Airedale NHS Foundation Trust Data Pack 18th November, 2013 · 2014-05-06 · Foster Hospital Guide 2012). The graph below was provided by the trust, and details their bed occupancy

Airedale NHS Foundation Trust

Data Pack

18th November, 2013

CQC Slide 2

CQC view If you have 5-10 minutes

‘At a glance’: 3-4

Context: 8

Safe: 26 - 27

Effective: 39 - 41

Caring: 46 - 48

Responsive: 56 - 59

Well-led: 62 - 63

If you have 2-3 hours All of the report

To help you

navigate through

the report, here is

some guidance on

which sections of

the report you

should read

depending on the

time you have

available.

At a

glance

Reading this report

CQC

Within the Picker Institute NHS Staff Survey 2012 the

proportion of staff that felt satisfied with the quality of

work and patient care they were able to deliver was

worse than expected. Other staff survey indicators

show similar or better than expected performance.

Individual SHMI results for the overall Trust, elective

and non elective are within range. However

exceptions of performance statistically worse than

expected are shown in Geriatric medicine and

Medical oncology. These are being driven by small

numbers of patient deaths above the expected value.

23 inpatient survey questions rate cancer care as

within the top 20% of trusts, including the proportion

of patients rating their cancer care as ‘excellent’ or

‘very good’. The CQC adult inpatient survey 2012

shows an improvement upon last years results,

excluding data for ‘the perception of waiting for a bed

upon arrival’, which decreased by 0.6 since 2011.

Background

Airedale NHS Foundation Trust is an acute services

provider with three sites and a total of 395 beds.

The local health economy in which the trust operates

serves a population of over 200,000. Cardiovascular

disease is a leading cause of death and the second

most significant cause of premature death. Cancer is

the leading cause of premature death and the second

most significant cause of all deaths in the area.

The acute trust sits on three sites; Airedale General;

Castleberg and Skipton General (though the latter is

covered by the other sites’ registration and is

therefore not an active location on CQC CRM).

Within a five mile radius there is also Burnley General

Hospital.

Operational and Clinical Performance

Between 1 May and 31 July 2013, 16 STEIS serious

incidents were reported, none of which were Never

Events. They are statistically within control limits for

the number of incidents by notification type (e.g.

Death, severe harm).

There was an elevated spike in new pressures ulcers

in January 2013, in addition to a spike in the rate of

falls within the over 70 age group in September 2012.

All infection control metrics are within range.

Slide 3

CQC view

Airedale NHS

Foundation Trust

is performing well

across a number

of metrics with no

flagged Tier 1

indicators.

Elevated mortality

is noted for a

number of

specialties and

diagnostic groups.

Monthly spikes

are noted in some

Patient Safety

Thermometer

indicators.

At a

glance

CQC

The trust is meeting the A&E national target; although

a significant drop in this was noted at Christmas 2012

and May 2013. A higher proportion of patients are

leaving A&E without being seen for treatment

compared to the national average. However the rate

of unplanned re-admittance within 7 days is lower

than the national average.

Airedale is performing above expected in the number

of cancelled operations. No Tier 1 indicators are

flagged within the Responsive domain.

The trust is incorrectly coding 14.2% of primary

procedures in comparison to the national rate off 7%.

All Tier 1 well-led indicators are within range. The

Board has remained stable over the years with the

Chairman being in post since 2005 and the Chief

Executive has been in post since 2010.

The NHS Staff Survey shows polarised results with a

number of higher or lower expected risk across a

number of indicators, while a number of audits are

also noted for review. This includes the Royal College

of Physicians Stroke Audit 2012, which showed a

number of areas where performance is trending

towards worse than expected.

Slide 4

CQC view

Contrasting views

are noted in a

number of

indicators from

surveys, with

some noted as

performance

better than

expected and

some with

elevated risk.

The stroke audit

identified a

number of areas

trending towards

worse than

expected.

The Trust’s

incorrect coding of

primary

procedures is

significantly above

the national

average.

At a

glance

CQC

Contents: By Domain

Slide 5

Responsive Safe

Effective

Caring

Well-led 62

26

39

46

56

Page No. Page No.

CQC Slide 6


Key Facts


(RCF )

Inspection pack prepared: August

2013

Reason for inspection: The trust

was selected for inspection as a

benchmark. It is considered a low

risk trust with no identified Tier 1

indicators flagged as ‘risk; or

‘elevated risk’.

FT status: Airedale NHS

Foundation Trust attained foundation

trust status on 1 June 2010.

What is a Tier 1 Indicator?

Tier 1 Indicators are the key metrics the CQC uses to help decide where and what to

inspect. These Tier 1 indicators have been selected on the basis of statistical robustness,

ability to identify poorly performing trusts and their ability (as a group) to cover multiple

dimensions of quality. These indicators are constantly being refined as more is learnt.

Within each of the five domains (Safe, Effective, Caring, Responsive and Well-led), there

are a number of indicators (items) that have been assessed for each trust. For each

indicator, the trust will be rated as ‘within expectations’, ‘risk’ or ‘elevated risk’. A summary of

the ‘risks’ and ‘elevated risks’ for Airedale are on the following page.

CQC Slide 7

Safe Effective Caring Responsive Well-led

Number of Items 8 76 8 10 10

Number of Risks 0 0 0 0 0

Number of

elevated risks 0 0 0 0 0

Domain risk

rating 0 0 0 0 0

Tier 1 Risks by Domain (Trust Level)

CQC

Context

Bed occupancy between April and

June 2013

The Board has remained stable over the

years with the Chairman being in post

since 2005

79.6%

Slide 8

98% Population

registered with a

GP

The trust serves a

population of over

200,000

Cardiovascular

disease is a

leading cause of

death

CQC

Trust Profile

There are three sites within the trust; Airedale General Hospital,

Castleberg Hospital, and Skipton General Hospital (although,

as it has no inpatient beds, this is covered by the other sites’

registration with the CQC). Airedale General is the main acute

hospital for the trust. Castleberg Hospital is a community

inpatient unit with 10 beds, providing intermediate care,

assessment and active rehabilitation, symptom control,

palliative care and end of life care to adult patients.

Slide 9

Departments and Services

Accident & Emergency; Cardiology; Children's & adolescent services;

Diabetic medicine; Dietetics; Diagnostic physiological measurement; Ear,

nose and throat; Endocrinology and metabolic medicine; Gastrointestinal

and liver services; General Surgery; Geriatric Medicine; Gynaecology;

Haematology; Maternity services; Neurology; Ophthalmology; Oral and

maxillofacial surgery; Orthopaedics; Orthotics and prosthetics; Plastic

surgery; Rheumatology; Sleep medicine; Surgery – breast; Surgery –

vascular and Urology.

Finance Information 2012-13 2013-14

Budgeted Income £141.0m *

Budgeted Expenditure** £137.9m *

Budgeted EBITDA £6.7m *

Budgeted Net Surplus

(deficit) £2181k *

Well-led Caring Effective Safe Responsive Context

Source: Trust Board minutes approved 22 May 13. Please see Appendix for site map of Airedale General Hospital.

Note: 2013-14 financial data not currently available.

*EBITDA: Earnings Before Interest, Taxes, Depreciation and Amortisation

CQC

Bed Occupancy

Between April and June 2013 the trust’s bed occupancy was

79.6%, compared to the England average of 86.5%. It is

generally accepted that, when occupancy rates rise above 85%,

it can start to affect the quality of care provided to patients and

the orderly running of the hospital (see, for example, the Dr

Foster Hospital Guide 2012).

The graph below was provided by the trust, and details their bed

occupancy between April 2010 and July 2013 by occupied bed

days per month.

The graph below details the bed occupancy as a percentage

of available beds occupied overnight for the time period

between April 2011 and June 2013.


Slide 10

0

2000

4000

6000

8000

10000

12000

14000

Ap

r-10

Jun

-10

Au

g-1

0

Oct-

10

Dec-1

0

Fe

b-1

1

Ap

r-11

Jun

-11

Au

g-1

1

Oct-

11

Dec-1

1

Fe

b-1

2

Ap

r-12

Jun

-12

Au

g-1

2

Oct-

12

Dec-1

2

Fe

b-1

3

Occu

pie

d b

ed

da

ys p

er

mo

nth

Occupied Bed Days per Month

75%

80%

85%

90%

95%

100%

Apr toJun

2011

Jul toSep2011

Oct toDec2011

Jan toMar2012

Apr toJun

2012

Jul toSep2012

Oct toDec2012

Jan toMar2013

Apr toJun

2013

Perc

en

tag

e b

ed

oc

cu

pa

ncy

Average Total Daily Percentage of Available Beds Occupied Overnight

Airedale NHS Foundation Trust 2011 to 2013

Airedale NHS Foundation Trust England Average

Source: Health Evaluation Data, Apr 10 – Mar 13 Source: NHS England Unify2 Data Collection, Apr 11 – Jun 13

CQC

Trust Board and Organisation Structure

The table to the right details the members of the trust board and

their roles.

The job of the Board of Directors is to agree policy, monitor the

delivery of that policy, ensure the financial viability of the trust,

and ensure clinical quality in the trust.

The Board's is regulated by its Standing Orders that govern: the

proceedings of Board meetings; the way responsibilities are

delegated; standards of business conduct and contract

procedure. Included in the Standing Orders are the Standing

Financial Instructions, which detail the financial policies,

responsibilities and procedures to be applied in the trust.

The board hold monthly public board meetings. Since becoming

a foundation trust in June 2010, they also have a Council of

Governors, which holds quarterly meetings in public.

All executive roles within the trust’s board are permanent.

Board Member’s Role Name

Chairman Colin Millar

Chief Executive Bridget Fletcher

Medical Director Andrew Catto

Director of Nursing Rob Dearden

Director of Finance Andrew Copley

Director of Strategy and Business

Development Ann Wagner

Non-Executive Director David Adam

Non-Executive Director Michael Toop

Non-Executive Director Ronald Drake

Non-Executive Director Sally Houghton

Non-Executive Director Anne Gregory


Slide 11

CQC

Trust Board and Organisation Structure

Colin Millar

Chairman

In post since:

December, 2005

Bridget Fletcher

Chief Executive

In post since:

November 2010

Dr Andrew Catto

Medical Director

In post since:

August 2009

Rob Dearden

Director of Nursing

In post since:

July 2012

Andrew Copley

Director of Finance

In post since:

January 2013

Ann Wagner

Director of Strategy

and Business

Development

In post since:

September 2006

David Adam

Non Executive

Director

In post since:

February 2007

Dr Michael Toop

Non Executive

Director

In post since:

February 2013

Ronald Drake

Non Executive

Director

In post since:

February 2007

Sally Houghton

Non Executive

Director

In post since:

February 2006

Anne Gregory

Non Executive

Director

In post since:

June 2012


Slide 12

CQC

FACT BOX

Population

Craven and Pendle have a combined population of

144,861, while Bradford has a population of 522,452.

Approximately 98% of the local population are

estimated to be registered with a GP, which is in line

with the national average.

The Royal College of Surgeons recommend that the "...catchment

population size...for an acute general hospital providing the full range of

facilities, specialist staff and expertise for both elective and emergency

medical and surgical care would be 450,000 - 500,000."

Index of Multiple

Deprivation

Of the 326 authorities nationally, Bradford, Craven

and Pendle are the 33rd, 241st and 41st most

deprived, respectively.

Ethnic diversity

95% of the population of Craven are White British. In

Pendle, 20% of the population belong to non-White

minorities. Of these, Pakistanis constitute the largest

ethnic group, with 17.1% of the population.

Pakistanis also account for 20% of the population of

Bradford

Rural or Urban Craven and Pendle are both rural regions, while

Bradford is an urban area,

Disease and poor

health

Diabetes diagnosis is statistically higher than the

national average in both Bradford and Pendle, as are

drug misuse and hospital stays for alcohol related

harm.

Life expectancy and

causes of death

Life expectancy is lower than the national average in

both Bradford and Pendle, while there are also local

concerns over infant and smoking related deaths.

However, life expectancy is above the national rate

in Craven.

Area Overview

Airedale is on the western edge of the Yorkshire Dales National

Park and, as with many of the dales, Airedale gets its name from

the river that runs through the valley.

Airedale NHS Foundation Trust provide personalised, acute,

elective, specialist and community care for a population of over

200,000 people from a widespread area covering West and

North Yorkshire and East Lancashire.

