ROYAL CORNWALL HOSPITALS NHS TRUST QUALITY … · Peninsula Trauma Network 9 Improved pathway for Glaucoma patients 10 Patient Experience 11 Quality of discharge including information

RCHT 2012/13 Quality Account: Final 1

ROYAL CORNWALL HOSPITALS NHS TRUST

QUALITY ACCOUNTS 2012/2013


CONTENTS PAGE

Contents Page Part 1: Chief Executive’s statement 4 Part 2: Priorities for Improvement 6 A. Review of 201 2/13 priorities f or improvement 6 Patient Safety 6 Patient flow including single point of access and ambulance turnaround times

6

Implementation of the Safety Thermometer: reducing incidents of harm

8

Clinical Effectiveness 9 Designation of RCHT as a Trauma Unit in the Peninsula Trauma Network

9

Improved pathway for Glaucoma patients 10 Patient Experience 11 Quality of discharge including information provision 11 B. Priorities for improvement 201 3/14 11 Patient Safety 12 Safety Thermometer, reducing harms 12 Clinical Effectiveness 13 Preventing admissions from high risk patients 13 Staff health and wellbeing 14 Patient Experience 15 Improving the discharge experience for patients and reducing unnecessary discharge delays

15

CARE campaign 16 C. Board statements of assurance 17 Review of our performance 2012/13 17 National priorities and existing commitments 17 Incident reporting and Never Events 20 Participation in Clinical Audits 21 Research and Development 27 Commissioning for Quality and Innovation (CQUIN) 29 How the NHS regulator, the Care Quality Commission, views the quality of our services

33

Data Quality 33 Information Governance Toolkit attainment levels 34 Clinical coding error rate 34 National Quality Indicators 36 Part 3: Review of the Trust’s quali ty performance 41 Patient Safety 41 Obstetrics and Gynaecology service review 41 Lower segment caesarean section surgical site 42


infection surveillance (SSI) Clinical Effectiveness 43 Lung cancer 43 Junior doctors in training 44 Cornwall Vascular Unit 47 Audiology 49 Laparoscopic colorectal surgery 51 Bariatric and Metabolic surgery 53 Patient Experience 55 National A&E (ED) Survey 55 National In-Patient Survey 56 Early supported discharge for stroke 57 Young Peoples takeover event in Sexual Health 59 Involvement and Stakeholder Engagement 60 Statements from Healthwatch, Health Overview and Scrutiny Committees and Clinical Commissioning Groups

62

Kernow Clinical Commissioning Group 62

Cornwall Health and Adults Overview and Scrutiny Committee

63

Healthwatch Cornwall 64 Isles of Scilly Health Overview and Scrutiny Committee

65

Healthwatch Isles of Scilly 65 Trust response to comments from third parties

66

Statement of Directors' Responsibilities in Respect of the Quality Account

66

Independent Auditors’ Report 68


Royal Cornwall Hospitals NHS Trust

Quality Accounts 2012/13 PART 1 Chief Executive’s statement on behalf of the Trust Board Welcome to this year’s Royal Cornwall Hospitals NHS Trust Quality Accounts. The report builds on last year’s quality accounts identifying our performance in 2012/13 and our improvement plans for 2013/14. ‘Our plans 2012 – 2017’ published in July 2012 continues our commitment to the delivery of better, safer, good value care outlined in our previous plans ‘2010-2014’. The Trust has consistently maintained ‘performing’ status since May 2009 which means, together with our unconditional CQC registration, our overall performance is viewed positively. The Trust continues to work towards being authorised as a Foundation Trust and continues to be the preferred provider of acute services for the people of Cornwall and the Isles of Scilly. The CQC visited the Trust in November 2012 as part of their scheduled inspection programme. I am pleased to say that the Trust was found to be compliant with all the outcomes assessed, at all the locations visited. I, together with the rest of the Trust Board, apologise unreservedly for the pain and distress caused to some of our patients by the care and treatment they received from one of our former gynaecology consultants. Throughout 2013/14 we will continue to implement the recommendations of the five review reports published in February this year. The information within this year’s quality accounts provides a good insight into the progress made against our objectives. Particular highlights are:

• No cases of MRSA bacteraemia for the second successive year • National recognition for our Lung Cancer Team in the Improving Lung

Cancer Outcomes Project • GMC commendation for 3 areas of best practice in junior doctors

training; more than any other Local Education Provider in the Peninsula • The achievement of CNST level 3 by our Obstetric service

In consultation with our staff, service users and stakeholders, the Trust has identified a number of areas for improvement for the forthcoming year:

• We will continue to reduce the levels of avoidable harm using the NHS Safety Thermometer

• We will work with our partners to identify and prevent the re-admission of high risk patients to our hospitals

• Our staff are essential in delivering high quality patient care; through the “Our people” workforce strategy we will support and develop our staff to their full potential


• We are committed to improving the quality of hospital discharge for our patients by improving the information we provide and reducing unnecessary delays in discharge

• The CARE campaign was launched in May 2012 focussing on the basic elements of nursing care. Success is measured through our patient experience survey. We will work to ensure our patients have a positive experience all of the time.

I am pleased to publish our fourth quality accounts and to confirm my personal commitment to providing high quality health care for the people of Cornwall and the Isles of Scilly. To the best of my knowledge the information in these quality accounts is accurate.

Lezli Boswell Chief Executive


PART 2 PRIORITIES FOR IMPROVEMENT A. Review of 2012/13 priorities for improvement Patient Safety 1. Patient flow including single point of access an d ambulance turnaround times As described in last year’s accounts, the Trust has undertaken a number of initiatives to improve the flow of patients through our hospitals. These include: The Ambulatory Care Unit opened in October. This is a GP led assessment area that aims to reduce hospital admissions. We have continued to develop the Integrated Hospital Discharge Team. Development of carepathways for elderly patients are now included in the Trust’s 5 year plan for 2018. The Clinical Site Development Plan for surgery is progressing according to plan:

• Vascular Surgery is now on Wheal Coates ward in Trelawny Wing. • The Ophthalmology out-patient department has moved to the Tower

Block. • Theatre Direct has been temporarily relocated to allow for redesign of

the facility. • Laminar flow is being installed in theatres 10 and 11 to provide a new

elective orthopaedic theatre suite followed by integrated laparoscopic theatres being installed in theatres 8 & 9; estimated to be completed by September 2013.

