Review via

HSMR

Review Ongoing

Completed Reviews

Sub-optimal care identified

Apr-14 100 2 0 N/A N/A

May-14 75 4 0 0 0

Jun-14 84 2 0 0 0

Jul-14 92 3 0 0 0

Aug-14 89 3 0 0 0

Sep-14 92 7 0 0 0

Oct-14 99 2 0 0 0

Nov-14 93 0 N/A N/A N/A

Dec-14 104 0 N/A N/A N/A

Jan-15 119 0 N/A N/A N/A

Feb-15 119 0 N/A N/A N/A

Mar-15 96 0 N/A N/A N/A

Totals 1162 23 0 0

The Trust is recording all mortality cases identified by HSMR within a mortality register to ensure that all cases that are identified for review are reviewed, with any cases that highlight recommendations for improvement being escalated through the appropriate Trust processes. Mortality Cases Identified for Review via Statistically Significant Relative Risk in SHMI In line with best practice, the Trust is working with the local CCG to arrange a review of mortality cases with a GP, which have been identified via SHMI. The diagnosis groups identified for review through SHMI were pneumonia, secondary malignancies (cancers) and acute and unspecified renal (kidney) failure. Savile Enquiry The Trust has had no involvement with Jimmy Savile at any time in in its history. On 10 May 2013 the Trust responded to Kate Lampard in her role as Independent Oversight of NHS and Department of Health Investigations into matters relating to Jimmy Savile. The Trust was able to confirm the following in relation to the specific queries raised:

Safeguarding policies – the Trust has a robust policy and procedure for Safeguarding Children and Adults which applies equally to patients, visitors, staff and volunteers. All staff receive annual training in relation to these policies. Furthermore, all staff and volunteers are subject to appropriate pre-employment checks, including Disclosure and Barring Service (DBS), and induction

Governance arrangements – any celebrities visiting the Trust, whether in a fund raising capacity or for any other purpose, are subject to the same governance arrangements as other visitors. That is, they register at a reception point and are provided with visitors badges and are accompanied at all times when on Trust premises


Complaints and Whistleblowing – the Trust has robust policies in place for dealing with patient complaints and for staff to raise issues of concern in a ‘safe’ way. The Trust can demonstrate that these policies are utilised effectively

The Trust also made our staff aware of how to contact Ms Lampard with any concerns they may have had regarding their own or their organisation’s dealings with Jimmy Savile. Further queries were raised to all trusts in September 2013 and the Trust responded as follows:

At the present time we undertake enhanced DBS checks for all new hirers and for existing staff who move between positions internally. We also conduct enhanced DBS checks for all volunteers

Safeguarding training is not routinely provided by the Trust for all Building or Engineering Contractors. However, the pre-construction health and safety plan will identify any risks to young persons or vulnerable adults and where necessary the Trust will request a DBS/CRB check. The check would generally be applicable to those contractors that are working unsupervised or indirectly supervised in high risk areas (for example Children’s Ward, Central Delivery Suite, etc.)

We have the following policies and procedures in place in relation to social media/internet access for staff: - Internet Use Policy - Social Media Policy - Website Policy.

A multi-disciplinary group was convened and met on 12 August 2014 to review the recommendations within the reports published to date. This group developed a plan for implementing these recommendations at the Trust, as appropriate. As further reports and recommendations are published, these will also be reviewed and incorporated into actions as required. On 26th February 2015 a further report was published regarding the allegations made against Savile in relation to his association with Stoke Mandeville Hospital. This report identified five themes for ‘lessons for learning’ and 8 recommendations. These have been cross referenced to the action plan developed by the Trust and the same multidisciplinary group will continue to review, update and take forward the outstanding actions.


External inspections Medicines and Healthcare Products Regulatory Agency (MHRA) The MHRA carried out a follow-up inspection of the Trust Transfusion service against the Blood Safety and Quality Regulations 2005 on 17th February 2015. The initial inspection was held on 5th and 6th December 2013 where three major non-conformances were found. These were reported on fully in the Trust’s Quality Report 2013/14 available here, page 68: http://www.jpaget.nhs.uk/media/226124/Quality-Rep-2013-4-FINAL-sig.pdf Findings

There was one major non-conformance identified:

Incident records are weak in the following respects:

Incidents have been closed prior to resolution of the issues.

The records lack: sufficient details of the events (for example the actual identity of the affected equipment), defined boundary of the event - to identify components potentially affected by the event (such as the time of the event and the units affected), clear root cause through the use of root cause analysis and clearly defined actions which will address the cause and prevent re-occurrence

What we have done about it

Updated relevant Standard Operating Procedures making all of these points absolutely clear

- Incidents must not be closed until all actions are complete

MHRA - What is it?

