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Quality Account 2015/16

Freeman Hospital (Headquarters)High HeatonNewcastle upon TyneNE7 7DNTelephone: 0191 233 6161Fax: 0191 213 1968

This information can be requested in large print

Unconditionally registered with the CQC since April 2010

graded as outstanding by CQC 2016

x162764_nuth_cvr_p7_sw.indd 1 28/06/2016 18:14

Quality Account 2015/16 1

3Part 1

Statement on quality from the Chief Executive 2

What is a Quality Account? 3

Part 2

Quality Priorities for Improvement 2016/17 4

Patient Safety 5

Clinical Effectiveness 8

Patient Experience 9

Statement of assurance from the Board 11

Part 3

Review of Quality Performance 2015/16 12

Patient Safety 13

Clinical Effectiveness 30

Patient Experience 37

Overview of Quality Improvements 46

Information on participation in clinical research 53

Information on the use of the CQUIN framework 60

Information relating to registration with the Care Quality Commission (CQC) 61

Information on the Quality of Data 61

Key National Priorities 2015/16 62

Core set of Quality Indicators 64

Workforce factors 70

Involvement and engagement 2015-16 71

Annex 1 Statement on behalf of the Health Scrutiny Committee 74

Statement on behalf of the Newcastle & Gateshead Clinical Commissioning Group Alliance 76

Statement on behalf of Newcastle Healthwatch 79

Statement on behalf of Northumberland Healthwatch 82

Annex 2 Abbreviations 85

Annex 3 Glossary of Terms 87

Annex 4 Feedback form 88

Contents

2 Quality Account 2015/16

2015/16 has proven to be another incredibly successful year for our Trust. Demand for our services has continued to grow and yet we have been able to meet this requirement whilst delivering the same innovative, high quality patient centred care for which we are renowned both

nationally and internationally. Without any shadow of doubt such demonstrable quality of care does influence choice and confidence with more patients each year deciding to come to us for their care and treatment.

We have offered pioneering revolutionary procedures to improve the efficacy of patient care. The Freeman is noted to be at the very forefront of robotic surgery and is the only centre in the UK to deliver such a diverse multi-speciality robotic surgery programme. In fact during 2015 we celebrated the 1000th procedure undertaken on our Da Vinci Robot. Last year also saw the our Breast Surgeons and Radiologists offer a new technique (Radioactive Seed Localisation) to enhance the accuracy of cancer treatment. We are proud to say that we are only centre in the UK to offer this treatment. All in all much of this pioneering work is a result of our commitment to research and a culture focussed on continuous improvement. The Trust currently tops the NHS Research Activity League; conducting more research programmes than any other NHS provider - an incredible 486 studies last year reflecting an increase on the previous year.

We have also been able to bring care closer to patients more than ever before by opening Newcastle Hospitals at Cramlington based at the Manor Walks Retail Centre. This fantastic new facility offers high quality outpatient based care and state of the art diagnostics in a location more convenient to 1000’s of our patients and we hope to expand the services on offer there soon.

This Quality Account is a celebration of our achievements and plans for the coming year. Our staff have worked tirelessly to ensure that patients receive the safest, most clinically effective care and a positive patient experience each and every time they use one of our services.

Patient safety continues to be our number one priority and the aim during 2015/16 has been to reduce avoidable harm and when an incident does occur, ensure that we learn and improve. This year we have worked hard to ensure reporting rates reflect disclosure of all incidents, these being reported per 1000 bed days and which have increased from 28.4 to 32.3. We have also achieved our target in regard to reducing the incidence of patient

falls – there being fewer falls than the national average. Harm free care continues to be reported at above the 95% national average also mortality rates have been below the national average for the last 12 months and consistently below all other providers across the North East and Cumbria.

As well as seeing more patients than ever before we have also received the best ever feedback from our patients. The National Inpatient Survey for 2015 shows that we have not only improved on our own performance from 2014 but also that we are one of the top performers nationally – scoring better than the national average on an impressive 85% of the survey questions asked. But of course we do not always get it right. Over the last 12 months we have continued to develop the “you said, we did” section of our public website to share examples of the improvements we have made following patient complaints or negative feedback and the ‘Take2Minutes’ newsletter continues to be circulated to staff sharing patient stories and feedback.

Over and above direct client feedback, we also benefit from being progressive whilst maintaining our traditional values. There is a legacy of resilience, personal commitment, innovation and energy that serves to underpin the organisation. Complementary to this is effective partnership working and in particular we wish to acknowledge amongst others, Newcastle University, Northumbria University, Newcastle City Council, the National Institute of Health Research and the Shelford Group of Hospitals.

I would like to commend all of our staff as without their diverse skill, loyalty and commitment we would not be advising of such success. And I have no doubt that 2016/17 will be just as successful. I give my assurance that Newcastle Hospitals will continue to put patients at the heart of everything we do, delivering healthcare at its very best, with a personal touch.

To the best of my knowledge the information contained in this document is an accurate reflection of outcome and achievement.

Sir Leonard FenwickChief ExecutiveThe Newcastle upon Tyne NHS Foundation Trust

Part 1 Statement on quality from the Chief Executive

It is with pride that I introduce the Newcastle upon Tyne Hospitals NHS Foundation Trust’s Quality Account for 2015/16.


2What is a Quality Account?

Quality Accounts are annual reports to the public from us about the quality of healthcare services that we provide. They are both retrospective and forward looking as they look back on the previous year’s data, explaining our outcomes and, crucially, look forward to define our priorities for the next year to indicate how we plan to achieve these and quantify their outcomes.

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Part 2 Quality Priorities for Improvement 2016/17


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Priority 1 – To reduce all forms of healthcare associated infection (HCAI), we will quantify our success in this by:

• Aiming for the annual number of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia cases to be no more than zero.

• Reducing hospital acquired infections related to Clostridium difficile (C. difficile) to be no more than 77 cases in the next year.

As well as MRSA and C. difficile, the Trust will continue to monitor rates of Methicillin-Sensitive Staphylococcus Aureus (MSSA) and Escherichia coli (E. coli) and implement strategies to try to reduce the number of patients acquiring these infections. This indicator will continue to be reported to the Trust Board, the Infection Prevention and Control Committee and other relevant forums.

Priority 2 – Sign up to Safety (Su2S)In 2015 The Trust signed up to the three year National “Sign up to Safety” Campaign. 2016/17 will see all projects progressing into their second year. This national project aims to save 6000 lives and reduce avoidable harm by 50% and in doing so have pledged to undertake work in relation to five patient safety priorities:

1. Deteriorating patient:

• To reduce avoidable harm and death associated with missed opportunities to detect/instigate initial management of the deteriorating patient by 50% by 2018 (Adults).

• To reduce the number of episodes of avoidable deterioration leading to PICU admission and/or activation of the resuscitation teams and/or death by 50% in the North East North Cumbria Region by 2018 (Paediatrics).

2. Medication safety:

• To reduce avoidable harm and death from medication errors by 50% by 2018.

3. Sepsis:

• To improve early detection and initial management of the severely septic/septic shocked patient by 50% by 2018 (Adults).

• To reduce the numbers of children treated inappropriately for sepsis by 50% by 2018. (Paediatrics).

4. Surgical Safety:

• To have no surgical never events.

• To reduce harm associated with post-operative care of patients undergoing spinal surgery, by 50% by 2018.

• To reduce adverse incidents associated with elective surgery in the diabetic patient by 50% by 2018.

• To reduce spinal surgery infection rates to <1% by 2018.

5. Obstetrics:

• To achieve a 50% reduction in the incidence of avoidable neonatal hypoxic injury sustained during childbirth.

By signing up to this campaign The Trust is aiming to promote an open learning culture and promote the importance of human factors, incident reporting, staff morale and quality improvement skills across the workforce. This indicator will be monitored in various ways including incident reporting, investigation outcomes and patient and carer feedback. This will be reported quarterly to the Trust Board via the Clinical Governance and Quality Committee.

Priority 3 – The delivery of ‘Harm Free Care’ for all patients is a national and Trust priority. This priority would be to continue to build on the work undertaken in 2015/16 to prevent avoidable harm, disability or death from:

• Falls.

• Pressure ulcers.

The Quality Priorities for 2016/17 in relation to Harm Free Care are to:

• Maintain and sustain the 20% reduction achieved in pressure damage.

• Have no deterioration in the falls/1000 bed days rate achieved in 2015/16 despite an increasing at risk population of patients.

Following discussion with the Board of Directors, the Council of Governors, patient representatives and clinicians the following priorities for 2016/17 have been agreed. Consideration has also been given to feedback received from patients, staff and the public. Presentations have been provided at various staff groups with the opportunity for staff to comment on the priority topics and a feedback form is provided for patients views.

Patient Safety 2


FallsInpatient falls prevention continues to be a priority for staff across the organisation. This is led by the by the Falls Prevention Coordinator who, with support of colleagues and clinical teams, will:

• Lead the ‘No Falls On My Patch’ campaign to drive improvement of practice through education, analysis of data and, the dissemination of learning from best practice.

• Provide evidence based advice to clinical teams on the individual management of patients with high risk, clinical needs, and overall best practice measures.

The Trust will continue to lead a Regional Patient Falls Prevention project, funded through the North East and North Cumbria Academic Health Science Network (NENC AHSN), which will continue until August 2016. This will ensure the implementation of best practice guidelines across six acute Wards within the Trust to drive quality and potentially reduce patient falls and associated harm. Learning from this will influence further practice development which will then be disseminated Trust-wide, and beyond.

Ongoing provision of evidenced based education is planned. The development of a new e-learning programme which is based on the Royal College of Physicians (RCP) best practice guidelines launched in April 2016 and the Falls Prevention Coordinator will provide ongoing face to face training on the Preceptorship programme, Trainee Assistant Practitioner study days and the Healthcare Assistants Academy.

It is intended to build on work undertaken in 2015/16 where training focussed on the delivery of excellent post fall care, particularly in relation to falls where serious harm is suspected. This training has been delivered to Nurse Clinical Educators who will disseminate this across the Trust in 2016/17.

We will continue to undertake detailed analysis of falls, reviewing data, undertaking root cause analysis of falls with harm to identify learning, and to provide assurance that all preventative measures were in place.

Pressure Damage The Tissue Viability Team continues to work with all Trust staff to achieve “zero tolerance” to Trust acquired pressure damage. Achieving our aim is a continuous challenge but we are determined to succeed, and several Wards have already achieved significant numbers of “harm free” days. We have some exciting success stories, for example, one busy surgical Ward that used to have 2-3 pressure ulcers per month, has now been pressure damage free for almost two years (Ward 46 at the Royal Victoria Infirmary); this was following the implementation of strict turning regimes for all their patients at risk of developing pressure ulcers as well as intensive skin care. Strong leadership and team-working complemented

their action plan and sustained their progress during the last two years.

Three Wards have been participating in a regional collaborative project to reduce damage by 50% and we will continue to support these teams in 2016/17 and share learning from this work to other priority areas in 2016/17.

Staff on every Ward and department continue to work hard in the Trust to reduce the number of pressure ulcers and moisture lesions developed whilst in our care. Their work continues to be supported by the Tissue Viability, Podiatry and Moving and Handling Teams.

The Trust will continue with a “zero tolerance” approach to Trust acquired pressure damage, supporting staff to report all instances of damage present on admission, and those that subsequently develop or deteriorate. This open reporting enables areas to be supported to reduce harm. It is demonstrated that overall progress is being made and, that at times of high clinical demand, incidence rates do increase and reduce again as acuity and workload reduces.

Both areas of this indicator will be monitored through incident reporting, prevalence audits and investigations. This will be reported to the Trust Board and the specific Trust Groups.

Priority 4 – Safeguarding The Quality Priorities for 2016/17 related to Safeguarding include:

• The protection of vulnerable adults and children, accessing services across all aspects of the Trust, from all forms of abuse including those at risk of, or subject to, Domestic Violence, Sexual Exploitation, or Female Genital Mutilation (FGM).

• Ensuring the Mental Capacity Act (MCA), and Deprivation of Liberty (DoLS) Safeguards are robustly applied.

• Ensuring that those with Learning Disability are recognised, flagged on Trust systems and appropriate, reasonable adjustments provided to ensure they can access and receive high quality safe care.

• Contribute to city wide work to enhance the protection of vulnerable adults and children through multi-agency working, including case review, education and policy and practice development.

• Ensure Specialist Safeguarding teams are supported to respond to increasing workloads, and that they are supported, and equipped to deal with the complexity and demanding nature of the work they undertake.

An agreed set of metrics will continue to be recorded, monitored, and analysed. These will include:


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• The number and types of ‘Cause for Concerns’ (CFCs) raised.

• Applications for Deprivation of Liberty Safeguards.

• Cases of Female Genital Mutilation.

• Contacts with individuals with Learning Disability.

• Training activity.

To achieve these priorities and to build on the existing robust safeguarding arrangements the newly appointed Head of Safeguarding will be supported to establish a Corporate Safeguarding Team, by bringing together the currently disparate arrangements, under one management structure whilst ensuring the individual clinical specialisms and expertise of the named professionals is recognised. Practices will be developed so that staff are empowered to raise concerns and can recognise the vital contribution they make to protecting the vulnerable, in order to enable this we will develop the content of existing training within the Trust so that staff continue to recognise and respond to safeguarding concerns.

Further work planned will include:

• Learning Disability mortality reviews, sharing learning and preparing for implementation of national review processes and engaging with national developments in this regard.

• Raise awareness of MCA/DoL across Trust by ongoing development of guidance and tools to help frontline staff understand where Deprivation of Liberty Standards may apply.

• Continue the development, support for, and number of Mental Capacity Act Champions.

• Ensure staff are aware of current risks in relation to sexual exploitation in the City and contribute to multiagency work to review and learn from past cases to inform future protection arrangements.

• Increase ability of staff to routinely and selectively enquire about Domestic Abuse and then respond appropriately, both in relation to patients and also recognising that as an employer of 14,000 staff, this is also a staff wellbeing issue.


• Ensure cases of Female Genital Mutilation are recognised and data reporting requirements met, with safeguarding risks responded to.

• Contribute to the improvement of health outcomes for Looked after Children.

• Ensure the voice and views of vulnerable individuals and those who support them is heard and applied to ensure continuous improvement of outcomes for all concerned.

• Continue to work in partnership with other agencies to support the work of the Newcastle Safeguarding Boards, for Children and Adults and also the Learning Disability Clinical Network, at both strategic and operational levels.

• Participate in multiagency case reviews including Serious Case Reviews, Domestic Homicide Reviews, Learning Reviews and Appreciative Enquiry in a way that supports open and critical appraisal of practice and sharing of learning across the organisation.

This indicator will be monitored through the Trust safeguarding management structure using results of audit, assurance work and case reviews which will be examined and challenged and progress against agreed actions monitored and reviewed. Regular reports will go to Trust Board

Priority 5 – Palliative & End of Life Care High quality care at the end of life is a key priority for Newcastle upon Tyne Hospitals NHS Foundation Trust and nationally. Dying occurs in hospitals and in the community and we have a responsibility to ensure that patients and families receive the information, support and care they require during this difficult time.

The ambitions for Palliative and End of Life Care published in 2015 states “As organisations with experience of, and responsibility for, palliative and end of life care we have made a collective decision to act together to do all we can to achieve for everyone what we would want for our own families.” With this in mind Newcastle upon Tyne Hospitals NHS Foundation Trust aspires to give patients and their carers sensitive, timely and evidence based holistic care.

To help achieve this we need staff who are delivering this care to be trained and supported. This will be done through mandatory education and support services such as the Specialist Palliative Care Service and the End of Life Team. The Trust has adopted a new regional document to guide staff in their care planning and delivery. The new Macmillan Support Worker Project aims to further enhance the care and experience for patients and their carers through dedicated one to one time.

Monitoring of care delivered will be achieved through bi-annual audit that also captures patient and carer views and we will act on any findings. In addition continued participation in the National End of Life Care Audit:

Dying in Hospital compares our care nationally. The End of Life team engages with Wards and departments on a daily basis to monitor the care delivered. Regular reports will go to Trust Board.

Clinical Effectiveness

Priority 6 – MortalityThe Trust will continue to monitor mortality rates with the aim of reducing avoidable deaths and build on developments achieved in 2015/16.

The Trust will continue to scrutinise national mortality indicators such as Summary Hospital Mortality Indictor (SHMI) and Hospital Standardised Mortality Ratio (HSMR) and aim to achieve a mortality rate within the ‘as expected’ category as a minimum. In depth case note reviews will continue in all clinical specialities that appear to have increased mortality rates. This process will complement the Trust’s traditional mortality and morbidity (M&M) meetings within each Directorate to ensure local learning and quality improvement.

Moving forward all mortality reviews (whether conducted centrally or within each clinical team) will be recorded on a new database making reviews more streamlined and enhancing Trust wide learning. This will also enhance current reporting mechanisms to the Board giving greater assurance.

This indicator will be monitored and reported to the Trust Board and the Clinical Risk Group.

Priority 7 – National Audits and Confidential EnquiriesWe will continue to participate in all National Audits and Confidential Enquiries that are applicable to our organisation and continue to ensure that we act on all the relevant recommendations arising from the reports.

We aim to further develop the Trusts processes for implementing the recommendations, where appropriate, from National Clinical Audit and Confidential Enquiries by ensuring learning is widely shared across the organisation. The action plans will be presented to the Clinical Effectiveness, Audit and Guidelines Committee and any areas of non-compliance will be monitored on a six monthly basis. This will then be reported into the Clinical Governance and Quality Committee.

Priority 8 – NICE Quality Standards (QSTs)National Institute for Health and Care Excellence (NICE) Quality Standards (QST) describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. They draw on existing guidance, which provides an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.



2We aim, where appropriate, to be compliant with NICE guidance and strive to ensure that the processes used within our services are based on the most up to date and best practice guidance available.

In 2015/16 three extremely challenging QSTs were selected as priority areas for the Trust. These were:

• QS1 Dementia – this NICE quality standard defines a high standard of care for patients with dementia. The Trust have previously implemented a number of new initiatives and strategies to improve the care patients receive with dementia and continue to strive to make further improvements in response to the needs of patients with cognitive impairment.

• QS49 Surgical site infection – This quality standard covers the prevention and treatment of surgical site infection for adults, children and young people undergoing surgical incisions through the skin, in all healthcare settings. It was published in October 2013 and is aligned to the Sign up to Safety Campaign.

• QS66 Intravenous fluid therapy in adults in hospital – This quality standard covers the assessment and management of adults’ intravenous (IV) fluid needs in hospital. IV fluid therapy is the provision of fluid and/or electrolytes directly into the vein. This quality standard does not cover the use of blood or blood products. It was published in August 2014 and has been selected because the Trust are committed to patient safety and wish to progress to full implementation of the standard.

Work will continue during 2016/17 to ensure that the organisation continues to monitor and improve services with the aim of fully complying with these standards. This indicator will be reported to the Clinical Governance and Quality Committee via the Clinical Effectiveness, Audit and Guidelines Committee.

Patient Experience

Priority 9 – Patient ExperienceThe Quality Priorities for 2016/17 related to Patient Experience including Equality, Diversity and Involvement are:

• To continue to perform well across a range of patient experience measures including the National Inpatient and Outpatient Surveys, whilst recognising that there is always the potential for further improvement. The Trust is committed to eliciting and monitoring feedback in order to further enhance the patient experience.

• The Trust will continue to build on the developments in 2015/16 with the Friends and Family Test (FFT), Open and Honest Care Reporting, and visibility of a “You Said ... We Did …” approach, including displays in public areas to demonstrate how much the Trust values and responds to feedback.

• The Trust will maximise opportunities for patient engagement to ensure that we understand patients and service user expectations and how these can be met.

• The Trust will continue to take forward work, as outlined in the Equality Delivery System, to ensure equal access and reduce inequality, by developing processes and practice to meet the needs of those with a Protected Characteristic, and ensure individualised care provides the best patient experience.

The Trust values the opinions of its patients and seeks feedback in many ways including formal surveys, Friends and Family reviews, NHS Choices, formal Complaints, Patient Liaison and Advice Service surveys, as well as formal and informal engagement with patients and the public. This includes Trust’s Community Advisory Panel, Governors’ Council and Trust Members who continue to be integral to enhancing the patient experience.

The Trust continues to demonstrate that, not only, are the concerns of patients and carers taken seriously, but that care matches up to the Trust’s stated core value, to put the patient at the heart of all we do, and will achieve this through actively seeking views of the people served by the Trust and the people that love and care for them.

The Trust aim to further develop its responsiveness, and care provision, by:

• Continuing to provide accessible mechanisms through which service users can provide feedback, and voice their opinions in order to inform service improvement.

• Further develop visibility and transparency of actions taken in response to patient experience, and clearly demonstrate the value the Trust places on feedback and patients views.

• Meeting the NHS and Social Care Accessible Information Standard.

• Completing work commenced during 2015/16 to identify and meet the needs of Carers, including Young Carers. This will include signing up to “Johns Campaign” to support the needs of Carers of those with Dementia.

• Develop new objectives for the Equality Delivery System and review grades for 2016.

• Complete the report on the experience of patients working with BSL Interpreters and progress the work on the British Sign Language Video Relay pilot.

• Undertaking partnership work across the Trust, Local Authority and third Sector so that the Trust can contribute to reducing social isolation and loneliness.

• Developing a robust equality analysis process for business development and Board papers.

The results of this indicator will be reported to the Trust Board and relevant internal and external forums.

2Patient Experience


Care Quality Commission (CQC) rate Newcastle Hospitals as outstanding

Managers and staff created a strong, visible, person-centred culture and were highly motivated and inspired to offer the best possible care.

“ “


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During 2015/16 the Newcastle upon Tyne Hospitals NHS Foundation Trust provided and/or sub-contracted 17 relevant health services.

The Trust has reviewed all the data available to them on the quality of care in all 17 of these relevant health services.

The income generated by the relevant health services reviewed in 2015/16 represents 100 per cent of the total income generated from the provision of relevant health services by the Trust for 2015/16.

The Newcastle upon Tyne Hospitals NHS Foundation Trust aims to put quality at the heart of everything we do and to constantly strive for improvement by monitoring effectiveness. High level parameters of quality and safety have been reported monthly to the Board and Council of Governors. In January 2016 a new style report was introduced which is aligned to the CQC domains of Safe, Effective, Caring, Responsive and Well-led. Activity is monitored in respect to quality priorities and safety indicators by exception and performance is compared with local and national standards.

Leadership walkabouts, coordinated by the Quality and

Assurance Lead, involving Executive and Non-Executive Directors and members of the Medical Director’s and Nursing and Patient Services Director’s teams have been regularly conducted in a variety of departments across the Trust. These are reported to the Corporate Governance Committee, a standing committee of the Trust Board, and any actions reported on acted upon and followed up.

The Trust Complaints Panel is chaired by a Non-Executive Director of the Trust and reports directly to the Trust Board, picking up any areas of concern with individual Directorates as necessary.

The monthly Clinical Assurance Tool (CAT) continues to provide clinical assurance to the Trust Board as an overview of performance against a wide range of clinical and environmental measures for each Ward and Directorate. The aim of the CAT is to measure and demonstrate compliance with the published documents and national drivers such as High Impact Actions, Saving Lives as well as providing useful data to support, verify and offer assurance for external inspectorates.

Feedback and, where necessary, reports on improvement actions are provided to the Corporate Governance Committee.

2Statement of assurance from the Board


Part 3 Review of Quality Performance 2015/16


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The Trust has consulted widely with members of the public and local committees in ensuring that the indicators presented in this document are what the public expect to be reported. Comments have been received from Newcastle Health Scrutiny Committee, Newcastle Clinical Commissioning Group (CCGs) and the Newcastle and the Northumberland Healthwatch teams. Amendments have been made in line with this feedback.

Patient Safety

Priority 1 - To reduce all forms of healthcare associated infection (HCAI), we will quantify our success in this by:

• Aiming for the annual number of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia cases to be no more than zero.

• Reducing hospital acquired infections related to Clostridium difficile (C. difficile) to no more than 77 cases in the next year.