• All of the above are required prior to the Surgical Receiving Unit being relocated in Trelawny wing alongside the new GI (Gastro-intestinal) ward due for completion in December 2013.

The Urgent Care Centre at West Cornwall Hospital opened in July and has been received positively by both the GPs who work there and our patients. An accelerated pathway is in place at St Michaels Hospital and working well so that patients requiring hip or knee replacement surgery have a one stop service and leave the hospital with their date for surgery. We are the only orthopaedic provider in Cornwall to provide this service. Feedback from patients is very good. Work is on-going to improve the flow of patients to West Cornwall Hospital (WCH) with the development of ‘live’ waiting lists for WCH. Single Point of Access is due to be delivered in summer 2014. Phase 1 of the Emergency Department (ED) build is nearing completion and the minor injuries area has been relocated into the old fracture clinic and now has its own


entrance and reception area. Phase 2 has commenced with work currently underway to refurbish Gerrans and increase trolley capacity for majors. The Medicine division has developed a bed strategy for the next three years which includes additional care of the elderly beds and a dedicated frailty unit. The 30 minute ambulance turnaround target remains a local contractual requirement; the Trusts performance over the year is reflected in the chart below.

73

16

3

10

8

15

1

12

7

97

78 83

75

70

30 8

1

28

10

2

11

3

11

4

20

2

17

1

10

5

46

13

7

67

64

10

7

82

25

0

31

3

0

50

100

150

200

250

300

350Ambulance Delays - Numbers waiting over 30 minutes

Actual

Ambulance handover delays continue to be similar to the regional average. This has occurred despite additional measures put in place for winter including a discharge lounge, additional ED staffing, medical MDTs, an Ambulatory Care facility and a 7 day therapy pilot. A number of new areas for improvement have been identified:

• ED environment improvement. Phase 1 of the ED re-development plan is nearing completion and the re-provision of minors and paediatrics is planned to be completed by the end of 2013. This will align the configuration of ED to better meet the needs of paediatrics, minors and majors.

• Reconfiguration of the bed base within medicine. • Reduce length of stay, initially focusing on patient stays of over 10 days. • Improved management of frail elderly patients. • Provision of ambulatory care facilities in Medicine. • Streamline surgical admissions.

Joint working arrangements between RCHT and SWAST have remained in place, with an action plan including escalation processes and daily validation in place, and SWAST being very supportive of the challenges being faced by RCHT during the winter months. The Trust is expecting to continue this close joint working into 2013/14.


2. Implementation of the Safety Thermometer: reduci ng incidents of harm In April 2012, the NHS Safety Thermometer Tool was successfully implemented in all inpatient areas. The Safety Thermometer Tool assesses all inpatients on a specific pre-set date on the basis of how well patients are protected from “4 harms”:

• Pressure Ulcers. • Falls. • Catheter Associated Urinary Tract Infection (CAUTI). • Venous Thromboembolism (VTE).

The data collected between April 2012 and March 2013 gave the Trust an overall monthly “harm free care” rating of between 89% and 94%.

RCHT Safety Thermometer - RESULTS REPORT

All Harms New Harms

Apr-12 89.38% 93.84%

May-12 90.60% 94.65%

Jun-12 91.61% 96.06%

Jul-12 91.76% 95.97%

Aug-12 92.40% 95.95%

Sep-12 92.92% 97.53%

Oct-12 93.60% 96.71%

Nov-12 93.45% 97.17%

Dec-12 94.15% 96.04%

Jan-13 92.71% 96.59%

Feb-13 92.20% 96.18%

Mar-13 93.11% 95.99%

SUMMARY FALLS VTE PRESSURE ULCER UTI

% Harm Free Care

36 33

23 24 2415

19 1623 22 24 25

2625

26 2521

28 18 22 11

2525

18

94%95%

96% 96% 96%98%

97% 97%96% 97% 96% 96%

89%91%

92% 92% 92% 93% 94% 93% 94%93% 92%

93%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

0

10

20

30

40

50

60

70

80

90

100

Harm Summarynew Harm old harm % New Harm Free % Harm Free

The term “harmfree” care directly associated with the Safety Thermometer is now recognised as a key goal in quality improvement. Reducing the number of pressure ulcers that develop in our hospitals has been given high priority by the nursing leadership. Actions identified last year to improve practice and process to prevent pressure ulcers are proving successful. Overall the Safety Thermometer evidence from April 2012 to March 2013 shows a reduction in new pressure ulcers from 2.89% to 1.76% which indicates that the action plan is succeeding in its intended goal, though further progress needs to be made. Changes in place include improvements in compliance with the SKIN (Surface inspection, Keep moving, Incontinence, and Nutrition) bundle and rolling out the lower limb pathway to all vulnerable patients at risk of pressure ulcers.