The MHRA is responsible for regulating all medicines and medical devices in the UK by ensuring they work and are acceptably safe. The MHRA is a centre of the Medicines and Healthcare Products Regulatory Agency which also includes the National Institute for Biological Standards and Control (NIBSC), and the Clinical Practice Research Datalink (CPRD). The MHRA is an executive agency of the Department of Health. The MHRA is responsible for regulating blood establishments and hospital blood banks. Statutory Instrument 2005 No. 50 and its Amendment (SI 2005/2898) about blood safety and quality became effective from 8 November 2005. The Regulations set the standards of quality and safety for the collection, testing, processing, storage and distribution of human blood and blood components.

http://www.jpaget.nhs.uk/media/226124/Quality-Rep-2013-4-FINAL-sig.pdf



- All relevant details of the event are recorded on the log on QPulse (Quality Management System)

- RCA is clear and accurately recorded

Formed a Laboratory Adverse Event Investigation Group to critically assess laboratory error reporting and ensure sufficient detail is recorded before the error is closed

Created checklists for common deviations e.g. fridge failure, to ensure a level of detail and consistency when reporting errors. Checklists form appendices to the updated Standard Operating Procedure

Outcome

Extract from MHRA letter dated 17th April 2015: ‘On the basis of the inspection of 17th February 2015, and your company’s subsequent commitments with regards to continuing improvements, I confirm that your operations are in general compliance with the principles and guidelines of good practice as laid down in Commission Directive 2005/62/EC. Continued support of your activities will be recommended to the Licensing Authority. The inspection escalation case is now closed and any matters arising from this case or subsequent correspondence will be reviewed at the next inspection.’

Clinical Pathology Accreditation (UK) Ltd. (CPA) The CPA carried out a follow up visit to the Trust on 1st October 2014 following suspension of the Trust’s accreditation. The initial visits were carried out on 2nd and 3rd October 2013 and the decision was taken that CPA was not able to maintain accreditation at that time under CPA standards v 2.02 due to the nature of the findings raised. These were reported on fully in the Trust’s Quality Report 2013/14 available here, page 69: http://www.jpaget.nhs.uk/media/226124/Quality-Rep-2013-4-FINAL-sig.pdf

CPA - What is it? Clinical Pathology Accreditation (CPA) is the leading provider of accreditation services in the health sector. CPA is a non-profit distributing organisation that acts in the public interest. It assesses and declares the competence of Medical Laboratories in the public and independent sector, and External Quality Assessment (EQA) Schemes in the UK and overseas. Although accreditation is voluntary, the majority of UK medical laboratories are currently enrolled, demonstrating that they have been assessed against the accepted standards.



Findings

The remaining findings had been satisfactorily cleared and the improvement actions had been implemented into the routine processes in the laboratory. Outcome

Extract from CPA letter dated 11th November 2014: ‘As all your non-conformities have now been cleared, I am pleased to inform you that suspension of CPA accreditation is lifted and accredited status is reinstated to the above department. The status on the website will be updated (your current certificate remains valid).’ PLACE – Patient Led Assessments of the Care Environment The 2014 Patient-Led Assessments of the Care Environment (PLACE) programme commenced on 2nd April 2014. Previously Lowestoft Hospital was included in the inspection, but the inpatient beds closed prior to the inspection. A number of briefing sessions were held prior to the day to ensure the team members were updated with the new assessment. This year we were more successful in recruiting patient representatives for this round of PLACE, this was recognised nationally as an issue. The Trust will need to continue to canvass patient volunteers to be involved in the process, taking into account the length of the inspection and the amount of walking involved. The results and feedback from the team were uploaded onto the “Health and Social Care Information Centre” website. The results were published nationally on 28th August 2014. The results for the James Paget University Hospital are as follows:

Cleanliness Food Privacy, Dignity &

Wellbeing Condition, Appearance

& Maintenance

Score 2013

Score 2014

National Average

Score 2013

Score 2014

National Average

Score 2013

Score 2014

National Average

Score 2013

Score 2014

National Average

99.38 98.56 97.25 83.08 87.43 88.79 93.91 80.97 87.73 93.61 93.66 91.97

Environmental Health 2000 meals are provided to patients, visitors and staff each day. All are home cooked, on site using local ingredients and suppliers wherever possible. On 19th March 2015 the Catering Department was awarded 5 Stars for Food Hygiene Standards, by the Great Yarmouth Borough Council Environmental Health team. Praise was given for the amount of work achieved in compliance with the new Allergen regulations.


General Pharmaceutical Council (GPhC)

The General Pharmaceutical Council carried out an unannounced inspection on 21st July 2014. Findings

There was one area where the standards were not met: Principle 4 (Services inc. Medicines Management), Standard 4.3 ‘Controlled drugs cannot be shown to be stored in accordance with safe custody regulations’. Outcome

The overall Indicative Inspection Judgement was that the ‘Pharmacy Department is: Satisfactory for the premises and standards for registered pharmacies’. What we have done about it

It was confirmed that the controlled drug room was built in accordance with the safe custody regulations in place at the time.

Moved one cabinet so that the rear of the cabinet sits on a solid wall

Bolted all cabinets to the wall and the floor

Removed all stationery including prescription pads from the cabinets (and placed pads in separate cupboard)

All controlled drugs are dispensed and checked immediately and returned to cabinets whilst awaiting collection, or dispensed and returned to cabinets immediately awaiting checking and collection.