As well as MRSA and C. difficile, the Trust monitors rates of Methicillin-Sensitive Staphylococcus Aureus (MSSA) and Escherichia coli (E. coli) bacteraemia.

The definition of MRSA is:Staphylococcus Aureus (S. aureus) is a bacterium that commonly colonises human skin and mucosa (e.g. inside the nose) without causing any problems. Although most healthy people are unaffected by it, it can cause disease, particularly if the bacteria enters the body, for example through broken skin or a medical procedure. MRSA is a

form of S. aureus that has developed resistance to more commonly used antibiotics. MRSA bacteraemia is a blood stream infection that can lead to life threatening sepsis which can be fatal if not diagnosed early and treated effectively.

The definition of C. difficile infection (CDI) is:C. difficile diarrhoea is a type of infectious diarrhoea caused by the bacteria Clostridium difficile, a species of gram-positive spore-forming bacteria. While it can be a minor part of normal colonic flora, the bacterium causes disease when competing bacteria in the gut have been reduced by antibiotic treatment.

The definition of MSSA is:As stated above for MSSA the only difference between MRSA and MSSA is their degree of antibiotic resistance: other than that there is no real difference between them.

The definition of E. coli is:Escherichia coli (E. coli) bacteria are frequently found in the intestines of humans and animals. There are many different types of E. coli, and while some live in the intestine quite harmlessly, others may cause a variety of diseases.

The bacterium is found in faeces and can survive in the environment. E. coli bacteria can cause a range of infections including urinary tract infection, cystitis (infection of the bladder), and intestinal infection. E. coli bacteraemia (blood stream infection) may be caused by primary infections spreading to the blood.

The information presented in this Quality Account represents information which has been monitored over the last 12 months by the Trust Board, Council of Governors, Clinical Governance and Quality Committee and the Clinical Policy Group. The majority of the Account represents information from all 17 Clinical Directorates presented as total figures for the Trust. The indicators to be presented and monitored were selected following discussions with the Trust Board. They were agreed by the Executive Team and have been developed over the last 12 months following guidance from senior clinical staff. The quality priorities for improvement have been discussed and agreed by the Trust Board and representatives from the Council of Governors.

Patient Safety


During the period April 2015 to March 2016, there have been:-

• Five MRSA bacteraemia cases finally assigned to the Trust. There is a ‘zero tolerance’ approach to MRSA infections

• 67 cases of hospital acquired C. difficile were reported against an annual target of 77 cases (94 cases were reported but 27 successfully appealed and were therefore not counted towards the target).

• 83 cases of MSSA bacteraemia

• 170 cases of E. coli bacteraemia

The graphs below indicate the position of the Trust as at the end of March 2016 and the progress made over time in respect of reducing the incidences of these hospital

acquired infections. The figures are reported to the Trust Board and Public Health England (PHE) on a monthly basis.For C. difficile, the graph below compares the Trust target to the number of reported cases (minus successful appeals) since 2008.

There are a number of strategies that the Trust has implemented to monitor and reduce the number of HCAIs, these include:

• HCAI action plans being regularly reviewed by Infection Prevention Control Committee (IPCC) and Infection Prevention & Control (IPC). HCAI is a standing agenda item at the Trust main forums and Directorate level communication and governance meetings.

• Following each case of MRSA bacteraemia a rapid review and Post Infection Review (PIR) Toolkit are completed. A Serious Infection Review Meeting (SIRM) is held and lessons learned are discussed and implemented. This information is collated in a quarterly report, which facilitates the sharing of lessons learned and best practice Trust-wide.

• Following each C. difficile case attributed to the Trust, a Root Cause Analysis (RCA) form is completed and the results compiled in a database. This information contributes to the production of the quarterly report. A SIRM is held where C. difficile is on the death certificate or where there are clear lessons to be learned (such as lapses in care). A period of increased incidence (two or more cases on a Ward within 28 days) leads to a Multi-Disciplinary Team (MDT) review to discuss the cases.

• The Trust has focused on areas where patients are identified at a higher risk of MSSA which include the Cardiothoracic and Renal Services Directorates. High risk patients are now identified and treated with chlorhexidine washes. A new RCA to examine the source and contributory factors of MSSA in the Trust is now in use across the Trust for all cases identified more than 48 hours after admission.

• Where patients have developed E. coli, the suspected source of the infection is recorded and monitored, with particular attention paid to those patients who had a urinary catheter in place at the time.

• Clinical Directors and Directorate Managers continue to update their Directorate HCAI action plans, which clearly identify compliance and progress with the HCAI Prevention Strategy. These action plans are updated regularly and the IPC Operational Group provides feedback when the action plans are submitted.

• Antibiotic stewardship is a standing agenda item at IPCC and a new policy underpinning the core principles has been drafted. Antibiotic champions have been appointed in the majority of medical specialties to lead on audit work. The new Take 5 audits require medical staff to submit an audit of five patients each month on each Ward. The audits have been in place since December 2015 and response rates are gradually improving. A number of the champions attend the Antimicrobial Steering Group meetings on regular basis to have input into the audit process. Pharmacy undertakes quarterly Ward usage audits to demonstrate trends and an annual Trust-wide prevalence audit.

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2007/08 2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

MRSA bacteraemia - 2007/08 to 2015 (minus Third Party Assignment)

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2008/9 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Cases Target Cases Target Cases Target Cases Target Cases Target Cases Target Cases Target Cases Target

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75 66 6580 67 77

C. difficile Cases 2008/09 to 2015/16 (minus appeals)


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Priority 2 - Sign up to SafetyThe Trust have signed up to the three year National “Sign up to Safety” Campaign which aims to save 6000 lives and reduce avoidable harm by 50% by 2018. The first year of the project has been dedicated to the collection of baseline data which will be vital in establishing the success of future interventions; year two will be focused on the implementation of interventions and year three will focus on measuring the impact of the changes in practice which have been made.

By ‘signing up to safety’ the Trust have pledged to undertake work in relation to five patient safety priorities

Deteriorating patient:• To reduce avoidable harm and death associated

with missed opportunities to detect/instigate initial management of the deteriorating patient by 50% by 2018 (Adults).

• To reduce the number of episodes of avoidable deterioration leading to Paediatric Intensive Care Unit (PICU) admission and/or activation of the resuscitation teams and/or death by 50% in the North East North Cumbria Region by 2018 (Paediatrics).

Following the launch of the Trusts National Early Warning Score (NEWS) charts for adults in December 2014 bimonthly Trust wide audits have demonstrated

continuing high compliance with the patients’ observations and scores, both consistently running around 90%. The audit process has moved from a central Trust governance function to a network of Ward based deteriorating patients champions. This was following an eight Ward validation audit, where both audits ran simultaneously and demonstrated comparative results for the different audit methodologies. The deteriorating patient champions consist of at least one nurse per Ward and a junior doctor attached to three-four Wards. The champions provide a voice for the Wards to identify areas of good practice, to share with the network of other champions and flag up issues that are specific to their Ward. Their first quality improvement project looked at the escalation contacts for each Ward. This identified multiple contact points on some Wards and has been a driver to simplify the system moving to an agreement for one Ward one number.

Compliance with escalation of deterioration remains the main challenge and local compliance runs from 50-70%, which is in keeping with nationally published audits for paper based systems. The early involvement of senior decision makers in deteriorating patients is now the main driver for quality improvement. A comprehensive business case to improve this situation has been supported by the Trust. A significant investment has been agreed to


develop electronic observation charts for local use to further improve compliance with the process and facilitate earlier involvement of senior decision makers with the deteriorating patients. An opportunity has arisen to work collaboratively with Oxford University to become an early adopter of a system that has been developed with Human Factors expertise and around £3.6 million of research funding. We are looking to develop this system for use with paediatrics and obstetrics patients after rolling it out to all adult Wards. We believe that an electronic system

will help us improve compliance in all areas.

From 1st April 2015 the resuscitation team started to deliver a 30 minute face to face standardised NEWS package to clinical staff on induction. A 10 minute update on NEWS has been incorporated into annual resuscitation training.

The Trust cardiac arrest rates remain consistently low at 0.79/1000 admissions for FH and 0.52/1000 admissions for RVI.

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In-hospital cardiac arrests 01/04/2015-30/09/2015 - (FH in red)

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In-hospital cardiac arrests 01/04/2015-30/09/2015 - (RVI in red)

Royal Victoria Infirmary Other Hospitals © NCAA 2015

Monitoring unplanned admissions to intensive care is one of the ways to assess the outcomes of deteriorating patients. Through the changeover to NEWS there has been no increase with the numbers of admissions across the four adult intensive care units. The Trust unplanned admissions average Standardised Mortality Ratio of less than one indicates more survivors than predicted for this group. A new tool has been developed using the Yorkshire Human Factors Framework to identify factors to help prevent the unplanned admission to intensive care cohort of patients.

A new Paediatric Early Warning system (PEWS) has been developed following a review of seven Paediatric centres PEWS, a review of published evidence and three design workshops using a modified Delphi approach. The pilot phase of PEWS has been completed on a medical and surgical Ward. Feedback has been sought and minor adjustments made to the next PEWS iteration. A PEWS training package has been developed in collaboration with the Trust Education Department and is being delivered prior to rolling out PEWS across Great North Children’s Hospital (GNCH). A cardiac specific PEWS has been developed for Freeman Hospital Ward areas.


3The Trust is involved in a National Royal College of Paediatrics and Child Health ‘SAFE Wave 2 Project’ a multiplatform project to improve patient safety in children’s hospitals using safety huddles. The process is being adapted to local needs and will be implemented after PEWS has been introduced across GNCH.

The steering group for electronic charting now includes paediatric medical and nursing staff. The aim is to develop an electronic algorithm appropriate for the paediatric age groups, in collaboration with Oxford University.

Medication safety:• To reduce avoidable harm and death from medication

errors by 50% by 2018.

Medication incident reporting data is published every 6 months from the National Reporting and Learning System. The below table highlights an increased reporting rate of 18% in the first six months of this year.

Medication incident reporting rates (acute teaching organisations) per 1000 bed days

Time period Trust rate National rate

Apr 14 – Sept 14 2.8 4.0

Oct 14 – Mar 15 2.7 3.7

Apr 15 –Sept 15 3.3* Not yet available

Oct 15 – Mar 16 3.4* Not yet available

*Internal Trust data – NRLS not yet available

Medication Factors

Did the incident involve an omitted drug?

Did the patient receive incorrect medication?

Did the patient receive an incorrect dose?

Did the patient receive the medication via the incorrect route?

Was the drug an injectable medicine

Were prescription details missing or unclear?

Did the e-prescribing system appear to contribute to the error?

Equipment factors

Was there a problem with the medicine delivery device?

Policy, protocol & procedure factors

Were local policies and procedures (if available) followed?

Physical Environment

Did the working environment contribute to the incident?

Time, workload and staffing

Did any time delays or Ward /unit pressure issues play a part in th is incident?

Patient Factors

Was there a reason why this incident was more likely to occur with this patient?

Communication

Did poor / difficult communication contribute to the incident?

Team and individual factors

Was the individual involved in the incident carrying out the ir usual role?

Did anything impact on the ability of staff to function as a team at the time of the incident?

Education and Training

Did issues with staff knowledge and skills contribute to the incident?

Has the individual involved in the incident been involved in any medication incidents before?

Medication Investigation Tool Format

Medication Incident Investigation ToolA medication incident investigation template was designed and tested in a variety of specialities using a range of incidents in improve the investigation process and as a consequence identify opportunities for learning.

The tool is now in use across the Trust. It has been shared outside the Trust with the Acute Teaching Hospitals Chief Pharmacists’ Group and presented at National Health Service Litigation Authority (NHSLA) sharing and innovation events.


Medication Safety ThermometerThe Medication Safety Thermometer is a measurement tool for improvement. It focuses on medicine reconciliation by a pharmacist, allergy status, medication omission and identifying harm from high risk medicines. It is currently being piloted in NHS Trusts across the country and national data is available for comparison to local Trust data.

Data has been collected on four Wards for 12 months and was recently submitted as part of the national pilot. Dashboards of results have been presented back to the Wards and these will be provided on a six monthly basis in order to monitor progress. Improvement initiatives have been implemented including monitoring of omitted doses and regular prescription chart review.

High Risk MedicinesThe high risk medicines which the Sign up to Safety Group decided to focus on during 2015/16 were: insulin, warfarin, novel oral anticoagulants (NOACs) and disease modifying anti-rheumatic drugs (DMARDs). The number of incidents have been collated and are displayed below. Interventions have been introduced in order to reduce harm from these high risk medicines such as:

• Campaign to encourage reporting in order to maximise learning opportunities from incidents

• Transfer to insulin e-prescribing with the planned roll-out of a new system for the peri-operative management of patients with diabetes

• Education and training relating to the use of novel oral anticoagulants for medical and pharmacy staff

• Implementation of an e-prescribing interaction alert for low molecular weight heparins and novel oral anticoagulants

• Implementation of Trust Warfarin Guidance

Sepsis:• To improve early detection and initial management of

the severely septic/septic shocked patient by 50% by 2018 (Adults).

• To reduce the numbers of children treated inappropriately for sepsis by 50% by 2018. (Paediatrics).

The objectives for Sepsis are to:

Improve Monitoring

Improve Recognition

Improve Communication

Improve time critical response

In order to be able to monitor our progress and the effectiveness of any future changes we make during this project, we started by collecting a wide range of baseline data. This included analysing data from the Emergency Department (ED), microbiology, time taken to administer antibiotics, a theatre audit of emergency laparotomies and an Intensive Care Units (ICU) audit of patients with sepsis. In addition a detailed review of meningococcal deaths in paediatrics has also been undertaken. We also wanted to measure staff knowledge around sepsis and so we conducted an electronic staff knowledge survey which included a variety of questions relating to sepsis which was completed by 2000 staff.

The results of the above audits demonstrated a need to improve compliance with the recognition of sepsis and the delivery of the ‘Sepsis 6’ (a set of 6 treatments and measures that have been proven to improve survival in patients with sepsis). Therefore a sepsis pathway was developed and is currently being tested in the ED. Sepsis teaching has been delivered to all ED staff. The following posters can be seen within the Trust to remind staff of the steps they need to take when they suspect a patient may have ‘Red Flag Sepsis’ - the ‘Sepsis 6’.


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During this last year we have focussed on ‘Red Flag’ sepsis as this captures the most unwell patients. This approach has been endorsed by the National Sepsis Trust.

A training video has also been developed that introduces all staff to the importance of sepsis, the recognition of Red Flag sepsis and the treatment of Red Flag sepsis. This can be accessed by all staff and have been placed on the Trusts YouTube channel.

Specific to paediatrics and based on the newly published national ‘Paediatric Sepsis 6 Pathway’ a separate educational sepsis package is being developed alongside a new pathway for treatment of sepsis in children. The aim is to roll this out after the implementation of the new PEWS charts for improved monitoring of deteriorating patients. The resources developed to date include:

• Power point presentation on sepsis

• Video on Sepsis

• Posters around paediatric sepsis

• Patient experience with sepsis films - in conjunction with Newcastle University documentary film students

Surgical Safety:• To have no surgical never events.

• To reduce harm associated with post-operative care of patients undergoing spinal surgery, by 50% by 2018.

• To reduce adverse incidents associated with elective surgery in the diabetic patient by 50% by 2018.

• To reduce spinal surgery infection rates to <1% by 2018.

Three surgical never events were reported:

• Wrong site anaesthetic block prior to dental treatment.

• Wrong site spinal surgery

• Wrong site anaesthetic block for cataract surgery

Never EventsInvestigation into these Never Events has resulted in lessons learnt and changes implemented to assist in the prevention of these events. Common to both wrong site block Never Events was failure to follow the ‘Stop before You Block’ process highlighting areas in the Trust that need further work to embed this into daily practice. This is in addition to the World Health Organisation (WHO) checklist for surgery. Marking the surgical site in dental surgery has now been made more robust by the introduction of a quadrant marking sticker placed on the patient’s bib for easier reference during the checking process prior to block and subsequent surgery. For the cataract surgery Never Event this highlighted the dependence on marking without reference to the consent/list and practice has been changed to base confirmation of procedure at every preparation step (including marking) with use of consent and list.

Reinforcement of the importance of using more than one patient identifier when using the Picture Archiving and Communication system was highlighted in the wrong level surgery investigation and is being addressed. Dissemination of the learning is provided through team meetings, governance meetings, Trust Patient Safety Briefings and the Trust Clinical Risk Group.

Post-operative care of patients undergoing spinal surgeryOther surgical safety audits have been conducted including patient identification, and surgical consent. Work has commenced to improve the WHO surgical checklist compliance with the development and pilot testing of an observational behavioural tool in three surgical theatres. Establishment of all the different areas within the Trust which undertake procedures which require WHO checklist or similar process has been undertaken and work started to ensure consistent robust implementation of it.


The ThinkSafe Project was introduced as a pilot for patients seen in the ‘majors’ pre-assessment surgery clinic at Freeman Hospital. A booklet and patient DVD provided patients with information on patient safety and patient involvement. The 3 month project has been undertaken and we are looking at what learning we can take from it and incorporating into our Trust protocols and guidelines.

Surgical Management of the Diabetic Patient A local snapshot audit of glycaemic control in diabetic patients undergoing surgery, and an audit of diabetic care standards in diabetic vascular surgical patients have been undertaken alongside participation in a National Diabetes Audit in 2013 and 2015.These all demonstrate areas for improvement in the standards of diabetic management in surgical patients in the Trust. A team of Consultants from Anaesthesia, Diabetes Medicine and Surgery have agreed pathways of care for all diabetic patients undergoing elective and emergency surgery which include, clear documentation of diabetes management for each individual patient with comprehensive information for Ward staff. These will be initiated from Pre-assessment Clinic in elective surgical patients and the Ward for emergency patients and follow through their intraoperative and postoperative pathway to discharge home. Robust clinical handover from PAC to Ward, to theatre, back to Ward and then discharge home is an integral part of this project. Updating of the Trust handbook of diabetes management and teaching for all staff groups has been implemented. Formal establishment of this new standard of care will start in April 2016.

Spinal SurgerySpinal surgery improvement work has included:

• Pre-operative care: A spinal surgery consent risks clarification exercise was undertaken with Orthopaedic and Neurosurgeons to establish a list of surgical risks.

• An audit of consent to spinal surgery focussing on risks and benefits was then completed. This has shown significant variation in practice and work is underway to agree a minimum set of risks/complications to be discussed with patients undergoing spinal surgery.

• Implementation of chlorhexidine washes issued at pre-assessment and suitable antibiotic prophylaxis to prepare patients for surgery to prevent spinal infections.

• During surgery: appropriate skin preparation to prevent spinal infections, for example routine chlorhexidine skin preparation and applying effective wound dressings.

• Post-operative: An audit and review of the recognition and response to complications post spinal surgery has included a ‘NEWs like’ process for routine limb observations to facilitate recognition and prompt

escalation of deterioration.

Spinal surgical infections are reported quarterly and the graph below highlights the rates of infections up to December 2015.

Alongside the work on improving informed consent and shared decision making is a review of all patient information leaflets for surgical patients. Provision of such information can underpin informed consent, patient expectation and patient confidence for recovery at home when discharged. Our aim for the SU2S project is to collate all such documents, update and standardise them and ensure all patients receive relevant ones.

Obstetrics:• To achieve a 50% reduction in the incidence of

avoidable neonatal hypoxic injury sustained during childbirth.

A successful National Health Service Litigation Authority (NHSLA) bid of £263,000 was awarded to contribute towards the reduction in the avoidance of neonatal injury sustained during childbirth.

Objectives• Improve fetal monitoring skills during labour

New Cardiotocography(CTG) monitoring equipment has been purchased for the induction Ward. The K2 Perinatal Competency Based Fetal Monitoring Training Programme is licensed for use for all clinical staff and completion is being encouraged. The numbers of staff trained is being monitored as below.

• Improve Provision of Midwifery Practice Support

Three new Practice Support midwife posts have been funded and successfully recruited to, in order to increase practice support from 12 hours/day to 24 hours/day.

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3A one day patient safety training event was delivered to practice support midwives and junior doctors. The session included: incident investigation and learning, human factors and simulation, complex case reviews where Hypoxic Ischaemic Encephalopathy (HIE) was sustained, behaviours in the workplace and quality improvement models. Six further training sessions are planned in 2016 for these professional groups.

• Improve availability of cooling equipment for neonatal transfer

Neonatal cooling equipment has been purchased. Since purchase, 5 transfers have occurred using this equipment and on all occasions the babies have had optimal temperature on arrival.

Priority 3 – The delivery of ‘Harm Free Care’ for all patients is a national and Trust priority. This priority would be to continue to build on the work undertaken in 2014/15 to prevent avoidable harm, disability or death from:

• Falls (Have no deterioration in the falls/1000 bed days rate achieved in 2014/15 despite an increasing at risk population of patients)

• Pressure ulcers (Maintain and sustain the 20% reduction achieved in pressure damage in September to December 2014)

Falls:The Trust has consistently reported below the National Acute Trust average of 6.6 falls/1000 bed days. The Trust’s average for 2015/16 is 6.2 falls/1000 bed days which is equal to 2014/15. The National Acute Trust average for falls with serious harm/1000 bed days is 0.19 (serious harm is classed as any incident graded as moderate or above). This Trust’s average for 2015/16 for falls with serious harm/1000 bed days is 0.14 (similar to the rate of 0.13 reported in 2014/15)

The funnel plot below demonstrates the Trust position in relation to the number of patient falls with harm against the national position of acute organisations, reported in the March 2016 Safety Thermometer prevalence audit:

Inpatient falls’ prevention and prevention of harm from falls remains a priority for staff across the organisation. The patient falls data is continually analysed by the Falls Prevention Coordinator who analyses data at Ward, Directorate and Trust level. Monthly, seasonal variation is recognised and comparisons are made with historical data but all significant increases at Ward or Directorate level are analysed closely to identify key themes and learning from incidences.

The Root Cause Analysis (RCA) process continues to be a useful tool to comprehensively investigate falls which result in serious harm for patients. This is done on an individual basis whereby lessons learnt and areas of good practice are shared with Directorate teams, and at Trustwide Nursing Forums to ensure shared learning.

The RCA’s are also analysed collectively on a quarterly basis and the lessons learnt and recurrent themes are disseminated as key messages across the Trust. In addition to this process, the Trust holds regular Directorate falls review meetings where Directorate teams are invited to present inpatient falls data from the past 6 months to discuss with members of the Trust’s Senior Nursing Team and the Falls Prevention Coordinator. These two processes continue to identify areas of improvement, and also drive service improvement with the identification of new falls prevention initiatives.

Education of staff remains a priority workstream for the Falls Prevention Coordinator. The development of a new e-learning programme, which is based on the Royal College of Physicians (RCP) best practice guidelines, is due to be launched in April 2016 and the Falls Prevention Coordinator conducts face to face training on the

Funnel plot for falls with harm

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Preceptorship programme, Trainee Assistant Practitioner study days, and the Healthcare Academy, for all newly recruited Healthcare Assistants. In 2015/16 part of this training has focussed on the delivery of excellent post fall care, particularly in relation to falls where serious harm is suspected. This training has been delivered to the Nurse Clinical Educators, who are based in Directorates throughout the organisation, with the view of disseminating this across the Trust.

In 2015/16 the Trust was successful in its application for funding from the North East and North Cumbria Academic Health Science Network (NENC AHSN) to lead on a regional Quality Improvement Project in relation to inpatient falls prevention. The Falls Project Lead from The Newcastle Hospitals is working with South Tees Hospitals NHS Foundation Trust and County Durham and Darlington Foundation Trust to implement RCP and NICE best practice guidelines, in order to drive up compliance with the implementation of multifactorial risk assessment and intervention plans for ‘at risk’ patients. This is recommended by NICE and the RCP as best practice for inpatient falls prevention.

Tissue Viability

Pressure Damage The Tissue Viability Team continues to work with all Trust staff to achieve “zero tolerance” to Trust acquired pressure damage. Several Wards have achieved significant numbers of days “harm free” including three Wards who have been harm free from pressure damage for over 1 year (Ward 20, 40 and 46 at the RVI).