Implementation of the Royal College of Physicians “fallsafe” care bundle was rolled out to the top 16 high risk ward areas in January 2013. The bundle includes the further embedding of CARE rounds (intentional rounding) across all wards and departments, a review of Multi-Disciplinary Team (MDT) practice to ensure that there is timely review of multifactorial risk factors (particularly after a fall) and an open review at the falls group of falls incidents where patients have come to harm. Intentional rounding is a process where nurses and support staff carry out regular checks with individual patients at set times. At the end of the check the patient is asked “Is there anything else I can do for you?” While there has been little improvement in our overall monthly falls rate across the Trust, we have achieved an assurance that all falls are now reported on Datix (the Trust’s incident reporting system) by doing a cross comparison of safety cross data, Datix and Safety Thermometer data. All health care organisations in the south west undertaking falls improvement work under the Quality and Patient Safety Improvement Programme (QPSIP) have reported the same difficulty with improving falls rates. All actions identified following a review of complaints relating to falls have been completed. Clinical Effectiveness 1. Designation of RCHT as a Trauma Unit in the Peni nsula Trauma Network Following the designation of the Trust as a Trauma Unit in the Peninsula Trauma Network the unit has worked hard to meet the requirements set by the network. Compliance with dataset submissions to the Trauma, Audit and Research Network (TARN) have continued to improve, however our comparison figures to HES (Hospital Episode Statistics) data suggest that we have only identified 65% of entries for 2012. We have looked into this and believe that the HES data is misrepresenting the TARN-eligible population. We have discussed this with TARN and they have looked in detail at our data submission. Of the 1 month dataset submitted to TARN using their identification algorithms, we had submitted over 80% and also identified additional eligible patients not picked up by the TARN algorithm, bringing us over 90% of expected. We will submit these findings to the Network and request a review of the base figures or acceptance that our dataset is robust. Patient satisfaction and feedback surveys have been developed and ratified by the Major Trauma Review Group. They are to be sent out to patients being entered into the TARN database. Unfortunately we haven’t been able to identify a patient representative to sit on our Major Trauma Review Group. The rehabilitation coordinator for the Peninsula Trauma Network has been appointed. The Trust is working with the coordinator to develop the directory of services.


Senior nursing staff from the Emergency Department (ED) have attended all three TNCC (Trauma Nursing Care Course) courses run by the Peninsula Trauma Network. Two sessions of the Trauma Intermediate Life Support course have been successfully completed by 21 ED staff nurses and 2 members of the Search and Rescue medical team. This course ensures all participants are trained in relevant trauma knowledge and skills. A further course is planned for late July 2013. The Trauma Team Training course is being run centrally in Derriford five times this year and we expect to send two teams to this. An audit of Trauma Team Attendance is nearing completion. The Primary Survey reporting of trauma scans is in place. Use of this tool has not been universal and therefore feedback has been provided to radiology staff reporting on the scans as well as to the radiology departmental audit meeting. The need for early request for Trauma CT has been highlighted to all trauma team leaders (ED consultants). Feedback is being provided to staff involved following trauma calls. The collection of Key Performance Indicators (KPIs) is still being decided at a Network level. Discussions between the Trust and the Peninsula Trauma Network as to what is expected and how this is to be achieved are ongoing. The Major Trauma Review Group continues to oversee multi-divisional pathways of care for major trauma patients as per its Terms of Reference. 2. Improved pathway for Glaucoma patients In 2012 the Glaucoma Assurance Group designed and implemented a new administrative process which identifies patients with Glaucoma on the Patient Administration System. This has enabled RCHT to identify patients with Glaucoma and produce a monthly management report showing the demand, for example Glaucoma patients on the pending list and whether they were overdue. The Service Lead then matched this with capacity; a shortfall was identified. The new Glaucoma Monthly Management Report also shows DNA (Did not Attend) rate for Glaucoma patients. For January 2013 the DNA rate for patients with Glaucoma was 5.26%. This is better than the national upper quartile for Ophthalmology. The Service Lead is currently implementing a recovery plan to address the shortfall identified. Additional staff are being recruited and a recovery plan developed to provide additional acute hospital based capacity which includes:

• Additional consultant clinics • Additional photography clinics

February 2013 saw the launch of the Primary Care Monitoring Ocular Hypertension and Suspected Glaucoma enhanced service. This will receive approximately 1500 referrals from RCHT to the community optometrists.


Patient Experience 1. Quality of discharge including information provi sion Across the medical wards daily multidisciplinary meetings occur in front of their electronic interactive bed status boards. The team will review all patient trajectories to make plans and prioritise work activities for the day. All areas have now adopted the new simplified template and new icons. Feedback from the teams continues to be positive in respect to better team decision making and prioritising, improved team communications and improving information about discharge plans to patients. The ‘When will I go Home?’ discharge booklet was re-launched over the spring of 2012. Monitoring of the booklet being issued to each inpatient is now reported quarterly for each ward in a new set of discharge related key performance indicators. We are currently reporting about half of patients have documented evidence that they have been given a copy – this new monitoring arrangement reported into ward level quality performance reports will now start to drive up the rate of booklet availability for inpatients. Progress on the development of bedside information was initially delayed due to problems securing a publisher. The new concept of launching a bedside ‘newspaper’ has progressed through engagement with our new Patient Ambassadors. The Trust’s ‘Readers Panel’ is reviewing content, specifically the content relating to discharge process and planning. The launch of this new publication is anticipated for the summer of 2013. B. Priorities for improvement 2013/14 Process for agreeing our priorities for improvement A list of priority areas for improvement was circulated to the Trusts stakeholders for comment in February based on the following evidence:

• Engagement during 2012/13 with our patients and the public in the community we serve.

• FT Quality Assessment. • The National Outcomes Framework. • NHS Information Centre. • Commissioning for Quality and Innovation (CQUIN) programme. • National and local patient experience surveys. • Royal Cornwall Hospitals NHS Trust Strategic Plans 2012-17. • Intelligence from our internal mechanisms for monitoring the quality of

our services. Feedback received was used to finalise the priority areas and also to inform the performance review section of these accounts.


Patient Safety 1. Safety Thermometer: reducing harms The safety of our patients is of paramount importance to the Trust. We have therefore decided to keep the Safety Thermometer as one of our key quality improvement measures for 2013/14. The aim of the Safety Thermometer is to achieve improvements based on a ‘harm free’ care rating which is drawn from a monthly point of care audit of all inpatients on a single specified day per month as previously described. The data collection method promotes the prevention of harm and patient safety by counting the cost from the patient’s perspective and experience. The primary aim is to prevent harm in our care and to work effectively with our partners in the community so that harm is reduced across the healthcare community as a whole. The intended outcome is to prioritise “harmfree” care among our frontline teams, then proactively put changes in place which prevent harm rather than just counting the consequences. In collaboration with our community partners a target for the prevention of pressure ulcers (PU) has been agreed based on the 2012/13 Safety Thermometer pressure ulcer baseline data.