General Pharmaceutical Council - What is it? The General Pharmaceutical Council (GPhC) is the independent regulator for pharmacists, pharmacy technicians and pharmacy premises in Great Britain. Their principal functions include:

approving qualifications for pharmacists and pharmacy technicians and accrediting education and training providers;

maintaining a register of pharmacists, pharmacy technicians and pharmacy premises;

setting standards for conduct, ethics, proficiency, education and training, and continuing professional development (CPD);

establishing and promoting standards for the safe and effective practice of pharmacy at registered pharmacies;

establishing fitness to practise requirements, monitoring pharmacy professionals' fitness to practise and dealing fairly and proportionately with complaints and concerns

http://www.pharmacyregulation.org/


A five-lever lock has been fitted to the door of the controlled drugs room, utilising a different key to the key used for entry to the department.

Swipe card access has been provided on the controlled drugs room door.

A key press is now used for the storage of controlled drug cabinet keys

The walk in fridge is locked at night to ensure that there are two walls to be breached before access can be gained to the non-compliant wall in the controlled drugs room

Norfolk Fire and Rescue Service

An inspection was undertaken by Norfolk Fire and Rescue Service on 24 March 2015 Findings

It was found that at the time of the visit, the fire safety arrangements in place were generally of a good standard. Further consideration was needed in the following areas: It was noted during the inspection that several bins used for waste (rubbish) are stored in the hospital streets. These bins reduce the width of the streets to less than three metres which is required as stated in the Communities and Local Government guide for fire safety in health care premises and also the Department of Health Technical Memorandum. It was advised that efforts should be made to relocate these bins away from the hospital streets. The level of false alarms at the hospital were also a cause for concern. This was to be discussed as a separate matter between the Chief Fire Officer, Norfolk Fire and Rescue Service and the Trust’s Fire Officer. What we have done about it

The Trust is currently looking into the options available as alternatives to keeping the bins on the hospital streets, including:

Proposals to provide wheelie bin style bins in sluice areas on wards for clinical waste and tiger bins could be widened to provide such bins for general and other waste if the sluice areas are cleared of redundant equipment and are made back to being sluice areas only.

The possibility of converting an existing stairwell into a storage area for waste bins or erecting a similar two storey construction in a courtyard


NHS Protect

The Trust had an NHS Protect security inspection on 26th March

2015.

A report following this inspection is awaited. No concerns were raised at the time of the inspection. Royal College of Obstetricians and Gynaecologists (RCOG) The Royal College of Obstetricians and Gynaecologists carried out an invited review of Maternity Services on 4th and 5th December 2014 The review was requested:

To review the current obstetric and gynaecology practice at James Paget University Hospital Trust in the context of patient safety.

To review the current outcome data supported by audit reports, serious incident/Never Event reports and other evidence collected within the clinical governance framework within the context of providing a safe and efficient service.

To advise on specific cases involving surgical practice in gynaecology and ante-natal, intra-partum care in obstetrics and make recommendations for change.

To make recommendations based on the findings of the review. Findings

Upon visiting the Trust, a number of issues were raised which were entered onto a comprehensive action plan that is monitored through the Strategic Risk Group. What we have done about it

The action plan is a live document and work to complete all actions within timescales is ongoing.

NHS Protect - What is it?

NHS Protect leads on work to safeguard NHS staff and resources from crime. It provides support, advice and guidance in this area to organisations across the NHS. By working to tackle crime ranging from bribery and corruption to theft and criminal damage, from fraud to violence against staff and help to ensure the proper use of NHS resources and a safer, more secure environment in which to deliver and receive care. The main areas of responsibility are:

Fraud, bribery and corruption (also known collectively as economic crime)

Criminal damage

Theft

Violence, harassment, abuse and anti-social behaviour

Other unlawful action (e.g. market fixing).

https://www.rcog.org.uk/


Delayed Transfers of Care (DTOC) Background

Patients admitted to hospital with straightforward post-hospital needs can usually be discharged very soon when they are medically fit for discharge. Some patients with complex needs can only be transferred or discharged when further care arrangements have been put in place and services and facilities have been arranged to enable them to be safe. Delays can have implications for a patient’s wellbeing and their ability to live independently together with creating worry and inconvenience for family and carers. Delays have other consequences including delays at the front door i.e. urgent admissions through A&E; cancelled operations and overall access to beds. Any delay in discharge is bad for patients, families, carers, NHS and local authorities. Minimising delayed transfers of care is fundamental to a person centred approach to health and social care that treats patients with dignity and respect as well as meeting their needs. The Trust reports on its DTOC data monthly to the Board of Directors. The indicator measures the average number of weekly delayed transfers of care, for Trust responsible delays only i.e. where the reason for delay is attributable to this Trust. DTOC April 2013 to March 2015

What we are doing about it

Working with our partner organisations to ensure those patients who are medically fit can be discharged, to allow others to have their bed.

Patient choice for discharge – our Trust policy is in place and we are working towards a joint policy county-wide.

Delayed Transfer of Care - What is it?

A Delayed Transfer of Care is experienced by an inpatient in a hospital, who is ready to move on to the next stage of care but is prevented from doing so for one or more reasons. The arrangements for transfer to a more appropriate care setting (either within the NHS or in discharge from NHS care e.g. a residential or nursing home) will vary according to the needs of each patient but can be complex and sometimes lead to delays.