The Trust is also involved in the Safety Thermometer monthly prevalence study which collects data regarding a patient’s worst pressure ulcer, which can be old or new and only includes pressure ulcers of category II and above.

Definition of old and new pressure ulcers: a patient is defined as developing an old pressure ulcer when they are admitted with it and a new pressure ulcer when it developed whilst in our care.

The published results of the Safety Thermometer data identifies that the Trust is ‘good performer’ in the context of Safety Thermometer data, which reports Trust acquired ulcers as “harm”, and has been consistently so since data submission commenced in April 2013. However the Trust incident data demonstrates that it has been difficult to sustain a reduction in all categories of harm other than moisture lesions.


3Data Analysis a) Safety thermometer: the worst ulcer is reported

as a New “harm” (Trust acquired) or Old “harm” (non-Trust acquired) on one specific day of the

month (true prevalence data). Safety Thermometer data continues to be collected on a monthly basis and is seen as a quality indicator of the Trust’s performance.

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Total number of pressure ulcers and moisture lesions April 2013 - April 2016

DATIX is the method by which staff report any category of ulcers and moisture lesion. The report highlights whether these ulcers are Trust acquired (hospital acquired and District Nurses’ case load acquired) or non-Trust acquired. These reports are the most accurate and useful to analyse. The trend since January 2013 is a general

reduction, especially with regards to moisture lesions and the most severe pressure ulcer (Category IV);

The below graph shows the total number of pressure ulcers and moisture lesions from April 2013 to April 2016, by depth of damage.

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The staff always introduced themselves and explained what was happening. I cannot suggest anything that could be improved. When I asked about something that the nurses were not sure about, they asked someone who knew the answer. I was impressed by the cleanliness and care.

“ “


3The Trust’s Pressure Damage Taskforce group continues to meet monthly. It has led work through the following initiatives:

a) Ongoing education regarding pressure damage prevention and the embedding of the Time2Turn initiatives continues. This includes use of different types of mattresses (Foam, RIK and StaticAir) as well as products used in the prevention of moisture lesions (i.e. SkinIQ, Bowel Management System, and urinary containment products).

b) Root Cause Analysis of all Trust acquired category III or IV pressure ulcers continues by clinical teams and tissue viability prior to reporting as Serious Untoward Incidents (SUI).

c) Presenting any lessons learnt at the Safety Briefing: lessons learnt from the Root Cause analysis were shared during these sessions twice during 2015.

Learning in acute care has related to:

- Patients not turned sufficiently and consistently

- Inconsistent documentation

- Staff not recognising that when patients deteriorate, their risk of developing pressure ulcers increases

- Where patients are not nursed in the speciality they would normally be, nurses need to understand the requirements of different patho-physiology diseases and how they affect their abilities for pressure prevention.

Learning in community care has related to:

- Need to undertake a holistic assessment, record the Braden score, plan preventative care and document these on the Systm1 templates.

d) Regional collaborative work: The Trust is participating in a regional Pressure Reduction Collaborative, led by South Tyneside Foundation Trust following funding from Academic Health Science Network. There are four Trust teams and one Newcastle Nursing Home participating.

- Ward 22 and 23 RVI (Trauma Orthopaedics)

- Ward 8 FH (Vascular)

- Ward 16 FH (Care of the Elderly)

- Whitfield Court also joined the collaborative. This home has always been very proactive in the prevention of pressure ulcers and their input will be beneficial to disseminate their learning to those Care Homes who are struggling to prevent pressure damage.

Aim: the aim of the collaborative is to achieve a 50% reduction of acquired pressure ulcers and this is achieved by a cycle of auditing, test-implement-test “Plan Do Study Act” cycles.

Objectives:

• Measure number of pressure ulcers and moisture lesions

• Audit of FOCUS charts to reach 100% and be sustained, as there is strong correlation that this enables Wards to prevent ulcers from developing.

• Introduce new practices individualised to each Ward that enhance pressure ulcer prevention and test/audit if these make any difference.

The participating Wards have taken on board this work embedding the above practices has taken time.

e) All other Wards targets:

From 1st of October 2015, Wards have been asked to demonstrate a reduction of 50% from their first six months data (April–September 2015), by the end of March 2016. This is an ambitious target but some Wards have achieved this. We have learnt that strong leadership and team working are essential to achieve a sustained reduction in pressure ulcers and moisture lesions.

Priority 4 – Human RightsTo include all aspects of Freedom from Exploitation and Respect for the Person, the Mental Capacity Act (MCA), Safeguarding and Deprivation of Liberty (DoLS). This will be achieved by:

• Continuing to build on the existing robust safeguarding arrangements and focus in particular on:

o Meeting the requirements of the Mental Capacity Act (MCA), recognising and supporting those without or with reduced capacity including application of the Deprivation of Liberty Standards (DOLs).

o Protecting those at risk of or subject to Domestic Violence, Sexual Exploitation, or Female Genital Mutilation.

o Ensuring that those with Learning Disability are recognised, flagged on Trust systems and appropriate reasonable adjustments provided to ensure they can access and receive high quality care. Specific work will be undertaken to review cancer screening pathways and deaths of patients with a Learning Disability to identify improvements and share best practice.

o Ensuring staff know how to respond to concerns and feel supported whilst proceedings are ongoing.

This section will also look at robust safeguarding arrangements within the Trust focusing on Practice Developments, also looking at Training and Engagement with the wider workforce.

• Re-launching the Regional Deciding Right programme in 2015/16.


• Building on the work achieved in relation to End of Life Care (EoL) for patients whist in hospital and the community setting.

• Continue to take forward work as outlined in the Equality Delivery System to ensure equal access and reduce inequality.

Deprivation of Liberty Safeguards (DoLS)The Trust Mental Capacity Act (MCA) Steering Group has continued its work to lead on the dissemination of practice and ensuring the timely and appropriate application for Deprivation of Liberty (DoLS) authorisations. A flow chart has been developed for Wards to support recognition of circumstances where these safeguards may apply. There has also been bespoke work undertaken to consider the application of DoLS within Critical Care settings to consider appropriate applications, this work has been shared regionally and nationally with the Law Commission.

Sexual Exploitation The Trust is actively contributing to a Serious Case Review related to sexual exploitation which is jointly commissioned by Newcastle Safeguarding Children and Safeguarding Adults Board. (NSCB and NSAB). NSCB and NSAB have developed joint Sexual Exploitation Guidelines which will be disseminated across the Trust and partner agencies. Safeguarding staff from all teams are continuing to be vigilant in relation to any concerns that would indicate sexual exploitation and share information or respond to requests for information from multi-agency partners.

Learning Disability Mortality Reviews The Trust has supported a project to develop a regional process to review Learning Disability (LD) mortality data. This is in response to the Confidential Inquiry into the Premature Death of People with a Learning Disability (March 2013) which identified patterns of care including errors and omissions which contributed to premature deaths.

Within the Trust it was identified that 21 people with learning disabilities had died between 1st January and 31st December 2015. The Trust has developed a robust process to review all deaths of people with a learning disability with specialist LD team scrutiny, and then review at a LD Mortality Panel.

The Trust’s Learning Disability Review Panel scrutinises all cases, and looks to identify “lessons to learn “and examples of good practice where evident in the delivery of person centred care. This work, including lessons to learn and best practice, has been shared widely across the Trust and used to inform the work of the Learning Disability Team.

This work has been undertaken in advance of the implementation of a National Learning Disability Mortality review process which is to be piloted in the North East.

The Trust is continuing with these reviews until the national process is established.

Robust Safeguarding ArrangementsThe protection of vulnerable adults and children continues to be a significant clinical and corporate priority. Safeguarding activity continues to be high, with increases in some areas. The number and types of ‘Cause for Concerns’ (CFCs) raised within the Trust are collated and reviewed and reported regularly to Trust Board and key stakeholders. These demonstrate that all teams, with the exception of Children’s Community Team, are continuing to see increases, when comparing activity 2015/2016 activity to the previous 2014/2015 activity. Key points to note are:

• Women’s safeguarding activity has seen an 11.8% increase in reported CFC’s

• There has also been an increase in the reporting of Female Genital Mutilation(FGM) due the Department of Health guidance and the education of staff. To date 46 FGM cases have been reported between 1st April to 29th February 2016 compared to 18 in the same time period for 2014/15.

• The combined figures for Children’s Safeguarding activity across the Hospital and the Community Teams remains relatively unchanged although over the whole year there is a reduction within the Community Team.


3• There have been significantly increased numbers of

Deprivation of Liberty (DoLs) applications made by the Trust; this is to be expected following “Cheshire West” ruling which lowered the “bar” for applications to be considered.

• Adult safeguarding activity has seen a 12.3% increase.

• MARAC (Multi Agency Risk Assessment Conference) referrals have also increased

Case ReviewsThe Trust has contributed actively to range of Case Reviews across the year including Adult and Children’s Serious Case Reviews, Domestic Homicide Reviews, and Lessons’ Learnt reviews. The Trust has robust processes in place to ensure independent management reviews are scrutinised to identify any areas for development and good practice. The Trust actively participates in the Multi-agency development of recommendations. Actions identified for the Trust have been progressed in year and The Trust Safeguarding Committee monitors progress against action plans.

The Trust has robust Child Death Review processes in place with effective links to the Safeguarding Committee.

Safeguarding Practice DevelopmentsThere are a number of areas of safeguarding practice that have been developed, either to enhance patients’ experience and ensure patient safety or to develop best practice especially in relation to multi-agency working. These are outlined below.

i) Restructure of Safeguarding Teams A proposal to bring together the Safeguarding Adults, Children and Maternity functions into a single corporate team within Patient Services under the direction of a new Head of Safeguarding has been developed, supported by the Executives and been enacted. This streamlines the corporate management of safeguarding teams, whilst maintaining the individual clinical expertise. It has also been possible to co-locate the teams in the one office base at the RVI which is enabling close working and enhanced communication.

The Named Doctor for Adult Safeguarding, has been appointed to and becoming established into post. His contribution in supporting the safeguarding team and front line clinicians has proven to be very valuable and is leading to developments in practice related to medical examination in the context of adult safeguarding concerns.

ii) Children and Young People In Adult AreasPatient Services undertook a scoping project to gather information around where Children and Young people (CYP) might be seen and treated out with the Great North Children’s Hospital (GNCH). The focus of the work was to ensure CYP are safe and safeguarded in all areas and departments across the Trust and that essential national standards of care are being met. This work demonstrated that within the Trust there are diverse clinical areas that have mixed services for adults and CYP across the sites within a number of specialities and directorates.

The project has led to the development of “Standards for Directorates offering services to Children and Young People”. The clinical areas have been allocated a link to a Children’s Matron to provide advice and guidance and support Action Plan development and progress. A ‘Safeguarding and Assurance Workshop’ regarding ‘Children Visiting Adult Services’, for the relevant Directorate Managers and Matrons has taken place.

iii) Safeguarding Challenge EventIn order to explore with “critical friends” whether Trust Safeguarding arrangements were robust, and to identify both strengths and areas for improvement, a multi-agency / multi professional “challenge” event was held in November 2015 with a panel of Safeguarding professionals, including the Independent Chairs for Newcastle’s Safeguarding Children and Adult Boards and the City’s Designated Professionals, the Trust’s Medical Director, the Director of Quality and Effectiveness and the Nursing and Patient Services Director as the Executive lead. The event was very useful, the panel consensus was that Safeguarding processes within the Trust were safe and Safeguarding professionals were hard working and committed. The panel felt the event was useful and demonstrated the diversity of Safeguarding within and across the Trust. The event demonstrated the Trust’s commitment to Safeguarding and its willingness to be open and transparent. Areas for development both across the locality and within the Trust were also identified.

Safeguarding Training and Engagement with Wider WorkforceWork has progressed to ensure compliance levels for mandatory training. A training needs analysis (TNA) was completed in October 2015 for over 14000 staff to ensure that the right training and the right competency level was linked to every position. The aim is to increase adherence to mandatory training and to make clear for staff what their requirements are. The TNA will need to be refreshed following the analysis of the Safeguarding Adults: Roles and Competencies for Health care Staff- Intercollegiate Document (NHS England) 2016 which has just been published and changes the requirements in relation to Adult Safeguarding.

To complement formal mandatory training a number of opportunities have been provided for staff from across the Trust to share good practice, care reviews, and enable front line staff to reflect on their own practice and case work. Within 2015/2016 this has included:

• Three very successful Safeguarding Communication Open Forums which have shared cases in relation to topics such as neglect, including self-neglect, Domestic Abuse, sexual exploitation, effective discharge arrangements and financial abuse.

• Safeguarding Newsletters


• Safeguarding Clinical Supervision, both one to one and for groups

• PREVENT workshops

• Case presentations and updates at Clinical Forums such as Matrons and Sisters

• Workshops for Senior Managers and Directors on Call

All of this work demonstrates the ongoing commitment of the Trust to the protection of vulnerable and at risk individuals which is contributing to year on year increases in referrals especially in relation to Adults at Risk, Female Genital Mutilation, Deprivation of Liberty Standards, Sexual Exploitation and Domestic Violence.

Equality Diversity and Human Rights: The Trust has continued to listen to the views and experience of diverse groups of people and individuals regarding their experiences of healthcare. Working in partnership with third sector and voluntary organisations some examples of Trust work to promote equality and diversity and meet the needs of people with protected characteristics over the last six months are outlined below:

Accessible Information Standard: The accessible information standard is a legal requirement to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need. The Trust was successful in developing a joint bid with 3rd sector partners to develop resources and training to support the implementation of the standard. Within the Trust we also have a stakeholders group and a senior management team to ensure we have systems and processes in place to comply with the requirement.

Gender Identity: In January 2016 meetings took place with ‘Be’ (an organisation working with people in relation to gender identity). Some of the things they told us were:

Health Care Professionals lack information and appreciation of trans issues which would help them to deliver better services for trans people. To address this we have:

• Reviewed the training we deliver with the Gender Identity Working Group and amended the training.

• Involved trans people in delivering training

• Delivered ‘Trans Questioning Young People’ training. This was developed and facilitated by DISC

• Included trans awareness in Equality and Diversity Week

• Included gender identity into staff awareness resources

• Developed and delivered unconscious bias training

After surgery it is difficult to get the medical help you need. To address this, the Trust has:

• Talked to hospital services to find out the correct referral route to get the help you need.

• If consultant advice is needed GPs in Newcastle can refer patients to Dr Diana Mansour; Consultant in Community Gynaecology and Reproductive Healthcare who will refer on for surgical revision if this is needed or to Dr Karen Brown Consultant Gynaecologist, Gynaecology Specialty

• We have shared this information with the group and asked the CCG to send this information out to GPs

More information about NHS jobs is needed and reassurance about how trans people are treated in the NHS. To address this the Trust has:

• Raised awareness of NHS Jobs Website which provides NHS Vacancy and career information with the working group for them to promote with their contacts

• As part of further developing an inclusive workforce and making the Trust an attractive place for trans people to work there is an LGBT Staff Network, and the Trust has incorporated trans awareness in equality week and awareness days.

Connecting People, Connecting Communities: Over recent years there has been growing public attention to loneliness in our communities and this has been accompanied by a shift in our understanding of its impact and in particular its implications for mental and physical health. In outreach work undertaken in Byker, loneliness and social isolation were also identified by the Men’s Health Inequalities Steering Group as an issue for men. The Trust is contributing to addressing this issue through:

• Using an asset based approach to working in partnership with 3rd sector and voluntary organisations, the CCG and Councils to find ways in which create an environment where people and communities can connect

• Working via a subgroup of the Equality Diversity and Human Rights Working Group to address loneliness in hospital

• The Volunteer Coordinator linking volunteers with patients who have few visitors

• Being a part of the Framework for good communities

Carers: In Newcastle, 25,644 people are providing unpaid care; 2,234 of which are Young Carers (Census 2011).The Trust has undertaken work with Newcastle Carers Centre over a number of years particularly in relation to supporting Carers of people who have Dementia. However the enactment of the Care Act 2014 introduced new duties to health and social care providers. The EDHR Working group are working in partnership with the Council, Newcastle Carers Centre, Barnardos Young Carers and Trust Staff to review how it currently support Carers and whether any improvements can be made. Some of the things in progress are a ‘Commitment to Carers’ with practical resources such as a Carers Pack, ‘Carers are Welcome Here’ poster and awareness training for staff.

Although the work with carers is ongoing this task and finish group is aiming to complete its work by August 2016.


3Black, Asian and Minority Ethnic People: The Census 2011 shows that 81.7% of Newcastle’s population (230,000 people) are White British and a further 3.7% are White Other. 14.7% (40,600 people) are non-white (compared with 6.9% in Census 2001). To promote services that are welcoming and accessible for Black, Asian and Minority Ethnic (BAME) people the Trust works in Partnership with the Health and Race Equality Forum (HAREF).The National BAME Equity and the NHS: Time for Action conference report 2015 highlights that health inequity based on ethnicity remains a major concern. They suggest that people in black and minority ethnic communities need to be involved in the development, improvement and performance management of NHS strategies for change. Although there is more to do HAREF in their summary of the conference wrote: ‘work to achieve race equality is complex and can be very challenging for everybody - this has not stopped people across sectors in Newcastle working together via the HAREF network, and more widely (e.g. through the Newcastle Hospitals Trust’s Equality, Diversity and Human Rights Group), to make a difference.’

Below are some examples of how the Trust is working to meet the needs of BAME patients:

• Provision of interpreting services - policy review and update

• Inclusion of patients communication needs on the Electronic Patient Referral System

• ‘Everyone Welcome’ training -Engaging and helping young BAME people to feel welcome and comfortable in health services

• Development of ‘Your NHS’ leaflet in plain English which explains NHS Systems

• Health Improvement Service for Ethnic Minorities Integrated pathways to support BAME children and families link services

• Health Improvement Service for Ethnic Minorities work with the Kurdish women’s focus group re: accessing services / Walk in Centre experience

• Supporting Newcastle Medical School, Refugee and Asylum Seeker training. This training is coordinated by HAREF

• Undertaking Ethnic Monitoring and robust Equality Analysis

• Race and Ethnicity included in mandatory and other equality training

Stonewall Health Care Index: The Stonewall Healthcare Equality Index is a benchmark for NHS organisations in relation to sexual orientation equality in service delivery. It helps the Trust to specifically measure progress on equality for their lesbian, gay and bisexual patients, families and carers. The index measures patient policy and practise, staff training, engagements and communication, data collection, health promotion, workplace practise and any additional good practice the Trust is involved in.

In 2013-14 the Trust was ranked 23rd out of 47 participating organisations.

In 2014-15 the Trust took part in Stonewall’s Health Care Champions programme and improved its position to 13th out of 39 participating organisations.

The Trust already had an excellent training programme in relation to sexual orientation within its Sexual Health Services but clearer messages have now been included within mandatory and additional training. Other actions undertaken included involvement at Northern Pride, a robust equality analysis system which reviews evidence in relation to sexual orientation and considering inclusive images and posters in Trust communications. The Trust improved its score in most measures; strengths were identified as patient policy and practise, staff training, engagements and communication and areas to continue improving; data collection, health promotion, workplace practise.

Human Resources have already improved the Trust position in relation to Stonewall’s Workplace Equality Index and are working with the lesbian, gay and bisexual (LGBT) staff network to continue the progress. The Stonewall Health Index process has now closed but we will continue to address areas where further improvements can be made.

End of Life care (EoLC) in Community and Acute Trust Settings Northern England Strategic Clinical Networks Caring for the Dying Patient documentation is now fully implemented within the Community setting. The End of Life and Palliative Care teams have made significant progress introducing the Care for the Dying Patient document across in the acute setting. This document is an individualised plan of care for patients in last days/hours of life and incorporates the 5 Priorities for Care in One Chance to Get it Right (LACDP 2014).

Real-time audits of end of life care will continue and demonstrate high quality care and excellent user patient and carer feedback.

The Trust participated in the National End of Life Care Audit – Dying in Hospital in 2015 and the results were published on March 2016. The Trusts results were excellent, with compliance across many of the quality domains well above the national averages. This evidences the high quality end of life care delivered by staff in the Trust.

Good progress against the Palliative and End of Life Care Strategies 2015-18 has been made after it was ratified by the Board in July 2015. Work is underway to disseminate the strategy across the Trust.

The Trust Board is consistently committed in providing and maintaining excellent standards of EoLC by providing substantive funding to support the full time role of the Lead Nurse for End of Life/Bereavement Care and 2 PAs per week for the Lead Clinician for End of Life Care.


External funding has been secured from Macmillan Cancer Support to implement a 3 year project aimed at supporting families/carers of patients approaching end of life. This project builds on from a successful pilot study to bridge gaps in the provision of end of life care identified through ongoing rigorous audits of EoLC. This commenced in February 2016.

The 4 year Macmillan AHP Project has now commenced scoping work in the community setting in the remaining 6 months of the Project funding.

The Specialist Palliative Care Service has successfully participated in a Public Health England pilot this year around data collection and outcome measures. It is one of only 3 acute Trusts nationally to be chosen to participate in this pilot.

The Specialist Palliative Care Service now has substantive funding to continue the 7 day rapid assessment service in the community, ED and AS to either prevent unnecessary admissions or rapidly discharge patient’s home at the end of life.

The Specialist Palliative Care Service now has substantive funding for 0.8 WTE Band 6 Nurse Specialist (Palliative Care) to work within care homes in Newcastle to support and educate staff.

The Palliative Care Primary Care Standards project has commenced. This project works with primary care teams in Newcastle to support patients and their carers in the last 6-12 months of life. This project is also working with some secondary care teams to promote advance care planning for patients with a non-cancer diagnosis.


Priority 5 – MortalityPriority 5 - To monitor mortality indicators with the aim of reducing avoidable deaths and look for any lessons that can be learned.

Over the past 12 months the Trust has continued to monitor the number of patients that die within our hospitals and also those who die shortly after being discharged. We carefully monitor our mortality rates comparing the number of patients one would expect to die (given the severity of their condition, their age etc.) by using nationally recognised models against the number of patients who actually die. To help us do this we use both the Summarised Hospital-level Mortality Indicator (SHMI) and the Hospital Standardised Mortality Ratio (HSMR). Over the last 12 months both the SHMI and HSMR indicators have shown us to have “as expected” mortality rates that are consistently the lowest in the region.

Despite consistently achieving “as expected” mortality ratings, the Trust is committed to reducing avoidable deaths and learning from outcomes. This is achieved by undertaking patient level reviews for all patients who were not expected to die. To do this we monitor the 140 different diagnostic groups that make up SHMI. If we notice any patterns or increased numbers of deaths in any areas we ensure that these are fully investigated by senior clinicians with expertise in that field. Within the past 12 months 16 such reviews have been undertaken with no areas of concern identified. The results of all reviews are presented to the Clinical Risk Group in order to ensure that any lessons that can be learnt are shared widely.

125

100

75

50

102

107

117119

105

113

99

104

114

123

106109

95 96

107109

100

106

Ave

rage

SH

MI /

HSM

R

CDD North Tees South Tees Gateshead SouthTyneside

Sunderland

Average SHMI Average HSMR England

Newcastle Northumbria North Cumbria

Source: NEQOS Hospital Mortality Monitoring: Report 28 Data extracted from HED March 2016

SHMI vs HSMR for North East Trusts Oct 2012 to Sep 2015



3The most recent available data shows mortality rates according to HSMR and SHMI are within expected levels. The table below shows Average SHMI and HSMR by Acute Trust, Oct 2012 to Sep 2015.

Over the past 12 months the Trust has also responded to two mortality alerts generated by Dr Foster Intelligence. The Dr Foster Intelligence Unit at Imperial College, London routinely analyses Hospital Episode Statistics (HES) data for a wide range of diagnoses and procedures and risk-adjusted mortality rates for hospitals. The unit routinely shares alerts and outliers with the Care Quality Commission. The Trust responded accordingly to the alerts, undertaking in-depth case note reviews led by senior clinicians. Neither of the reviews showed any concerns with the care delivered to the patient groups in question. The results were presented to the Clinical Risk Group in order to discuss findings and share lessons learned. The results were also shared with the Care Quality Commission who commended the Trust for the calibre of the report and are currently looking to change the approach in assessment alerts.