Apr 12

May 12

Jun 12

Jul 12

Aug 12

Sep 12

Oct 12

Nov 12

Dec 12

Jan 13

Feb 13

Mar 13

Percentage of patients with either an old or new pressure ulcer

6.79 5.83 6.18 4.87 4.82 5.1 4.84 4.63 3.61 3.72 4.62 4.49

Percentage of patients with a new RCHT acquired pressure ulcer

2.89 1.94 1.77 0.84 1.2 1.53 1.9 1.72 1.89 0.78 1.43 1.76

No. of patients (RCHT) 589 617 566 595 581 588 578 583 581 645 628 624

While the target has been agreed for this year to focus on pressure ulcers, the Trust will make full use of the Safety Thermometer initiative to reduce all four of the avoidable harms. The Safety Thermometer working group will review activity with the relevant harm groups to assist plans and prevent harm across all the harm domains. Identified areas for improvement:

• Ensure full compliance with the on-going Safety Thermometer data collection for all inpatients.

• Reduce the incidence of hospital acquired pressure ulcers.


• Achieve a reduction in falls using the fallsafe care bundle and co-ordinating falls reduction with other groups within the southwest Quality and Patient Safety Improvement Programme.

• Achieve compliance with trustwide implementation of CARE rounding and SKIN bundle to prevent falls and pressure ulcers.

• Implementation of the single system catheter for the prevention of catheter associated urinary tract infection.

• Reduce the incidence of patient falls resulting in harm by 50% from 2009 to 2013.

• Reduce the incidence of combined harm over the four harms identified above.

A Safety Thermometer working group of key stakeholders will remain in place to ensure that there is compliance with the monthly data collection from April 2013 and that the target for harm reduction is achieved by reviewing planned activity from the harm groups. Data from the Safety Thermometer tool will be amalgamated to achieve a trust wide “harm rating” for inpatients and uploaded to the NHS Information Centre (NHSIC). This data is available in the public domain and is made available for comparison with other trusts. Results are distributed to all ward areas within one week of data collection and are a key safety indicator on the Performance Assurance Framework (PAF). Performance and learning outcomes are formally reported to the Governance Committee and the Divisional Quality and Learning Group. Clinical Effectiveness 1. Preventing re-admissions from high risk patients The Trust continues to monitor the rates of patients requiring re-admissions following patients being discharged from the Trust. A detailed audit was conducted of re-admissions and the vast majority were found to be unavoidable or unrelated to the original admission. The rate of re-admissions is monitored on a monthly basis by each of the clinical divisions and is a vital component of the PAF which is used to monitor clinical performance and ensure we detect any changes in performance. For 2013/14 the Trust plans on-going work with the wider heath community and social services to devise new strategies to ensure that patients are not readmitted to hospital unnecessarily. Examples include ensuring that patients who are discharged have full electronic discharge plans sent to their GP at the time of discharge to ensure there is a clear plan for treatment and follow up of chronic conditions such as diabetes, chronic lung disease and heart failure. In addition steps will be put in place that relevant specialist follow up is arranged with patients after admission with certain conditions, such as diabetic ketoacidosis, to ensure patients have received all the appropriate education to avoid further admissions.


2. Staff health and wellbeing The Health and Wellbeing strategy was initiated following the Boorman review of NHS health and wellbeing. Dr Boorman gathered a wealth of evidence of the state of health and wellbeing in the NHS, its impact on care and cases of best practice. Health and wellbeing is increasingly being acknowledged as a vital element in supporting and developing the workforce. It is now a key part of the "Our People" Human Resources strategy. Through "Our People" The Health and Wellbeing strategy aims to:

1. Create a safe and healthy working environment 2. Improve physical and emotional well being 3. Encourage and support employees to develop and maintain a healthy

lifestyle 4. Support people with manageable health problems or disabilities to

maintain access to or regain work 5. Improve staff satisfaction, recruitment and retention

To achieve these aims we will introduce wellbeing initiatives, employee support mechanisms and joint working with staff, their representatives and local partners to identify and address areas for improvement. Through the “Listening into Action" programme and redesigning services in line with the aims in "Our People" we will work with employees to ensure our organisation identifies and minimises those issues which may impact negatively on staff health. Principal aims in addition to those outlined above are:

• To proactively work with staff to prevent ill health occurring. • When staff are unwell, to help them access timely and appropriate

services that will facilitate their recovery. • To work in partnership with staff to provide a fair and consistent policy,

treating staff with dignity and respect. Key indicators

The Launch of the Listening into Action (LIA) programme in 2012 resulted in Health and Wellbeing becoming one of 10 key LIA projects. The Health and Wellbeing workstream is personally chaired by the Chief Executive and initiated three areas of activity:


• The agreement to investigate options for an Employee Assistance programme

• To undertake work with staff on values and behaviours • A new sickness absence policy developed in partnership with staff side