As Airedale is a geographical area, it is not possible to collect

data for it from the ONS or Health profiles, as these are based

on local authority boundaries. Therefore, data has instead been

provided for Bradford, Craven and Pendle, three of the primary

regions served by the trust.

Percentage of Population Registered with a GP

Approximately 98% of the population of Airedale are registered

with a GP, which is in line with the national average. This figure is

based on the average across the various Local Authority areas

covered by Airedale; Yorkshire and Humber (100%), Bradford

and Airedale Teaching (98%), North Yorkshire and York (98%)

and East Lancashire Teaching (96%).

Sources: Office for National Statistics, statistics.gov.uk, Royal College of Surgeons, data.gov.uk,

2011 Census for England and Wales, Public Health Observatories – area health profiles


CQC

Area Overview

Area Demographics

The area demographic pyramid to the right demonstrates the

combined population distribution for Bradford, Craven and

Pendle. The majority of the population of the area is evenly

distributed between 0 and 69, although the age distribution is

more skewed towards the younger age groups than is typical

nationally, with a greater than average proportion of the

population concentrated in the 0-9 and 10-19 age bands. There

is minimal difference between the male and female figures.

Area Deprivation

Health profiles are designed to help local government and health

services identify problems in their areas and decide how to

tackle these issues. They provide a snapshot of the overall

health of the local population and highlight potential differences

against regional and national averages.

The graph to the right shows the levels of deprivation in

Bradford, Craven and Pendle compared nationally. As can be

seen from the graph, in which higher values represent greater

degrees of deprivation, there is significant variation between the

three unitary authorities.

Deprivation by Unitary Authority Area

Source: 2011 Census, Office for National Statistics


Slide 14

Pendle

Craven

Source: Public Health Observatories – Area Health Profiles

Bradford

20% 15% 10% 5% 0% 5% 10% 15% 20%

0-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

Over 80

Area Demographics

England Male England Female

CQC

Area Overview continued…

Health profiles are designed to help local

government and health services identify problems in

their areas and decide how to tackle these issues.

They provide a snapshot of the overall health of the

local population and highlight potential differences

against regional and national averages. The tables

below outline Bradford, Craven and Pendle’s health

profile information in comparison with the rest of

England.


Slide 15

Craven is

performing above

the national

average for all six

‘Communities’

indicators.

However,

deprivation, child

poverty, and

GCSE attainment

are all concerns in

Pendle. These

concerns are also

present in

Bradford, which

also suffers from a

high incidence of

long-term

unemployment.


CQC view

CQC


The table below further details the health profiles for

Bradford, Craven and Pendle unitary authorities.


Slide 16

The incidence of

smoking during

pregnancy and

teenage

pregnancy are

higher and a

cause for concern

in both Bradford

and Pendle.

Bradford also has

a high prevalence

of obesity

amongst children.

Alcohol-specific

hospital stays for

under 16 year olds

are also more

common in Pendle

than England on

the whole.

Bradford can be

seen to be

performing worse

than its peers for

levels of both

healthy eating and

obesity among

adults.


CQC view

CQC





Slide 17

Diabetes is

statistically more

prevalent in

Bradford and

Pendle than in the

nation on the

whole, as are

hospital stays for

alcohol related

harm,

tuberculosis, drug

misuse, and

hospital stays for

self-harm.

Craven is

performing

significantly better

than the nation on

the whole for four

of the six

indicators in this

domain.


CQC view

CQC





Slide 18

Life expectancy

amongst both men

and women is

below the national

rate in Pendle,

while the area is

also performing

significantly worse

than average for

infant deaths, and

road injuries &

deaths.

Bradford also

suffers from low

life expectancy,

while there is also

a high incidence of

infant and

smoking related

deaths.

Life expectancy in

Craven, however,

is above the

national average

for both men and

women.


CQC view

CQC

Airedale Geographic Overview

The map on this page shows the location of the main sites belonging to Airedale NHS Foundation Trust, located on the western

edge of the Yorkshire Dales National Park. The trust has three locations; Airedale General Hospital, Skipton General Hospital (not

registered with CQC) and Castleberg Hospital. All three sites are located within a ten mile radius of each other.

Slide 19

Source: © Google Maps


CQC Slide 20

CQC Inspection History

The diagram below details the timeline of Airedale’s most recent inspections:

Airedale NHS Foundation Trust (RCF) has been inspected five times since registration, which occurred on 1 April 2010.

Airedale General Hospital

This location has been inspected three times since it was registered with CQC and has never been judged non-compliant.

Outcomes covered in the three inspections were 1 (R17) Respecting and involving people who use services, 4 (R9) Care and

welfare of people, 5 (R14) Meeting nutritional needs and 21 (R20) Records.

Castleberg Hospital

This location has been inspected twice since it was registered with CQC. During the August 2012 inspection, it was judged non-

compliant minor impact for outcome 1 (R17) Respecting and involving people who use services and outcome 21 (R20) Records.

Both were judged compliant in the follow up inspection in March 2013.

Other outcomes inspected at this location are 5 (R14) Meeting nutritional needs, 7 (R11) Safeguarding people who use services

from abuse and 13 (R22) Staffing.


CQC Slide 21


The current compliance of Airedale General Hospital by outcome is detailed in the table below:

Location Outcome Latest Judgement Judgement Date

Airedale General

Hospital

Outcome 1 (R17) Respecting and involving people who use

services June 2011

Outcome 2 (R18) Consent to care and treatment April 2010

Outcome 4 (R9) Care and welfare of people who use services December 2012

Outcome 5 (R14) Meeting nutritional needs June 2011

Outcome 6 (R24) Cooperating with other providers April 2010

Outcome 7 (R11) Safeguarding people who use services from

abuse April 2010

Outcome 8 (R12) Cleanliness and infection control April 2010

Outcome 9 (R13) Management of medicines April 2010

Outcome 10 (R15) Safety and suitability of premises April 2010

Outcome 11 (R16) Safety, availability and suitability of equipment April 2010

Outcome 12 (R21) Requirements relating to workers April 2010

Outcome 13 (R22) Staffing April 2010

Outcome 14 (R23) Supporting staff April 2010

Outcome 16 (R10) Assessing and monitoring the quality of service

provision April 2010

Outcome 17 (R19) Complaints April 2010

Outcome 21 (R20) Records June 2012


Compliant Non-Compliant -Moderate Impact

CQC Slide 22


The current compliance of Castleberg Hospital by outcome is detailed in the table below:

Location Outcome Latest Judgement Judgement Date

Castleberg Hospital

Outcome 1 (R17) Respecting and involving people who use

services March 2013

Outcome 2 (R18) Consent to care and treatment March 2011

Outcome 4 (R9) Care and welfare of people who use

services March 2011

Outcome 5 (R14) Meeting nutritional needs October 2012

Outcome 6 (R24) Cooperating with other providers March 2011

Outcome 7 (R11) Safeguarding people who use services

from abuse October 2012

Outcome 8 (R12) Cleanliness and infection control March 2011

Outcome 9 (R13) Management of medicines March 2011

Outcome 10 (R15) Safety and suitability of premises March 2011

Outcome 11 (R16) Safety, availability and suitability of

equipment March 2011

Outcome 12 (R21) Requirements relating to workers March 2011

Outcome 13 (R22) Staffing October 2012

Outcome 14 (R23) Supporting staff March 2011

Outcome 16 (R10) Assessing and monitoring the quality of

service provision March 2011

Outcome 17 (R19) Complaints March 2011

Outcome 21 (R20) Records March 2013


Compliant Non-Compliant – Moderate Impact

CQC

CQC Inspection Comments

It should be noted that only negative comments from CQC inspections have been displayed here.

Section Outcome Name Comment Comparison

with Expected

Date of

comment

Section 1 – Information

and Involvement

Outcome 1 (R17)

Respecting and involving

people who use services

Castleberg Hospital; Nursing care - The provider was not meeting this

standard. We judged this had a minor impact on people using the service

and action was needed for this essential standard. Suitable arrangements

had not been made to ensure patients had participated in making decisions

relating to their care and treatment by means of involving people in their care

planning.

Negative

Comment 04/10/2012

Section 5 – Quality and

Management

Outcome 21 (20)

Records

Castleberg Hospital; Nursing care - The provider was not meeting this

standard. We judged this had a minor impact on people using the service

and action was needed for this essential standard. Accurate records and

care plans had not been maintained to ensure that service users are

protected from the risks of unsafe or inappropriate care.

Negative

Comment 04/10/2012


Slide 23

CQC

Performance of Local Health Care Providers

To give an informed view of the trust’s performance

it is important to consider the service levels of non-

acute local providers. For example, slow ambulance

response times will greatly increase the risk of

mortality. NHS England collects data on three key

performance indicators for England’s Ambulance

services. These are:

• Category A (Red 1) incidents: presenting

conditions, which may be immediately life

threatening. National target 75%

• Category A (Red 2) incidents: presenting

conditions, which may be life threatening but less

time-critical. National target 75%

• Category A calls (Red 1 and Red 2) resulting in

an ambulance arriving at the scene of the incident

within 19 minutes. National target 95%

The following graphs show the performance of

ambulance services in England over a three month

period, April to June 2013. The graphs show that the

Yorkshire Ambulance Service met or exceeded the

targets for all three of the indicators.

Category A (Red 1) Incidents: Presenting Conditions which may

be Immediately Life Threatening – National Target 75%


Slide 24

Source: NHS England, Apr 13 – Jun 13

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ea

st M

idla

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Ea

st of E

ngla

nd

Isle

of W

ight

London

Nort

h E

ast

Nort

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est

So

uth

Centr

al

So

uth

East C

oast

So

uth

Weste

rn

West M

idla

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Yo

rksh

ire

Apr-13 May-13 Jun-13 National Target

CQC

Performance of Local Health Care Providers continued…

Category A (Red 2) Incidents: Presenting Conditions which may

be Life Threatening but Less Time-critical - National Target 75%

Category A Calls (Red 1 and Red 2) Resulting in an

Ambulance Arriving at the Scene of the Incident Within 19

Minutes - National Target 95%


Slide 25

66%

68%

70%

72%

74%

76%

78%

80%

82%

84%

Ea

st M

idla

nds

Ea

st of E

ngla

nd

Isle

of W

ight

London

Nort

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ast

Nort

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est

So

uth

Centr

al

So

uth

East C

oast

So

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Weste

rn

West M

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90%

91%

92%

93%

94%

95%

96%

97%

98%

99%

Ea

st M

idla

nds

Ea

st of E

ngla

nd

Isle

of W

ight

London

Nort

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ast

Nort

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est

So

uth

Centr

al

So

uth

East C

oast

So

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Weste

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Source: NHS England, Apr 13 – Jun 13

CQC

Rate of

falls is

above

national

average

Within

expected

range for

all Tier 1

indicators

NO Never Events reported by the trust

in the past 12 months.

Safe

New

pressure

ulcer

spike in

January

2013

39% of

NRLS

incidents

occurred in

General

Medicine

Slide 26

CQC

Safe Dashboard

Framework Section Indicator RAG

Avoidable infections

MSSA infections (Trust apportioned) -

May 2012 - April 2013 N/A

MRSA infections (Trust apportioned)

C. Diff infections (Trust apportioned) -

May 2012 - April 2013

E-coli infections - May 2012 - April

2013 N/A

Under-reporting

NRLS under-reporting across all

notifications (Death, Severe Harm,

Moderate Harm, Abuse)

NRLS under-reporting of Death and

Severe Harm notifications

Never Events Never Events reported to STEIS

Deaths in low risk

conditions / procedures

Dr Foster: Deaths in low risk

conditions

Well-led Caring Effective Responsive Context

Slide 27

Additional Information RAG

STEIS Never Events

STEIS Serious Incidents

NRLS Notifications

Pressure Ulcers

VTE

Falls

Staff Survey

Additional Information

Additional information has been included in the pack to provide a

more holistic view of the trust’s performance. These are listed

below.

`

Safe

‘Risk’ or ‘Elevated Risk’

Within expectations

CQC Slide 28

STEIS Data

Never Events

Between 1 April 2011 and 31 July 2013 there has been no Never

Events report by the trust. A Never Event is classified as such

because they are so serious that they should never happen.

Serious Incidents

Between 1 May and 31 July 2013, 16 serious incidents were

reported. None were classified as Never Events. The incidents

reported by the trust took place between 27 April and 24 July

2013.