Priority 6 - National Audits and Confidential EnquiriesDuring the period, 2015/16 the Trust looked to improve upon two key issues relating to national clinical audit, these were:

• Establishing an acceptable level of data validation for cases to be included in the respective national clinical audits.

• Ensuring a completed action plan is received for published national clinical audits indicating whether the Trust is compliant with any issues or recommendations and in addition, establishing where the Trust performs well.

In terms of establishing an acceptable level of data validation, there has been a significant amount of debate

initially at the Clinical Governance and Quality Committee and the Clinical Policy Group. The Clinical Policy Group, acknowledging the importance of accurate data, have considered options such as cross Directorate working and locally agreed sampling techniques. Ownership for data validation resides with the nominated clinical lead.

In relation to the receiving of completed action plans for nationally published audit results, Clinical Governance and Risk Department have developed a template for lead clinicians to complete. The template requires a balanced overview of the national audit report’s findings with the identification of areas of good practice and the highlighting of any areas of practice which require further action. This has been a successful project and the actions arising are reported in the monthly Trust Board ‘Quality Report’ and to the Clinical Effectiveness, Audit and Guidelines Committee for monitoring.

Priority 7 - NICE Quality Standards (QSTs) NICE quality standards are concise sets of prioritised statements designed to drive measurable quality improvements within a particular area of health or care. They are derived from the best available evidence such as NICE guidance and other evidence sources accredited by NICE. They are developed independently by NICE, in collaboration with health and social care professionals, their partners and service users. Quality standards cover a broad range of topics (healthcare, social care and public health) and are relevant to a variety of different audiences, which will vary across the topics. There have currently been more than 100 quality standards issued by NICE with no sign of abatement. During 2015/16, the Trust identified three key quality standards which it aimed to improve upon in terms of implementation and these were QS1 Dementia, QS49 Surgical site infection Qs66 IV fluid therapy in adults in hospital. The following tables give an overview on progress on each of these standards stating where we are in terms of compliance.


Standard Statement Current Position Status

1 People with dementia receive care from staff appropriately trained in dementia care

All adult Wards and clinical departments in the Trust have a minimum of one nominated Dementia Champion (Nursing and Therapists). This is because patients with dementia can be cared for in any adult Wards / department in the Trust. The Champions are responsible for cascading relevant education and information to colleagues in their clinical area and for championing high quality dementia care. Champions meet every two months. All new starters attend a dementia awareness session (30mins)as part of their Induction All staff have access to 7 learning modules on dementia awareness via Breeze. A dementia care study day continues to be held every month.

Four dementia experts working at Band 6 / 7 were identified (nursing and therapies) and undertook a post graduate course in dementia studies which started in September 2014 and was completed in December 2015. A further three staff have been identified to undertake this course.

A cumulative total of 9,634 staff have required tier 1 training since April 2012 (as of December 2015) 807 tier 2 training and seven tier 3 training.

A band 7 Dementia Nurse Specialist was recruited in March 2015 who supports and trains clinical staff to care for people with dementia. The CCG’s have supported and funded an additional two band 6 Dementia Nurse Specialists who will commence employment in January 2016.

Mostly Met

2 People with suspected dementia are referred to a memory assessment service specialising in the diagnosis and initial management of dementia.

Monitored as part of the national contract for emergency admissions over the age of 75yrs.

Met

3 People newly diagnosed with dementia and/or their carers receive written and verbal information about their condition, treatment and the support options in their local area.

Information is available on dementia either in the form of a leaflet in Ward rack or can be accessed by staff from Alzheimer’s Society website via Intranet. Information on sources of local support is being given out on Wards, Signposting and Support (Newcastle Carers Centre, Age UK Newcastle, Alzheimer’s Society).

Questionnaires and focus groups have been undertaken with carers to review information and support. A new process is to be implemented in 2016 with these groups. Funding has been required from the Special Trustees to purchase “forget me not” bags which will have information in for carers.

Met

4 People with dementia have an assessment and an ongoing personalised care plan, agreed across health and social care that identifies a named care coordinator and addresses their individual needs.

New Hospital Care plans are being piloted in 2015/16 which will be rolled out across the Trust in 2016/17.

Mostly Met

5 People with dementia, while they have capacity, have the opportunity to discuss and make decisions, together with their carer/s, about the use of: advance statements, advance decisions to refuse treatment, Lasting Power of Attorney, Preferred Priorities of Care.

This aspect of dementia care usually resides with the GP and is carried out using the Deciding Right documentation. Geriatricians currently advise patients and families about LPA at the point of diagnosis.

Met

Quality Standard 1 – Dementia


3Standard Statement Current Position Status

6 Carers of people with dementia are offered an assessment of emotional, psychological and social needs and, if accepted, receive tailored interventions identified by a care plan to address those needs.

CQUIN 2014/15 in Community Rehabilitation and Reablement Team to identify patients with cognitive impairment and carers needs. New process implemented to do this.

Mostly Met

7 People with dementia who develop non-cognitive symptoms that cause them significant distress, or who develop behaviour that challenges, are offered an assessment at an early opportunity to establish generating and aggravating factors. Interventions to improve such behaviour or distress should be recorded in their care plan.

Trust has Guidelines on: Managing Behavioural Problems and Agitation in Dementia. Managing Delirium in Inpatients Core care plan on Managing Behavioural and Psychological Symptoms of Cognitive Impairment is currently being piloted on 5 Wards. Core care plan will then be rolled out across all Wards.

Met

8 People with suspected or known dementia using acute and general hospital inpatient services or emergency departments have access to a liaison service that specialises in the diagnosis and management of dementia and older peoples mental health.

Liaison Psychiatry well established throughout the Trust. Met

9 People in the later stages of dementia are assessed by primary care teams to identify and plan their palliative care needs.

The Trust works very closely with the Primary Health Care Team e.g. patients are referred to them on discharge dependent upon need.

Met

10 Carers of people with dementia have access to a comprehensive range of respite/short-break services that meet the needs of both the carer and the person with dementia.

Respite services not provided by Trust. N/A

All the care I received during my stay in hospital was excellent - first class, from all personnel, consultants, nurses, cleaners etc and the food was also very good.

“

“


Quality Standard 49 – Surgical Site Infection


1 People having surgery are advised not to remove hair from the surgical site and are advised to have (or are helped to have) a shower, bath or bed bath the day before or on the day of surgery.

In their admission letters, all patients who are to have an operation or investigation are advised to have a bath or shower before coming into hospital as it is indicated that this will help prevent infection. Patients are also advised that if they are unable to bathe or shower before coming into hospital to inform a nurse on admission.

There is currently no guidance to patients regarding the removal of hair from the surgical site area. However, it has been suggested that this is something which could be incorporated into the Patient Information leaflet “Coming into Hospital – Information for Inpatients and Day Case Patients”.

Partly Met

2 People having surgery for which antibiotic prophylaxis is indicated receive this in accordance with the local antibiotic formulary.

Varying practice across the directorates with certain areas indicating that local specific microbiology guidelines, relevant to the Directorate were in use within the Trust and these were reviewed on an annual basis by the microbiology team. Audit had shown compliance.

In other areas, audit evidence showed limited compliance with the Trust antibiotic guideline.

Partly Met

3 Adults having surgery under general or regional anaesthesia have normothermia maintained before, during (unless active cooling is part of the procedure) and after surgery.

A significant amount of work has been undertaken in relation to this statement. In particular, theatres have introduced a number of changes in practice / trialled in the directorate. These have included ensuring patients are managed at 21 degrees, tympanic membrane or nasopharyngeal temperature should be undertaken at the commencement of the case and every 30 minutes thereafter (minimum), every patient to have a warm sheet wrapped around them (from warming cupboard) at start of case and again and the end, using the underbody mattress on the trolley for prolonged anaesthetic time and in theatre if available, actively warming patients if surgery is greater than 30 minutes duration and if less than 30 minutes but cold (less than 36.50) then a Bair Hugger should be used and this can continue to be used in recovery.

Mostly Met

4 People having surgery are cared for by an operating team that minimises the transfer of microorganisms during the procedure by following best practice in hand hygiene and theatre wear, and by not moving in and out of the operating area unnecessarily.

No specific issues had been identified in relation to this statement and comments received stating Standard Operating Department policies in place to cover this domain.

Mostly Met

Whilst the standards relate to several clinical directorates, completed baseline assessments have been received from four directorates. The responses indicated below are taken from the directorates who had provided completed assessments.


3Standard Statement Current Position Status

5 People having surgery and their carers receive information and advice on wound and dressing care, including how to recognise problems with the wound and who to contact if they are concerned

No specific issues identified and comments were received stating that it was best practice for nurses to give patients information on discharge regarding dressings wound care and if appropriate catheter care. Where this does occur, there is documentation in the nursing notes to this effect.

Mostly Met

6 People with a surgical site infection are offered treatment with an antibiotic that covers the likely causative organisms and is selected based on local resistance patterns and the results of microbiological tests.

The Trust identified no specific issues in relation to this statement and comments received stated that there are microbiology guidelines in place to provide advice on treatment of surgical site infections and these are easily accessible via the Trust’s Intranet.

Mostly Met

7 People having surgery are cared for by healthcare providers that monitor surgical site infection rates (including post-discharge infections) and provide feedback to relevant staff and stakeholders for continuous improvement through adjustment of clinical practice.

The Trust position is that no specific issues identified in relation to this statement, comments were received stating that complications are discussed in monthly “mortality and morbidity” meetings, including unplanned readmissions.

Mostly Met


Quality Standard 66 – Intravenous fluid therapy in adults in hospital


1 Hospitals have an intravenous (IV) fluids lead who has overall responsibility for training, clinical governance, audit and review of IV fluid prescribing, and patient outcomes.

Senior clinician identified to lead on work Met

2 Adults receiving intravenous (IV) fluid therapy in hospital are cared for by healthcare professionals competent in assessing patients’ fluid and electrolyte needs, prescribing and administering IV fluids, and monitoring patient response.

The Trust has an extensive teaching programme in place to ensure that staff are trained in line with the quality standard. As the Trust Education Group decided not to support making IV fluid training a mandatory training requirement, other avenues were explored to ensure staff have the appropriate levels of knowledge and skills.

The clinical educators have now attended their train the trainer sessions and have rolled this out in their areas. Feedback received has been very positive although certain issues were experienced in relation to releasing staff to attend training at Ward level. Moving forward and in order to overcome some of the difficulties experienced, particularly in terms of new staff it has been added to the preceptorship for all new nurses into the Trust and appears in certain directorate induction days for example critical care. The medical and surgical education teams have also added it to their induction programmes. F1 and F2 doctors all receive training in relation to all elements of the process.

Met

3 Adults receiving intravenous (IV) fluid therapy in hospital have an IV fluid management plan, determined by and reviewed by an expert, which includes the fluid and electrolyte prescription over the next 24 hours and arrangements for assessing patients and monitoring their plan.

• 73% of patients had an IV management plan.

• 60% of the IV plans contained details of fluid and electrolyte prescription over next 24 hours.

• 70% of IV plans contained details of assessment.

• 69% of IV plans contained details of monitoring plan.

• 50% of plans met all elements of the standard.

Partly Met

4 For adults who receive intravenous (IV) fluid therapy in hospital, clear incidents of fluid mismanagement are reported as critical incidents.

IV incidents are reported through the Trust DATIX system and in the last 12 months, 51 incidents were reported with 44/51 ranked minor /insignificant and 7/51 ranked moderate.

Met


3Priority 8 – Patient ExperienceThe Trust regularly seeks the opinions of its patients and receives feedback from a number of National Patient Experience Surveys. Whilst the Trust continues to perform well in patient experience measures such as the National Inpatient and Outpatient Surveys it recognises that there is always the potential for further improvement and is committed to monitoring and improving the patient experience. We will continue to build on the developments in 2014/15 with the Friends and Family Test (FFT) with further roll out planned in Children’s Services and Community Services.

We want to demonstrate that not only do we take the concerns of patients and carers seriously, but we want to demonstrate that our care matches up to our vision ‘healthcare at its very best - with a personal touch’; and will do this through actively seeking views from the people we serve and the people they love.

The Francis Report (2013)4 and the Keogh Report (2013)5 both stressed the importance of the patient and carer’s voice. It was the persistence of family members who brought around the in-depth review and one of the findings was that if patients and carers had been listened to, it may well have saved lives.

The results of this indicator will be reported to the Trust Board and various patient experience committees and relevant forums.

To make sure a welcoming approach is embedded in everything that we do, the Trust is to embrace the national campaign based on the simple but vital courtesy of introducing yourself. Founded by Dr Kate Granger, a Consultant in Elderly Care and herself a patient with terminal cancer, this new scheme was introduced in January 2015 with over 80 NHS organisations now signed up. This was officially launched in May 2015 across the Trust.

In line with the Patient, Carer and Public Involvement Strategy 2015-17 we have continued and developed our processes for engagement activity. We have:

• arranged a number of listening events open to patients and the public in community venues. In addition, the Trust was represented at the Healthwatch Newcastle listening event in November 2015.

• carried out a review of internally supported engagement activity was undertaken to understand the level of involvement and engagement work that is carried out at directorate and department level. We will further expand this survey to ensure that details of all activity is captured and utilised.

• further developed a ‘You said… We did’ approach to our reporting of the use of patient feedback. Large displays are now installed in the main entrances of each site which provides examples of changes in practice and services as a result of patient feedback.

Some of these changes include:

o The introduction of free Wi-Fi access for patients and visitors

o A poster at all Ward and department entrances explaining ‘Who’s who’ in terms of uniforms

o The Trust sign up to the ‘#Hellomynameis’ campaign to highlight and remind staff of the need to make introductions as a basic courtesy.

• continued to support our Community Advisory Panel. The Panel are a group of volunteers who have been, or still are, users of Trust services. They give us a valuable insight into the patient experience and are consulted on new ideas and developments as well as taking part in a number of groups and activities.

With regard to the national requirements for patient experience, the Trust continues to support and respond to the requirements for:

• The NHS Friends and Family Test – we continue to encourage patients to give us their feedback and utilise the results and comments made at Ward and department level. We monitor response rates and consider mechanisms in place for completion of the test to best meet the preferences of patients.

• The National Patient Survey Programme – The programme for 2015-16 included the annual adult inpatient survey and a national maternity survey. The Trust performed well in both surveys and action plans are developed and monitored by the Patient, Carer and Public Involvement Group.

• Patient Reported Outcome Measures – The Trust contributes as necessary for patients undergoing one of four procedures – knee replacement, hip replacement, groin hernia and varicose vein removal.

ComplaintsThe Trust remains committed to listening to feedback from patients, their families and carers in order to continuously improve the services we provide. Complaints are an essential source of this feedback and efforts have been made to make the complaints process as accessible and straightforward as possible.

Following the appointment of the Head of Patient Experience, a number of changes have been initiated to increase the focus on improving the patient experience, address common issues raised in complaints and ensure robust action plans are produced. We have instigated a process of Early Resolution Meetings aimed at early identification of the focus of concerns from patients or their carers who wish to make a formal complaint. This enables us to address the key issues and resolve concerns in a more timely manner. In all areas, we aim to resolve any concerns at the earliest opportunity and have introduced a new poster aimed at encouraging people wo use our services to provide their feedback (positive and negative) in order to help us to improve.

Patient Experience


In addition, following each monthly Complaints Panel meeting, a mailer is circulated to key Trust staff with key themes and learning. This is aimed at sharing learning from complaints Trustwide to ensure that staff in all areas, and across all sites, learn the valuable lessons from complaints.

The PALS service is firmly established in the Trust and deals with around 500 contacts per month. The Patient Relations Department and PALS have standard procedures in place to refer to each other if the required level of concern or investigation is required.

A quarterly Patient Experience dashboard is produced for each Directorate showing all positive and negative patient feedback specific to that speciality. This information informs decision making and service development within clinical teams, highlight trends and provides Directorates with the information necessary to further understand their patients’ needs.

Over the next 6 months our priorities are:

• Meeting the NHS and Social Care Accessible Information Standard

• Develop new objectives for the Equality Delivery System and review grades for 2016

• Completing the new work with carers

• Complete the report on the experience of patients working with BSL Interpreters

• Progress the work on the British Sign Language Video Relay pilot

• Partnership work across the Trust, Local Authority and 3rd Sector so that the Trust can contribute to reducing social isolation and loneliness

• Developing a robust equality analysis process for business development and Board papers

Duty of Candour Although not identified as a priority last year we have been asked this year by NHS England to include an overview on how we are implementing the Duty of Candour (DoC) initiative.

Promoting a culture of openness is a prerequisite to improving patient safety and the quality of healthcare systems. It involves explaining and apologising for what happened to patients who have been harmed or involved in an incident as a result of their healthcare treatment. It ensures communication is open, honest and occurs as soon as possible following an incident. It encompasses communication between healthcare organisations, healthcare teams and patients and/or their carers.

A contractual requirement to implement the Being Open guidance, called the Duty of Candour was introduced on the 1st April 2013. A statutory requirement to implement

Duty of Candour was also introduced in October 2014 as part of CQC registration requirements.

We started this work in 2013 reviewing the Being Open Policy and Serious Incidents Reporting and Management Policy to include the new requirements. The Datix incident report form was adapted to prompt the incident reporter to insert an initial severity grading thus allowing immediate notification to senior staff when incidents are graded moderate or above with the reporting system set up to ensure that all Matrons and Directorate Managers receive e-mail notification when an incident is graded as moderate harm or above.

Serious Incident report templates were revised for falls, pressure ulcers and general incidents to include a section to record that an apology and explanation were given to the patient and/or their relatives. This is subject to regular audit and monitoring.

Awareness raising sessions and reports were presented at Clinical Risk Group May 2013, Matron’s Forum and Directorate Managers’ meeting. This contained a summary of key requirements and template letters for communication. In July 2014 there was a presentation to Clinical Leader Forum (Sisters/Charge Nurses) regarding update requirements and actions they need to take to improve compliance. September 2015 - saw additional slides added to Incident Investigator training providing more details with regard to the definition of a notifiable incident and the process that must be followed if the incident meets DoC criteria. In December that same year a presentation went to the Clinical Policy Group providing an update on the national perspective. Workshops were held in December 2015 and January 2016 for Matrons and other senior staff. Patient Safety Briefings continue to be used to emphasise the importance of the Duty of Candour.

Progress has been made with regard to consistent implementation of Duty of Candour, particularly following a serious incident. When a serious incident occurs DoC implementation is discussed at the SI Panel so there is now a more robust record in place for these incidents. Duty of Candour (Being Open) Intranet page was set up containing frequently asked questions; template letters, meeting templates and patient leaflet. All departments were made aware of this resource. Questions related to Being Open (DoC) were added to Datix when it triggered a patient incident having an initial grading of moderate or above. The Requirement to Be Open with patients when things go wrong is included in monthly incident investigator training.

The incident grading guidance attached to DATIX was updated to provide actual examples of appropriate incident severity grading.


3

I found that all the staff were friendly, caring and professional. The standard of hygiene is very high. Any questions that I had were answered promptly and fully in a language that was easily understood.

“ “


This is a representation of the Quality Report data presented to the Trust Board on a monthly basis in consultation with relevant stakeholders for the year 2015/16. The indicators were selected because of the adverse implications for patient safety and quality of care should there be any reduction in compliance with the individual elements.

Part 3 – Other Information - Overview of monthly Board assurance 2015/16

Patient Safety Data source

Standard Actual 2014/15

Target 2015/16

Monthly Target

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Actual 2015/16

Screening MRSA: electives *

Internal National definition

(2009)

100% 100% 100% 100% 100% 100% 100% 100%

Screening MRSA: emergency *

Internal National definition

(2009)

100% 100% 100% 100% 100% 100% 100% 100%

Hand Hygiene audits (opportunity)

Internal Local CAT tool

99.54% 98% 98% 99.85% 99.59% 99.49% 99.52% 99.61%

Hand Hygiene audits (technique)

Internal Local CAT tool

99.11% 98% 98% 99.63% 99.11% 99.19% 98.24% 99.24%

Total number of patient incidents reported (Datix)

Internal Datix

Incident reporting system

Local Incident Policy

14,787 Not defined

Not defined

4,095 4,213 4,376 4,475 17,519

Rate per 100 admissions of patient incidents reported (Datix)

Internal Datix


National definition

6.7 7 7 7.53 7.65 7.95 8.23 8

Slip, trip and fall - patient (Datix)

Internal Datix


N/A 3,283 Not defined

Not defined

801 835 789 882 3,308

Slip, trip and fall - patient (Datix) per 1,000 bed days

Internal Datix


National definition

6.21 6.8 6.8 5.92 6.41 5.89 6.69 6.23

Slip, trip and fall - patient (Datix) per 1,000 bed days

Internal Datix


Local (agreed by

Trust Board)

6.21 6.2 6.2 5.92 6.41 5.89 6.69 6.23

Total number of CNST claims

Internal Legal

Services Department

National NHSLA

definition

235 Not defined

Not defined

55 66 68 51 240

Number of radiation incidents reported to HSE and CQC

Internal Datix


National IRMER

definition

24 Not defined

Not defined

12 11 10 7 40

Never Event Internal Datix


National definition

1 0 0 1 0 0 2 3

Inpatients acquiring pressure damage

Internal Datix


National 617 Not defined

Not defined

166 145 174 204 689

Community patients acquiring pressure damage

Internal Datix



Not defined

0 1 2 0 3


3Patient Safety Data

sourceStandard Actual

2014/15Target

2015/16Monthly Target

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Actual 2015/16

Medication incidents Internal Datix


Local 1,646 Not defined

Not defined

492 456 521 474 1943

General Internal Datix


Local SUI Policy

70 100% Ongoing 15 20 18 28 81

HCAI Internal Datix


Local SUI Policy

8 100% Ongoing 4 1 2 2 9

Information Governance

Internal Datix


Local SUI Policy

0 100% Ongoing 1 0 2 0 3

Percentage of patient incidents that resulted in severe harm or death

Internal Datix


Local 1.1% Not defined

Not defined

0.7% 1.1% 0.5% 0.9% 0.8%


Patient Experience Data source


Target 2015/16

Monthly Target

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Actual 2015/16

Number of complaints received

Internal Datix


Local Complaints

Policy

728 Not defined

Not defined

181 160 144 139 624

National Inpatient Survey

CQC National standard

52% Not defined

Not defined

N/A N/A N/A N/A 54%

Friends and Family response rates (inpatients and A&E)

Locally collected reported

National standard

N/A Not defined

Not defined

16% 1.1%

16.4% 1.1%

15.3% 2.4%

15.6% 2.6%

N/A


Data source


Target 2015/16

Monthly Target

Quarter 1

Quarter 2

Quarter 3

Quarter 4

Actual 2015/16

Breast feeding initiation (Cumulative)

Integrated Performance

Measures Return (IPMR)

No National Target

69.6% Not defined

Not defined

72.6% 68.5% 67.7% 70% 69.8%

Breast Feeding 6-8 weeks

Integrated Performance

Measures Return (PMR)

National Standard

45.8% 45.8% No monthly target – quarterly 45.8%

46.3% 48% 45.4% 45.7% 46.4%

Cancelled operations rescheduled within 28 days

Quarterly Monitoring Cancelled Operations Data Set (QMCO)

National Standard

0.4% <0.8% <0.8% 0.18% 0.19% 0.25% 0.35% 0.24%

Those not admitted within 28 days

Quarterly Monitoring Cancelled Operations Data Set (QMCO)

National Standard

4 0 0 9 3 7 3 22

Percentage high risk TIA cases treated within 24 hours

Best Practice Tariff

National Standard

96.8% Apr-Dec

60% 60% 100% 100% 100% 93.3% 99%

Stroke - 80% of people with stroke to spend at least 90% of their time on a stroke unit

Locally Collected

National Standard

90.8% Apr-Dec

80% 80% 82% 82% 88% 85% 84%

eReferral: Slot issues C&B National

Systems & Reports

National Standard

13.7% Not defined

Not defined

27.3% 31.6% 22.6% 21.4% 25.6%

NICE guidelines (non-compliant)

Locally Collected


Not defined

65 67 75 82 82

Percentage of NICE guidelines (non-compliant)

Locally Collected

National 14.3% Not defined

Not defined

13.9% 13.6% 14.6% 15.4% 15.4%

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (non-compliant)

Locally Collected


Not defined

3 4 4 4 4


3Inconsistencies in data reported in the 2014/15 report:

Incident Reporting Incident numbers and rates have continued to increase each quarter in response to the Sign up to Safety campaign. This has led to an increase in the number of incidents reported as serious incidents however the percentage of incidents resulting in serious harm or death has decreased when compared with last year.