In addition to this work the Trust has for the second year participated in the evaluation for the “Cornwall Healthy Workplaces Award” and will be awarded “gold” status. The Trust is also redesigning Occupational Health services to focus on prevention and Health and wellbeing support for staff, introducing an “Employee Treatment Support Programme” to help staff who are awaiting treatment. Work has been completed to understand the reasons for absence in the Trust. As a result of this we are working with the European Centre for Environment and Human Health to devise an action plan to tackle stress in the workplace. We are also working with NHS Employers using dedicated support to develop an action plan. Each division has a dedicated Human Resources professional supporting managers in understanding the local patterns in key areas and responding to staff needs. We also produce workforce information identifying current rates of absence and trend data. This data is published monthly to divisional management teams and discussed weekly at the Operational Management Group. Each division is performance managed though the Trust performance management process. Following the launch of the “Our People” strategy for Human Resources work is due to commence to develop a manager ‘self-service’ IT solution, enabling the reporting of absence to payroll and absence data to be available to managers in real time. Patient Experience 1. Improving the discharge experience for patients and reducing unnecessary discharge delays This area of collaborative care planning involves the person in hospital, often their carer and family members and a wide multiprofessional team. The process forms part of the vast majority of our patient journeys. From the ‘simple’ to the most ‘complex’ discharges, they all require the skilful co-ordination of tasks, individuals and teams, as well as expectations to be successful. Increasingly we have seen a rise in the number of people in hospital delayed for various reasons which is not good for the person who no longer needs an acute hospital bed. In many ways discharge is an art rather than an exact science and for this reason such a simple sounding and routine process can sometimes go wrong. We are committed to making sure we get it right every time, and when we don’t, to learn from the issues identified to improve our services.


Identified areas for improvement

• Improve compliance with our best practice policy on discharge. • Increase multiprofessional educational opportunities in aspects of the

discharge process. • Monitor the impact of educational initiatives. • Establish a mechanism to learn from discharges that don’t go right. • Minimise the bureaucratic burden of the current discharge process.

Key initiatives to deliver in 2013/14

• Introduce service improvement methods to improve compliance with delivery of the discharge policy.

• Scope and introduce creative multiprofessional discharge training opportunities in areas of discharge practice.

• Develop measurement tools to monitor the impact of education on discharge.

• Develop and implement electronic information sharing systems to communicate discharge information between care partners.

2. CARE campaign The Trust publically launched its commitment to the CARE campaign in May 2012 in collaboration with the Patients Association and the Nursing Standard. The campaign focuses on the four aspects of care that the Patients Associations’ national help-line received most concerns about:

C - Communicating with compassion. A – Assisting with toileting needs, maintaining dignity. R – Relieving pain effectively. E – Ensuring adequate nutrition.

These elements of care are central to the Trust’s ambition to focus relentlessly on the quality of care we give to remain the preferred provider of acute and specialist healthcare to the people of Cornwall and the Isles of Scilly. CARE is the central element of the Trust’s Nursing and Midwifery Strategy. Since the campaign’s launch, through the Trust’s patient experience survey, we have measured these four aspects of care through eight key questions. The survey results report high patient satisfaction with, on average, 99% of patients responding positively to the questions (combined ‘yes always’ and ‘yes sometimes’ response options). The most improved area of CARE has been in ‘Ensuring adequate nutrition’, improving from 94% to 99%. In 2013/14 the Trust aims to address the variability in CARE patient’s report we give, with a target to reduce the ‘yes, sometimes’ responses and increase the ‘yes, always’ responses to the eight questions in our survey. In the December 2012 survey results the average variability (‘yes, sometimes’ responses) was 11%.


Key indicators: Increase the ‘Yes, always’ response rate to the CARE questions (halving the ‘Yes sometimes rate):

C - Communicating with compassion from 90% to 95%. A – Assisting with toileting needs, maintaining dignity from 92% to 96%. R – Relieving pain effectively from 88% to 94%. E – Ensuring adequate nutrition from 88% to 94%.

Progress will be monitored through the continuation of the eight questions within the revised friends and family test patient survey. C. Board statements of assurance These accounts have been developed taking into regard any guidance issued by the Secretary of State which relates to Chapter 2 of the 2009 Health Act. During 2012/13 the Royal Cornwall Hospitals NHS Trust provided and/ or sub-contracted 80 NHS services. The Royal Cornwall Hospitals NHS Trust has reviewed all the data available to them on the quality of care in 80 of these NHS services. The income generated by the NHS services reviewed in 2012/13 represents 100 per cent of the total income generated from the provision of NHS services by the Royal Cornwall Hospitals NHS Trust for 2012/13. Review of our performance 2012/13 National Priorities and Existing Commitments As a non-Foundation NHS Trust, the Trust is assessed against the Department of Health’s Performance Framework as either ‘performing’, ‘performance under review’ or ‘underperforming’. Performance against the Framework in 2012/13 is summarised overleaf. The Trust has sustained ‘performing’ status consistently since Q2 2009/10.


DH Performance Framework 2012-13

Indicator Higher Lower Timings Weighting Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Maximum waiting time of 4 hours in ED 95% 94% monthly 1.0 0 0 0 3 3 3 3 3 0 2 0 0

MRSA bacteraemias1 in

2012/13<1sd ytd 1.0 3 3 3 3 3 3 3 3 3 3 3 3

Clostridium Difficile Post 72 hour infections41 in

2012/13<1sd ytd 1.0 3 3 3 3 3 3 3 3 3 3 3 3

RTT admitted pathways (overall

performance)90% 85% monthly 1.0 3 3 3 3 3 3 3 3 3 3 3 3

RTT non-admitted pathways (overall


RTT incomplete pathways (overall


RTT delivery in all specialties (including

admitted, non-admitted and incomplete)0 >20 monthly 1.0 3 3 2 2 2 2 2 2 2 3 2 2

Diagnostic tests (% within 6 weeks) 99% 95% monthly 1.0 3 3 3 3 3 3 3 2 3 3 3 3

Cancer indicators Various

5% lower

than

upper

monthly 3.0 8.5 9 8.5 9 9 9 8.5 7.5 8.5 7.5 8.5 8.5

Delayed transfers of care YTD <3.5% 5% monthly 1.0 2 3 2 3 3 3 2 2 3 0 2 3

Mixed sex accommodation 0.0% 0.5% monthly 1.0 3 3 3 2 3 2 3 3 3 3 3 3

VTE risk assessment 90% 80% monthly 1.0 3 3 3 3 3 3 3 3 3 3 3 3

Total 14.0 37.5 39 36.5 40 41 40 39.5 37.5 37.5 36.5 36.5 37.5

Score 2.68 2.79 2.61 2.86 2.93 2.86 2.82 2.68 2.68 2.61 2.61 2.68

Status on Service Performance Performing Performing Performing Performing Performing Performing Performing Performing Performing Performing Performing Performing

Thresholds Achieved Projected

Colour code

0.0 no or low risk

0.0 achievement predicted but higher risk

1.5 points dropped on indicator - lower threshold achieved

0 both thresholds failed for indicator


Emergency Department Access The main performance difficulty encountered by the Trust in 2012/13 has been the consistent achievement of the ED 4 hour target which was failed in Q1 and in Q4. A number of actions have been put in place including:

• Establishment of an Executive Whole System Patient Flow and Delayed Discharges Improvement Group, with an action plan to improve patient flow across the system.