Num

ber

of

DT

OC


The three month trial of an Ambulatory Care Unit (AmbU) was a success and the prospect of setting up a permanent service is now being investigated. Through the identification and management of patients who should not require an overnight hospital stay; changing our processes and Point-of-Care testing we have seen:

a 40.8% reduction in patient length of stay

59 saved bed days

85% of patients seen and discharged on the same day

whole blood test results available at the bedside within 5 minutes


Monitor’s Governance Indicators

Area Indicator National Standard 2014/15

JPUH 2014/15

Acce

ss

1 Maximum time of 18 weeks from point of referral to treatment in aggregate

9

– admitted 90% 86.15%

2 Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted

95% 98.63%

3 Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway

92% 92.79%

4 A&E: maximum waiting time of four hours from arrival to admission/ transfer/discharge

95% 95.34%

5 All cancers: 62 day wait for first treatment from:

urgent GP referral for suspected cancer10

85% 87.27%

NHS Cancer Screening Service referral 90% 91.96%

6 All cancers: 31 day wait for second or subsequent treatment, comprising:

surgery 94% 100%

anti-cancer drug treatments 98% 100%

radiotherapy 94% N/A

7 All cancers: 31-day wait from diagnosis to first treatment 96% 99.91%

8 Cancer: two week wait from referral to date first seen, comprising

all urgent referrals (cancer suspected) 93% 97.46%

for symptomatic breast patients (cancer not initially suspected)

93% 98.09%

Ou

tco

mes

16 Clostridium (C.) difficile – meeting the C. difficile objective 17 cases de minimis

n=12 12

20 Certification against compliance with requirements regarding access to health care for people with a learning disability

Compliance Compliant

NB: Indicators 9-11, 14, 15 and 17-19 are relevant to Mental Health Services Only Indicators 12 and 13 are relevant to Ambulance Trusts only Indicator 21 is relevant to Community Services only

9 The full definition for this indicator can be found on page 81 10

The full definition for this mandated indicator can be found on page 81


Annex 1 Statements from stakeholders

Page

Great Yarmouth and Waveney Clinical Commissioning Group 69

Council of Governors 71

Healthwatch Norfolk 72

Healthwatch Suffolk 72

Health Overview and Scrutiny Committee 73

This section contains responses and comments from out key stakeholders in relation to the quality of services provided by us. The commissioners have a legal obligation to review and comment on our Quality Report. Healthwatch organisations and Overview and Scrutiny Committees provide comment on a voluntary basis.


Great Yarmouth and Waveney Clinical Commissioning Group

Great Yarmouth & Waveney Clinical Commissioning Group as a commissioning organisation of JPUH supports the organisation in its publication of a Quality Account for 2014/15. We are satisfied that the Quality Account incorporates the mandated elements required based on available data. The information contained within the Quality Account is reflective of the Trust over the previous 12 month period.

In our review, we have taken account and support the clinical quality improvement priorities identified for 2015/16 and support the identified improvement objectives in the quality and safety of care provided to Great Yarmouth & Waveney residents. The Trust will do this by:

Improving Patient Safety;

The Trust will develop and embed a process to identify the learning from medical negligence claims, aligned to the Trust’s Sign up to Safety pledges.

The Trust will set a standard for falls assessment to ensure that patients receive a comprehensive assessment to reduce the incidence of avoidable inpatient falls. We are pleased to see that the Trust has identified this as one of their priorities for 2014/15. Progress against this priority will be monitored by the CCG on a monthly basis at the Quality Meeting.

The Trust will develop and embed an improved governance process for reporting, investigating and learning from incidences of hospital-associated venous thromboembolism.

Improving Clinical Effectiveness;

Following on from 2014/15, the Trust will continue to implement and embed Service Development Plans which include moving towards and achieving the relevant NICE Quality Standards and achieving compliance with associated NICE Clinical Guidelines.

The Trust will implement and embed the Quality Strategy and new assurance framework related to the new Care Quality Commission inspection regime.

We are pleased to see that the Trust is working with the two other Norfolk acute Trusts to amalgamate Trust clinical guidelines and the intention to develop a standardised process for producing, reviewing and ratifying Trust clinical guidelines.

The Trust will continue to work towards implementing seven day services for the ten identified clinical standards within the Seven Day Services Transformation Improvement Programme (SDSTIP). We are committed to working as a system to improve weekend discharges including senior clinical involvement with patients, improving access to diagnostic services and increasing non-medical support at weekends.

Improving Patient and Staff Experience;

The Trust will reduce patients being moved out of hours to improve patient experience and reduce complaints about noise at night.

We are pleased to see that the Trust is committed to ensuring that staff feel comfortable and confident to raise concerns without fear of judgement or reprisal following the annual staff survey results for Key Finding 15.

The Trust is committed to improving information provided to patients on discharge following feedback from the National Inpatient Survey, complaints and patients’ comments from the Friends and Family Test (FFT).


Great Yarmouth and Waveney CCG also notes the quality priorities identified within the previous Quality Account for 2014/15. We recognise the inclusion of extremely comprehensive updates on the progress made with these priorities.

We note the section within the report about Clinical Audits and National Confidential Enquiries where the Trust has stated that there was 76% (26 out of 34) participation with national clinical audits that the Trust was eligible to participate in. The CCG looks forward to seeing an improved compliance with national clinical audits during 2015/16. We commend the significant inclusion of actions and learning arising from national clinical audits.