Radiation Incidents There has been a change to the 2014/15 figure from 21 to 24, the explanation for the change is that the figure previously quoted (21) omitted 3 incidents that occurred in 2013/14 but were not reported to the CQC until April 2014.

This year has seen an increase in reported radiation incidents from 24 – 40. The increase in the number of incidents reported is due to changes in service and is attributable to an increase in the volume of imaging undertaken. Increase in imaging is due to two significant changes in service delivery which has increased demand. Firstly within the last 18 months four units now image all patients daily, where previous imaging had been undertaken on average weekly. Furthermore, within the last year a unit has started a new breast imaging service.

Never Event Three incidents were categorised as Never Events this year which is more than last year, however two of the incidents relate to wrong side nerve block and this was not part of the Never Event criteria last year.

Falls The end of year falls/1000 bed days average of 6.2 falls for 2015/16 equals the average falls/1000 bed days rate for 2014/15. This can be considered an achievement considering the increasing age, frailty, and acuity of patients that the Trust has seen. The directorate of Medicine/Care of the Elderly consistently reports the highest number of falls within the Trust, however this year they have reported a further reduction in falls/1000 bed days despite a year on year increase in admissions of the highest risk patients i.e. patients aged 65 years and over (falls/1000 bed days rate in Medicine/Care of the Elderly for 2015/16 was 9.2 compared to 9.3 in 2014/15 and 10.5 in 2013/14).

Pressure Ulcers Reducing Trust acquired pressure ulcers and moisture lesions remains a challenge for the Trust, and it is disappointing to see an increase in reported numbers this year although this is in the context of increased activity. The Trust is continuing to ensure staff assess every patients risk of developing pressure damage, plan care accordingly to try and prevent pressure damage occurring. To investigate when damage occurs identifying any lessons to learn. Pressure Ulcers are prevented by a strict regime of turning and skin care, and any delay in recognising

increased risk of damage or strict turning can precipitate damage occurring. Ensuring the required staffing resource is available can be challenging in the context of national and local Registered Nurse shortages. The Trust continues to monitors staffing levels closely, pro-actively recruit to vacant posts, including overseas recruitment and develop new roles to ensure care needs are met. We are hoping that our recruitment strategy will be successful and help in the ongoing drive to reduce pressure damage and influence the number of pressure ulcers and moisture lesions that occur within our organisation. The Tissue Viability team will continue to work with the Ward Sisters and staff to deliver education, provide advice and lead improvement work across 2016/17.

Those not admitted within 28 days The increase from last year is due to a number of reasons including increased attendance impacting on capacity and more urgent cases taking earlier slots.

eReferral Slot Issues – formerly Choose & Book Slot IssuesChoose and Book was replaced by eReferral in June 2015. HSCUIC have spent a lot of time and effort working on the stability of the system, rather than reporting or moving the service forward. The service is now stable and we hope to shortly start to see some of the changes made possible by the transition.

The current take-up of eReferral is approximately 50% nationally; our figure in December 2015 was 49%, compared to 47% for the North East and Cumbria region.

NHS England have set a target of 60% for September this year 2016, 80% by September 2017 and 100% by September 2018. This applies to new appointments only. Failure to achieve the new targets may result in the withholding of payments to referrers and providers.

Complaints:The Trust complaints reporting system is a live database resulting in fluctuations in actual numbers of complaints reported as investigations are processed through the system. The fluctuations are due to:

• timing issues – the Patient Relations Department (PRD) reports the number of complaints received to the Clinical Governance and Risk Department at the end of each month, but at the end of each month there are complaints received but not yet registered on the Datix system which are carried forward into the next month and with a final adjustment at the end of the last month of the year, hence the change in total.

• some complainants will contact us to withdraw or abandon their complaint having had second thoughts, and also some Patient Related Enquiries (anything other than a complaint received from patients e.g.


telephone enquiry about issues re treatment, waiting times etc. which the PRD team will action and get back to the patient as soon as possible to advise of the outcome, i.e. general patient enquiries) can be re-designated as a complaint where full investigation is felt to be merited, and this can also alter the figures, after having reported the numbers each month. Many complaints received at the very end of March are still work in progress until the end of May and this can cause further fluctuations.

• We run a full check and adjustment annually to produce the KO41 statistics for the DOH, and which is the total figure used for this and for the Trust Annual reports etc.

There were 624 formal complaints received during the year ending March 2016. This represents a 14% decrease in the number of complaints compared to the previous year. In 2015/16 the rate of complaints per 1000 patient contacts was 0.34 which is a 16% decrease compared to the 0.40 per 1000 patient contacts for 2014/15.

The Trust welcomes feedback from patients, their families and carers as an invaluable tool in helping to identify areas for improvement. It is recognised that service user feedback is central to on-going improvement and so we consistently look to create as many opportunities for this feedback to be provided. Feedback is invited via staff, the Patient Relations Department (email, letter or telephone calls), PALS, the Trust and NHS websites, advocacy agencies or other nominated third parties.

Efforts have been made over the past 12 months to make the complaints process as accessible and uncomplicated

as possible for members of the public. These developments reflect best practice guidance set out by the Parliamentary and Health Service Ombudsmen and NHS England. The methods available to log a complaint are advertised throughout the Trust and on the website, complainants are provided with a nominated contact in the Patient Relations team who keeps them updated throughout their complaint and can resolve any queries. The learning and actions resulting from complaints are shared with patients and the public through several mediums including the ‘You said… we did’ boards which are displayed in all Trust reception areas.

The Trust Complaints Panel continues to monitor compliance with responses being provided to complainants within the individually negotiated or re-negotiated timescales on a monthly basis. The Panel maintains a commitment to providing open, honest and thorough responses to all complaints as this is fundamental to the long term success of the Trust. Quality assurance systems have been reviewed and updated to ensure that complaint responses remained at the highest standards and learning identified from complaints was put into action. Complainant satisfaction has been monitored via satisfaction questionnaires sent out with a sample of responses and this is being extended to all complaint responses from January 2016. In order to underpin the Trust-wide learning from complaints, staff in all areas are provided with monthly feedback from the Complaints Panel detailing themes identified in the month’s complaints and what best practice guidance should be put in to place in all teams to avoid re-occurrence.


3

Friends and Family response rates (inpatients and A&E)The noted drop in response rates for A&E was due to the removal of the token unit as per national guidance. A number of methods have been tried to obtain a better response rate within the area such as texting a request to complete the survey online, cards available within the department and a tannoy announcement reminding staff to ask patients to provide their feedback.

With regard to the documented drop in Inpatient response rate – this was due to the inclusion of all NHS patients from April 2015. This meant that the dominator for the rate included all inpatient, daycases and paediatric patients. The actual number of responses per month has been relatively consistent.

Common theme in complaints Action taken during 2015/16

Some patient were unaware how to make a complaint and some staff were unable to signpost them appropriately

A full refresh of complaints posters was undertaken and they are now displayed in all public and patient areas throughout the Trust. Complaints leaflets are also available in all areas.

Education programme being delivered to all staff detailing the various options available for patients to provide feedback to the Trust, both formally and informally.

Clinic cancellations and communications relating to them Staff have been provided with further education regarding the timely communication of clinic changes and a new Patient Administration System is currently being assessed which will offer greater functionality for long term booking, which should reduce future cancellation rates.

Not responding to requests for informal meetings to discuss issues and complaints process could be lengthy

A pilot for Early Resolution Meetings is underway to assess the benefits of inviting complainants in to the Trust to discuss complaints upon receipt before written responses are produced. It is anticipated that this will reduce the length of time taken to resolve complaints, reduce the anxiety and stress for complainants and enable the Trust to take action more swiftly where change is needed.

Communication could between clinicians and families could be improved

Customer Service Training is available for the development of identified individuals or groups of staff.


Pages 47-52 give some examples of other quality improvement initiatives the Trust have implemented or been involved in throughout the year.

Overview of Quality Improvements

My hospital visit went very well. I thank most sincerely the doctors, nurses and all the staff for the expert care and attention I received at all times. The NHS is a truly wonderful organisation. Thank you all yet again.

“ “


3

The Newcastle Hospitals uses the Gateshead College-led Project Choice initiative to offer supported internships to people with learning

difficulties or disabilities, and those with autism.

The Trust’s HR projects team looks at entry level jobs and works with managers to ensure tasks can be clearly understood and the right learner supported into the role. Reasonable adjustments are made to HR processes to support students during interviews and use alternative ways to assess their skills such as progress reports from job trials.

Managers at the Trust now use Project Choice students as their first call for process based work. Many have ideal skills for this, focusing for long periods and thriving in roles requiring accuracy. Staff are trained to become mentors, helping Project

Choice learners with their skills as well as integrating them into the team.

Young people spend at least 10 weeks in a placement, and are given a work plan with key targets to enable them to achieve the goal of employment. Bespoke aids are designed to assist learning, such as image lists for memory tasks.

At the point of submitting this award entry, the Trust had supported over 36 interns with 77 per cent going into employment.

The judges were unanimous that this is an “exceptional” and “inspirational” project that should be delivered nationally, and described the scheme as therapeutic and efficient, enhancing the work life of co-workers.

NEWCASTLE HOSPITALS SCOOP THREE HSJ AWARDS: WORKFORCE - “EXCEPTIONAL” AND “INSPIRATIONAL”

Members of the Project Choice Team receive their award from Sports Personality, Clare Baldwin


Patients living in and around Cramlington will now benefit from the expertise of the Newcastle Hospitals being closer to home, as a new

Outpatient Centre at Manor Walks Shopping and Leisure opens its doors.

The new outreach facility – next to Frankie & Benny’s Restaurant in the South Mall of the hugely popular shopping centre – will bring the high quality care and expertise the Newcastle Hospitals are renowned for, closer to thousands of patients from South Northumberland and North Tyneside.

Sir Leonard Fenwick, Chief Executive of the Newcastle Hospitals explains: “We have somewhere in the region of 1.3 million outpatient attendances in our clinics at both the Royal Victoria Infirmary and Freeman Hospital each year.

Nearly a quarter of a million of these patients come from East Northumberland and in particular Cramlington and Blyth Valley areas, hence we have decided to introduce a brand new, state of the art outpatient centre in the very heart of Cramlington. The new centre will provide many specialist clinics, diagnostic tests and other services in a location

convenient to them. By offering greater accessibility and more choice, we aim to enhance the experience for patients and supporters alike.”

The new Outpatient Centre means that patients can now ask to be referred to be seen in Cramlington rather than travel down to hospitals in Newcastle for certain services.

Sir Leonard continues: “All of our services are provided by experts from the Newcastle Hospitals and thereby can be assured of the same standards of excellent patient care they would expect from any of the Trust’s other hospitals and health centres.”

Bruno Coppola, General Manager at Manor Walks Shopping and Leisure, says: “We are delighted to welcome the Healthcare and Diagnostic Centre from The Newcastle upon Tyne Hospitals NHS Foundation Trust to the community here at Manor Walks.

As part of our commitment to ensuring Cramlington remains a vibrant and welcoming place to live, work and visit, we are passionate in providing our loyal customers with a wide variety of services from retail and leisure to fitness and health right in the heart of their community. The arrival of the state-of-the-

NEWCASTLE HOSPITALS OPEN NEW OUTPATIENT CENTRE IN CRAMLINGTON

Pictured: The team at Newcastle Hospital @ Cramlington, Manor Walks


3art Healthcare and Diagnostic Centre will allow its outpatients to access vital services in a more central location, with excellent transport links.”

Gordon Elder, Outpatient and Medical Records Manager for the Newcastle Hospitals adds:

“We’re delighted to be a part of the Manor Walks Shopping and Leisure in Cramlington. This new Centre offers a range of outpatient clinics supported by planned X-ray and diagnostic facilities, all built to superb specifications and in a pretty unique setting for the NHS.

“The patient was always at the heart of the process when designing the new centre, to ensure that they would receive the very best care. In particular, we considered services where patients were having to travel to Newcastle for specialised services and treatment.

“This approach has led us to develop ‘one-stop’ clinics wherever possible. These allow patients to have their initial consultation with a doctor or nurse, and then, if appropriate, receive their treatment on the same day or soon afterwards, without having to spend another day travelling further afield.”

The vast majority of clinics to be available in Cramlington are for services which only Newcastle Hospitals provide for patients residing in North Tyneside and Northumberland. These include Ear, Nose and Throat (ENT), Ophthalmology and Dermatology.

Other specialties that shall be provided from this new facility will be for services where the Trust is required to see an ever growing attendance in its city centre hospitals.

Dr Alistair Blair, Chief Clinical Officer for NHS Northumberland Clinical Commissioning Group, said: “Northumberland patients can already access a range of NHS providers locally, with some services provided by Newcastle Hospitals only.

“This new facility in Manor Walks continues to bring these services closer to Northumberland residents and reduce the need to travel into Newcastle. Patients who need hospital care can discuss the different referral options on offer with their GP.”

THE EMERGENCY DEPARTMENTWE KEEP OUR PATIENTS SAFE BY ENSURING WE SCREEN PATIENTS AS THEY ARE TRIAGED IN ED FOR SIGNS OF ‘RED FLAG SEPSIS’.

Sister Lindsey Udberg and her brilliant team have developed a new sicker to help identify patients who may have severe sepsis and ensure that they

receive the treatment they need as quickly as possible. The sticker clearly details what treatments must be delivered within the first hour of care, which can dramatically improve a patient’s chance of survival. This innovative piece of work forms part of a Trust wide project to improve the care delivered to patients with sepsis, which is being led by Dr Ben Messer as part of the national Sign Up To Safety campaign.

Pictured: Louise Scammell, Lindsey Udberg & Philippa Laverick


DA VINCI ROBOT CARRIED OUT 1000TH OPERATION IN NEWCASTLE

In July 2012, the Freeman Hospital in Newcastle was the first in the North East to start using the £2m robot in prostate cancer surgery. The Trust

has since purchased a second Da Vinci robot which is being used across other surgical specialities including gynaecology, ear, nose and throat, lung, colorectal and pancreatic surgery.

The robots have how carried out 1,000 operations making Freeman Hospital the only centre in the UK using robotic surgery across six surgical specialities. The extraordinary technology has helped save hundreds of lives and, with greater precision and smaller incisions than is possible for a surgeon, dramatically reduced recovery times for patients.

Professor Naeem Soomro, Associate Medical Director and Consultant Urologist at Freeman Hospital, says: “We are delighted to have reached such a tremendous milestone in such a relatively short space of time. We are now expanding this technique across other surgical specialities where we can offer robotic surgery to benefit many more patients all the time. Minimally invasive surgery is certainly the way forward – it’s so much better for the patient both in terms of how we surgically treat them, and enabling them to be back on their feet much, much sooner than before.”

1,000th operation The Freeman is noted to be at the very forefront of this type of robotic surgery and is certainly the only centre in the UK today in terms of delivering a diverse multi-speciality robotic surgery programme. Professor Soomro adds: “The future as far as robotic surgery

is concerned is very exciting. In Urology alone, my colleagues and I are looking at how we can use the application of robotic technology for all different types of procedures which would traditionally involve major, open surgery.

“For example, surgery that involves multiple organs in the pelvic region can be extensive and on occasions radical, which means removing an entire organ such as the bladder or prostate. We are able to use robotic techniques to conduct this often life-changing surgery, keeping post-operative recovery to a minimum, and clinical outcomes to an optimum.”

Robotic Surgery Training: Freeman Hospital has now been designated as a robotic surgery training centre by the Urology Foundation and has reached an agreement with the Intuitive surgical to provide an additional Da Vinci system for training. This would allow us to be the only centre which would undertake robotic surgical training course in Urology, Ear, Nose and Throat, Lungs and Gynaecology in 2016.

And for the futureProfessor Soomro continues: “I think we will start to see more and more robotic techniques which can be controlled remotely from the outside including ability for the surgeon to see nerves, blood vessels and differentiate between cancerous from healthy tissues in real time while operating. The ability to conduct microscopic surgery in practically every part of the body - perhaps even using tiny robotic devices which are placed directly into the body. It’s certainly an exciting field of medicine to be in.”

1000th operation da Vinci team L-R: Emma Dickson, Sister Catherine Birnie, Sara Cross, Laura Waterworth, Professor Naeem Soomro, Paul Renforth, Rajan Veeratterapillay and Senior Sister Maggie Birkbeck


3MACMILLAN END OF LIFE PROJECT OUR END OF LIFE CARE TEAM WELCOMES NEW MACMILLAN NURSE

Following a successful pilot project in early 2015, the Newcastle Hospitals’ End of Life Care Team is delighted to have successfully secured Macmillan

funding for a three year project to support patients in last days or hours of life, and their families.

Laurie Fortunato has been recruited as a Macmillan Staff Nurse to coordinate the role of three newly appointed Macmillan Healthcare Assistants who will complement the excellent end of life care currently being delivered across the organisation.

It is expected that the project will provide an individualised service to our patients and families across the acute setting regardless of diagnosis. The project

will be fully evaluated and will provide additional information on where there may be opportunities to develop a service for volunteers in the future.

UK FIRST FOR BREAST CANCER TREATMENTBreast Specialists at the RVI in Newcastle are the

first in the UK to offer a new technique to ensure the surgical treatment their patients receive is

as accurate and safe as possible. This procedure is currently only available in Newcastle.

The pioneering new approach is called Radioactive Seed Localisation; during the treatment, a Specialist Radiologist, using ultrasound as a guide, inserts a tiny, very low dose radioactive ‘seed’ into the tumour to be surgically treated. The seed - about the size of a grain of rice - serves as a beacon during the surgery, guiding the Surgeon to the exact location of the cancer. This is a highly specialist technique, only carried out in a handful of hospitals in the world.

It took over a year to set up the service from scratch. This is a truly multi-disciplinary approach involving specialist training for our staff from the Breast Scree ning Unit, Operating Theatres, Patho logy and Nuclear Medicine. NuTh was the first and on ly UK centre authorised by the Administration of Radioactive Substances Advisory Comm ittee (ARSAC) for the use of iodine seeds.” Patient Linda Rowe, sharing her story

with the Daily Mail.


MEET FUDGE - THE NEW MASCOT FOR THE GREAT NORTH CHILDREN’S HOSPITALBased at Newcastle’s Royal Victoria Infirmary, the

Great North Children’s Hospital is now one of the biggest children’s hospitals in the UK.

Current and former patients joined doctors and nurses, VIPs and a whole range of well-known characters to celebrate the children’s hospital’s fifth birthday. Guests of all ages enjoyed lots of activities from face painting to dressing up to hula-hooping and throwing soaked sponges at doctors in the stocks!

There was music of all kinds to entertain the crowds and children were delighted to get the chance to sit in a fire engine, set off the siren and wear helmets as they were joined by firefighters from the Byker Community Fire Station.

Fudge’s name was picked by Ryan Wood, seven, from Prudhoe, after hospital bosses asked readers of the Sunday Sun and sister publications, the Chronicle and Journal, to come up with a suitable name.

Ryan, a patient aged 7 from Prudhoe, decided on Fudge because a giraffe’s spots remind him of the tasty treat.

Dr Mike McKean, co-clinical director for the Hospital said: “When we moved into the Great North Children’s Hospital five years ago we knew we were experiencing something really special.

“The move brought together several important services under one roof, making us one of the biggest children’s hospitals in the UK, and means our child health experts work side by side learning and supporting each other towards one common goal – to give the special and extraordinary young people we see every day, the best possible care. To help them get better and return home where they belong, with specialist community nursing support if needed.

“Whether you work at or visit the hospital you soon realise it is like a very busy hive run, not only by healthcare professionals like doctors and nurses, but teams of other essential people – our therapists, dietitians, play specialists, pharmacists, radiologists, porters, admin staff – the lists goes on. We couldn’t have such a positive impact on children’s lives without them all.”

Sir Leonard Fenwick, chief executive of Newcastle Hospitals, said: “We’ve always been proud of our children’s services here in Newcastle which has a long and rich history for providing exceptional healthcare for children.

“We believe there is no better place for a child to be than the hospital and feel very privileged to support children with many types of different illnesses, not only from Newcastle, but from all over the North East and Cumbria, and even occasionally from abroad.”

• The Great North Children’s Hospital at the RVI in Newcastle is one of the largest in the UK, offering more services than any other children’s hospital outside of London.

• An internationally leading research centre into childhood diseases, it aims to improve the treatments of the future for young patients.

• The hospital cares for children from as far north as Berwick upon Tweed, across to Whitehaven and down to Teesside, and some children from Northern Ireland and beyond.

Pictured: Ryan Wood and family with Jean-Christophe Novelli and winning name Fudge


3Information on Participation in National Clinical Audits and National Confidential Enquiries

During 2015/16, 53 national clinical audits and 6 national confidential enquiry reports / review outcome programmes covered NHS services that the Newcastle upon Tyne Foundation Hospitals NHS Foundation Trust provides (National Confidential Enquiry into Patient Outcome and Death had 4 separate studies each a study in their own right i.e. Mental health,Acute Pancreatitis,Sepsis and Gastrointestinal haemorrhage. In addition, the Child Health Outcome Review programme and the Maternal, Newborn and Infant Clinical Outcome Review Programme. Hence 4+2 =6). In addition, the National Confidential Enquiry into Patient Outcome and Death, which features within the clinical outcome review programme, has undertaken a further four separate studies during this period.

During that period, the Newcastle upon Tyne Hospitals NHS Foundation Trust participated in 100% national clinical audits and 100% of the national confidential enquiries / review outcome programmes which it was eligible to participate in.