• New building works now underway within the department to expand the currently limited space available which impacts on the patient experience.

• Piloting ambulatory care in MAU and the establishment of an Urgent Care Centre at West Cornwall Hospital.

• Ongoing work with Peninsula Community Health and Adult Social Care to make sure where clinically appropriate patients are transferred to community hospitals or return home with packages of care.

• Internal actions within the Emergency Department, such as improved breach analysis and increased staffing at peak times.

RTT/ Waiting Times The progress which was noted in last year’s quality accounts has largely been sustained and the national admitted, non-admitted and incomplete pathway standards have been sustained all year. C Difficile and MRSA The Trust has met both of these standards for 2012/13. During the year there were 26 instances of C Difficile, which means that the Trust is doing slightly better than the 2013/14 England ambition levels of 13 cases per 100,000 bed days. There have been no cases of MRSA all year. Venous Thromboembolism (VTE) Risk Assessments The Trust assessed 97.02% of patients on admission for the risk of VTE during 2012/13. The national target of 95% was exceeded every month. Delayed Transfers of Care The level of delayed transfers of care increased in 2012/13 for the second year running. The Trust continues to work with key partners including Peninsula Community Health and Adult Social Care through the Whole Systems Resilience Network to ensure that patients are discharged in an appropriate and timely fashion. Indicators for Cancer There are several indicators to which the NHS must work for cancer referral and treatment. The data in the DH Performance Framework table includes standards which relate to the percentage of patients with a:


• Maximum waiting time of two weeks from referral to the date first seen for all urgent suspected cancer referrals (target 93%).

• One month (31 days) wait from diagnosis to treatment: o For subsequent treatments for all cancers (surgery 94%, drug

98%, radiotherapy 94%). o Of all cancers (96%).

• Maximum two month (62 days) wait for first treatment from either: o Urgent GP referral (85%). o Consultant screening referral (90%).

Each of these targets was achieved on a quarterly and full year basis. The Trust is well placed to maintain ‘performing’ status into 2013/14. During 2012/13, the Trust has also assessed itself against Monitor’s Compliance Framework for aspirant Foundation Trusts. It has achieved the following results with the only penalty points incurred relating to ED performance in Q1 and Q4: Q1 Q2 Q3 Q4

RCHT Monitor

Compliance Framework

Amber-

green Green Green

Amber-

green

Incident Reporting and Never Events A high incident reporting rate is considered to be one of the indicators of a safe organisation. There has been a notable increase in the total number of incidents reported with 11396 incidents reported during 2012/13 compared to 10117 in 2011/12. During the period 1 April to September 2012 the Trust's reporting rate was 5.9 incidents per 100 admissions compared to median of 6.2 for large acute trusts in the Southwest. The data for 1 October 2012 to 31 March 2013 has not yet been received from the National Reporting and Learning System (NRLS). The Trust reported 54 Serious Incidents during 2012/13. The rate of patient safety incidents that caused serious harm or death reported during the same time period is 0.81%. Please note this is a different indicator to that included in the National Quality Indicators section on pages 39/40. The Trust has an approved process for managing all incidents, including those classified as 'Never Events' by the National Patient Safety Agency (NPSA). During the period 1 April 2012 to 31 March 2013, two Never Events occurred at the Royal Cornwall Hospitals NHS Trust. These are listed below by category and date:

• Retained vaginal pack: subsequently removed following readmission (September 2012)

• Wrong sided prosthesis component (1 out of 4) implanted: returned to theatre and changed for correct prosthesis (March 2013)

The incidents were investigated in line with the Trust's Serious Incident Policy to identify the root cause and immediate actions taken as a result of the


investigation. All serious incidents are discussed at the Divisional Quality and Learning Group to ensure organisational wide learning. The first investigation identified a lack of processes for swab, needle and instrument counts during a vaginal delivery or suturing. Revised paperwork has been implemented within the delivery suite to reflect new processes for swabs, instrument and needle counts. The second investigation identified that although safety checks are generally rigorous, they are not strictly standardised and this may have been a factor in this case. A strict standardised check has been developed and is being implemented and audited. Participation in Clinical Audits During 2012/13, 39 national clinical audits and 9 national confidential enquiries covered NHS services that the Royal Cornwall Hospitals NHS Trust provides. During that period the Royal Cornwall Hospitals NHS Trust participated in 93% of national clinical audits and 100% of national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.