We note the section within the report about the Care Quality Commission inspection undertaken in October 2014 and are pleased to note that the Care Quality Commission found the previous areas of non-compliance to be fully compliant and has not taken any enforcement action against the Trust during 2014/15.

The CCG recognises the significant inclusion of infection, prevention and control activities within the Quality Account. The CCG notes that the incidence of Clostridium Difficile at 22 cases in the year breached the nationally set ceiling of 17 cases, however, the CCG acknowledges that 10 of these cases were recognised on review to be unavoidable and that two further cases are currently under review within the external appeals process. The CCG recognises the contribution of the Trust in the system wide improvement programme and commends the level of engagement and ownership by the Trust Board in tackling Clostridium Difficile.

Whilst the CCG was disappointed to note the incidence of a Never Event, a significant improvement is observed when compared with 2013/14; this indicates that staff education and training around Never Events and systems and processes to reduce the risk of occurrence are in place.

The CCG notes the section on Patient and Staff Experience and that the Trust has developed and implemented a Patient Experience and Engagement Strategy during 2014/15 which details progress to date with engaging and involving patients and service users. It is pleasing to see that all sources of feedback are explored and shared, that trends and themes are identified and analysed and that service improvements are implemented when needed.

We note the section on the Trust being ‘A Listening Organisation’ where all comments entered on NHS Choices about care that they received are responded to and that the Trust has designed a new website which includes a more effective patient experience and feedback section.

In terms of suggested improvements the following would enhance the Quality Account:

Examples of staff members or teams that have been recognised for their contribution to enhancing care and support to patients, relatives or their colleagues.

Direct feedback from service users about their experiences.

Information on the international nurse recruitment strategy; in particular the feedback from the nurses recruited would be both interesting and informative.

The Great Yarmouth & Waveney Clinical Commissioning Group looks forward to working with the JPUH during 2015/16. Cath Gorman Director of Quality & Safety Great Yarmouth and Waveney Clinical Commissioning Group


Council of Governors

The Trust’s Quality Report for 2014-2015 is easy to read and to understand. The report offers a clear view on how the organisation is performing and where there have been improvements. Weaknesses are detailed, as are the ways in which these are being addressed.

The Staff Survey report shows an improved response rate, with the Trust being 5% above the national average. The percentage of staff feeling satisfied with the quality of work and patient care they are able to deliver, also increased by 3%. Staff appraisals, though still above the national average, were down by 5% and less favourably, the Trust came below the national average for staff feeling comfortable in raising concerns. Work is going on to improve matters, with action plans detailing a range of events and initiatives across the Trust.

It was good to see that improvements had been made and weaknesses acted upon in the following areas;

An 8% reduction in the number of inpatient falls in 2014-15 and the figures reported are the lowest in the last three years. The number of falls with harm graded as Minor (non-permanent) Harm or higher has also shown a decrease of 18% for 2014-15 with serious incidents falling below 2012-2013 levels.

It is clear that work continues towards comprehensive seven day working involving whole system change. The perceived improvements in patient experience contained within this movement, are welcomed and supported by the Council of Governors.

A range of actions taken in Medicines Management procedures resulted in a CQC re-inspection in September 2014 finding the Trust’s robust, effective, sustainable systems for the safe and secure handling of medicines was meeting the necessary standard.

Whilst enquiries to PALS (Patient Advice and Liaison Service) have risen in 2014 -2015, it is pleasing to note the numbers of complaints continues to decline. Regarding the Friends and Family Test, it is also good to see that positive responses over all the indicators are contributing to the Trust’s improving position.

Achievement of a satisfactory rating for Information Governance in 2014-2015 which indicates an improved situation from 2013-2014.

The report tells us ‘Patient and Staff Experience’ has received an overhaul. The renamed CAPE (Carer and Patient Experience) Committee will consider information from a range of sources, and priorities have been re-focused to ensure carer and patient experience is considered in all aspects of service design and delivery. A continuing cause for concern to Governors is there is no carer/patient representative on CAPE. A welcome step, however, is the Trust’s patient experience lead has, during the year, become the link to the Governors’ Patient Experience and Public Engagement Committee (PEPE).

This report presents us with an open review of many aspects of patient care. There are clear plans set out as to how improvements will be made in areas where the Trust is not doing so well. As in previous years, the Council of Governors has been involved in setting the quality priorities. A decision was made at a meeting of the Council in March to add ‘delayed transfers of care’ to the two mandatory priorities that help the Trust to focus on particular aspects for improvement of patient and carer experience.

This document is required reading for all those concerned with the care of our patients so that improvements can continue to be made to the quality and delivery of services.

Angela Woodcock, Lead Governor On behalf of the Council of Governors


Healthwatch Norfolk Healthwatch Norfolk is pleased to have the opportunity to comment on the Quality Account. Overall we believe the document is clearly laid out but it would be helpful to include reference to how to access the report and the different formats available. The priorities for the past year are clearly identified and we note that in many instances the document demonstrates improvement e.g. in-patient falls. However, support for the improvements could be better illustrated through root-cause analysis and the audit of training programmes. The priorities for the forthcoming year are also clearly identified but again the monitoring and auditing of the achievements could be made more clear and robust. More information about the progress of how the goals set will be delivered and monitored would provide clear assurance to members of the public. For example: In the section about the 7-day Services, a plan to indicate how the working group chaired by the Medical Director will monitor progress would be helpful. More information about how the actions listed in the document are to be supported to achieve the goals would add significantly to the information provided about the Trust’s goals. However, overall we would like to reiterate that the document provides a great deal of information about the issues which are important to all stakeholders including members of the public. Finally Healthwatch Norfolk confirms that we will continue to ensure that any feedback we receive from patients, carers and their families is fed back to the Trust as part of our developing relationship with all health and social care providers in Norfolk. Alex Stewart Chief Executive May 2015

Healthwatch Suffolk The Quality Account of the JPUHFT is readable and accessible to the general public. It is noteworthy that the Trust is making the report available in languages other than English and also in large print.