11 of the reports relate to incidents that occurred at Airedale

General Hospital (as opposed to incidents reported that occurred

in the community – in patient’s homes and residential care

settings, for example). Of these 11 reported incidents:

• three concerned grade 3 pressure ulcers;

• three concerned slips, trips and falls;

• two concerned unplanned maternity admissions to the ITU;

• one unexpected death of an inpatient being treated for

mental health concerns;

• one delayed diagnosis; and

• one incident classified as ‘maternity service’.

Source: Strategic Executive Information System (STEIS) Data, May – Jul 13


CQC

Incident Reports to the NRLS

Since 2004 trusts have been encouraged to report all patient

safety incidents to the NRLS, and since 2010 it has been

mandatory for them to report all death or severe harm incidents

to the CQC via the NRLS.

There were 115 incidents reported by Airedale NHS Foundation

Trust to the NRLS between June 2012 to May 2013.

Incidents Reported between June 2012 to May 2013

Slide 29

Org

Name Abuse Moderate Severe Death

Total #

Incidents

Airedale

NHS FT 36 69 4 5 115

Death:

Out of the five deaths, two occurred within Medical Specialties,

one within Obstetrics and Gynaecology, one in ‘other’ and one

A&E. Two incidents may have involved incorrect drug

administration, including one incidence of a drug not being

administered.

Severe Harm:

Three of the four incidents involved patient accidents from slips,

trips or falls; these patients were found by their respective beds

or trolleys, and two patients required care for lacerations.

Source: National Reporting Learning System (NRLS) , 1 Jun 12 – 31 May 13


CQC

Incident Reports to the NRLS continued…

Moderate Harm:

42 of the 69 moderate harm notifications related to treatment or

procedure, followed by 22 for patient accidents.

Abuse:

25 out of the 36 abuse notifications were reported under the

category type patient abuse (by staff /third party). 12 of these

incidents occurred within medical specialties.

An additional 11 incidents were recorded for disruptive,

aggressive behaviour (including patient to patient).

Slide 30

Location of incidents


0 20 40 60 80 100 120

Community hospital

General / acute hospital

Primary care setting

Number of notifications

Location (level 2) of notification Number of notifications

Accident (A) / minor injury unit / medical

assessment unit 7

Inpatient areas 89

Other 14

Outpatient department 4

Support Services 1

Total 115


CQC


Patient safety incidents by date June 2012 to May 2013

Slide 31

CQC view

The number of

notifications

received is primarily

attributable to

Medical specialties

followed by

Surgical specialties

and Primary

Care/Community

specialties.


Specialty Abuse Deaths Moderate Severe (blank) Grand Total

Accident and Emergency (A&E) 3 1 3 7

Medical Specialties 20 2 33 2 1 58

Obstetrics and Gynaecology 1 1 4 6

Other 4 1 2 1 8

Primary Care / Community 5 12 17

Surgical Specialties 3 15 1 19

Grand Total 36 5 69 4 1 115


CQC


Z-score Analysis

For any set of values, a z-score is a measure of how far any

single value is from the mean of all of the values. It is expressed

in standard deviations, with zero indicating a value equal to the

mean, a negative Z-score indicating a value less than the mean,

and a positive Z-score indicating a value greater than the mean.

Analysis of the z-scores for all patient safety incidents (June

2012 to May 2013) across all specialties indicates that the trust’s

reporting is statistically acceptable within control limits for all

notification categories.

The table below details the trust’s z-score for all notifications and

combined severe harm and death notifications.

The table below details the Trust’s z-score for all notifications

and combined severe harm and death notifications.

Slide 32

Notification

type Z score value RAG

Observed

value

Expected

value

All -0.88 115 209

Abuse 0.73 36 20

Moderate -1.04 69 168

Severe + Death -0.92 10 21

Severe -1.08 5 16

Death 0.02 5 5

Significantly high number of

notifications

Statistically acceptable; within

control limits


Please note: The expected values have

been rounded to whole numbers


CQC

Pressure Ulcers – New

This slide outlines the percentage of patients in

hospital on the date of a monthly survey who had a

pressure ulcer acquired after their admission to the

trust. Due to the effects of seasonality on hospital

acquired pressured ulcer rates, the national rate has

been included. However caution should be used

when comparing the trust to the national average as

this does not account for trust-to-trust variation in

the demographic make-up of the population.

Airedale has a higher than the national average for

most months over the time period. This includes

periods where the pressure ulcers rates are over

double the national average, during the winter of

2013.

Pressure Ulcers - New Patients Over 70

Over the 13 month period the trust’s rate of new

pressure ulcers has been generally above the

national average. However, between November 12

and February 13, the trust was over double the

national rate, as seen with the overall new pressure

ulcer trend.

CQC view

The proportion of

patients with new

pressure ulcers on

the day of survey

spiked in January

2013, but has

remained at a low

level since then. It

is important that

precautions are

put in place to

ensure that such a

spike cannot

happen in future.

Source: Safety Thermometer, Jul 12 – Jun 13


Slide 33

0

2

4

6

8

10

12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Perc

en

tag

e o

f p

ati

en

ts

Pressure Ulcers – New

Airedale National Average

0

2

4

6

8

10

12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Perc

en

tag

e o

f p

ati

en

ts

Pressure Ulcers - New Patients over 70


CQC

VTE (Venous Thromboembolism)

VTE– New

This slide outlines the percentage of patients

suffering from new VTE on the date of a monthly

survey. If treatment for the VTE was started after

the patient was admitted to the service, it is counted

as a new case of VTE. Again, the rate of new VTE

cases is similar to that of the national average.

It must be noted that caution should be used when

comparing the trust to the national average as this

does not account for trust-to-trust variation in the

demographic make-up of the population.

The proportion of

patients with new

VTE on the day of

the survey has

fluctuated above

and below the

national average

with a peak in

December 2012.

Since April 2013

the trust has been

broadly in line with

the national

average, the trust

should continue to

manage this

effectively.


Slide 34


CQC view

0

2

4

6

8

10

12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Perc

en

tag

e o

f P

ati

en

ts

VTE - New


CQC

Catheter & UTI

For urinary infections in patients with a catheter

over the last 13 months the trust has been close to

the national average. There is a similar trend for the

patients in the over 70s patient group.

It must be noted that caution should be used when

comparing the trust to the national average as this

does not account for trust-to-trust variation in the

demographic make-up of the population.

The trust’s is

performing close

to the national

average for

Catheter and UTI

infections

throughout the

period. The trust

should continue to

effectively manage

this.


Slide 35

0

2

4

6

8

10

12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Perc

en

tag

e o

f p

ati

en

ts

Catheter & UTI

Airedale All

0

2

4

6

8

10

12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Perc

en

tag

e o

f p

ati

en

ts

Catheter & UTI – Patients Over 70

Airedale All


CQC view

CQC

Falls

Over the last 13 months the trust has been above

the national rate in all but three months. There is a

similar trend for patients in the over 70s age group.

The trust’s fall rate

spiked in

September 2012

due to an increase

in falls

experienced by

patients in the

over 70s age

group. Steps to

mitigate the

chances of

another spike

occurring in the

run up to Winter

2013 should be

taken.


Slide 36

0

2

4

6

8

10

12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Perc

en

tag

e o

f p

ati

en

ts

Falls

Airedale All

0

2

4

6

8

10

12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13

Ap

r-13

Ma

y-1

3

Jun

-13

Jul-1

3

Perc

en

tag

e o

f p

ati

en

ts

Falls – Patients Over 70

Airedale All

Source: Safety Thermometer, Jul 12 – Jul 13

CQC view

CQC

Data item

source Data item RAG

Department

of Health,

Survey of

NHS Staff

(Sep 12-

Dec 12)

KF5. % working extra hours

KF12. % saying hand washing materials are

always available

KF14. % reporting errors, near misses or

incidents witnessed in the last month

General

Medical

Council,

National

Training

Surveys

(Mar 13 –

May 13)

Trainees rated their clinical supervisor on

whether they felt forced to cope with clinical

problems beyond their competence or

experience

This measures the quality of educational

supervision by asking trainees about the

support and management they were getting in

their training from their educational supervisor

This asked trainees to assess their overall

workload to establish how appropriate it was

to learning and developing experience and

skills during their training

Picker

Institute

Europe,

NHS Staff

Survey

(2012/13)

78% of staff felt satisfied with the quality of

work and patient care they are able to deliver

59% of staff would recommend the trust as a

place to work or receive treatment

28% of staff witnessed potentially harmful

errors, near misses or incidents in last month

The trust scored in

the bottom 20% of

all trusts for the

percentage of staff

who felt satisfied

with the quality of

work and patient

care they were

able to deliver.

Worse than expected

Similar to expected

Better than expected


Slide 37

Staff Survey Data Items Relevant to the Safe

Domain

Sources: NHS Staff Survey, Sep 12 – Dec 12; GMC National Training Surveys, Mar 13 – May 13; Picker Institute Europe, NHS Staff Survey, 12/13

CQC view

CQC

Infection Control Data - Airedale NHS Foundation

Trust

C. difficile Infections

During the 12 months from July 2012 to June 2013,

the trust reported 15 cases of C. difficile infections.

Statistical analysis of C. difficile infection data over the

period July 2012 to June 2013 shows that the number

of infections reported by Airedale NHS Foundation

Trust is lower than the expected number, taking into

account the trust’s size and the national level of

infections.

MRSA Infections

During the 12 months from July 2012 to June 2013,

the trust reported one case of MRSA infection in

August, 2012.

Statistical analysis of MRSA infection data over the

period April 2012 – March 2013 shows that the

number of infections reported by Airedale NHS

Foundation Trust is in line with the expected number,

taking into account the trust’s size and the national

level of infections.

MSSA Infections

During the 12 months from July 2012 to June 2013, the

trust had a total of five infections; one a month in July,

August, November, January and April.

Statistical analysis of MSSA infection data over the

period July 2012 – June 2013 has not been undertaken

as the MSSA is a relatively new infection control

indicator, for which the relationship to the quality of care

is yet to be fully established.

The trust’s

infection rates for

C. difficile are

statistically better

than expected,

while MRSA and

MSSA rates are

statistically within

the expected

range. The trust

should continue to

effectively control

infection rates.

Bacteria 2012 2013

Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun

C. difficile 1 2 1 2 3 1 2 0 0 2 1 0

MRSA 0 1 0 0 0 0 0 0 0 0 0 0

MSSA 1 1 0 0 1 0 1 0 0 1 0 0


Slide 38

CQC view

CQC Slide 39

SHMI

96

Elective

SHMI

103

Non-elective

SHMI

96

Effective Treatment specialties with “above expected” SHMIs

Geriatric

Medicine

978

Medical

Oncology

333

CQC

Effective Dashboard


Slide 40

Framework Section RAG

Trust level

Urogenitary care and conditions/ Renal failure

A&E and trauma care

Stroke

Cardiac conditions and care/ Acute myocardial infarction

Cardiac conditions and care/ Cardiac surgery

Vascular conditions and care/ Aneurysms

Cardiac conditions and care/ Cardiac arrhythmia

Respiratory conditions and care/ Chronic obstructive

pulmonary disease

Skin conditions and care/ Skin diseases

Cardiac conditions and care/ Heart failure

Cardiac conditions and care

Nervous system conditions and care/ Craniotomy

Endocrine, metabolic and nutritional disorders/ Diabetes

Endocrine, metabolic and nutritional disorders/Malnutrition

and dehydration Musculoskeletal conditions and interventions/ Fracture of

neck of femur

Musculoskeletal conditions and interventions

Gastro-intestinal tract conditions and care

Framework Sections Indicators (were relevant) RAG

Respiratory conditions and care

Gastro-intestinal tract conditions and care/ Conditions of the

upper GI tract

Skin conditions and care

Endocrine, metabolic and nutritional disorders

Haematology

Urogenitary care and conditions

Musculoskeletal conditions and care

Vascular conditions and care

Respiratory conditions and care/ Pneumonia

Elderly care pathway

Sepsis

Musculoskeletal conditions and interventions/ Spine and back

Paediatric pathway

Maternity and women's health

CQC

Effective Dashboard (continued)


Slide 41

Framework Section RAG

Mental Health No

data

Miscellaneous

Nervous system conditions and care

Please note: A full list of the indicators for the Effective

domain can be found in the Appendix.