• 100% participation in the National Clinical Audit and Patient Outcomes Programme (NCAPOP)

• 84% participation in “other national clinical audits The national clinical audits and national confidential enquiries that the Royal Cornwall Hospitals NHS Trust was eligible to participate in, and for which data was collected in 2012/13, are listed below alongside the percentage / number of submitted cases for that audit or enquiry:

Audit/Confidential Enquires Acronym Participation Percentage or

number of cases submitted

National Confidential Enquiries

Asthma Deaths NRAD Yes 100%

Child Health Review CHR-UK Yes 100%

Maternal Infant and Perinatal Deaths Yes 100%

Alcohol Related Liver Disease (NCEPOD) Yes 100%

Bariatric Surgery (NCEPOD) Yes 100%

Cardiac Arrest Procedures (NCEPOD) Yes 100%

Subarachnoid Haemorrhage (NCEPOD) Yes 100%


Tracheostomy Procedures (NCEPOD) Yes 100%

Elective Surgery (National PROMs Programme) Yes 87%

Suicide and Homicide in Mental Health NCISH Not relevant

National Clinical Audit & Outcomes Programme (NCAPO P)

Acute Coronary Syndrome or Acute Myocardial Infarction MINAP Yes 900 cases

Bowel Cancer NBOCAP Yes 100%

Cardiac Arrhythmia HRM Yes 100%

Carotid Interventions CIA Yes 100%

Coronary Angioplasty Yes 100%

Diabetes (Adult) ANDA Yes

100% inpatient audit. Electronic solution required

to enable participation in the

outpatient audit

Diabetes (Paediatric) PNDA Yes 100%

Epilepsy 12 (Childhood Epilepsy) Yes 100%

Head and Neck Oncology DAHNO Yes 100%

Heart Failure HF Yes Minimum achieved

Heavy Menstrual Bleeding HMB Yes 6%

Hip Fracture Database NHFD Yes 100%

Inflammatory Bowel Disease IBD Yes Round 4 data

collection period still open

Lung Cancer NLCA Yes 100%

National Joint Registry NJR Yes 90%

Neonatal Intensive and Special Care NNAP Yes 100%

Oesophago-gastric Cancer NAOGC Yes 100%

Pain Database Yes Data collection ongoing

Stroke National Audit Programme (combined Sentinel and SINAP) SSNAP Yes 100%

National Audit of Dementia NAD Yes 100%


Chronic Obstructive Pulmonary Disease COPD Not applicable No data collection

this year

Emergency Laparotomy Not applicable No data collection this year

Falls and Bone Health NAFBH Not applicable No data collection this year

Adult Cardiac surgery ACS Not applicable

Congenital Heart Disease (Paediatric cardiac surgery) CHD Not applicable

Paediatric Intensive Care PICANet Not applicable

Psychological Therapies Not applicable

Schizophrenia NAS Not applicable

Other national clinical audits

Adult Asthma BTS Yes 100%

Adult Community Acquired Pneumonia BTS Yes Data collection

closes 31 May

Adult Critical Care ICNARC CMP Yes 100%

Bronchiectasis BTS Yes 100%

Emergency Use of Oxygen BTS Yes 100%

Fever in Children CEM Yes 100%

Fractured Neck of Femur CEM Yes 100%

Non-invasive Ventilation BTS Yes Data collection closes 31 May

Paediatric Asthma BTS Yes 100%

Paediatric Pneumonia BTS Yes 100%

Potential Donor Yes 100%

Renal Colic CEM Yes 100%

Renal Registry UKRR Yes 100%

Renal Transplantation (NHSBT UK Transplant Registry) Yes 100%

Trauma TARN Yes 58%

Vascular Surgery (VSGBI Vascular Surgery Database) NVD Yes 100%

Cardiac Arrest NCAA No

Health Promotion in Hospitals NHPHA No


Parkinson's Disease No

Cardiothoracic Transplant Not applicable

Comparative Audit of Blood Transfusion Not applicable No data collection

this year

Pulmonary Hypertension Not applicable

Prescribing Observatory for Mental Health

POMH- UK Not applicable

The reports of 21 national clinical audits were reviewed by the provider in 2012/13 and the Royal Cornwall Hospitals NHS Trust intends to take the following actions to improve the quality of healthcare provided. Below are examples of national clinical audits reports published in 2012/13 and reviewed by the Royal Cornwall Hospitals NHS Trust: Heart Failure - report published January 2012.

• Results presented to the Governance Committee and the Clinical Audit and Outcomes Group.

• Overall prognostic drug and echo targets have been met and the Trust’s performance has steadily improved.

Paediatric Bronchiectasis (British Thoracic Society) - report published April 2012.

• Results presented at the Child Health Audit Meeting in June 2012. • Most standards have been met. • Plans to encourage parents to take cough/sputum swab before

antibiotics. National Paediatric Diabetes Audit - report published September 2012.

• Results presented at a Paediatric Diabetes Away Day in December 2012.

• There has been major investment in the paediatric diabetes service in 2012 that has included additional psychology, diabetic nurse, dietitian and administration appointments. The first dedicated psychologist for paediatrics was appointed in 2012.

European COPD (British Thoracic Society) – report published September 2012.

• Results presented at the Respiratory Department Educational Meeting in December 2012.

• The Trust is a pilot site for the BTS COPD admission bundle to improve diagnosis, oxygenation, NIV and early pharmacological interventions.

• The Trust is also a pilot site for the BTS COPD discharge bundle to improve checking inhaler technique, smoking cessation, pulmonary rehabilitation and community follow up.

• A non-invasive ventilation care pathway has been introduced and is being piloted.


• A discharge pathway has been developed by the respiratory Local Implementation Group for implementation by June 2013.

UK Gynaecology Oncology Surgical Outcomes & Complications

• Results presented at 8th National Cancer Research Institute Conference in November 2012.

• Work is continuing to further reduce our operative morbidity which is 23% less than national data. Continuing to use techniques such as cell salvage and assessment of new haemostatic products to reduce blood loss.

• One of the Trust’s consultants is a recognised national trainer for courses run by the Royal College of Surgeons and is planning to start a national course for gynaecology beginning in Truro for the SW trainees.

Myocardial Infarction (MINAP) - report published November 2012

• Results discussed at the Cardiology Department governance meeting in February 2013.

• The “call to balloon time” is below the national benchmark, therefore the Trust is working with South Western Ambulance Service (SWAST) to resolve technical problems with the MOBIMED recording system.

Sentinal Stroke National Audit Programme – Organisational Report published November 2012.

• The results were discussed at the Operational Stroke Group meeting in January 2013. Changes have already been made including the introduction of Early Supported Discharge Team cover for the whole county. Also faster admission to acute stroke unit has been achieved.