Priorities for 2015/16 Healthwatch Suffolk welcomes the priorities for improvement in the year ahead. The Trust is focussing on important issues including inpatient falls, hospital associated thrombosis, noise at night and seven day working; all of which will undoubtedly improve the experience of patients. We are particularly pleased to note the focus on improving information provided to patients upon discharge. This was a key theme expressed by patients in our research that supported a national inquiry into discharge from health and care services. In response to public feedback, we consider that there is a legitimate argument that patients in Suffolk are not receiving sufficient information upon discharge to enable them to self-care or understand their support choices. Information is not always presented to patients at the right time and can also be confusing for patients. We will monitor the progress made in this area with interest.


Medical Negligence Claims: The draft quality account we received contained no detail as to how this objective will be achieved or how progress will be monitored.

Inpatient Falls: There has been an 8% reduction in the number of incidents in 2014/15 however the number remains significant. Healthwatch Suffolk hopes that the revised falls policy will include a requirement for the regular reporting and review of actual events.

Hospital Associated Thrombosis (HAT): The report envisages the appointment of a medical lead for HAT together with the development of new pathways. Healthwatch Suffolk would welcome more information regarding the way in which the effectiveness of the new procedures will be evaluated.

The Trust has set out its’ priorities in a structured form that includes the standards, an explanation as to why they were chosen and how it will deliver and monitor progress. It has an ambitious programme of improvement which is welcomed.

The review of targets for the previous year 2013/14 shows that there has been a reduction in “never events”. This is pleasing to note however, the draft gives no indication of any increase in staff education and training. Healthwatch Suffolk is also pleased to see that the re-inspection of the Trust by the CQC in September found controls and procedures met the required standard for medicines management and documentation.

Healthwatch Suffolk has been unable to comment on patient complaints received by the Trust because the information was not present in the draft we received.

James Paget University Hospital NHS Foundation Trust’s Quality Account for last year (2013/14) made mention of enhancing relationships with Healthwatch and other patient groups. Our work with the Trust this year has been positive and we are satisfied that responses to patient concerns raised by us have been treated seriously and appropriate action taken to improve services where appropriate.

Feedback received by Healthwatch Suffolk in the year has been generally good with some specific issues which we have raised directly with the Trust. Healthwatch Suffolk looks forward to working with James Paget University Hospital NHS Foundation Trust (JPUHT) in the year ahead and to hearing of progress made to improve services and outcomes for patients and service users in Suffolk and Norfolk. Dr Tony Rollo Chair

Health Overview and Scrutiny Committee The Suffolk Health Scrutiny Committee does not intend to comment individually on the NHS Quality Accounts for 2015. This should in no way be taken as a negative response. The Committee has, in the main, been content with the engagement of local healthcare providers in its work over the past year. The Committee has taken the view that it would be appropriate for Healthwatch Suffolk to consider the content of the Quality Accounts in light of views and comments received from patients and local residents, and comment accordingly. County Councillor Michael Ladd On behalf of the Suffolk Health Scrutiny Committee


Annex 2 Statement of Directors’ responsibilities for the quality

report

The directors are required under the Health Act 2009 and the National Health Selice {Quality Accounts}Regulations to prepare quality accgunts lor each financialyear.

Mcnitor has issued guidance to NH$ loundation trust boards on the fann and csntent of.annualqualityrepafis {which incorporate lhe above legal requirernents} and on the anangements that NHS foundationtrust boards should put in place to suppart the d*ta guality for the preparation of the quality report.

In preparing the Quality Report, directors are required lo take steps tc satisfy themselves that:

r the content ol the Quality Report meets the requirements set out in the NHS Foundation Trust AnnualReporling Manual 2414115 and suppo*ing guidance

r the content af the Quality Report is nat inconsistent with internal and extemal sources of infon'naiionincluding:

- 5oard rninutes and papers for the period 25tt April 2014 to 28tn May 2015- papers relating to Ouality repo*ed to the board over the period 25tn April 2014 ta 2atn May- feedbaek from the cornmissioners dated 1lu Mav 2015

- ;:*33:l li:il *X1''::f-**n':,r:[iJ.1::",? dared r8m say ?015 {Norrork} and 2?d r!,,ay r0r5 {$urrork}- feedback from Overview and $crutiny Committee dated 14"' May 2015* the trusl's complaints report published under regulation 18 of the Lacal Authori$ $ocial Serviees and NHS