Within expectations

CQC

Mortality

The table below details the mortality related data items that were rated as comparatively ‘better’ or ‘worse’ (a full table can be

seen in the appendix for the period 1 January to 31 December 2011):

Slide 42

Data item source Data item Comparison with

expected

Information Centre for Health & Social Care (IC),

Hospital Episode Statistics (HES) (1 February 2012 to

31 January 2013)

Standardised in-hospital mortality rates by CCS diagnosis

group: Haematology

Standardised in-hospital mortality rates by CCS diagnosis

group: Neurology

Information Centre for Health & Social Care (IC),

Hospital Episode Statistics (HES) (1 January to 31

December 2011)

Total 30 day mortality rates by Health Resources Group

chapters: F - Digestive system


chapters: J - Skin, breast & burns


chapters: K - Endocrine & metabolic system


chapters: P - Diseases of childhood


Better than expected Tending towards better than expected Within expectations

Tending towards worse than expected Risk or elevated risk

CQC

Summary Hospital-level Mortality Indicator (SHMI)

The table below shows Airedale’s Summary Hospital-level

Mortality Indicator (SHMI) broken down by admission type.

The breakdown illustrates the overall SHMI is 96, which is within

the expected range. The table identifies that the trust’s SHMI for

elective and non-elective admissions occurring on both

weekdays and weekends are within the expected range.

Slide 43

Weekend Week All

Elective n/a

Non-elective

All


Source: Health Evaluation Data (HED), May12 – Apr13

Higher than expected (above

the 95th confidence interval)

Within expected range

Lower than expected (below

the 95th confidence interval)

CQC Slide 44

SHMI Tree

CQC view

Mortality trees provide a

breakdown of SHMI into

elective and non-elective

admissions. The SHMI score for

non-elective admissions has a

greater impact on the overall

indicator as it accounts for a

greater proportion of the total

number of expected deaths.

Due to the complexities of

hospital care and the high

variation in the statistical

models, all deviations from the

expected have been highlighted

using a Random Effects funnel

plot.

The tree shows that Airedale

has an overall SHMI of 96,

which is within the expected

range.

Two elective treatment

specialties , Geriatric Medicine

and Medical Oncology were

highlighted as having higher

than expected SHMIs.

- - - - - - - - - - - - - - - - - - - - - -

Vascula

r Surg

ery

Uro

logy

Tra

um

a &

Orth

opaedic

s

Thora

cic

Medic

ine

Rheum

ato

logy

Paedia

trics

Ora

l surg

ery

Ophth

alm

olo

gy

Obste

trics

Neuro

logy

Medic

al O

ncolo

gy (3

33 ; 6

)

Gynaecolo

gy

Geria

tric M

edic

ine (9

78 ; 3

)

Genera

l Surg

ery

Genera

l Medic

ine

Gastro

ente

rolo

gy

Ear, N

ose a

nd T

hro

at

Dia

betic

Medic

ine

Denta

l Medic

ine

Clin

ical H

aem

ato

logy

Card

iolo

gy

Bre

ast S

urg

ery

Overall

Trust

Elective

SHMI 96

SHMI 103

SHMI 96

Diagnosis (113 ; 1 )

SHMI Observed deaths that are higher than the expected

Key

- - - - - - - - - - - - - - - - - - - - - - - - -

Well B

abie

s

Vascula

r Surg

ery

Uro

logy

Tra

um

a &

Orth

opaedic

s

Thora

cic

Medic

ine

Rheum

ato

logy

Rehabilita

tion

Paedia

trics

Paedia

tric S

urg

ery

Obste

trics

Neuro

logy

Neonato

logy

Mid

wife

Epis

ode

Medic

al O

ncolo

gy

Gynaecolo

gy

Geria

tric M

edic

ine

Genera

l Surg

ery

Genera

l Medic

ine

Gastro

ente

rolo

gy

Endocrin

olo

gy

Dia

betic

Medic

ine

Clin

ical H

aem

ato

logy

Card

iolo

gy

Bre

ast S

urg

ery

Accid

ent &

Em

erg

ency

Treatment Specialties

Treatment Specialties

Higher than expected (above the 95%h control limit)

Within control limits

Lower than expected (below the 95% control limit)

Non

Elective



CQC

SHMI Sub-tree

CQC view

The SHMI sub-tree indicates

the specialties with a

statistically higher SHMI

than expected.

These elective treatment

specialties with higher SHMI

than expected were broken

down into the respective

diagnostic groups for further

analysis.

Some diagnostic groups

were not included as they

had either less observed

deaths than expected or the

same as expected.

With the exception of cancer

of colon, the diagnostic

groups included have one

death higher than expected.

This shows that the sample

case was relatively small for

one death to skew the SHMI

flagging it as higher than

expected. These groups will

have to be observed for a

longer period.

Slide 45

Diagnosis (113 ; 1 )

SHMI Observed deaths that are higher than the expected

Key

Treatment Specialty

Diagnostic

Groups

Elective (103; 1)

Medical Oncology (333; 6)*

Cancer of colon (1671; 3)

Cancer of esophagus (1532; 1)

Cancer of bronchus; lung (837; 1)

Secondary malignancies (1303; 1)

Other liver diseases (1369; 1)

Heart valve disorders (1406; 1)

Phlebitis; thrombophlebitis and

thromboembolism (7611; 1)

Pneumonia (566; 1)

Geriatric Medicine (978 ; 3)

Overall (96; -42)



Higher than expected (above

the 95%h control limit)

Within control limits

Lower than expected (below

the 95% control limit)

*Due to the inclusion of further diagnostic groups with lower than expected deaths, the treatment specialty-level number of excess deaths

can be less than the some of those diagnostic groups shown.

CQC

Proportion of patients rating

their cancer care as ‘excellent’

or ‘very good’

in top 20% of all trusts nationally

6 out of 12

wards above

national

average on

Inpatient

F&F Test

Top 20% for

23 of 63

Cancer

Patient

Experience

Survey

questions

Trend of

increasing

engagement

on F&F Test

Performing ‘about

the same’ as other

trusts on all 10 of

the domains on

Inpatient Survey

Caring

Slide 46

CQC

Caring Dashboard


Additional information has been included in the pack to provide a

more holistic view of the trust’s performance. These are listed

below.

Framework section Indicators RAG

Overall experience How was your overall

experience?

Trusting relationships

"Did you have confidence and

trust in the doctors treating

you?"

"Did you have confidence and

trust in the nurses treating you?"

Compassionate care

"Did you find someone on the

hospital staff to talk to about

your worries and fears?”

Treatment with dignity and

respect

"Overall, did you feel you were

treated with respect and dignity

while you were in the hospital?"

Meeting physical needs

Did you get enough help from

staff to eat your meals?

Do you think the hospital staff

did everything they could to help

control your pain?

Involvement in decision

making

Were you involved as much as

you wanted to be in decisions

about your care and treatment?

Source: CQC Adult Inpatient Survey 2012


Slide 47


Friends and Family Test

National Bereavement Survey

Cancer Patient Experience Survey

Further Sources (Qualitative Information)


Within expectations

CQC

CQC’s Adult Inpatient Survey 2012

Analysis of data from the CQC’s Adult Inpatient

Survey 2012 overall indicates that Airedale scores

within the expected range for all ten areas of

questioning, as can be seen from the table below.

At the more granular level, the trust performed

‘better than most other trusts’ on the five following

individual questions.

When comparing scores with those achieved in

2011, Airedale’s performance can be seen to have

significantly changed on the following four questions:

For all other questions, Trust performance remained

broadly consistent across the two years. Slide 48

Airedale can be

seen to be

performing in line

with other trusts

on the Adult

Inpatient Survey

2012, scoring

‘about the same

as other trusts’ for

all ten areas of

questioning.

Source: CQC Adult Inpatient Survey 2011, 2012

Area of Questioning RAG

The Emergency/A&E Department

Waiting List and Planned Admissions

Waiting to Get to a Bed on a Ward

The Hospital and Ward

Doctors

Nurses

Care and Treatment

Operations and Procedures

Leaving Hospital

Overall Views and Experiences

Better than other trusts

Worse than other trusts

About the same as others

Question 2011 2012 Trend

“How do you feel about the length of

time you were on the waiting list?”

8.3 9.3

“Were you told how you could expect

to feel after you had the operation or

procedure?”

6.8 7.6

“Did you receive copies of letters

sent between hospital doctors and

your GP?”

2.4 3.8

“From the time you arrived in the

hospital, did you feel that you had to

wait a long time to get a bed on a

ward?”

8.6 8

Question RAG

“How do you feel about the length of time you were on

the waiting list?”

“Were hand-wash gels available for patients and

visitors to use?”

“Were you told how you could expect to feel after you

had the operation or procedure?”

“Did the anaesthetist or another member of staff

explain how he or she would put you to sleep or

control your pain?”

“Did hospital staff discuss with you whether additional

equipment or adaptations were needed in your

home?”

Comparison with 2011 Results


CQC view

CQC

Overall Performance

Airedale NHS Foundation Trust scored 56 in the

June A&E Friends and Family Test, which was in-

line with the national average. However, the trust’s

response rate was over double the national rate.

The trust scored 74 in the latest Inpatient test,

which was above the national average of 72, and

represented the continuation of a trend of improving

month-on-month performance. The response rate

for both A&E and inpatient was significantly above

the national average and suggests a continuing

engagement with the Friends and Family Tests.


Since April 2013, patients have been asked whether

they would recommend hospital wards to their

friends and family if they required similar care or

treatment, the results of which have been used to

formulate NHS Friends and Family Tests for

Accident & Emergency and Inpatient admissions.

Scores are calculated as follows:

• The proportion of respondents who state that

they would be “extremely likely” to recommend

the service to their friends and family, minus

those who responded “neither likely or unlikely,”

“unlikely,” or “extremely unlikely” to do so.

• Scores can range from -100 to 100, with a higher

score indicative of better performance. It should

be noted that this score is not a percentage.

• Further guidance is available via NHS England.

It should be noted that low response rates are

common across the country for both A&E and

Inpatient Friends and Family Tests, so caution

should be exercised when considering this data.

Slide 49

The Friends and

Family Tests have

been introduced to

give patients the

opportunity to give

feedback on the

quality of care

they receive.

Airedale can be

seen to be

performing above

the national

average on the

Inpatient test, and

in-line with the

national rate on

the A&E section.


Source: NHS Friends and Family Survey, Apr – Jun 13

CQC view

CQC

Inpatient Performance

In the most recent month examined, 361 people

undertook the Inpatients Friends and Family Test at

Airedale, 94.5% of which were ‘extremely likely’ or

‘likely’ to recommend the ward they stayed in. The

trust’s score of 74 was above the national average,

and continued a trend of improving month-on-month

performance since the test started.

The response rate observed at Airedale was above

the national average for the two most recent

months, and increased in each of the three months

examined.

Month

April May June

Score

Airedale

NHS FT 68 72 74

England 71 72 72

Response

Rate

Airedale

NHS FT 9.6% 20.7% 38.7%

England 21.7% 24.4% 27.1%


Accident & Emergency Performance

In June, a total of 716 people completed the test at

Airedale NHS Foundation Trust, with 91.1% of

patients ‘extremely likely’ or ‘likely to recommend

the A&E department to friends of family. The trust’s

score of 56 in June is above the national average

for the month, although the Airedale does fall in the

bottom 50% of services eligible for the survey

nationally.

The trust’s response rate of the A&E Friends and

Family Test has exceeded the national average for

two of the three months examined, and was over

double the rate for all English trusts in June.

Month

April May June

Score

Airedale

NHS FT 48 55 56

England 49 55 54

Response

Rate

Airedale

NHS FT 7.7% 5% 24.1%

England 5.6% 7.5% 10.3%

A&E Friends and Family Test, April – June 2013

Inpatient Friends and Family Test, April – June 2013


Slide 50


CQC view

The tables to the

right document the

trust’s

performance in the

A&E and Inpatient

sections of the

Friends and

Family Test.

CQC

on a single response. Other low scoring wards

included Wards 6, 10 and 15 with scores of 44, 45

and 49, respectively.

Discounting ITU, six wards scored above the trust

average of 74, namely Ward 5, Ward 7, Ward 9,

Ward 13, Ward 16 and Ward 19. Ward 5 was the

highest achieving of these, scoring 77 based on a

response rate of 62.9%, with all 22 respondents

‘extremely likely’ or ‘likely’ to recommend the service

provided to their friends and family.


Wards and Specialties

12 wards at Airedale NHS Foundation Trust were

included in the June 2013 Inpatient Survey. These

wards experienced varying response rates, from

12.5% in Ward 17 to 62.9% in Ward 5, though only

four wards had response rates above 50%.