The national clinical audits and national confidential enquiries that the Newcastle upon Tyne Hospitals NHS Foundation Trust was eligible to participate in during 2015/16 and the national clinical audits and national confidential enquiries that the Newcastle upon Tyne Hospitals NHS Foundation Trust participated in during 2015/16 are as follows:

National Clinical Audits National Confidential Enquiries

Acute Coronary Syndrome or Acute Myocardial Infarction

Major Trauma – The Trauma and Audit Research Network

Neonatal Intensive and Special Care

Maternal, Newborn and Infant Clinical Outcome Review Programme

Bowel Cancer National Adult Cardiac Surgery Audit

Nephrectomy Medical and Surgical Programme: National Confidential Enquiry into Patient Outcome and Death:

• Mental Health• Acute Pancreatitis• Sepsis• Gastrointestinal Haemorrhage

Cardiac Rhythm Management National Cardiac Arrest Audit National Audit of Oesophago-gastric Cancer

Child Health Outcome Review Programme

Case Mix Programme (adult Critical Care)

National Chronic Obstructive Pulmonary Disease Audit Programme – Pulmonary Rehabilitation

Paediatric Asthma

Chronic kidney disease in primary care

National Chronic Obstructive Pulmonary Disease Audit Programme – Primary care workstream

Paediatric Intensive Care

Congenital Heart Disease (Paediatric Cardiac Surgery)

National Chronic Obstructive Pulmonary Disease Audit Programme – Secondary Care workstream

Prescribing Observatory for Mental Health

Coronary Angioplasty / National Audit of PCI

National Comparative Audit of Blood Transfusion – Blood use in elective surgery

Radical prostatectomy

Cystectomy National Comparative Audit of Blood Transfusion – Use of blood in Haematology

Renal Replacement Therapy (Renal Registry)

National Diabetes Footcare audit

National Complicated Diverticulitis Audit

Procedural Sedation in Adults (care in Emergency Departments)

National Pregnancy in Diabetes audit

National Emergency Laparotomy Audit

Pulmonary Hypertension

Diabetes (Adult) includes National Diabetes Inpatient Audit

National Heart Failure Percutaneous Nephrolithotomy

Diabetes (Paediatrics) National Joint Registry Rheumatoid and Early

Inflammatory Arthritis

Elective Surgery (National PROMs Programme)

National Ophthalmology Audit Sentinel Stroke National Audit Programme includes SINAP

Emergency Use of Oxygen National Prostate Cancer Stress and urinary incontinence in women


The national clinical audits and national confidential enquiries that the Newcastle upon Tyne Hospitals NHS Foundation Trust participated in, and for which data collection was completed during 2015/16, are listed

below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

National Clinical Audits National Confidential Enquiries

Falls and Fragility Fractures Audit Programme – Falls Audit

National Vascular Registry, including CIA and elements of NVD

UK Cystic Fibrosis Registry (Adults)

Falls and Fragility Fractures Audit Programme – Fracture Liaison Service Database


UK Cystic Fibrosis Registry (Paediatrics)

Falls and Fragility Fractures Audit Programme – National Hip Fracture Database

Nephrectomy UK Parkinson’s Audit

Inflammatory Bowel Disease - Biologics

National Audit of Oesophago-gastric Cancer

Urethroplasty

Inflammatory Bowel Disease Programme - Audit

National Prostate Cancer Vital Signs in Children (Care in Emergency Departments)

Lung cancer National Vascular Registry, including CIA and elements of NVD

VTE risk in lower limb immobilisation (care in Emergency Departments)

National Audit issue

Sponsor / Audit What is the Audit about? Trust participation in 2015/16

Percentage Data completion

Outcome

Acute Myocardial Infarction

National Institute for Cardiovascular Outcomes Research (NICOR)

The Myocardial Ischaemia National Audit Project (MINAP) was established in 1999 in response to the National Service Framework (NSF) for Coronary Heart Disease, to examine the quality of management of heart attacks (Myocardial Infarction) in hospitals in England and Wales.

�

100% Action plan developed

Bowel Cancer (NBOCA)

Health & Social Care Information Centre

Colorectal (large bowel) cancer is the most common cancer in non-smokers and second most common cause of death from cancer in England and Wales. Each year over 30,000 new cases are diagnosed, and bowel cancer is registered as the underlying cause of death in half of this number.

�


Cardiac Rhythm Management

NICOR The audit aims to monitor the use of implantable devices and interventional procedures for management of cardiac rhythm disorders in UK hospitals.

�

100% Report due to be published April 2016

Case Mix Programme (Adult Critical Care)

Intensive Care National Audit and Research Centre (ICNARC)

The aim of the audit is to improve resuscitation care and patient outcomes for the UK and Ireland. �

100% Compliant

Child Health Clinical Outcome Review Programme

National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

The programme uses both data linkage and case note review to build on the work of previous child health confidential enquiries which have highlighted a number of issues, in particular that children with chronic conditions, principally neurological comprise the majority of deaths in children over 1 year.

�

100% No specific reports as audit gives an overview of child deaths across four different countries

Congenital Heart Disease (Paediatric Cardiac Surgery)

NICOR The congenital heart disease website profiles every congenital heart disease centre in the UK, including the number and range of procedures they carry out and survival rates for the most common types of treatment.

�



3National

Audit issueSponsor / Audit What is the Audit about? Trust participation

in 2015/16Percentage Data

completionOutcome

Coronary Angioplasty / National Audit of PCI

NICOR This project looks at percutaneous coronary intervention (PCI) procedures performed in the UK. The audit collects and analyses data on the nature and outcome of PCI procedures, who performs them and the general health of patients. The audit utilises the Central Cardiac Audit Database (CCAD) which has developed secure data collection, analysis and monitoring tools and provides a common infrastructure for all the coronary heart disease audits.

�

100% Compliant

Cystectomy British Association of Urological Surgeons (BAUS)

In 2016 cystectomy data (2014-2015) will be published for the first time. �

100% Compliant

National Diabetes Footcare Audit


National Diabetes Foot Care Audit enables all diabetes foot care services to measure their performance against NICE clinical guidelines and peer units, and to monitor adverse outcomes for people with diabetes who develop diabetic foot disease.

�


National Pregnancy in Diabetes


The National Pregnancy in Diabetes (NPID) Audit aims to support clinical teams to deliver better care and outcomes for women with diabetes who become pregnant.

�


Diabetes (Inpatient Adult)


The National Diabetes Audit is considered to be the largest annual clinical audit in the world, providing an infrastructure for the collation, analysis, benchmarking and feedback of local data across the NHS.

�


Diabetes (Paediatric)

Royal College of Child Health and Paediatrics (RCPH)

The audit covers registrations, complications, care process and treatment targets.

�

90% Compliant

Elective Surgery (National PROMS Programme)


The audit looks at the change in patients’ self-reported health status for groin hernia surgery, hip replacement, knee replacement and varicose vein surgery.

�

100% Compliant

Emergency Use of Oxygen

British Thoracic Society

This audit aims to encourage best practice in the use of emergency oxygen therapy.

�


Falls and Fragility Fractures Audit Programme – Fracture Liaison Service Database

RCPH The Falls and Fragility Fracture Audit Programme (FFFAP) is a national clinical audit run by the Royal College of Physicians designed to audit the care that patients with fragility fractures and inpatient falls receive in hospital and to facilitate quality improvement initiatives.

�

100% Compliant

Falls and Fragility Fractures Audit Programme including National Hip Fracture database


�






Outcome

Falls and Fragility Fractures Audit Programme – Falls Audit


�


Inflammatory Bowel Disease - Biologics

RCP The purpose of this audit is to measure the efficacy, safety and appropriate use of biological therapies in patients with inflammatory bowel disease in the UK.

�

100% Compliant

Inflammatory Bowel Disease - Audit

RCP The UK Inflammatory Bowel Disease (IBD) Audit seeks to improve the quality and safety of care for IBD patients in hospitals throughout the UK. It will do this by assessing individual patient care and service resources and organisation against the National Service Standards for the care of patients.

�

100% Action plan currently being developed

Lung Cancer (NLCA)


Lung cancer has the highest mortality rate of all forms of cancer in the western world and there is evidence that the UK’s survival rates compare poorly with those in the rest of Europe. There is also evidence that, in the UK, standards of care differ widely. The audit was set up in response to The NHS Cancer Plan, to monitor the introduction and effectiveness of cancer services.

�


Major Trauma: Trauma Audit & Research Network

Trauma Audit Research Network (TARN)

TARN is working towards improving emergency health care systems by collating and analysing trauma care

�


Maternal Infant and Newborn Clinical Outcome review Programme

Mothers and Babies - Reducing Risk through Audits and Confidential Enquiries across the UK

The programme investigates the deaths of women and their babies during or after childbirth, and also cases where women and their babies survive serious illness during pregnancy or after childbirth.

�


NCEPOD –Mental Health in General Hospitals study

NCEPOD To explore the overall quality of mental health and physical health care provided to patients with a significant mental disorder (listed in study population criteria) who are admitted to a general hospital.

�

100% Report due to be published Autumn /

Winter 2017

NCEPOD – Acute Pancreatitis

NCEPOD To explore remediable factors in the processes of care of patients, aged 16 or over, who are admitted to hospital with a diagnosis of Acute Pancreatitis.

�

81.8% Report due to be published in July

2016

NCEPOD – Sepsis NCEPOD The aim of the study was to identify and explore remediable factors in the process of care for patients with sepsis.

�

100% Action plan

developed

NCEPOD – Gastrointestinal Haemorrhage

NCEPOD To identify the remediable factors in the quality of care provided to patients treated for a GI bleed who received 4 or more units of blood.

�



3National



completionOutcome

National Adult Cardiac Surgery

NICOR This audit looks at heart operations. Details of who undertakes the operations, the general health of the patients, the nature and outcome of the operation, particularly mortality rates in relation to preoperative risk and major complications.

�

100% Compliant

National Cardiac Arrest

ICNARC The purpose of the audit is to monitor the incidence of, and outcome from, in-hospital cardiac arrest in the UK and Ireland.

�

Adults & Paediatrics both

97%

Action plan developed

National Chronic Obstructive Pulmonary Disease – Secondary Workstream

RCP / BTS / Primary Care Respiratory Society / British Lung Foundation

The audit programme brings together primary care, secondary care, rehabilitation and patient experience, marking a ground breaking, partnership approach with multidisciplinary, collaborative working to drive improvements in COPD patient care. This new audit programme supports the Department of Health (DH) aim to improve the quality of services for people with COPD by measuring and reporting the delivery of care as defined by standards embedded in guidance.

�


National Chronic Obstructive Pulmonary Disease – Pulmonary Rehabilitation

RCP / BTS / Primary Care Respiratory Society / British Lung Foundation

The audit programme brings together primary care, secondary care, rehabilitation and patient experience, marking a ground breaking, partnership approach with multidisciplinary, collaborative working to drive improvements in COPD patient care. This new audit programme supports the Department of Health (DH) aim to improve the quality of services for people with COPD by measuring and reporting the delivery of care as defined by standards embedded in guidance.

�


National Comparative Audit of Blood Transfusion – Blood Use in Elective Surgery

NHS Blood and Transplant

Audit of Patient Blood Management in adults undergoing elective, scheduled surgery.

�


National Comparative Audit of Blood Transfusion – Use of Blood in Haematology

NHS Blood and Transplant

Audit of Red Cell & Platelet transfusion in adult haematology patients.

�

100% Data collection has just closed and no date yet known for the publication of

results

National Complicated Diverticulitis Audit

The National CADS Project.

Acute complicated diverticulitis is a common surgical emergency with significant implications for patients like major surgical intervention, intensive care support and life-long stoma. However, there is currently no standardization of care or unified national guidelines. This audit aims to generate baseline data to inform future RCTs.

�

100% Report due to be published April 2016

National Emergency Laparotomy

Royal College of Anaesthetists

NELA aims to look at structure, process and outcome measures for the quality of care received by patients undergoing emergency laparotomy.

�






Outcome

National Heart Failure

NICOR The aim of this project is to improve the quality of care for patients with heart failure through continual audit and to support the implementation of the national service framework for coronary heart disease.

�


National Joint Registry

National Joint Registry Centre

The audit covers clinical audit during the previous calendar year and outcomes including survivorship, mortality and length of stay.

�

100% Compliant

National Ophthalmology Audit

Royal College of Ophthalmologists

The project aims to prospectively collect, collate and analyse a standardised, nationally agreed cataract surgery dataset from all centres providing NHS cataract surgery in England & Wales to update benchmark standards of care and provide a powerful quality improvement tool. In addition to cataract surgery, electronic ophthalmology feasibility audits will be undertaken for glaucoma, retinal detachment surgery and age-related macular degeneration (AMD).

�

100% Report due to be published in April

2016

National Prostate Cancer

Clinical Effectiveness Unit, Royal College of Surgeons

This first audit covers organizational elements of the service and whether key diagnostic, staging and therapeutic facilities are available on site for each provider of prostate cancer services.

�

100% Compliant

National Vascular Registry including CIA and elements of NVD

RCS The audit addresses the outcome of surgery for patients who underwent two types of vascular procedure. The first is an elective repair of an infra-renal abdominal aortic aneurysm (AAA). The second is a carotid endarterectomy (CEA).

�

100% Compliant


BTS To assess whether babies requiring specialist neonatal care receive consistent high quality care and identify areas for improvement in relation to service delivery and the outcomes of care.

�


Nephrectomy BAUS In 2015, PCNL data was published for the first time. �

100% Compliant

Oesophago-gastric Cancer


The oesophago-gastric (stomach) cancer audit aims to examine the quality of care given to patients and thereby help services to improve. The audit evaluates the process of care and the outcomes of treatment for all O-G cancer patients, both curative and palliative.

�

100% Compliant

Paediatric Asthma British Thoracic Society

The audit covers key domains in relation to children and young people with asthma.

�100% Date of publication

yet to be confirmed

Paediatric Intensive Care

University of Leeds PICANet was established in 2002 and aims to continually support the improvement of paediatric intensive care provision throughout the UK by providing detailed information on paediatric intensive care activity and outcomes.

�


Radical Prostatectomy

BAUS In 2015, Radical Prostatectomy data was published for the first time. �

100% Compliant


3National



completionOutcome

Renal Replacement Registry

UK Renal Registry The Registry contains analyses of data submitted via clinical information systems relating to direct clinical care and laboratory permit analyses.

�


Procedural Sedation in Adults (Care in Emergency Departments)

Royal College of Emergency Medicine

This audit looks at adult patients past their 16th birthday, undergoing procedural sedation at all levels (minimal, conscious, moderate, dissociative and deep).

�

100% Report due to be released End

Summer / beginning Winter 2016

Pulmonary Hypertension

Health and Social Care information Centre

The Pulmonary Hypertension Audit measures the quality of care, activity levels, access rates and patient outcomes of pulmonary hypertension services.

�

100% Compliant

Percutaneous Nephrolithotomy (PCNL)

BAUS In 2015, PCNL data was published for the first time. �

100% Compliant

Rheumatoid and Early Inflammatory Arthritis

British Society of Rheumatology

The overall aim of the audit is to improve the quality of care provided by specialist rheumatology services in the management of early inflammatory arthritis.

�


Sentinel Stroke National Audit Programme


The audit collects information about care provided to stroke patients in first three days of hospital. Data is continuous.

�


Stress Urinary Incontinence (SUI) in Women

BAUS In 2015, SUI data was published for the first time. �

100% Compliant

UK Cystic Fibrosis Registry (Paediatrics)

Cystic Fibrosis Trust

The audit aims to examine both life expectancy and quality of life for children with Cystic Fibrosis. �

100% Action plan is being developed.

UK Cystic Fibrosis Registry (Adults)

Cystic Fibrosis Trust

The audit aims to examine both life expectancy and quality of life for adults with Cystic Fibrosis.

�


UK Parkinson’s Audit

Parkinson’s UK The UK Parkinson’s Audit helps healthcare professionals measure their services for people with Parkinson’s against national guideline

�

100% Action plan is being

developed

Uerethroplasty BAUS In 2015, Uerethroplasty data was published for the first time. �

100% Compliant

Vital Signs in Children (Care in Emergency Departments)


This audit looks at Children (patients less than 16 years of age) who present to the ED with a medical illness, including rashes and abdominal pain. By medical illness, we mean presentations unrelated to trauma. The child may be ambulatory or non-ambulatory

�



VTE Risk in Lower Limb Immobilisation (Care in Emergency Departments)


This audit looks at patients 17 years of age and above who present to an ED or an Minor Injuries Unit that is part of the ED with a lower limb injury and are discharged with temporary immobilisation of the limb using a plaster cast

�




An additional 10 audits have been added to the list for inclusion in 2016/17 Quality Accounts and all 10 audits are relevant to services provided by the Trust. The 10 audits include:

• Adult Asthma

• Asthma - Paediatric and Adult (Care in Emergency Departments)

• Endocrine and Thyroid National Audit

• Head and Neck Cancer Audit

• Learning Disability Mortality Review Programme

• National Audit of Dementia

• National Neurosurgery Audit Programme

• Paediatric Pneumonia

• Severe Sepsis and Septic Shock (Care in Emergency Department)

• Specialist Rehabilitation for Patients with Complex Needs

Lead clinicians for each of the national audits included in the Quality Account provide the Clinical Governance and Risk Department with six monthly status positions on the implementation of each reports finding and this is discussed at the Clinical Effectiveness, Audit and Guidelines Committee.

The reports of 53 national clinical audits were reviewed by the provider in 2015/16 and the Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions to improve the quality of healthcare provided:

• During 2015/16 a reporting template was developed which included the identification of good practice and where areas for improvement are identified the lead clinician is asked to complete an action plan and present this to the Clinical Effectiveness, Audit and Guidelines Committee

• On an annual basis the Committee receives a report on the projects in which the Trust participates and requires the lead clinician of each audit programme to identify any potential risk, where there are concerns action plans will be monitored on a three monthly basis

• In addition, each Directorate is required to present an Annual Clinical Audit Report to the Clinical Effectiveness, Audit and Guidelines Committee detailing all audit activity undertaken both national and local. Clinicians are required to report all audit activity using the Trust’s Clinical Effectiveness Register

• Involvement in National audits is monitored at the Patient Safety and Quality Reviews where a data pack is provided that contains audit compliance

• Compliance with National Confidential Enquiries is reported to the Clinical Governance and Quality Committee and exceptions subject to detailed scrutiny and where compliance cannot be achieved this is evidenced onto the Trust Risk Register and monitored accordingly

• Non-compliance with recommendations from National Clinical Audit and National Confidential Enquiries are considered in the Annual Business Planning process.

The reports of 700 local clinical audits were reviewed by the provider in 2015/16 and the Newcastle upon Tyne Hospitals NHS Foundation Trust intends to take the following action to improve the quality of healthcare provided:

• Each Clinical Directorate is required to present an Annual Clinical Audit Report to the Clinical Effectiveness, Audit and Guidelines Committee detailing all audit activity undertaken both national and local.

Information on participation in clinical researchThe number of patients receiving relevant health services provided or sub-contracted by the Newcastle upon Tyne Hospitals NHS Foundation Trust in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was 16,158 of which 11,930 were UKCRN National Portfolio studies which equates to 37% of all patients recruited to National Portfolio studies in the region.

Information on the use of the CQUIN framework The Commissioning for Quality and Innovation (CQUIN) payment framework is designed to support the cultural shift to put quality at the heart of the NHS. For 2015/16 due to national tariff options we did not progress a CQUIN scheme. For 2016/2017 the Trust plans to participate fully in the CQUIN programme, working closely with our commissioners to develop the areas of focus over the next 12 months.


3The Newcastle upon Tyne Hospitals NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is ‘Registered Without Conditions’. The Newcastle upon Tyne Hospital NHS Foundation Trust is registered with the CQC to deliver care from five separate locations and for eleven regulated activities.

The Care Quality Commission has not taken enforcement action against the Newcastle upon Tyne Hospitals NHS Foundation Trust during 2015/16.

The Newcastle upon Tyne Hospitals NHS Foundation Trust received a full inspection of all services during January 2016. Following this inspection Newcastle Hospitals was graded as ‘Outstanding’.

Information on the Quality of Data The Newcastle upon Tyne Hospitals NHS Foundation Trust submitted records during 2015/16 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data (April 2015 – January 2016). The percentage of records in the published data:

- which included the patients valid NHS number was:

• 99.0% for admitted patient care;

• 99.3% for outpatient care;

• 97.6% for accident and emergency care.

- which included the patients valid General Medical Practice Code was:

• 100% for admitted patient care;

• 100% for outpatient care;

• 100% for accident and emergency care.

Score for 2015/16 for Information Quality and Records Management, assessed using the Information Governance Toolkit

The Newcastle upon Tyne Hospitals NHS Foundation Trust Information Governance Assessment Report score overall score for 2015/16 is 87% and was graded green (satisfactory). An action plan to improve this is in place and progress is being monitored by the Information Governance Committee.

Clinical Coding InformationThe Newcastle upon Tyne Hospitals NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2015/16 by the Audit Commission due to significant improvements in previous years.

The Trust’s annual Information Governance Audit 2015/16 for diagnosis and treatment coding of inpatient activity achieved IGT level 3 (good) in two out of the four coding indicators set by the Health and Social Care Information Centre (HSCIC) which is the highest level of attainment. However, the Trust’s accuracy of primary diagnoses and secondary procedures was marginally lower than last year achieving level IGT level 2.

Please see table below for results:

The Newcastle upon Tyne Hospitals NHS Foundation Trust will be taking the following actions to improve data quality:

• Review the resources allocated the Clinical Coding Team with a view to reducing the number of episodes coded annually per coder to allow the coding from case notes in all specialities.

• Feedback the areas of error found during the audit to the clinical coding team, including the importance of re-visiting histology results and updating the coding.

• Review the process for completing discharge summaries to ensure they contain relevant co-morbidities.

The performance of the Trust compared with the national average error rate of 6.2%, measured against the proportion of episodes changing payment, places it in the top 25% of best performing Trusts.

Levels of Attainment

Area Level Two Level Three NUTH Score

Primary diagnosis >=90% >=95% 94.5%

Secondary diagnosis >=80% >=90% 93.6%

Primary procedure >=90% >=95% 97.5%

Secondary procedure >=80% >=90% 89.8%

Levels of attainment of coding of inpatient activity

Information relating to registration with the Care Quality Commission (CQC)


The key national priorities are performance targets for the NHS which are determined by the Department of Health and form part of the CQC Intelligent Monitoring

Report. A wide range of measures are included and the Trust’s performance against the key national priorities for 2015/16 are detailed in the table below.

Operating and Compliance Framework Target Target Annual Performance 2015/16

Incidence of Clostridium difficile No more than 77 67 ( 94 minus 27 appeals)

Incidence of MRSA Bacteraemia No more than Zero 5

All Cancer Two Week Wait 93% 95.8%

Two Week Wait for Symptomatic Breast Patients (Cancer Not initially Suspected)

93% 94.8%

31-Day (Diagnosis To Treatment) Wait For First Treatment 96% 97.7%

31-Day Wait For Second Or Subsequent Treatment: Surgery 94% 96.4%

31-Day Wait For Second Or Subsequent Treatment: Drug treatment

98% 98.5%

31-Day Wait For Second Or Subsequent Treatment: Radiotherapy

94% 98.9%

62-Day (Urgent GP Referral To Treatment) Wait For First Treatment

85% 86.6%

62-Day Wait For First Treatment from Consultant Upgrade Late referrals Excluded in Local Target

85% 83%

62-Day Wait For First Treatment From Screening Service 90% 96.5%

RTT – Referral to Treatment - Admitted Compliance 90% 90.9%

RTT – Referral to Treatment - Non-Admitted Compliance 95% 95.8%

RTT – Referral to Treatment - Incomplete Compliance A 92% 95.1%*

Maximum waiting time of 4 hours in A&E A 95% 93.8%

Delayed Transfers Minimal 0.21%

Cancelled operations – those not admitted within 28 days 0 22

Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways

92% 94.2%

Maternity bookings within 12 weeks and 6 days 90% 93.7%

Data completeness: Community Services comprising: Referral to treatment information

>50% 99.80%

Data completeness: Community Services comprising: Referral information

>50% 93.86%

Data completeness: Community Services comprising: Treatment activity information

>50% 97.03%

Certification against compliance with requirements regarding access to health care for people with learning disabilities

Compliant Achieved

Table - Trust Key National Priorities

* The indicator percentage has been restated following external audit procedures from 94.1% to 95.1%.

Key National Priorities 2015/16


3• 62-Day Wait For First Treatment from Consultant

Upgrade Late referrals Excluded in Local Target – this is below the target set rational for this includes Complex pathways, capacity and patient choice.

• Cancelled operations – those not admitted within 28 days, this number is due to capacity issues and more urgent cases taking precedent.

A Mandatory Indicators

1. Percentage of incomplete pathways within 18 weeks for patients on incomplete pathways (RTT)

2. Percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge.

RTT The indicator is expressed as a percentage of incomplete pathways within 18 weeks for patients on incomplete pathways at the end of the period.

The indicator is calculated as the arithmetic average for the monthly reported performance indicators for April 2015 to March 2016.

The clock start date is defined as the date that the referral is received by the FT.

The indicator includes only referrals for consultant-led service meeting the definition of the service whereby a consultant retains overall clinical responsibility for the service, team or treatment.

A&E The indicator is expressed as the percentage of unplanned A&E attendances (whether admitted or not) in the year ended 31 March 2016 that have a total time in A&E of four hours or less from arrival time (as recorded by the clinician (nurse or doctor) carrying out initial triage, or A&E reception, whichever is earlier) to admission, transfer or discharge home.

A&E means all types of A&E provision including

Type 1, Type 2, Type 3, Type 4 departments and urgent care centres that average more than 200 attendances per month, with this average being calculated over a quarter.