Ccrnplaints Regulations e$0g, dated 25ur July 20"t4- the 2414 natianal patien: survey A&JA4fi4- the 2014 nationalstaff surv€y 25&2/15- the Head of Inlernal Audit's annual opinion over the *ust's control environment dated 28m May 2015- CCC lntelligent Monllaring Repo*s da*dA7ftA14 a*d 1212Q14

r the Qualily Fleport presents a balanced picture of lhe NHS foundation trust's perfonnance over theperiod covered

r the performance information reported in the Quality Report is reliable and accurater there are proper internalcontrols over the collection and reporting of the measur€s of perlorrnance

included in the Quality Repo*, and these controls are subject to revlew to confirm that they are workingelfectively in practice

r the data underpinning the measures of performance reported in ihe Quality Flepart is robust andreliable, conforms tc specified data quality standards and prescribed definitions, is subject to appropriatescrutiny and review; and

r the Quality Report has been prepared in accsrdance with Monitor's annual reporting guidance {whichlnco rpo ra tes theQua | i t yAccoun i sRegu |a t i ons } {pub } i sheda t }as well as the standards to supporl data quality for the preparation ol the Quality Fleport {available atwww" monilor. gcv.ukla*:ual reportinqmanual)

The Directors confirm to the best of their knowledge and belief they have cornplied with ihe aboverequirements in preparing the Quality Repcrt.

By order of the Board

Zy S tq oate *T)JL:

--:> -t-,"7 Chairman

,LE .-9. \S Oate CSOlf*a Chiel Fxecutive

ilate Director of Operalions

Medical Dlrector

Director of Nursing, Quality and PatientExperience

zEl5/t5 Oate

NB: sign and date in any colour ink except black

Jarnes Paget Universiiy l-lospitals NHS Fcu*daticn TruslQuali iv neua*,241$15 t 3

http://www.monitor.gov.uk/annualreportingmanual

http://www.monitor.gov.uk/annualreportingmanual


Glossary of terms and

abbreviations


Term Meaning

A&E Accident and Emergency department

AmbU Ambulatory Care Unit

ANS Association of Neurophysiological Scientists

ARMD Age-related macular degeneration

BSCN British Society for Clinical Neurophysiology

C.diff Clostridium difficile

CAPE Carer and Patient Experience Committee

CCG Clinical Commissioning Group

CDI Clostridium difficile infection

CMP Case mix programme

CNST Clinical Negligence Scheme for Trusts

COPD Chronic obstructive pulmonary disease

CPA Clinical Pathology Accreditation

CPD Continuing Professional Development

CPES Cancer Patient Experience Survey

CPRD Clinical Practice Research Datalink

CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation

CRB Criminal Records Bureau

CRM Cardiac rhythm management

CT Computerised tomography

DAHNO National Head and Neck Oncology Audit

DBS Disclosure and Barring Service

DiPC Director for Infection Prevention and Control

DON Director of Nursing, Quality and Patient Experience

DoW Director of Workforce and Corporate Affairs

DTOC Delayed Transfer of Care

DVT Deep vein thrombosis

EDIS Emergency Department Information System

EQA External Quality Assessment

FallSafe Quality improvement project focused on prevention and management of falls in clinical hospital wards in Southern England SHA

FFFAP Falls and Fragility Fractures Audit Programme

FFT Friends and family Test

GDH Glutamate dehydrogenase - a chemical (enzyme) found in C.difficile

GI Gastrointestinal

GP General Practitioner

GPhC General Pharmaceutical Council

HAT Hospital-associated thrombosis

HES Hospital Episode Statistics

HSMR Hospital Standardised Mortality Rate

IBD Inflammatory Bowel Disease

IG Information Governance

IGT Information Governance Toolkit

IV Intravenous

JAG Joint Advisory Group on GI Endoscopy


Term Meaning

JPUH James Paget University Hospitals NHS Foundation Trust (the Trust)

KLOE Key Lines of Enquiry

MBRRACE-UK Maternal, Newborn and Infant Clinical Outcome Review Programme

MD Medical Director

MHRA Medicines and Healthcare Products Regulatory Agency

MINAP National Audit - Acute Coronary Syndrome of Acute Myocardial Infarction

MRI Magnetic Resonance Imaging

NAOGC National Oesophago-Gastric Cancer Audit

NBOCAP National Bowel Cancer Audit

NCAA National Cardiac Arrest Audit

NCEPOD National Confidential Enquiry Into Patient Outcome# and Death

NED Non-Executive Director

NELA National Emergency Laparotomy Audit

NHS National Health Service

NHSLA National Health Service Litigation Authority

NIBSC National Institute for Biological Standards and Control

NICE National Institute for Health and Care Excellence

NJR National Joint Registry

NLCA National Lung Cancer Audit

NNAP Neonatal Intensive and Special Care Audit

NNUH Norwich and Norfolk University Hospitals NHS Foundation Trust

NOK Next of Kin

NPDA National Paediatric Diabetes Audit

NPSA National Patient Safety Agency

NRLS National Reporting and Learning Service

OPD Outpatient department

PACE Patient and Carer Experience Committee (replaced by CAPE)

PALS Patient Advice and Liaison Service

PbR Payment by Results

PE Pulmonary Embolism

PGD Patient Group Direction

PICANet Paediatric Intensive Care Audit

PLACE Patient Led Assessments of the Care Environment

POMH Prescribing Observatory for Mental Health

PPG Patient Participation Group

PRN Pro re nata - when required (in relation to taking medicines)