There were six wards that scored less than the trust-

wide average of 74, the details of which are provided

on the table below. Of these, Ward 17 scored the

lowest with a score of zero, although this was based

Ward Name Responses Eligible Response

Rate Score

Ex’

Likely Likely Neither Unlikely

Ex’

Unlikely

Don't

Know First specialty

Second

specialty

Ward 14 48 162 29.6% 71 35 12 1 0 0 0 General

Surgery Urology

Ward 1 24 54 44.4% 61 15 7 1 0 0 1 Geriatric

Medicine

General

Medicine

Ward 15 56 94 59.6% 49 34 14 5 0 2 1 General

Medicine

Geriatric

Medicine

Ward 10 11 57 19.3% 45 7 2 1 0 1 0 Trauma &

Orthopaedics N/A

Ward 6 9 51 17.6% 44 * * * * * * Geriatric

Medicine

General

Medicine

Ward 17 1 8 12.5% 0 * * * * * * Paediatrics N/A

Wards that Scored Below the trust Average in the June 2013 Inpatient Friends and Family Test.

Of the 12 wards at

Airedale included

in the June

Inpatient test, six

scored below the

trust-wide average

of 74. Six wards

scored above the

overall Trust, with

Ward 5 recording

the highest rate.


Slide 51


CQC view

CQC

Cancer Patient Experience Survey (CPES)

However, the trust was also rated among the

bottom 20% of trusts nationally on two questions,

including those relating to:

• patients not being asked whether they would like

to take part in cancer research; and

• patients receiving conflicting information.

Overall the proportion of patients rating their cancer

care as ‘excellent’ or ‘very good’ was within the top

20% of all trusts nationally.

Comparison with 2010/11 Results

A comparison with the 2010/11 Survey

demonstrates some decline in the trust’s provision

of cancer care. During that year, Airedale featured

among the top 20% of all trusts nationally for 34

questions, without falling within the bottom 20% for

any questions.

Cancer Patient Experience Survey

The Cancer Patient Experience Survey (CPES) is

designed to monitor national progress on cancer

care. 160 acute hospital NHS trusts took part in the

2011/12 survey, the key points of which are detailed

below.

Of the 63 questions for which the trust had a

sufficient number of survey respondents on which to

base findings, Airedale was rated by patients as

being in the top 20% of all trusts nationally for 23.

These included questions relating to:

• staff explaining completely what would be done

during tests;

• possible side-effects being explained in an

understandable way;

• patients being given complete explanation of test

results in understandable way;

• admission dates not being changed by hospital;

• patients not thinking hospital staff deliberately

misinformed them;

• hospital staff doing everything to help control pain

all of the time;

• hospital staff definitely giving patients enough

emotional support;

• patients thinking their doctor spent about the right

amount of time with them; and

• patients being given the right amount of

information about condition and treatment.

Slide 52

Based upon the

Cancer Patient

Experience

Survey, Airedale

can be seen to be

performing well in

the provision of

cancer care,

featuring in the top

20% of all trusts

nationally for 23 of

the 63 questions,

and in the bottom

20% for just two.

Source: Cancer Patient Experience Survey, National Cancer Intelligence Network, 2010/11 and 2011/12

Question 2011 2012 Change

Number of questions Trust

ranked in top 20% nationally 34 23 -11

Number of questions Trust

ranked in bottom 20% nationally 0 2 +2


CQC view

CQC

However, it should be noted that 36 of the

comments contained positive feedback. Praise was

directed at various wards and departments,

including A&E; Wards 2, 5, 7, 9, 14, 17, 19 and 20;

the medical assessment unit; the breast clinic; the

endoscopy unit; ENT; the day surgery unit; the

stroke unit and the Dales Suite.

These positive comments included mentions of

friendly and reassuring staff, people being treated

with respect and dignity, short waiting times,

excellent communication and listening skills, good

pain management, and people being made to feel

safe.

NHS Choices also allows users to rate the various

aspects of the care they received out of five stars.

The ratings left on NHS Choices currently give

Airedale General a score of 4.5 out of 5 overall,

while at the more granular level the trust is rated at

4.5 for ‘Staff Co-Operation’, ‘Dignity and Respect’,

‘Involvement in Decisions,’ and ‘Same-Sex

Accommodation’; and 4 for ‘Cleanliness’.

The trust regularly responds to comments left on

NHS Choices, these responses are not generic and

try to address any issues raised.

No reviews were provided for Skipton General

Hospital or Catsleberg Hospital for this time period.

Further Sources

NHS Choices

The NHS Choices website currently lists 169

‘reviews’ of Airedale General posted between 16

August 2011 and 1 June 2013, 40 of which have

been included in this analysis.

Five of comments listed contained negative

feedback on the trust. Particular concerns

expressed included a “lack of concern” for patients

among staff on Ward 6, while there were also

numerous issues regarding Ward 15, including

prolonged waiting times for being allocated a bed

following admission, poor pain management

practices, and a lack of communication between

staff and patients. Comments also highlighted long

wait times, staff rudeness, and cleanliness issues

within the A&E department, as well as non-ward

specific issues such as a lack of patient focus and

personalised care. It was also noted that there was

no working lift at the West entrance and that, as the

pharmacy closed at 4pm, it was impossible to

receive pain medication to take home if discharged

after that time.

Slide 53

The comments

provided by the

NHS Choices

survey highlights a

number of positive

and negative

areas of

performance for

Airedale General

Hospital. The

comments indicate

good performance

for staff co-

operation and for

patients being

treated with dignity

and respect.

Source: NHS Choices, 16 Aug 2011 – 1 Jun 2013


CQC view

CQC

Further Sources

Share Your Experience

Share Your Experience is a service organised by

the Care Quality Commission, whereby patients are

asked to provide feedback on the standard of care

they have received.

There are four Share Your Experience comments

for the trust, one of which was positive and three of

which were negative. The example of the former

describes end of life care received in A&E and on

Ward 6, particularly praising the level of respect and

dignity shown towards patients.

Negative comments describe particular issues with

dignity and cleanliness, such as elderly and infirm

patients not being helped to wash or given

opportunities for baths or showers in very extended

periods of time and sometimes being left in urine.

Negative comments also highlight the absence of

lavatory paper or hand wipes with commodes or

waste bags for rubbish. There are also comments

about poor communication, staff not listening to

patients’ needs and rudeness.

Further Sources

Patient Opinion

The Patient Opinion website currently lists 185

comments for Airedale. The service currently has a

rating of 5/5 for ‘Environment’, ‘Information’ and

‘Listening’, though it must be noted that these

scores are based on just two submissions each.

Domains in which there is deemed to be room for

improvement include ‘Cleanliness’, ‘Medical’,

‘Nursing’, and ‘Respect’, each of which are rated

3/5.

Individual comments refer to the “outstanding care”

that was “thorough, compassionate and kind,”

although some users have complained about the

services provided, with one reviewer stating that

they were “disgusted by the level of care” received

in the A&E department.

Slide 54

The Patient

Opinion and Share

Your Experience

surveys highlight

the levels of

cleanliness and

the degree of

dignity shown

towards patients

as potential areas

of review.

Source: Patient Opinion; NHS Share Your Experience


CQC view

CQC

Further Sources

• It was felt to be very positive that staff took time

to review the scheme and made changes to

improve it

• It was noted that having volunteers help patients

released staff and gave them more time to attend

very needy patients

• The visiting team were impressed by the

enthusiasm and openness shown by Trust staff

involved in the scheme

• It was noted that initial problems with retaining

volunteers was being addressed by the provision

of a more structured and supportive approach,

and that the policy of protected mealtimes was

given high priority.

Further Sources

Healthwatch

A search for feedback about the trust from

Healthwatch England and the local Healthwatch,

Bradford and District, did not yield any relevant

further information. However, one recent report of

an Enter and View visit conducted by Healthwatch

Bradford and District’s predecessor, Bradford LINk

(local involvement network), was found.

Dated 18 April 2012, this visit examined the

‘Feeding Buddy Scheme’ at Airedale General

Hospital. The visit was prompted by reports that the

scheme was an example of good practice in

ensuring that, with the help of trained volunteers

and more experienced buddies, all patients

(particularly those deemed frailer or more

vulnerable) received enough to eat and drink. The

visiting team concluded that:

• The scheme was an excellent idea and that

procedures were very clear and detailed

• It was felt that the additional input of a volunteer

on the scheme was extremely useful in providing

examples of the kinds of feeding issues

presented by vulnerable elderly people, and

contributed to greater understanding

Slide 55

A recent report of

an Enter and View

visit praised the

trust’s

implementation of

a ‘Feeding Buddy

Scheme’ at

Airedale General

Hospital for

ensuring that all

patients received

sufficient food and

drink during their

stay.

Source: Enter and View Visit Report, Bradford LINk, 18th Apr 2012


CQC view

CQC Slide 56

Meeting the

95% A&E

wait time

target

Within the

expected

range for

patient

discharge

Performing

above

expected in

both key

metrics

relating to

cancelled

operations

Performing

above

average for

un-planned

readmittance

within A&E

CQC analysis rated the trust

as low green for access to

secondary care through A&E

Responsive

CQC

Responsive Dashboard


Access measures

A&E waiting times under 4 hours

Referral to treatment times under 18

weeks: admitted pathway

Referral to treatment times under 18

weeks: non-admitted pathway

Diagnostics waiting times: patients

waiting over 6 weeks for a diagnostic

test

All cancers: 62 day wait for first

treatment from urgent GP referral

All cancers: 62 day wait for first

treatment from NHS cancer

screening referral

All cancers: 31 day wait from

diagnosis

The proportion of patients whose

operation was cancelled

The number of patients not treated

within 28 days of last minute

cancellation due to non-clinical

reason

Discharge and Integration

Ratio of the total number of days

delay in transfer from hospital to the

total number of occupied beds


Slide 57


A&E wait from decision to admit to being admitted

Distribution of A&E wait times (within 4 hours)

Delayed Discharges

CQC Thematic Review


Additional information has been included in the pack to

provide a more holistic view of the trust’s performance. These

are listed below.


Within expectations

CQC

96% A&E patients seen

within 4 hours

A&E Wait Times

A&E wait times and RTT times may indicate the

effectiveness with which demand is managed.

The graph below represents the percentage of A&E

attendances that are admitted or discharged within four

hours at the trust; this shows how the trust compares to the

national target of 95% of patients with an A&E transit time

of less than four hours.

The average percentage of patients admitted or discharged

within the national target time was 95.5%, therefore the

trust is hitting the 95% target. From the graph below, it can

be seen that for most weeks the trust is exceeding the

national target. However, there are some weeks where the

trust has a significantly lower percentage of patients being

seen within the target time, namely two weeks in December

and a week in April.

Slide 58

CQC view

At times, the availability of beds in wards can

cause a back log of patients in A&E, which

may elongate A&E transit times. For this

reason, it can be useful to look at the waiting

times between the decision to admit and the

time at which the patient is admitted.

From the graph below, you can see that the

trust’s data is significantly better than the

national average. The trust has seen no

patients waiting between four and 12 hours

between the decision to be admitted and

being admitted from December 2012.

75%

80%

85%

90%

95%

100%

08/0

4/1

2

08/0

5/1

2

07/0

6/1

2

07/0

7/1

2

06/0

8/1

2

05/0

9/1

2

05/1

0/1

2

04/1

1/1

2

04/1

2/1

2

03/0

1/1

3

02/0

2/1

3

04/0

3/1

3

03/0

4/1

3

03/0

5/1

3

02/0

6/1

3

02/0

7/1

3

01/0

8/1

3

Target England… Trust

0.0%

3.0%

6.0%

9.0%

12.0%

08/0

4/1

2

08/0

5/1

2

07/0

6/1

2

07/0

7/1

2

06/0

8/1

2

05/0

9/1

2

05/1

0/1

2

04/1

1/1

2

04/1

2/1

2

03/0

1/1

3

02/0

2/1

3

04/0

3/1

3

03/0

4/1

3

03/0

5/1

3

02/0

6/1

3

02/0

7/1

3

01/0

8/1

3

England average Trust

Percentage of A&E Attendances that are

Admitted, Transferred or Discharged less

than 4 hours from Arrival

Percentage of A&E Admissions Waiting 4-

12 hours from the Decision to Admit Until

Being Admitted

The trust is exceeding

the national objective of

seeing 95% of A&E

patients within four

hours of their arrival.