A&E attendance includes unplanned follow up attendances but does not include planned follow up attendances (e.g. to an A&E clinic or a planned follow up to remove sutures).

For ambulance cases, arrival time is when hand over occurs or 15 minutes after the ambulance arrives at A&E, whichever is earlier.

Transfer is to the care of another NHS organisation or other public/private sector agency (for example social services).

Time of admission is the time when the patient leaves A&E to go to: an operating theatre; a bed in a Ward; or an x-ray or diagnostic test or other treatment directly en route to a bed in a Ward or operating theatre; however, leaving A&E for a diagnostic test or other treatment (if not en route to a bed in a Ward/operating theatre) does not count as time of admission.

Where a period of assessment/observation of greater than 4 hours is required before a decision to admit or discharge is made, patients are to be accommodated in an observation/assessment Ward away from A&E; where these patients remain in A&E or are accommodated in an environment that not does meet the criteria set out in FAQ 6.5, they remain within the total time count until they are admitted, transferred or discharged.

Where a patient is transferred to another A&E Department, even if run by another organisation, on the same campus as the first attended A&E, the clock does not stop. Should the patient’s overall stay exceed 4 hours then both organisations record the breach.


Measure 1. The value and banding of the summary hospital-level mortality indicator (“SHMI”) for the Trust. The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Trust continues to perform well on mortality indicators. Mortality reports are regularly presented to the Trust Board following careful independent interpretation provided by the North East Quality Observatory (NEQOS). The Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions to improve this, and so the quality of its services by closely monitoring mortality rates and conducting detailed investigations when rates increase. The introduction of a systematic mortality review process has also been implemented to ensure that all deaths in hospital are subject to a clinician led review. No further information after July 2014-June 2015.

Measure 2. The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the Trust. The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The use of palliative care codes in the Trust has remained static and aligned to the national average percentage over recent years. The Newcastle upon Tyne Hospitals NHS Foundation Trust intends to take the following actions to improve this indicator, and so the quality of its services, by involving the Coding team in routine mortality reviews to ensure accuracy and consistency of palliative care coding. No further information after July 2014-June 2015.

Core set of Quality Indicators

(Data is compared nationally when available from the NHS Information Centre, otherwise it is compared regionally from the North East Quality Observatory or stated not available) Any and all updated data is presented.

MeasureData

SourceTarget Value 2015/16 2014/15 2013/14

1. The value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust

NHS Information Centre Portal https://indicators.ic.nhs.uk/webview/

Band 2“as

expected”

Oct 14- Sept 15 NUTH Value:Await data

July 14- June 15

NUTH Value:0.99

April 14-March

15NUTH Value:0.99

Jan 14- Dec 14

NUTH Value:0.98

Oct 13- Sept

14 NUTH Value:

0.96

July 13- June 14 NUTH Value:0.95

April 13-March

14NUTH Value:0.94

Jan 13- Dec 13

NUTH Value:0.90

Oct 12-Sept 13

NUTH Value:0.91

July 12 - June

13NUTH Value: 0.91

April 12 -

March 13 NUTH

Value: 0.92

Jan 12-Dec 12

NUTH Value:0.93

Not available

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

NUTH:Band 2

National average

Not available

1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.0

Highest national

Not available

1.21 1.21 1.24 1.20 1.20 1.20 1.18 1.19 1.16 1.17 1.19

Lowest national

Not available

0.66 0.67 0.66 0.61 0.54 0.54 0.62 0.63 0.63 0.65 0.70

2. The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust

NHS Information Centre Portalhttps://indicators.ic.nhs.uk/webview/

N/A Not available

24.3% 24.2% 24.4% 24.16% 23.9% 23.9% 22.9% 21.1% 19.6% 18.2% 18.4%

National average

Not available

26% 25.7% 25.7% 25.3% 24.6% 23.6% 22.0% 20.9% 20.3% 19.9% 19.5%

Highest national

Not available

48% 51% 48% 49.4% 49% 48.5% 46.9% 44.9% 44.1% 44% 42.7%

Lowest national

Not available

0% 0% 0% 0% 0% 0% 1.3% 0% 0% 0.1% 0.1%


3Measure Data Source Value 2013/14 2012/13 2011/12 2010/11 2009/10

3. The patient reported outcome measures scores (PROMS) for groin hernia surgery (average health gain score)

NHS Information Centre Portalhttp://www.hscic.gov.uk/proms

0.07 0.10 0.10 0.08 0.08

National average: 0.08 0.09 0.09 0.09 0.08

Highest national: 0.14 0.15 0.14 0.12 0.14

Lowest national: 0.01 0.01 0.03 0.03 0.01

4. The patient reported outcome measures scores (PROMS) for varicose vein surgery (specific health gain)

NHS Information Centre Portalhttp://www.hscic.gov.uk/proms

Trust score: 0.11 0.10 0.10 0.13 0.12



Lowest national: - 0.02 0.01 0.05 -0.01 0.00

5. The patient reported outcome measures scores (PROMS) for hip replacement surgery (average health gain)

NHS Information Centre Portal http://www.hscic.gov.uk/proms

Trust Score 0.43 0.43 0.42 0.42 0.42



Lowest national: 0.31 0.32 0.32 0.26 0.29

6. The patient reported outcome measures scores (PROMS) for knee replacement surgery (average health gain)

NHS Information Centre Portal http://www.hscic.gov.uk/proms

Trust Score 0.33 0.32 0.31 0.34 0.30



Lowest national: 0.21 0.21 0.18 0.20 0.17

Measure 3. The patient reported outcome measures scores (PROMS) for groin hernia surgery. The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Trust continues to report a similar score as the National average. It is felt that this is because of the low day case rate for this particular surgery. There is limited clinical evidence regarding NICE guidance with laprosopic groin hernia surgery. The Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions to improve this indicator, and so the quality of its services, by continuing to review the patient pathway. No further information after 2013/2014.

Measure 4. The patient reported outcome measures scores (PROMS) for varicose vein surgery. The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Trust is above the National average because it offers all modalities of patient treatment in relation to varicose veins. The Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions to improve this indicator, and so the quality of its services, by continuing to review the patient pathway. No further information after 2013/2014.

Measure 5. The patient reported outcome measures scores (PROMS) for hip replacement surgery.The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The data shows PROMS score remains static at 0.43 over the 12 month period. The Newcastle upon Tyne Hospitals NHS Trust has an average outcome for hip replacement surgery as many of the

simpler cases are outsourced to another provider due to current capacity pressures. This results in more complicated cases being performed by the Trust and therefore the health gain increase could be expected to be less, if the simpler patients were included the Trust believes that the increase would be more significant, however it is important to note that even with a more complex casemix the Trust still provides an ‘expected’ level of improvement. The Newcastle upon Tyne Hospitals NHS Foundation Trust intends to take the following actions to improve this indicator, and so the quality of its services, by working with the Specialist Orthopaedic Alliance in benchmarking best practice for both hip and knee replacement surgery to identify areas for potential future improvement. No further information after 2013/2014.

Measure 6. The patient reported outcome measures scores (PROMS) for knee replacement surgery.The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The data shows in increase in PROMS scores to 0.33 from 0.32 over the 12 month period. The Newcastle upon Tyne Hospitals NHS Foundation Trust provides a statistically significant (2SD) higher outcome for knee replacement surgery than the local average. The Trust believe this signifies the high level of care that the Trust provide and this is also the case when work is outsourced to other providers due to capacity issues. The Newcastle upon Tyne Hospitals NHS Foundation Trust intends to take the following actions to improve this indicator, and so the quality of its services, by working with the Specialist Orthopaedic Alliance in benchmarking best practice for both hip and knee replacement surgery to identify areas for potential future improvement. No further information after 2013/2014.


Measure 7. The percentage of patients aged— (i) 0 to 15; and (ii) 16 or over readmitted. The last set of data provided by the Health and Social Care Information Centre covers the period 2011/12 and was uploaded in December 2013, with the next versions due ‘early 2016’. The Trust have contacted the Health and Social Care Information Centre to question the age of the data available and asked when it will next be updated. The Trust was informed that these indicators are currently being re-developed as the contract with the old data supplier has now terminated and they are looking to bring them in-house.

Therefore the Trust have reviewed their own internal data and used their own methodology of reporting readmissions within 28 days (without PbR exclusions).

The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Trust has a robust reporting system in place and adopts a systematic approach to data quality improvement. The Newcastle upon Tyne Hospitals NHS Foundation Trust intends to take the following actions to improve this indicator, and so the quality of its services, by continuing with the use of an electronic system.

Measure Data Source Value 2013/14 2012/13 2011/12 2010/11 2009/10

7a. Emergency readmissions to hospital within 28 days of discharge from hospital: Children of ages 0-15


Trust value Unavailable see below Unavailable see below 12.50 11.71 12.25

National average: Unavailable see below Unavailable see below 10.01 10.15 10.18

Highest national: Unavailable see below Unavailable see below 14.94 14.11 15.35

Lowest national: Unavailable see below Unavailable see below 0.00 0.00 0.00

7b. Patient readmitted to hospital within 28 days of being discharged aged 16+


Trust Value Unavailable see below Unavailable see below 11.87 12.45 12.31

National average: Unavailable see below Unavailable see below 11.45 11.43 11.18

Highest national: Unavailable see below Unavailable see below 13.80 14.06 13.30

Lowest national: Unavailable see below Unavailable see below 0.00 0.00 0.00

YearTotal number of

admissions/spellsNumber of readmissions (all)

Emergency readmission

rate (all)

20/11/12 31,548 2,500 7.9

2012/13 31,841 2,454 7.7

2013/14 32,242 2,648 8.2

2014/15 34,561 3,570 10.3

2015/16 38,769 2,875 7.4

YearTotal number of

admissions/spellsNumber of readmissions (all)

Emergency readmission

rate (all)

20/11/12 175,836 9,435 5.4

2012/13 173,270 8,788 5.1

2013/14 177,867 9,052 5.1

2014/15 180,380 9,446 5.2

2015/16 182,668 10,076 5.5

7a. Emergency readmissions to hospital within 28 days of discharge from hospital: Children of ages 0-15

7b. Patient readmitted to hospital within 28 days of being discharged aged 16+


3

Measure 8. The Trust’s responsiveness to the personal needs of its patients.The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The data shows that the trust scores above the national average. The Newcastle upon Tyne Hospitals NHS Foundation Trust intends to take the following actions to improve this indicator, and so the quality of its services, by continuing to implement processes to capture patient experience and improve its services. No further information after 2014/2015.

Measure 9. The percentage of staff employed by, or under contract to, the Trust who would recommend the Trust as a provider of care to their family or friends.

The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: the Trust has improved on last year’s score and is well above the National average. The Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions to improve this percentage, and so the quality of its services, by continuing to listen to and act on all sources of staff feedback. No further information after 2014/2015.

Measure Data Source Value 2014/15 2013/14 2012/13 2011/12 2010/11

8. The trust’s responsiveness to the personal needs of its patients


Trust percentage 76.8% 77.3% 74.2% 72.2% 70.5%

National average: 68.9% 68.7% 68.1% 67.4% 67.3%

Highest national: 86.1% 84.2% 84.4% 85% 82.6%

Lowest national: 59.1% 54.4% 57.4% 56.5% 56.7%

Measure Data Source Value 2015 2014 2013 2012 2011

9. The percentage of staff employed by, or under contract to, the trust who would recommend the trust as a provider of care to their family or friends

http://www.nhsstaffsurveys.com/Page/1006/Latest-Results/2013-Results/

Trust percentage 89% 85% 87% 86% 79%

National average: 69% 65% 64% 62% 62%

Highest national: 89% 89% 89% 86% 89%

Lowest national: 46% 38% 40% 35% 33%

MeasureData

SourceTarget 2015/16 2014/15 2013/14 2012/13

10. The percentage of patients that were admitted to hospital who were risk assessed for Venous thrombo-embolism (VTE)

NHS Infor-mation Centre Portal 2013/14 http://www.england.nhs.uk/statistics/statisti cal- work- ar-eas/ vte/

Trust (CQUIN Target- 95%)

Q1 95.9%

Q2 96.4%

Q3 96.2%

Q4 Await

Q1 96.4%

Q2 95.8%

Q3 95.5%

Q4 95.7%

Q1 95.8%

Q2 96.3%

Q3 97.4%

Q4 97%

Q1 95%

Q2 95%

Q3 95.2%

Q4 95.4%

National average

96% 95.8% 95.4% Await 96.2% 96.2% 96% 95.9% 95.5% 95.8% 95.7% 96%

Highest national

100% 100% 100% Await 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Lowest national

86.1% 75% 100% Await 87.2% 86.4% 89.6% 90.8% 78.8% 81.7% 74.1% 78.9% 84.6% 87.9%

Measure 10. The percentage of patients that were admitted to hospital who were risk assessed for Venous thromboembolism (VTE) The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Trust has a robust reporting system in place and adopts a systematic approach to data quality improvement. The Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions

to improve this percentage, and so the quality of its services, by completion of assessment being electronic to allowing capture of compliance rates and the implementation of the Safety Thermometer. The Trust has continued with use of the electronic reporting system developed in 2014/15 to assist the process in practice and continues to undertake root cause analysis (RCA) on patients who develop a hospital acquired VTE. No further information after Q3 2015/2016.


Measure Data Source Target 2014/15 2013/14 2012/13 2011/12 2010/11

11. The number and rate per 100,000 bed days of cases of C.difficile infection reported within the trust amongst patients aged 2 or over

NHS Information Centre Portal http://www.hpa.org.uk/web/HPAweb&Page&H-PAwebAu-toListName/

Trust number 89 National figure 73 Local figure

75 76 101 150

Trust Rate 18.5 18.2 15.4 21.4 32.2

National Average rate 12.1 14.7 17.4 22.2 29.7

Highest National rate Not available 37.1 31.2 58.2 71.2

Lowest National rate Not available 0 0 0 0

12. The number and rate per 100 admissions of patient safety incidents reported

NB: Changed to rate per 1000 bed days April 2014

NHS Information Centre Portal http://www.nrls.npsa.nhs.uk/patient-safe-ty-data/organisa-tion-patient-safe-ty-incident-reports/

Trust Number Oct 2014 - March 2015 7313

April 2014-Sept 2014 7084

Oct 2013- March 2014 6619 (Trust

data for 2013/14 13,275)

April 2013- Sept 2013 5727

Oct 2012- March 2013 5138

April 2012- Sept 2012 4573

Oct 2011- March 2012 4204

April 2011- Sept 2011 4311

Oct 2010 - March 2011 4259

April 2010- Sept 2010 3527

Trust Rate 29.66 28.4 5.3 5.4 4.8 4.3 4.1 4.2 4.4 3.4

National Average 35.3 35.1 8.7 8.0 7.7 7.0 6.9 6.5 6.2 6.0

Highest National 82.2 74.9 14.9 12.8 13.7 12.12 10.7 9.22 9.74 10.76

Lowest National 3.6 0.24 4.6 4.9 3.2 2.77 0.94 4.14 4.43 3.39

Measure 11.The rate per 100,000 bed days of cases of C.difficile infection reported within the trust amongst patients aged 2 or over The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Trust has a robust reporting system in place and adopts a systematic approach to data quality improvement. The Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions to improve this rate, and so the quality of its services, by having a robust strategy that includes the review of all Trust-apportioned cases to ensure no avoidable cases occur: completion of root cause analysis (RCA) forms for all such cases; Antibiotic Champions undertaking regular audits of Stop and Review including a review of the Policy and awareness sessions; Quarterly HCAI Report to share lessons learned and best practice from the RCAs and Serious Infection Review Meetings. C. difficile awareness campaigns took place with staff, alongside regular ongoing hand hygiene and cleanliness audits. Clinical Directorates have also produced HCAI Action Plans to demonstrate how lessons learned are shared with all staff in order to encourage best practice. There is a differential between local and National data for this indicator. The Nationally reported figure is 89, locally it is 73 – this figure reflects successful appeals (16) whereas the National data does not take appeals into consideration. No further information after 2014/15.

Measure 12. The number and rate of patient safety incidents reported: The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Trust take the reporting of incidents very seriously and have an electronic reporting system (Datix) to support this. The Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions to improve this number and rate, and so the quality of its services, by undertaking a campaign to increase awareness of incident/near miss reporting. Incidents are graded, analysed and, where required, undergo a root cause analysis investigation to inform actions, recommendations and learning. Incident data are reported on a monthly basis to the Trust Board. Serious incidents are also reviewed at the Trust Corporate Governance Committee bimonthly meetings. Analysis of this data is considered by the Trust Integrated Governance Committee and reported to the Clinical Risk Group to inform our organisational learning themes which are reported to the Board. This data now includes any cardiac arrest deaths which may account for the increase number between 2013/2014 and 2014/2015. The number and rate per 100 admissions of patient safety incidents reported changed to rate per 1000 bed days April 2014. No further information after 2014/15.


3Measure Data Target 2014/15 2013/14 2012/13 2011/12

13. The number and percentage of patient safety incidents that resulted in severe harm or death

NHS Infor-mation Centre Portal http://www.nrls.npsa.nhs.uk/patient- saf ety- data/organi-sation- patient- safety- incident- reports/

Trust no. Oct 2014 - March 2015

Severe Harm

27

Oct 2014 - March 2015

Death

2

April - 2014 Sept 2014

Severe Harm

30


Death

0

Oct 2013 - March 2014

Severe Harm

18

Oct 2013 - March 2014

Death

0


Severe Harm

18


Death

0

Oct 2012 - March 2013

Severe Harm

29

Oct 2012 - March 2013

Death

1

April 2012 - Sept 2012

Severe Harm

23


Death

0

Oct 2011 - March 2012

Severe Harm

25

Oct 2011 - March 2012

Death

3


Severe Harm

35

April 2011 Sept 2011

Death

2

Trust % 0.4% 0% 0.4% 0% 0.3% 0% 0.31% 0% 0.56% 0.19% 0.5% 0% 0.6% 0.1% 0.8% 0%

National average

0.4% 0.1% 0.4% 0.1% 0.3% 0.1% 0.2% 0.1% 0.33% 0.1% 0.4% 0.1% 0.5% 0.1% 0.5% 0.1%

Highest National

5.2% 1.1% 74.3% 8.6% 0.9% 0.3% 0.8% 0.3% 1.3% 0.28% 1.6% 0.5% 2.6% 0.4% 2% 0.4%

Lowest National

0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

As from 2014/15 the Trust is now included in a new much larger group of Trusts (140 instead of 30) and these vary in size and complexity therefore the data is more variable.

Measure 13. The number and percentage of patient safety incidents that resulted in severe harm or death: The Newcastle upon Tyne Hospitals NHS Foundation Trust considers that this data is as described for the following reasons: The Trust takes incidents resulting in severe harm of death very seriously. The rate of incidents resulting in severe harm or death is consistent with the national average. This reflects a culture of reporting incidents which lead to, or have the

potential to, cause serious harm or death. The Newcastle upon Tyne Hospitals NHS Foundation Trust has taken the following actions to reduce this number and rate, and so the quality of its services, by the Board receiving monthly reports of incidents resulting in severe harm of death. (The Trust would classify major and catastrophic as permanent harm or death. This would include a fracture following a fall if the patient did not fully recover their normal level of independence. No further information after 2014/15.


2015 NHS Staff Survey Results Summary A standard survey was sent directly to a random sample of 1500 staff from across the Trust in October 2015 via email. This methodology had been agreed with the Executive Team last year with the intention of increasing the sample size across the Trust, and to move to an on line survey only.

A total 401 staff participated in the 2015 survey, equalling a response rate of 27%. Whilst this response rate is very disappointing and is the lowest benchmarked within the region and against Shelford comparators, nationally overall the response rate has fallen.

The results of the NHS Staff Survey are structured under seven headings as follows:

• The four staff pledges from the NHS Constitution:

o To provide all staff with clear roles and responsibilities and rewarding jobs for teams and individuals that make a difference to patients, their families and carers and communities

o To provide all staff with personal development, access to appropriate education and training for their jobs and line management support to enable them to fulfil their potential

o To provide support and opportunities for staff to maintain their health, wellbeing and safety.

o To engage staff in decisions that affect them and the services they provide individually, through representative organisations, and through local partnership working arrangements. All staff will be empowered to put forward ways to deliver better and safer services for patients and their families.

• Plus three additional themes of Staff Satisfaction, Equality and Diversity and Patient Experience

A number of the questions are either new or have been amended and therefore, year on year comparisons are not a straightforward as would have been liked. Where possible, these will be commented upon.

Workforce factors

Wellbeing – the tables below provide data on the loss of work days. Table 15 reports on the Trust and Regional position rate (data taken from the NHS Information Centre) and Table 16 provides an update on the Trust number of staff sick days lost to industrial injury or illness caused by work. No further information after November 2015.

Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15

The Newcastle Upon Tyne Hospitals 4.07% 3.79% 3.68% 3.65% 3.77% 3.74% 4.04% 4.05%

City Hospitals Sunderland 4.82% 4.65% 4.58% 4.63% 4.51% 4.83% 5.19% 5.57%

County Durham and Darlington 4.33% 4.42% 4.31% 4.13% 3.93% 4.07% 4.34% 4.48%

Gateshead Health 5.11% 4.83% 4.25% 4.53% 4.32% 4.60% 4.73% 4.96%

North Tees and Hartlepool 4.20% 4.13% 4.10% 4.56% 4.61% 4.36% 4.16% 4.63%

Northumbria Healthcare 3.89% 3.73% 3.53% 3.58% 3.75% 3.62% 4.05% 4.38%

South Tees Hospitals 4.72% 4.44% 4.37% 4.37% 4.41% 4.34% 4.80% 4.78%

South Tyneside NHS 6.04% 5.73% 5.66% 5.48% 5.08% 5.25% 6.11% 6.02%

England 3.99% 3.90% 3.94% 3.98% 3.92% 4.00% 4.24% 4.30%

Year Quarter 1 Quarter 2 Quarter 3 Quarter 4 Year Total

2009/2010 no. of days 251 414 581 298 1,544

2010/2011 no. of days 118 254 267 366 1,005

2011/2012 no. of days 253 299 247 153 952

2012/2013 no. of days 154 138 174 209 675

2013/2014 no. of days 489 331 785 147 1,752

2014/2015 no. of days 333 284 178 206 1,001

2015/2016 no. of days 360 194 365 219 1,138

loss of work days (rate)

The number of shift staff sick days lost to industrial injury or illness caused by work


3Overall Staff Engagement

The overall indicator of staff engagement is calculated using the response to three Key Findings (KF) questions – (a) staffs’ perceived ability to contribute towards improvements at work, (b) willingness to recommend the trust as a place to work or receive treatment, and (c) the extent to which they feel engaged and motivated with their work.

For the Trust, this score was 3.90 (out of possible 5) having marginally improved from 2014; it remains better than average for both Shelford Group (3.84) and Acute and Community Trusts (3.79).

The Trusts Top Ranking Scores (Acute and Community Scores):

• KF1 Staff recommendation of the trust as a place to work or receive treatment: 4.06/5.00 (3.71)

• KF18. Percentage of staff feeling pressure in the last 3 months to attend work when feeling unwell: 53% (58%)

• KF23. Percentage of staff experiencing physical violence from staff in last 12 months: 1% (2%)

• KF21. Percentage of staff believing that the

organisation provides equal opportunities for career progression or promotion: 91% (87%)

• KF20. Percentage of staff experiencing discrimination at work in last 12 months: 7% (10%)

A cause for concern, and an area in which the Trust ‘s performance was significantly worse, is the % staff reporting issues - errors or incidents, experience of violence or harassment, bullying or abuse: 48% (52%) KF24 and 30% (38%) (KF27) Conversely, there has been an improvement in staff confidence and security in reporting concerns about unsafe clinical practice: 3.72 (3.65) (KF31), and perceived fairness and effectiveness of procedures for reporting: 3.80 (3.71) (KF30).