PROMs Patient Reported Outcome Measures

PSI Patient Safety Incident

QC Queen's Counsel

QEHKL The Queen Elizabeth Hospital, Kings Lynn

RCA Root Cause Analysis

RCOG Royal College of Obstetricians and Gynaecologists

RCOphth Royal College of Ophthalmologists

RCR Royal College of Radiologists

SAD Acronym used as a mnemonic screening tool for suicide risk in those who have self-harmed

SDSTIP Seven Day Services Transformational Improvement Programme


Term Meaning

SHMI Summary Hospital Mortality Level Indicator

SI Serious Incident

SSNAP Sentinel Stroke National Audit Programme

SUS Secondary Uses Service

TARN Trauma Audit and Research Network

TTO Medicine to take home (on discharge from hospital)

UK United Kingdom

UMR Unified Mortality Review

UNE Ulnar Neuropathy at Elbow

VTE Venous thromboembolism

WHO World Health Organisation


Monitor mandated indicator

definitions


Maximum time of 18 weeks from point of referral to treatment in aggregate

Indicator description The percentage of Referral to Treatment (RTT) pathways within 18 weeks for completed admitted pathways, completed non-admitted pathways and incomplete pathways. Lines within indicator E.B.1: The percentage of admitted pathways within 18 weeks for admitted patients whose clocks stopped during the period on an adjusted basis. E.B.2: The percentage of non-admitted pathways within 18 weeks for non-admitted patients whose clocks stopped during the period. E.B.3: The percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period. Data definition A calculation of the percentage within 18 weeks for completed admitted RTT pathways, completed non-admitted RTT pathways and incomplete RTT pathways based on referral to treatment data provided by NHS and independent sector organisations and signed off by NHS commissioners11. Accountability Performance will be judged against the following waiting time standards:-

Admitted operational standard of 90% – the percentage of admitted pathways (on an adjusted basis) within 18 weeks should equal or exceed 90%

Non-admitted operational standard of 95% – the percentage of non-admitted pathways within 18 weeks should equal or exceed 95%

Incomplete operational standard of 92% – the percentage of incomplete pathways within 18 weeks should equal or exceed 92%

Maximum waiting time of 62 days from urgent GP referral to first treatment for all cancers

Detailed descriptor E.B.12: Percentage of patients receiving first definitive treatment for cancer within two months (62 days) of an urgent GP referral for suspected cancer. E.B.13: Percentage of patients receiving first definitive treatment for cancer within 62-days of referral from an NHS Cancer Screening Service. E.B.14: Percentage of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade their priority status. Lines within indicator E.B.12: All cancer two month urgent referral to first treatment wait Denominator: Total number of patients receiving first definitive treatment for cancer following an urgent GP (GDP or GMP) referral for suspected cancer within a given period, for all cancers (ICD-10 C00 to C97 and D05).

11

The definitions that apply for RTT waiting times are set out in the RTT Clock Rules. Suite found here: https://www.gov.uk/government/publications/right-to-start-consultant-led-treatment-within-18-weeks

https://www.gov.uk/government/publications/right-to-start-consultant-led-treatment-within-18-weeks


Numerator: Number of patients receiving first definitive treatment for cancer within 62-days following an urgent GP (GDP or GMP) referral for suspected cancer within a given period, for all cancers (ICD-10 C00 to C97 and D05). E.B.13: 62-day wait for first treatment following referral from an NHS cancer screening service Denominator: Total number of patients receiving first definitive treatment for cancer following referral from an NHS Cancer Screening Service within a given period (covers any cancer ICD-10 C00 to C97 and D05). Numerator: Number of patients receiving first definitive treatment for cancer within 62-days following referral from an NHS Cancer Screening Service during a given period (covers any cancer ICD-10 C00 to C97 and D05). E.B.14: 62-Day wait for first treatment For cancer following a consultants decision to upgrade the patient’s priority Denominator: Total number of patients receiving first definitive treatment for cancer following a consultant decision to upgrade their priority status within a given period. Numerator: Number of patients receiving first definitive treatment for cancer within 62-days of a consultant decision to upgrade their priority status. Scope: Patients included in this indicator will not have been referred urgently for suspected cancer by their GP or referred with suspected cancer from an NHS Cancer Screening Service with suspected cancer (routine referrals from these services where cancer was not initially suspected may be upgraded). Data definition Numerator and denominator details are defined above. Accountability E.B.12-13: Performance is to be sustained at or above the published operational standard Details of current operational standards are given in the ‘Everyone Counts: Planning for Patients 2014/15 – 2018/19’ guidance12. E.B.14: There is no current operational standard for this component, therefore this will not be centrally assessed against a set threshold. These performance data will however be monitored and published as national statistics.

12

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

http://www.england.nhs.uk/wp-content/uploads/2013/12/5yr-strat-plann-guid-wa.pdf

Page 100 James Paget University Hospitals NHS Foundation Trust Annual Report 2012/13 www.jpaget.nhs.uk

Documents

Quality Report 2014/15 - James Paget Hospital · Healthwatch Norfolk Healthwatch Suffolk Council of Governors Health Overview and Scrutiny Committee The annexes also include a glossary