However, there are

some weeks where the

trust has below 90% of

patients seen within the

target time. It is

important to review the

management of patient

flows at busier times

(e.g. Christmas), to

ensure the service is as

responsive as possible.

The trust have had no

patients waiting over

four hours from the

decision to be admitted

since December 2012;

it would be beneficial to

understand what

catalysed this

improvement to share

with other trusts.

Source: NHS England, Apr 12 – Aug 13


CQC

Source: Healthcare Evaluation Data (HED). Apr 12 – Mar 13

0%1%2%3%4%5%6%7%8%

Ap

r-12

Ma

y-1

2

Jun

-12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10 11% o

f p

ati

en

ts s

till

wait

ing

in

A&

E

Time to depart A&E (hours)

Trust Performance National Performance

-75

-50

-25

0

25

50

75

0 1 2 3 4 5 6 7 8 9 10 11

-ve v

alu

es =

lo

wer

tha

n a

vera

ge

+ve v

alu

es =

hig

he

r th

an

avera

ge

Time to depart A&E (hours)

Distribution of A&E Waiting Times

Whilst there is the national target for all patients to be admitted or

discharged within 4 hours of arriving at A&E, it is important to see

how long patients are waiting within this target time.

Whilst Airedale is behind the national performance for the first two

hours following arrival, the trust has a lower proportion of patients

still waiting in A&E beyond this point than is average for English

trusts, indicating effective management of patient flows within the

department. This is further highlighted by the graph on the right,

which shows that the trust is seeing to more of its patients within

one and three hours of their arrival than is average for trusts

nationally.

The trust’s seven day unplanned readmittance rate has been

below the national average for all twelve months shown, although

the percentage of patients leaving A&E before being seen for

treatment may highlight an area for review.

Slide 59

Number of Patients Departing A&E at Each Time

Interval, Compared to the National Average

Percentage of Unplanned Re-admittance within

Seven Days of a Previous Attendance at A&E

Source: Healthcare Evaluation Data (HED). Apr 12 – Mar 13


0%

2%

4%

6%

Ap

r-12

Ma

y-1

2

Jun

-12

Jul-1

2

Au

g-1

2

Se

p-1

2

Oct-

12

Nov-1

2

Dec-1

2

Jan

-13

Fe

b-1

3

Ma

r-13

Percentage of Patients that Left A&E Before Being Seen for Treatment

Percentage of Patients Still Waiting in A&E by Time Waited

Source: CQC Analysis, Feb 13


CQC Slide 60

The trust is

performing better

than expected in

both metrics

relating to

cancelled

operations and

within expected for

metrics relating to

patient discharge.

Cancelled Operations

The Department of Health monitor the proportion of

cancelled elective operations. This can be an

indication of the management, efficiency and the

quality of care within the trust. The trust was rated

as better than expected for both measures.

Patient Discharge

The ability for a trust to conduct safe and timely

discharges is important for overall patient flow

through the hospital. Patients need to be discharged

when ready and any information and support

provided to ensure the patient does not need to be

re-admitted into hospital.

Within the Adult Inpatient Survey, there are two

questions that refer to the process of discharge. The

trust performed similar to expected for both.

Framework Sections RAG

Number of patients not treated

within 28 days of last minute

cancellation due to non-clinical

reason

The proportion of patients whose

operation was cancelled

Worse than expected

Similar to expected


Framework Sections RAG

The proportion of respondents to

the adult inpatient survey who

stated they were not given enough

notice about when they were to be

going to be discharged

The proportion of respondents to

the adult inpatient survey who

stated that their discharge was

delayed for more than four hours,

due to waiting for medicine, to see

a doctor or for an ambulance


Source: Cancelled Operations: DoH QMCO Jan13-Mar13;

Source: Delayed discharges CQC Survey of Adult Inpatients June12 – Aug12

CQC view

CQC Slide 61

The trust is

performing better

than the national

expected level in

terms of access to

secondary care

through A&E,

scoring low green.

However the trust

is performing

below the

expected level for

access to elective

secondary care

from general

practice.

CQC Access to NHS Secondary Care Thematic

Review – February 2013

Some patients in England still wait too long for

secondary care. The King's Fund's quarterly reports

provide national data on A&E waiting and referral to

treatment times that give an indication of

performance averaged-out across the NHS.

According to this report, in 2012/13:

• 35 of 203 trusts were breaching the target on

this measure in the first quarter

• The proportion of patients waiting more than 4

hours from arrival in A&E to admission, transfer

or discharge in the third quarter rose by 21%

compared with the previous year

• In the last quarter, despite trusts remaining on

target, more than 232,000 patients were waiting

more than 4 hours in A&E

In terms of referral to treatment waiting times,

overall NHS performance has been stable since

2010. Following a peak of 11% of patients waiting

more than 18 weeks for treatment in January 2011,

CQC Access to NHS Secondary Care Thematic Review – February 2013

the proportion of patients still on lists and waiting fell

to 5% across the NHS by November 2012.

It is clear that there is variation in patient access on

these two measures. However, these sources do

not identify which trusts exceed targets, which ones

fall short, and to what degree. By comparing

performance between trusts, the data presented in

the thematic review can be used to identify outliers.

There were two key measures identified in this

review:

• Access to secondary care through A&E – the

trust scored Low Green

• Access to elective secondary care (diagnostics

and treatment) from general practice – the trust

scored Low Green

The trust was not identified as an outlier for any of

the individual measures contained within the above

key measures.


CQC view


CQC

Staff

reporting

errors, near

misses or

incidents

tending to

worse than

expected

Staff job

satisfaction

tending

towards

worse than

expected

Above

average

work

pressure felt

by staff

Runner-up in

Dr. Foster

Good

Hospital

Guide ‘Trust

of the Year’

2012

Well-led

Slide 62

14.2% of primary procedures

recorded incorrectly compared to

national average of 7%

CQC


Audit Data

Board Stability

Governance Structures

NHS Staff Survey

Other


Additional information has been included in the pack to

provide a more holistic view of the trust’s performance. These

are listed below.

Well-led Dashboard

Framework Sections Indicator RAG

Staff surveys

NHS staff survey – responses to

question asking if “Care of

patients is top priority?”

Junior doctor survey – overall

satisfaction score

Survey of trainee nurses (TBD) No data

Staffing Staff sickness rates

Utilisation

BED08 Department of Health:

Average daily number of

consultant led available and

occupied beds, NHS

organisations in England, Q4

2012-13

BED09 Department of Health,

Adult Critical Care Beds,

monthly sitreps - April 2013

BED10 Department of Health,

Paediatric and Neonatal Critical

Care Beds, monthly sitreps -

April 2013

BED11 Department of Health:

Total number of Non-Consultant

Led available and occupied

beds, NHS organisations in

England, Q2 2012-13

No data

Monitor Rating Governance risk rating of red No data

Financial risk rating of 1 or 2 No data


Slide 63


Within expectations

O

Value

Observed

Value

E

Value

Expected

Value

CQC

Indicators RAG

14.2% of primary procedures were recorded

incorrectly in the period. Against an expected

rate of 7%, this is tending towards worse than

expected.

7.8% of secondary procedures were recorded


rate of 7%, this is similar to expected.

11% of primary diagnoses were recorded



5.7% of secondary diagnoses were recorded



Audit Commission - Payment by Results Data

(PbR) Assurance (2011/12)

Payment by Results aims to support NHS

modernisation by paying hospitals for the work they

do, rewarding efficiency and quality. It also carries

risks that need to be managed effectively both

locally and nationally. Since 2007, the Audit

Commission has delivered an assurance

programme for Payment by Results looking at the

quality of clinical coding.

For the 2011/12 financial year, there were a number

of indicators and items of qualitative intelligence for

the trust from the Audit (see table on the right).

It is worth noting that the trust supplied more recent

data from the 2012/13 audit which showed the

following:

• 7.1% primary procedures were recorded

incorrectly

• 13.0% secondary procedures were recorded

incorrectly

• 6.0% primary diagnoses were recorded

incorrectly

• 9.0% secondary diagnoses were recorded

incorrectly

Slide 64


Within expectations


In the 2011/12

audit, Airedale

performed within

the expected

range for three

PbR indicators,

although they were

above the national

average for two of

these. The

percentage of

primary

procedures

incorrectly

recorded highlights

a risk for the trust.

The trust supplied

more recent data

from the 2012/13

audit which

showed a

reduction in the

percentage of

primary procedure

coding errors.


Source: Audit Commission - Payment by Results Data (PbR) Assurance (2011/12)

CQC view

CQC

Trust Board and Organisation Structures

The table below details the members of the trust

board and their roles.

Slide 65

The Board has remained stable over the years

with the Chairman being in post since 2005 and

the Chief Executive has been in post since 2010.

The most recent Executive appointments have

been Andrew Copley as Director of Finance who

took up post in January 2013 having previously

been Deputy Director of Finance. He joined

Airedale from Calderdale and Huddersfield NHS

Foundation Trust where he was assistant finance

director. Andrew trained as a radiographer at

Source: Trust Website

Board Member’s Role Name

Chairman Colin Millar

Chief Executive Bridget Flethcher

Director of Finance Andrew Copley

Director of Nursing Rob Dearden

Medical Director Dr Andrew Catto

Director of Strategy and

Business Development Ann Wagner

Non-Executive Director David Adam

Non-Executive Director Dr Michael Toop

Non-Executive Director Ronald Drake

Non-Executive Director Sally Houghton

Non-Executive Director Anne Gregory

A stable board, as

is seen at Airedale,

may be

advantageous.


Pinderfields and Pontefract Hospital and later joined

St Luke’s Hospital in Bradford and Ms Stacey Hunter

is the new Director of Operations.

The trust has a new member to the Non-Executive

Board. Dr Michael Toop joined in February 2013 and

is a retired consultant in chemical pathology and

previously managed the chemical pathology

department at Harrogate hospital for 25 years.

Governance and Clinical Structures

From September 2012 the Board of Directors

meetings have been held in public and are held

monthly.

Since becoming a Foundation Trust in June 2010, the

trust has a Council of Governors, which also holds

quarterly meetings in public. The Council of

Governors has 32 members consisting of: 20 public

governors (elected by public members), six staff

governors (elected by staff members) and six

stakeholder governors (nominated by partner

organisations

CQC view

CQC

NHS Staff Survey

The results of the 2012 NHS Staff Survey are

organised into 28 key findings.

The trust scored the worst nationally in the following

key findings:

The trust scored the best for the following key

findings:

Slide 66

Indicators RAG

Percentage of staff feeling pressure in last 3 months to attend work when feeling unwell (34%

against an average score for acute trusts of 29%)

Percentage of staff agreeing that their role makes a difference to patients (87% against an average

score for acute trusts of 89%)

Work pressure felt by staff (3.18 against an average score for acute trusts of 3.08)

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

(73% against an average score for acute trusts of 78%)

Percentage of staff reporting errors, near misses or incidents witnessed in the last month. (88%

against an average score for acute trusts of 90%).


Within expectations


Tending towards worse than expected

Tending towards better than expected

Indicators RAG

Percentage of staff believing the trust provides equal opportunities for career progression or

promotion. (93% against an average score for acute trusts of 88%).

Percentage of staff experiencing discrimination at work in last 12 months. (8% against an average

score for acute trusts of 11%).

Percentage of staff having equality and diversity training in last 12 months. (72% against an

average score for acute trusts of 55%)

Percentage of staff saying hand washing materials are always available (67% against an average

score for acute trusts of 60%)

Percentage of staff able to contribute towards improvements at work. (71% against an average

score for acute trusts of 68%).

A number of

indicators in the

2012 Staff Survey

show performance

that is an elevated

risk or worse than

expected.

The trust scored

the bottom

nationally for five

of the 28 key

findings, although

it also recorded

the best score for

five findings.


Source: NHS Staff Survey 2012

CQC view

CQC

NHS Staff Survey continued…

A number of indicators have shown improvement as well as deterioration; these are detailed below.

Slide 67

Indicators RAG

Percentage of staff feeling pressure in last 3 months to attend work when feeling unwell. (34%

compared to a 2011 score of 26%)

Percentage of staff appraised in last 12 months. (85% compared to a 2011 score of 92%)

Percentage of staff receiving health and safety training in last 12 months (76% compared to a

2011 score of 84%)

Staff job satisfaction. (3.62 compared to a 2011 score of 3.45)

Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month

(31% compared to a 2011 score of 38%).

Staff recommendation of the trust as a place to work or receive treatment (3.65 compared to a

2011 score of 3.48).