The Trust remaining lowest ranking scores were (average for acute and community trusts shown in brackets): These are the key findings where the Trust compares least favourably with other acute trusts in England:

• KF15 Percentage of staff satisfied with the opportunities for flexible working patterns: 41% (59%)

• KF12 Percentage of staff working extra hours 75% (72%).

1 2

3.90

Scale summery score

Poorly engaged staff Highly engaged staff

Trust score 2015

Trust score 2014

National 2015 average for combined acute and community trust

3.89

3.79

3 4 5

Staff Engagement:

Overall Staff Engagement (the higher the score the better)

These KF’s are taken from the report issued to the Trust, the actual detail and make up may change of each KF as they develop them year on year however they do say they are comparable:

Percentage score

Trust score 2015

Trust score 2014


Best 2015 score for combined acute and community trusts

0 25 50 75 100

47%

48%

52%

80%

Key Finding 24. Percentage of staff /colleagues reporting most recent experience of violence(the higher the score the better)


From April 2014, NHS England introduced the Staff Friends and Family Test (FFT) in all NHS trusts providing acute, community, ambulance and mental health services in England. NHS England’s vision for Staff FFT is that all staff should have the opportunity to feedback their views on their organisation at least once per year. It gives staff the opportunity and confidence to speak up.

This indicator has been chosen as one of the limited assurance report indicators this year.

Percentage score

Trust score 2015

Trust score 2014


Best 2015 score for combined acute and community trusts

0 25 50 75 100

30%

32%

38%

51%

Key Finding 27. Percentage of staff /colleagues reporting most recent experience of harassment, bullying or abuse(the higher the score the better)

Q1. How likely are you to recommend the Trust to friends and family if they needed care or treatment?

Trust Total Quarter 4 2015/16

National Q4 2014/15

Total


National Q2 2015/16

Total

Trust Total Full Year 2015/16

1. Extremely Likely 252 73% 47613 32% 450 68% 43035 33% 1350 67%

2. Likely 78 23% 67907 45% 184 28% 60915 46% 564 28%

3. Neither Likely or Unlikely 10 3% 20881 14% 21 3% 17374 13% 67 3%

4. Unlikely 1 0% 7538 5% 2 0% 5933 5% 6 0%

5. Extremely Unlikely 3 1% 3711 2% 4 1% 2840 2% 10 0%

6. Don’t Know 0% 1956 1% 1 0% 1548 1% 4 0%

Q2. How likely are you to recommend the Trust to friends and family as a place to work?


National Q4 2014/15

Total


National Q2 2015/16

Total

Trust Total Full Year 2015/16

1. Extremely Likely 138 40% 31487 21% 201 30% 28220 22% 631 32%

2. Likely 124 36% 60452 41% 296 45% 53217 41% 859 43%

3. Neither Likely or Unlikely 50 15% 27643 19% 108 16% 23103 18% 320 16%

4. Unlikely 12 4% 17153 12% 36 5% 14783 11% 122 6%

5. Extremely Unlikely 16 5% 11080 7% 17 3% 10124 8% 55 3%

6. Don’t Know 2 1% 1312 1% 5 1% 1654 1% 13 1%


3Additional Themes linked to the NHS Constitution

Your ManagersThe Trust scores in this section are very positive with the answers to many questions placing the Trust in the top 20% compared to sector:

• Staff agreeing they know who senior managers are in the Trust (91% compared to 82%)

• Immediate managers taking an interest in an employee’s health and wellbeing increased 17& to 68%

Whilst still better than sector average, only 44% (Sector 39%) of staff agreed that communication between senior management and staff is effective.

Your Health and Well-beingResults in this section are broadly similar to the sector average. For example, 33% of staff, compared to a sector average of 36%, reported feeling unwell due to work-related stress. However, as mentioned, staff actually reporting incidents of physical violence, harassment, bullying or abuse at work, the Trust’s performance was significantly worse than the sector average and placed it well within the bottom 20%.

Year on year comparisons show little significant change but there had been a marked improvement in the number of staff saying they know how to report concerns about unsafe clinical practice - up from 87% to 94%.

Your Personal DevelopmentSeven of the ten questions relating to personal development ranked the Trust in the top 20% nationally including:

Agreeing that training helped to do their job more effectively whilst delivering a better patient experience

99% of staff receiving mandatory training in the last 12 months.

91% of staff being appraised in the last 12 months and the appraisal helping them to improve how they did their job.

Noticeably the patient experience measure which included questions regarding effective use of patient feedback is also significantly higher than sector average (3.94 compared to 3.73)

Involvement and engagement 2015-16The Newcastle upon Tyne Hospitals NHS Foundation Trust is committed to patient, carer and public involvement and engagement at all levels to ensure our services are planned around the needs of patients and that continuing improvements in the patient experience are achieved.

Involvement and Engagement activity is monitored in the Trust via the Patient Experience Steering Group and the Health Equality and Wellbeing Committee. Reporting to these forums, we have the Patient, Carer and Public Involvement Group and the Equality, Diversity and Human Rights Working Group. These groups bring together representatives from community and voluntary sector organisations and Trust staff to ensure that patients and the public have equal access to services and that we listen and respond to patient feedback.


Annex 1: Statement on behalf of the Health Scrutiny Committee


Corroborative statement from Newcastle Gateshead, Northumberland and North Tyneside Clinical Commissioning Groups (CCGs) for Newcastle Upon Tyne Hospitals NHS Foundation Trust Quality Accounts 2015/16

The CCGs welcomes the opportunity to review and comment on Newcastle Upon Tyne Hospitals NHS Foundation Trust’s Quality Account for 2015/16 and would like to provide the following commentary.

As commissioners, Newcastle Gateshead, Northumberland and North Tyneside Commissioning Groups (CCGs) are committed to commissioning high quality services from Newcastle Upon Tyne NHS Foundation Trust’s and take seriously their responsibility to ensure that patients’ needs are met by the provision of safe, high quality services and that the views and expectations of patients and the public are listened to and acted upon.

Throughout 2015/16 the CCGs have held bi-monthly quality review group meetings with the Trust; these meetings were well attended and provided positive engagement for the monitoring, review and discussion of quality issues. Newcastle Gateshead CCG has continued throughout 2015/16 to conduct regular commissioner led assurance visits to the Trust to gain assurance and an insight into the quality of care being delivered to patients.

The Quality Account for 2015/16 provides a comprehensive description of the quality improvement work undertaken within the Trust and an open account of where improvements in priorities have been made. The CCGs recognise the work the Trust has achieved to date in the delivery of the 2015/16 priorities and in the ongoing delivery of the quality measures. The CCGs acknowledge that the Trust received a full inspection from the Care Quality Commission (CQC) in January 2016 where the initial feedback was very positive; however the outcome of the inspection is awaited.

The CCGs appreciate the challenge in reducing the incidence of healthcare acquired infections and would like to congratulate the Trust on being below the national trajectory for Clostridium Difficile. The Trust has been working with the CCGs to put in place processes to ensure learning from root cause analysis investigations are communicated and shared. It is disappointing that despite their best efforts the Trust has not achieved the zero tolerance target for MRSA bacteraemia. However, the CCGs fully support the ongoing work the Trust is undertaking in analysing themes arising from investigations and subsequent implementation of actions.

We would like to congratulate the Trust on the work they have done to date on the Sign Up to Safety Campaign and the CCGs recognise the achievements made across all of these areas.

The CCGs appreciate the challenges in reducing the incidence of hospital acquired pressure ulcers and moisture lesions. Whilst it is disappointing that the Trust has seen

Statement on behalf of the Newcastle & Gateshead Clinical Commissioning Group Alliance


an increase in numbers this year the CCGs acknowledge that there has been an increase in patient numbers and fully support the initiatives the Trust has in place to prevent such incidents re-occurring.

The CCGs acknowledge the ongoing work the Trust is undertaking to promote a safety culture within the organisation by encouraging staff to report incidents, errors and near misses; which is evidenced by the Trust’s improved NRLS position. It is disappointing that the Trust reported three ‘Never Event’ during 2015/16 however the CCGs are assured that there are robust processes in place for the investigation of serious incidents to minimise risk of occurrence and that learning is widely disseminated across the organisation.

The CCGs fully support the Trust approach in establishing a Corporate Safeguarding Team to bring together arrangements under one management structure. The CCGs recognise the work the Trust has undertaken to date relating to safeguarding and the further worked planned for 2016/17 to build on the existing robust arrangements.

The CCGs would like to commend the Trust on the work they have undertaken to improve the care and experience of patients with learning disabilities; including supporting a project to develop a regional process to review mortality data, sharing of learning and best practice, staff training and education.

The CCGs acknowledge that the Trust continues to perform well in a number of patient experience measures such as the national surveys and positive comments are also received as part of the Friends and Family Test (FFT). However the CCGs would like to emphasise to the Trust the importance of increasing the FFT response rates above the England averages which will provide a more representative sample of patient experience. The CCGs are aware that the Trust is currently exploring a variety of different ways of promoting FFT and it is hoped that these will help to improve the response rates during 2016/17.

The CCGs recognise the quality improvements undertaken by the Trust including the new outpatients centre in Cramlington which allows Northumberland patients to be seen closer to home. The CCGs would like to congratulate the staff for winning the Health Service Journal workforce award for the Project Choice initiative by offering internships to people with learning difficulties or disabilities, and those with autism.

The CCGs would also like to commend the Trust for carrying out their 1000th procedure using the Da Vinci robot and for the innovative achievements made including being the only centre in the UK using robotic surgery across six specialities; the only centre in 2016 offering robotic surgical training in urology, ENT, Lungs and Gynaecology.

In so far as we have been able to check the factual details, the CCGs view is that the report is materially accurate. It is clearly presented in the format required by NHS England and the information it contains accurately represents the Trust’s quality profile.

Finally, the CCGs would like to offer congratulations to the Trust on the achievements outlined in this report which we believe accurately reflects the Trust commitment to delivering a high quality, patient centred services.


The CCGs look forward to continuing to work in partnership with the Trust to assure the quality of services commissioned in 2016/17.


Statement on behalf of Newcastle Healthwatch

Healthwatch Newcastle Broadacre House Market Street Newcastle upon Tyne NE1 6HQ

0191 338 5720 www.healthwatchnewcastle.org.uk

Healthwatch Newcastle’s statement for Newcastle Upon Tyne Hospitals NHS Foundation Trust’s Quality Account 2015/2016 Firstly we want to thank Newcastle upon Tyne Hospitals NHS Foundation Trust (NUTH) for the efforts made to improve the ease in reading the Quality Account (QA), with less technical language which makes it much more accessible. However we view it as ‘work in progress’ to continue to strive to simplify and shorten it for next year. The report clearly shows the tremendous hard work underway to improve some 2014/2015 priority areas, with an impressive number of initiatives and innovations that make encouraging reading. We appreciate you have also chosen challenging priorities. However as the QA’s aim is to make quality improvements within NUTH in specific key areas our overall impression from the 2014/15 QA review, based on the present report’s content , is that it is a mixed year with only limited improvements made. We will qualify this impression and give more detailed comments related to the 2015/16 results: Priority 1: Healthcare Associated Infections For MRSA the incidence has remained similar for the last five years, with the same incidence this year as last. We understand that significant work has been done in the past and incidence is at a low rate and wonder what further action is planned to reduce levels further and, hopefully, achieve the target of zero cases. We are very pleased that you have exceeded your target for C. difficile in the reporting period. However we see that the incidence has remained similar for the last three years, whereas the national trend has reduced significantly in 2013/14 and 2014/15 (national quality indicators measure 11). We appreciate improvement is challenging from a good incidence rate but we are keen to understand why NUTH isn’t continuing to progress in this area. It would have been helpful to provide previous annual data for MSSA bactaraemia and E.Coli bacterium to show if there is an improving trend with these results. Priority 2: Sign up to Safety (SU2S) We are pleased to read about the initiatives underway with SU2S. We appreciate that base-line data is being collected at the present time, but hope that for the coming year some interim indicators results can be provided to quantify progress in this area. We note that a 50-70% compliance with the ‘escalation of deterioration’ protocol is within acceptable levels nationally and that collaborative research with Oxford University will take place to improve compliance. However, the present compliance sounds like a disappointing result compared to the usual high standard that NUTH attains and we would encourage the trust to push to improve this level. Priority 3: ‘Harm Free Care’, fall and Pressure Ulcers It is pleasing to see that NUTH’s average for falls is below the national average, and significantly below the national average for falls with serious harm. However for this priority area there hasn’t


been improvement over the reporting period. The average fall rate is the same as the previous year and for falls that cause serious harm there has been a slight increase. For pressure ulcers the situation is similar as from the graph it looks like there has been a small increase in cases over the reporting year. It would have been helpful to have simple annual totals between the reporting year and the previous period to show improvement. Priority 4: Human Rights In relation to the learning difficulty mortality reviews, it is unclear from the report if there have been any premature deaths identified in 2015, as it only mentions that 21 people with learning disability died, but not if they were categorized as premature death. If the 21 deaths are premature then this is clearly a cause for concern, however, more information is needed to contextualize this number. There has been a significant increase in reported cases for women’s safeguarding related ‘Cause for Concern’. If this reflects a deeper understanding of the issues concerned and a readiness to report then we welcome this increase. We would like to understand better any action that has been taken that has led to the increased reporting. Priority 5: Clinical Effectiveness In regard to the two mortality indicators (SHMI and HSMR) it is good to read that they are in the ‘as expected’ rates and the lowest in the region. However, from the National Indicators the SHMI rate is slightly increasing, and has been consistently over recent years. For HSMR there is no data provided from previous years to know if the avoidable death rates are reducing. Priority 8: Patient Experience The standout result in this QA from our perspective is the impressive 16% reduction in complaints in 2015/16 compared to the previous year. The increased focus on patient experience, and responding to feedbacks appears to be showing positive outcomes. We believe it would be of public interest to know more information about the listening events conducted by NUTH in the reporting year. How many were conducted on what themes? How many people have attended? It would also be good to see some examples on what service users have said and how you have responded to their requests/suggestions. We would be keen to know more about the development plan for the ‘Friends and Family’ test within NUTH to increase utilisation. In relation to the Duty of Candour, we would like to know more related to how you have progressed with the Duty of Candour initiative, including the implementation of the Datix incident reporting. It would appear an omission to have not mentioned about the ‘cause of significant concern’ rating given to NUTH from the first national public ranking for openness and transparency called the ‘Learning from Mistakes League’ launched by Monitor and the NHS Trust Development Authority. Although the Trust questions the methodology of this league table, With NUTH’s low ranking in this league we think it is in the public’s interest to explain what measures are being taking to improve openness and transparency. Key National Priorities 2015/2016 The A&E wait time under four hours indicator was just missed and we understand, from discussion with trust managers that this has been impacted on by the pressures in other hospitals over the winter. It would be helpful to know what plans there are to reduce the impact and achieve the indicator in the coming year.


We are pleased to read the significant reduction in the 0-15 years re-admission rate within 28 days. However the over 16’s hospital re-admission with 28 days rate has increased. Again, we would be keen to know what has caused this and what plans the trust has to reduce it. It is good to see that the latest data shows that the percentage of staff who would recommend NUTH to others has improved we would like to congratulate you for being the highest ranked trust nationally according to the report. There has been over a 60% increase in the number of patients safety incidents reported that resulted in severe harm or death between 2013/14 and 2014/15 (from 36 to 59). In 2013/14 there were no deaths as a result of safety incidents but two in 2014/15. Again if this reflects a deeper understanding of the issues and a readiness to report then we welcome this increase. We would like to understand better any action that has been taken that has led to the increased reporting. Involvement and Engagement It would be of public interest to hear how the contributions of the four involvement-related trust forums mentioned in the report have made an impact to patient experience. We are disappointed to see that there appears to have been very little public involvement in the review of 2015/2016 and the setting of priorities for 2016/17. We understand that there are constraints as some priorities are nationally set, some are multi-year and most are technical in nature. However we feel strongly that it is important to gather service user’s input when developing this report and this must be seen as a missed opportunity. A better understanding of service users’ priorities would improve the priorities chosen, bringing together NUTH’s internal priorities with those of the public. We would urge NUTH to rethink this for the coming year, and view the involvement of the public in the review and priority setting as a project in itself and include public events as part of the process. We are happy to discuss how this could be done with NUTH’s diverse patient population. Northumberland, Tyne and Wear NHS Foundation Trust has run several events with the public and patient groups, including an online poll for priority setting, for its Quality Account this year. We wish NUTH every success in the coming year to make improvements in the priority areas set and look forward to receiving updates on progress. We will continue to work together to further increase public involvement this year and beyond. Luke Arend Project Manager Direct: 0191 338 5718 Mobile: 07977 872473 Skype: lukearend Healthwatch Newcastle listening event, Wednesday 6 July 2016 Book now at www.healthwatchnewcastle.org.uk/listening-event

Broadacre House Market Street Newcastle upon Tyne NE1 6HQ


Statement on behalf of Northumberland Healthwatch


Annex 2: Abbreviations

Abbreviations

AAA Abdominal Aortic Aneurysm

A&E Accident & Emergency

BAME Black, Asian and Minority Ethnic

BAUS British Association of Urological Surgeons

BTS British Thoracic Society

CAT Clinical Assurance Tool

C&B Choose & Book

CCGs Clinical Commissioning Group

C.diff (CDI) Clostridium difficile

CEA Carotid Endarterectomy

CFCs Cause for Concerns

CIA Carotid Interventions Audit

CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation (CQUIN) payment framework

CT Computersied tomography

CTG Cardiotocography

CYP Children and Young People

CQC Care Quality Commission

CQUIN Commissioning for Quality and Innovation (CQUIN) payment framework

CT Computersied tomography

CTG Cardiotocography

CYP Children and Young People

DMARDs Disease Modifying Anti-Rheumatic Drugs

DOH Department of Health

DoLS Deprivation of Liberty

DVT Deep Vein Thrombosis

E.coli Escherichia coli

ED Emergency Department

ENT Ear Nose and Throat

EoL End of Life

FT Friends and Family Test

FH Freeman Hospital

FGM Female Genital Mutilation

FT Foundation Trust

GP General Practitioner

FGNCH Great North Children’s Hospital

HAREF Health and Race Equality Forum

HCAI Healthcare Associated Infection

HES Hospital Episode Statistics

HIE Hypoxic Ischaemic Encephalopathy

HSCIC Health and Social Care Information Centre

HSMR Hospital Standardised Mortality Ratio

ICNARC Intensive Care National Audit and Research Centre

IPC Infection Prevention and Control

IPCC Infection Prevention and Control Committee

IV Intravenous


Abbreviations

KF Key Finding

LD Learning Disability

LGBT Lesbian, Gay & Bisexual Staff network

MARAC Multi Agency Risk Assessment Conference

MCA Mental Capacity Act

MDT Multi-Disciplinary Team

M&M Morbidity & Mortality

MRSA Methicillin-resistant Staphylococcus aureus

MSSA Methicillin Sensitive Staphyloccus Aureus

N/A Not Applicable

NBOCA National Bowel Cancer Audit

NCEPOD National Confidential Enquiries into Patient Outcome & Death

NENCAHSN North East and North Cumbria Academic Health Science Network

NEQOS North East Quality Observatory

NEWS National Early Warning Score

NHS National Health Service

NHSLA National Health Service Litigation Authority

NICE National Institute for health and clinical excellence

NICOR National institute for clinical outcome research

NOACs Novel Oral Anticoagulants

NRLS National Reporting & Learning System

NUTH Newcastle upon Tyne NHS Foundation Trust

PCNL Percutaneous Nephrolithotomy

PEWS Paediatric Early Warning system

PHE Public Health England

PICU Paediatric Intensive Care Unit

PIR Post Infection Review

PROMs Patient Reported Outcome Measures

QSTs Quality Standards

RCA Root Cause Analysis

RCS Royal College of Surgeons

RCP Royal College of Physicians

RCPH Royal College of Paediatric Health

RCS Royal College of Surgeons

RTT Referral to Treatment Time

RVI Royal Victoria Infirmary

SHMI Summary Hospital-level Mortality Indicator

SIRM Serious Infection Review Meeting

SUIs Serious Untoward Incidents

SUS Secondary Users Service

Su2S Sign up to Safety

TNA Training Needs Analysis

UK United Kingdom

VTE Venous thromboembolism

WHO World Health Organisation


Glossary of Terms

1. CQC The Care Quality Commission (CQC) is the independent regulator of all health and adult social care in England. The aim being to make sure better care is provided for everyone, whether that’s in hospital, in care homes, in people’s own homes, or elsewhere.

2. CQUIN – Commissioning for Quality and Innovation

The CQUIN framework was introduced in April 2009 as a national framework for locally agreed quality improvement schemes. It enables commissioners to reward excellence by linking a proportion of English healthcare provider’s income to the achievement of local quality improvement goals.

3. DATIX DATIX is an electronic risk management software system which promotes the reporting of incidents by allowing anyone with access to the Trust Intranet to report directly into the software on easy -to-use-web pages. The system allows incident forms to be completed electronically by all staff.

4. HSMR The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the death rate at a hospital is higher or lower than would be expected.

5. KO41 The reference used by the Department of Health Statistics Branch(HSIC) to refer to the form used to collect annual information from each Trust about the NHS Written Complaints received during the year, and which in future will be collected quarterly from 1st April 2015, by HSIC and shared with CQC etc.

6. Monitor Monitor is the independent regulator of NHS foundation trusts. Established in January 2004 to authorise and regulate NHS foundation trusts it is independent of central government and directly accountable to Parliament

7. National Reporting and Learning System (NRLS)

The NRLS was established in 2003. The system enables patient safety incident reports to be submitted to a national database. This data is then analysed to identify hazards, risks and opportunities to improve the safety of patient care.

8. Near Miss An unplanned or uncontrolled event, which did not cause injury to persons or damage to property, but had the potential to do so.

9. NHS Safety Thermometer

The NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and “harm free” care. This tool measures four high-volume patient safety issues (pressure ulcers, falls in care, urinary infection (in patients with a catheter) and treatment for venousthromboembolism (Pulmonary embolus or deep vein thrombosis DVT).

10. North East Quality Observatory (NEQOS)

Since 2009 NEQOS has been providing a quality measurement service to NHS trusts (both providers and commissioners) across the North East region. These are delivered with high level analytical skills and clinical epidemiological expertise.

11. NPSA The National Patient Safety Agency leads and contributes to improved, safe patient care by informing, supporting and influencing the health sector.

Annex 3: Glossary of Terms


Annex 4: Feedback form

We would like to hear your views on our Quality Account. The Department of Health directs some of the content of this account i.e. quality measures, that every organisation must publish.

However, the Newcastle upon Tyne Hospitals NHS Foundation Trust has an opportunity to publish information about local quality initiatives. Your feedback will give us an opportunity to include the initiatives you want to hear more about. The results of this feedback will contribute to the development of the Quality Account 2016/17.

An easy read version is available on the Trust website.

Please fill in the feedback form below, tear it off, and return to us, in the post, at the following address:

The Quality and Effectiveness TeamClinical Governance and Risk Department, The Newcastle upon Tyne Hospitals NHS Foundation Trust,Queen Victoria Road, Newcastle upon Tyne, NE1 4LP

Or alternatively e-mail your comments to: [email protected]

Feedback Form (please circle all answers that are applicable to you)

What best describes you: Patient/carer/member of public/staff/other

Did you find the Quality Account easy to read? Yes No

Did you find the content easy to understand? Yes all of it Most of it None of it

Did the content make sense to you? Yes all of it Most of it None of it

Did you feel the content was relevant to you? Yes all of it Most of it None of it

Would the content encourage you to use our hospital? Yes all of it Most of it None of it

Did the content increase your confidence in the services we provide? Yes all of it Most of it None of it

Are there any subjects/topics that you would like to see included in next year’s Quality Account?

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In your Opinion, how could we improve Our Quality Account?

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Thank you for your time.

Quality Account 2015/16

Freeman Hospital (Headquarters)High HeatonNewcastle upon TyneNE7 7DNTelephone: 0191 233 6161Fax: 0191 213 1968

This information can be requested in large print

Unconditionally registered with the CQC since April 2010

graded as outstanding by CQC 2016

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