Percentage of staff having equality and diversity training in last 12 months (72% compared to a

2011 score of 63%).


Within expectations




The trend towards

‘worse than expected’

witnessed in the

percentage of staff

feeling pressure to

attend work when

unwell is cause for

concern, but the

increased levels of

job satisfaction and

augmented

willingness of staff to

recommend the trust

as a place to work or

receive treatment is

encouraging.


Source: NHS Staff Survey 2012

CQC view

CQC

Coding Analysis

Information Centre for Health & Social Care (IC), Secondary

Uses Service Data Quality Dashboard (2012/2013) Data for the

following areas is covered in the Data Quality Dashboards:

• Finished general episode admitted patient care;

• Outpatients; and

• Accident and emergency.

Airedale NHS Foundation Trust scored between ‘similar

expected’ to ‘better than expected’ for the number of errors made

during coding.

Information held by CQC from the Audit Commission Payment by

Results Coding Audit from 2011/2012 found Airedale NHS

Foundation Trust was ‘tending toward worse than expected’ for:

• Proportion of primary procedures recorded incorrectly.

The trust was ‘similar to expected’ for:

• Proportion of primary diagnoses recorded incorrectly;

• Proportion of secondary diagnoses recorded incorrectly; and

• Proportion of Secondary procedures recorded incorrectly

The Audit Commission, Unsafe to Audit (2011/2012) check

indicates Airedale NHS Foundation Trust is ‘tending toward

better than expected’ for the proportion of finished consultant

episode (FCE) records determined as unsafe to audit.

Slide 68


CQC view

The ‘trending towards

worse than expected’

performance in the

proportion of primary

procedures recorded

incorrectly highlights

an are for review,

although the trust

does score within the

expected range for

several further coding

metrics.

CQC

Audit Findings

National Clinical Audit Support Programme -

National Bowel Cancer Audit Project

The National Bowel Cancer Audit Project aims to

improve the quality of care and survival of patients

with bowel cancer, and meets the requirements as

set out in the NHS cancer plan, NICE guidelines

and the report of the Bristol Royal Infirmary inquiry.

Information in the audit includes audit participation

by NHS Trust and data completeness for key fields,

measures about the process of care given to

patients and information about care outcomes and

treatment.

In 2013, there were 119 cases reported by the trust

to the audit:

Slide 69


CQC view

Source: National Bowel cancer Audit Programme 2013

The trust performs

comparatively well

within the National

Bowel Cancer

Audit Programme

with some areas

of better than

expected

performance

Indicator RAG

116 cases were identified in HES, meaning a case ascertainment rate of 103% (as more were identified by the

trust). This is considered ‘good’. The national rate was 86%.

100% of cases reported to the audit were discussed at multidisciplinary team (MDT) meetings. The national level

was 97.8%.

There were 78 cases (65.5%) having major surgery. For these cases, data completeness was 95%. This is

considered ‘good’. The national level was 79%.

100% of cases had a CT scan reported. The national rate was 89.1%.

86.4% of patients were seen by a clinical nurse specialist. The national rate was 87.7%.

70.5% of patients having major surgery had a hospital stay of more than five days. The national rate was 68.9%.

The observed 2 year mortality rate for these patients was 18.8%, and the adjusted rate was 17.3%. The national

rate was 24.5% both observed and adjusted.

TBC


Within expectations




CQC

Audit Findings continued…

National Institute for Clinical Outcomes Research

- Myocardial Ischaemia National Audit Project

The Myocardial Ischaemia National Audit Project

(MINAP) began in late 1998 when a broadly based

Steering Group developed a dataset for acute

myocardial infarction. The dataset has been further

expanded to cover the management of other acute

coronary syndromes. The Steering group represents

key stakeholders including professional bodies,

national government and patient representation, in

conjunction with the British Cardiovascular Society. It

is the long term aim of the project to continue to

provide, for all interested groups, including patients,

commissioning bodies, cardiac networks of care, and

academic researchers, first class data on the care for

acute coronary syndromes within England and Wales.

Slide 70

National Institute for Clinical Outcomes Research -

Myocardial Ischaemia National Audit Project

Data held about the trust for the 2011/12 financial year

shows:


CQC view

Airedale performs

similar to the

expected level on

the MI National

Audit programme,

with the proportion

of eligible patients

with a discharge

diagnosis of

nSTEMI who were

seen by a

cardiologist or

member of their

team tending

towards better

than expected.

Indicator RAG

The proportions of eligible patients with a

discharge diagnosis of nSTEMI (non-ST segment

elevation myocardial infarction) who were admitted

to a cardiac unit or ward and who were referred for

or had angiography were both similar to expected.

The proportion of eligible patients with a discharge

diagnosis of nSTEMI who were seen by a

cardiologist or member of their team


Within expectations




Source: National Institute for Clinical Outcomes Research - Myocardial Ischaemia National Audit 2011/12 Project

CQC


Royal College of Physicians - Audit of Falls &

Bone Health in Older People

The national audit of falls and bone health was a

programme of work which examined the organisation

and commissioning of services provided to older

people for falls prevention and bone health, the clinical

care delivered to people that have fallen and fractured

a bone and patient’s experiences of fall services.

In 2010 both an organisational and clinical audit were

performed together as part of the falls and bone health

audit programme. Data held about the trust from this

2010 audit shows:

Indicator RAG

Is there a mechanism to record patients’ views of the falls and bone health service using questionnaires and/or

interviews?

Are older people who fall and attend EDs or MIUs routinely screened for risk of future falls?

Was adequate analgesia administered within 60 minutes of hospital attendance, or prior to attendance by

ambulance personnel (Hip)?

Is there further assessment and management of all appropriate fracture patients coordinated by a fracture liaison

nurse or similar designated person?

Does an occupational therapist routinely assess for potential hazards within the patient’s home?

Are evidence-based therapeutic exercise programmes (Otago or FaME) used for falls prevention, with a standard

duration of over 12 weeks?

Slide 71


CQC view

On the Audit of

Falls & Bone

Health, trust

performance was

similar to expected

in a number of

questions,

although, as

detailed on the

next page,

Airedale is

performing below

the expected level

on several

questions, which

may highlight an

area for review.

Source: Royal College of Physicians - Audit of Falls & Bone Health in Older People, 2010


Within expectations




CQC

Indicator RAG

Are there documented lying and standing blood pressure readings (Hip)?

Are there documented lying and standing blood pressure readings (Non-Hip)?

Did the patient attend an exercise programme within 12 weeks of the fall (Hip)?

Was home hazard assessment performed in the patient’s own environment (Hip)?

Was the patient prescribed bisphosphonate or other appropriate anti-resorptive therapy for

osteoporosis (Non-Hip)?

Has the trust calculated its serious injuries in-patient falls rate against activity (e.g. per admission or

occupied bed day)?

Was a formal assessment of cognitive function, including where indicated a delirium screen (e.g.

Confusion Assessment Method), performed within 72 hours of surgery (Hip)?

Was an attempt made within 24 hours of surgery to mobilise the patient (Hip)?

Was the patient prescribed bisphosphonate or other appropriate anti-resorptive therapy for

osteoporosis (Hip)?

Was home hazard assessment performed in the patient’s own environment (Non-Hip)?

Is it documented within the medical, nursing or therapist notes that written falls prevention information

has been given to the patient or their carer (Hip)?

Is it documented within the medical, nursing or therapist notes that written falls prevention information

has been given to the patient or their carer (Non-Hip)?

Did the patient attend an exercise programme within 12 weeks of the fall (Non-Hip)?


Within expectations





Slide 72


Source: Royal College of Physicians - Audit of Falls & Bone Health in Older People, 2010

CQC


Royal College of Physicians - Stroke

Improvement National Audit Programme

The Stroke Improvement National Audit Programme

(SINAP) is a national clinical audit, which collected

information from hospitals about stroke patient care

in the first three days in hospital. SINAP was run by

the RCP Stroke programme on behalf of the

Slide 73


Royal College of Physicians - Stroke Improvement

National Audit Programme

Intercollegiate Stroke Working Party (ICSWP) and

commissioned by the Healthcare Quality Improvement

Partnership (HQIP).

The results of the 2012 audit for the trust show:


Indicator RAG

Number of patients for whom their prognosis/diagnosis was discussed with relative/carer within 72 hours where

applicable

Number of patients who had continence plan drawn up within 72 hours where applicable

Number of patients scanned within 1 hour of arrival at hospital (15% against an expected rate of 37%)

Seen by nurse and one therapist within 24 hours and all relevant therapists within 72 hours (40% seen by a nurse

and one therapist within 24 hours and all relevant therapists within 72 hours, against an expected rate of 68%)

Nutrition screening and formal swallow assessment within 72 hours where appropriate (60% against an expected

rate of 87%)

Number of patients scanned within 24 hours of arrival at hospital

Number of patients who arrived on stroke bed within 4 hours of hospital arrival (when hospital arrival was out of

hours)

Number of patients seen by stroke consultant or associate specialist within 24 hours

Number of patients with a known time of onset for stroke symptoms

Number of potentially eligible patients thrombolysed

Patients first ward of admission was stroke unit and they arrived there within four hours of hospital arrival

Patient given antiplatelet within 72 hours where appropriate and had adequate fluid and nutrition in all 24 hour

periods

Source: Royal College of Physicians – Stroke Improvement Programme, 2012

CQC view

Airedale performs

within the

expected range for

a number of

indicators on the

SINAP. However,

the trust scores

poorly on three

measures,

including the

number of patients

scanned within

one hour of their

arrival at hospital,

which was

significantly below

the national rate.

Risk or elevated risk Within Expectations Better than expected

CQC


UK National Screening Committee - Antenatal

and Newborn Screening Education Audit

The trust Education & Training For Screening

Annual Audit Tool 2009/10 was developed by the

National Screening Committee’s (NSC) Regional

Screening Teams to assist Trust Screening

Coordinator’s (LCO) assess the appropriateness,

effectiveness, and accessibility of locally held

educational initiatives pertaining to antenatal and

the newborn screening programmes. This audit tool

assists in the continuing development of quality

evidence-based training initiatives and feeds into

regional and national education and training

strategy for screening.

Data held for the 2011/12 financial year shows the

trust used the National Screening Committee

antenatal and newborn induction resource for all

relevant new staff, had a designated person

responsible for co-ordination and education

regarding antenatal screening programmes, had a

named individual responsible for (antenatal and

newborn) screening education and audit and

included either antenatal and/or newborn screening

education in its mandatory training programme.

Slide 74

Source: UK National Screening Committee – Antenatal and Newborn Screening Education Audit


CQC view

The trust can be

seen to be taking

the necessary

steps to ensure

the provision of

antenatal and

newborn

screening

education to its

staff.

CQC

Foundation Trust Status

Airedale attained foundation trust status on 1 June

2010.

Monitor publishes quarterly reports covering the

performance and risk ratings for NHS foundation

trusts, but also updates the risk ratings in 'real time'

to reflect, for example, a decision to find a trust in

significant breach of its terms of authorisation or the

Care Quality Commission's regulatory activities.

These provide a summary of the performance of the

foundation trust sector, and also give individual NHS

foundation trusts the opportunity to understand their

own performance in relation to other foundation

trusts.

Financial risk rating (rated 1-5, where 1 represents

the highest risk and 5 the lowest); and governance

risk rating (rated red, amber-red, amber-green or

green).

Monitor have amended the trusts financial risk

rating from 4 to 3 in Q3 of 2012/13 due to the

deterioration in the trust’s financial position.

The governance risk rating for the Foundation Trust

was AMBER-GREEN as at Quarter 1 due to the

failure of the 95% A&E target. This was an overall

improved position from the Quarter 4 rating of

AMBER-RED.

The Foundation Trust has declared C difficile and

A&E as potential risk standards for 2013/2014.

Slide 75

Dr Foster Good Hospital Guide

Airedale NHS FT was one of two runners-up in the

Good Hospital Guide for the ‘Trust of the Year’

award in 2012, scoring well on good outcomes of

care and being efficient in its use of resources.

Other Information

The trust recently opened a new £2.4m Endoscopy

unit, which will also house some or all of the A&E

services while the department is given a £6m

refurbishment following on from the development of

a full business case, with work planned to start in

October.

Source: Dr Foster Good Hospital Guide 2012

Airedale placed as

one of two runners-up

in the Dr. Foster

Good Hospital of the

Year Guide for the

‘Trust of the Year’

award in 2012,

indicating good

performance within

care and efficient use

of resources. The

trust’s investment in

it’s A&E department

should further

enhance its ability to

deliver in an area in

which it already

performs above the

national rate for

several metrics.


CQC view

CQC

Appendices

CQC

Effective domain Tier 1 indicators

Slide 77


Trust level

SHMI (April 2013)

HSMR (2011/12)

HSMR weekday (2011/12)

HSMR weekend (2011/12)

Urogenitary care and

conditions/ Renal failure

Mortality outlier alert: Acute and

unspecified renal failure

Mortality outlier alert: Chronic renal

failure

Respiratory conditions and

care

Mortality outlier alert: Acute bronchitis

Mortality outlier alert: Other upper

respiratory disease

Respiratory medicine

Emergency readmissions following

elective cases - Respiratory medicine


emergency cases - Respiratory medicine

Stroke

Mortality outlier alert: Acute

cerebrovascular disease

Cerebrovascular

Cardiac conditions and

care/ Acute myocardial

infarction

Mortality outlier alert: Acute myocardial

infarction


care/ Cardiac surgery

Mortality outlier alert: Adult cardiac

surgery

Mortality outlier alert: CABG (other)


Vascular conditions and

care/ Aneurysms

Mortality outlier alert: Aortic, peripheral,

and visceral artery aneurysms

Mortality outlier alert: Clip and coil

aneurysms

Mortality outlier alert: Repair of

abdominal aortic aneurysm (AAA)


care/ Cardiac arrhythmia

Mortality outlier alert: Cardiac

dysrhythmias


care/ Chronic obstructive

pulmonary disease

Mortality outlier alert: Chronic obstructive

pulmonary disease and bronchiectasis

Skin conditions and care/

Skin diseases

Mortality outlier alert: Chronic ulcer of

skin

Mortality outlier alert: Skin and

subcutaneous tissue infections


care/ Heart failure

Mortality outlier alert: Congestive heart

failure; nonhypertensive


care

Mortality outlier alert: Coronary

atherosclerosis and other heart disease

Cardiology

Nervous system conditions

and care/ Craniotomy

Mortality outlier alert: Craniotomy for

trauma

Endocrine, metabolic and

nutritional disorders/

Diabetes

Mortality outlier alert: Diabetes mellitus

with complications


nutritional

disorders/Malnutrition and

dehydration

Mortality outlier alert: Fluid and

electrolyte disorders

CQC

Effective domain Tier 1 indicators (continued)

Slide 78


Musculoskeletal conditions

and interventions/ Fracture

of neck of femur

Mortality outlier alert: Fracture of neck of

femur (hip)

Mortality outlier alert: Reduction of

fracture of neck of femur


and interventions

Mortality outlier alert: Head of femur

replacement

Mortality outlier alert: Pathological

fracture

Mortality outlier alert: Reduction of

fracture of bone (upper/lower limb)

Musculoskeletal

Gastro-intestinal tract

conditions and care

Mortality outlier alert: Intestinal

obstruction without hernia

Mortality outlier alert: Therapeutic

endoscopic procedures on biliary tract

A&E and trauma care

Mortality outlier alert: Intracranial injury

Mortality outlier alert: Open wounds of

extremities

Mortality outlier alert: Shunting for

hydrocephalus

Mortality outlier alert: Superficial injury;

contusion

Other injuries & conditions due to

external causes

Trauma and orthopaedics

Urogenitary care and

conditions

Mortality outlier alert: Liver disease,

alcohol-related

Gastroenterology and hepatology

Genito-urinary medicine

Nephrology



and care

Mortality outlier alert: Other connective

tissue disease

Vascular conditions and

care

Mortality outlier alert: Peripheral and

visceral atherosclerosis

Vascular

Mortality outlier alert: Transluminal

operations on the femoral artery


care/ Pneumonia Mortality outlier alert: Pneumonia

Elderly care pathway

Mortality outlier alert: Senility and organic

mental disorders

Mortality outlier alert: Urinary tract

infections

Sepsis

Mortality outlier alert: Septicaemia

(except in labour)

Infectious diseases


and interventions/ Spine

and back

Mortality outlier alert: Spondylosis,

intervertebral disc disorders, other back

problems

Gastro-intestinal tract

conditions and care/

Conditions of the upper GI

tract

Mortality outlier alert: Therapeutic

operations on jejunum and ileum

Skin conditions and care Dermatology


nutritional disorders

Endocrinology


elective cases - Endocrinology


emergency cases - Endocrinology

CQC

Effective domain Tier 1 indicators (continued)

Slide 79


Haematology Haematology

Mental Health Mental illness No data

Miscellaneous Miscellaneous

Nervous system conditions

and care

Neurology


elective cases - Neurology


emergency cases - Neurology

Paediatric pathway Paediatrics and congenital disorders

Maternity and women's

health

Maternity outlier alert: Elective

Caesarean section

Maternity outlier alert: Emergency

Caesarean section

Maternity outlier alert: Maternal

readmissions

Maternity outlier alert: Neonatal

readmissions

Maternity outlier alert: Perinatal mortality

Maternity outlier alert: Puerperal sepsis


Within expectations

O

Value

Observed

Value

E

Value

Expected

Value

CQC

NHS Litigation Authority Standards

The trust has achieved Level 1 in NHSLA Risk Management Standards providing Acute and Community Services and NHS Litigation

Authority Clinical Negligence Scheme – Maternity Clinical Risk Management Standards for 2012/13.

NHSLA Risk Management Standards 2012-13 for NHS Trusts Acute and Community Services

Assessment date Monday 28 and Tuesday 29 January 2013, follow up on Friday 26 April 2013

Level prior to assessment Level 2

Level achieved at assessment Level 1

Organisations providing a mix of acute and community services are assessed against Standards 1 to 5, each containing ten criteria

giving a total of 50 criteria.

In order to maintain compliance at Level 1 the organisation was allowed a period of clarification and was required to pass at least 30

criteria overall. The organisation scored as follows:

Domain Score Compliant?

Governance 8/10 Compliant

Learning from Experience 6/10 Non compliant

Competent & Capable Workforce 7/10 Compliant

Safe Environment 6/10 Non compliant

Acute and Community

Services

7/10 Compliant

Overall compliance 34/50 Compliant at Level 1

Slide 80

CQC

NHS Litigation Authority Clinical Negligence Scheme for Trusts - Maternity Clinical Risk Management Standards 2012-13

Assessment Date Thursday 6 December 2012 Level Achieved Level 1

The maternity service was assessed against five standards each containing ten criteria giving a total of 50 criteria. In order to gain compliance at Level 1 the organisation was required to pass at least 40 of these criteria, with a minimum of seven criteria being passed in each individual standard. The organisation scored as follows:

Ofsted

In May 2012 an integrated inspection of safeguarding and services for looked after children took place in the NHS Airedale, Bradford and Leeds PCT cluster, of which Airedale NHS Foundation Trust participated. The following recommendations were identified which directly relate to Airedale NHS Foundation Trust, together with Bradford City Council:

• To review outcomes and to strengthen the coordination of emotional health and well-being services in order to reduce demand on specialist mental health provision.

• To address gaps in service provision and inconsistencies in assessment for children and young people with complex health needs or disabilities.

• To ensure all children who are looked after and care leavers have the level of support they need to maintain good health and well-being.

Domain Score Compliant?

Organisation 8/10 Compliant

Clinical care 10/10 Compliant

High risk conditions 10/10 Compliant

Communication 10/10 Compliant

Postnatal & new-born care 10/10 Compliant

Overall compliance 48/50 Compliant

Slide 81

CQC Slide 82

Map of Airedale General Hospital

CQC

Safety

Trust Board Agenda and then Chief Executive’s Report– July 2013 (Source: Trust board agenda: Wednesday 26 June 2013)

This section has reduced the trusts board agenda and chief executive report, dated July 2013, down to the actions that were recommended to the board. Please see the original documents for details around the issues discussed. This report does not determine who at the trust is responsible for each action.

Chief Executive’s Report 24 July 2013

Improvements to the hospital environment for patients continue: The refurbished maternity unit was opened on 18 July. This also launched My Airedale Midwife (MAM) the trusts new personalised service offering individual midwifery care to pregnant women.

A new £2.4m endoscopy unit is also open. Including an extra procedure room so that more people can be treated in the future which will address current capacity issues.

The trust is working on the full business case for a new A&E department is underway.

Accident & Emergency (A&E) 4 Hour Treatment Time Standard

There were improvements in the June position that saw 98.2% achieved for the month, the Quarter 1 (Q1) position for patients being admitted, treated or discharged within 4 hours in A&E was 94.3% against a 95% threshold. This is contributing to a financial year 13/14 performance of 94.7%.

There is an issue around the required level of performance which continues to be challenging. Currently the trust is meeting the target for July, but there are service pressures resulting in long waits for patients. Board will require reassurance that the trust is able to meet the winter planned targets.

Breaches of the standard in Q1 were a result of either bed holds or patients waiting in A&E for admission. Action currently being taken to try and improve the position includes further strengthening the development of the senior acute physician input through the Clinical Assessment Team and the implementation of an Urgent Care Board to oversee the management of the primary and secondary care interface. The trust has also recently commissioned bed modelling work which suggests some additional beds shall continue to be required in the short term to support the delivery of this standard.

Slide 83

CQC

Accident & Emergency (A&E) 4 Hour Treatment Time Standard continued…

As a result of the Amber/Red (downgraded from Amber/Green in Q3 2012/13) rating, Monitor shall assess if further requirements are

needed for assurance purposes. These could include:

• Exception Reports and Action Plans to be forwarded against which progress shall be monitored.

• Requirement to seek or report on external support for correcting the position (e.g. Intensive Support Teams, Consultants etc).

• Possible escalation

It should be noted that as part of the Compliance Framework 2013/2014, Monitor may apply a Red Governance risk rating and consider

a Foundation Trust for investigation if the trust fails to meet the A&E indicator in any two quarters over a twelve month period and fails the

indicator in a quarter during the subsequent nine month period or the full year.

There is an action plan in place and the following information on the progress to date is available:

• A review of the nurse training and competency base has been completed and gaps are now prioritised for training within the next two

months.

• The A&E Unit Manager and Senior Matron have attended a Best Practice Event hosted by IMAS event to share learning from other

organisations.

• The practice of proactively streaming patients to LCD (Local Care Direct) Out of Hours has continued.

• The shift leaders within A&E are now managing their workload more effectively and focus on the signs of increased activity to avoid

late first assessments at the front end of the pathway.

• There have been significant changes to ambulance handover processes which have shown an improvement in handover times within

15 minutes of arrival (up from 65% April-June to 95% in July).

Slide 84

CQC

Actions in Progress:

The Business case for potential expansion of Consultant presence in the department is still pending. Options are being considered

by the Clinical Director and his colleagues and will be presented to the Executive Directors for consideration over the coming weeks.

• Options to extend minor injuries streaming to 11pm area are also being considered, which may mitigate some of the requirement

for extending the consultant rota hours.

• A review of see and treat pathways for minor injury patients to improve scope, effectiveness and efficiency of these pathways will

commence in August 2013.

• The Matron post for A&E and Urgent care has been appointed and is due to commence on the 5th August. This will further

strengthen leadership and provide increased capacity and capability in the department.

Hospital Acquired Infection Rates

There were no cases of C Difficile during the month of June, total for 2013/14 so far is three. This is within an expected range.

There were three cases of Clostridium Difficile infections in Q1. This is below the 12 applied in the Compliance Framework, no

penalty points are applied. Achievement of the Clostridium Difficile threshold for 2013/2014 however remains at risk and this was

declared to Monitor in the Annual Plan submission in May. The risk is based on the low centrally set target of 9 which, Directors do

not feel is achievable in given the prevalence of C Difficile that exists in the community.

There were no cases of MRSA this month.

All other standards are achieving the required thresholds or within expected limits, however close monitoring is taking place to

ensure continued delivery of these.

Slide 85

How to contact us

Call us on: 03000 616161

Email us at: [email protected]

Look at our website: www.cqc.org.uk

Write to us at: Care Quality Commission

Citygate

Gallowgate

Newcastle upon Tyne

NE1 4PA

Follow us on Twitter: @CareQualityComm

http://www.cqc.org.uk/

Documents

Airedale NHS Foundation Trust Data Pack 18th November, 2013 · 2014-05-06 · Foster Hospital Guide 2012). The graph below was provided by the trust, and details their bed occupancy