The reports of 139 local clinical audits were reviewed by the provider in 2012/13 and the Royal Cornwall Hospitals NHS Trust intends to take the following actions to improve the quality of healthcare provided. Local clinical audits are reviewed at Divisional and Specialty audit and governance meetings. Examples of actions resulting from local clinical audits are listed below: Oxygen prescription and target saturations (National Patient Safety Agency, Oxygen safety in hospitals, Rapid Response Report) Report circulated to respiratory team in April 2012. Actions:

• A respiratory consultant is delivering education sessions to all the nursing staff.

• E-learning module available to all healthcare professionals. • Oxygen prescription and practice to be part of Ward performance data.

Audit of paediatric palliative care on Sennen Ward Paediatric Oncology Unit The report presented at Child Health audit meeting in June 2012. Actions:

• Regular meetings to be held with the Psychology service.


• Introduction of an advanced care plan document (“Wishes Document”). – already used by the local Children’s Hospice.

Constipation in chronic pain patients on analgesic medication – patient survey Report presented at the Pain Society's annual scientific meeting April 2012 and the Trust Pain Department meeting May 2012. Actions:

• The audit suggests that patient awareness and self-management could be improved. A patient leaflet has been developed.

Parenteral Nutrition Report presented at the Nutrition Steering Group in August 2012. Actions:

• Parenteral Nutrition guidelines submitted for consultation and ratification in May 2012.

• Care plan piloted in May 2012. • Study days on parenteral nutrition from September 2012.

NICE Technology Appraisal 247 Rheumatoid Arthritis – Tocilizumab Report presented at the Rheumatology Department meeting April 2012 Actions:

• Report shows compliance with this NICE Technology Appraisal. • Rheumatoid biologics pathway will continue to be followed and this has

been agreed with the local PCT / prescribing committees.

Trust wide audit of nutrition Results were discussed at the Nutritional Steering Group in August 2012. Actions:

• Patient Safety Advisory Group used to disseminate the message and discuss issues.

• Nutritional Web-ex sessions set up as a learning resource.

Laparoscopic cholecystectomy – complications and readmissions Report presented at the Surgery audit meeting in May 2012. Actions:

• 54% of readmissions were for pain therefore information on what to expect after surgery to be improved.

• Increase awareness of the need for analgesia on discharge. Paediatric sepsis and timeliness of antibiotics Presented at the Child Health audit meeting in August 2012. Actions:

• Development of a local guideline to be produced for the management of paediatric sepsis.

HIV testing in haematology patients Presented at the GU Education meeting & the Haematology audit meeting in July 2012. Actions:


• A checklist system introduced on a new patient proforma for clinic. • Summary of recommendations added to the haematology handbook. • Re-audit planned 6 months after all changes made.

Adult head injury audit at WCH Urgent Care Centre Results presented to the junior doctors, the nursing manager for WCH Urgent Care Centre and GP lead for the Urgent Care Pilot in November 2012. Actions:

• New adult head injury pro-forma from December 2012. • Implementation of the pro-forma by April 2013.

Anastomotic leak rates following colorectal surgery Report presented at the Surgery audit meeting in December 2012. Actions:

• All consultants – lower than nationally accepted standard. Therefore plan to review 5 years of data to provide further assurance.

Review of nutritional intake for patients with fractured neck of femur in the peri-operative period Presented at the Nutritional Steering Group in December 2012. Actions:

• Active prescribing of peri-operative supplements introduced. Research and Development The number of patients receiving NHS services provided or sub-contracted by the Royal Cornwall Hospitals NHS Trust in 2012/13 that were recruited during that period to participate in research approved by a research ethics committee, was 2133. Research, Development and Innovation (RD&I) is recognised as core business for the RCHT as contributing to evidence based practice and improving the effectiveness of care. RD&I works closely with the Peninsula College of Medicine and Dentistry (PCMD) and the European Centre for Environment and Human Health (ECEHH) as part of the research agenda. We also work in partnership with the Cornwall Partnership Foundation NHS Trust and NHS Cornwall and Isles of Scilly. This year the Trust continues to strengthen its ties with industry, working directly with our business partners and contract research organisations. Raising our profile and increasing income from external sources has also helped to ensure our patients get access to the latest therapies and medical devices. The Trust had 365 active research studies in 2012/13 representing an increase of 22% on the previous year. The number of participants recruited in 2012/13 was 1870 (network) and 263 (non-network) which shows that there is a trend towards studies that are registered on the National Institute of Health Research (NIHR) portfolio.


• 285 were network adopted. o 5 – Dementias and Neurodegenerative Diseases Research

Network (DeNDRoN). o 12 – Diabetes Research Network. o 21 – Medicines for Children. o 147 – National Cancer Research Network. o 14 – Stroke Research Network. o 86 – Comprehensive Research Network.

• 80 were not network adopted. The number of studies active during 2012/13 is broken down by disease group below:

• 82 – Oncology. • 54 – Haematology. • 39 – Paediatrics. • 20 – Neurology. • 18 – Rheumatology. • 15 – Obstetrics & Gynaecology. • 14 – Diabetes. • 14 – Stroke/rehab. • 12 – Gastroenterology. • 10 – Genetics. • 9 – Renal. • 8 – General Surgery. • 6 – Anaesthetics. • 6 – Cardiology. • 6 – Dermatology. • 5 – Histopathology.

o Diagnostics, Therapeutics & Cancer. o Mermaid/ Breast. o Ophthalmology.

• 35 – Other. 84 studies were approved to commence in 2012/13.

• 67 were network adopted. o 1 – Dementias and Neurodegenerative Diseases Research

Network (DeNDRoN). o 2 – Diabetes Research Network. o 7 – Medicines for Children. o 20 – National Cancer Research Network. o 4 – Stroke Research Network. o 33 – Comprehensive Research Network.

• 17 were not network adopted. Of the studies approved in 2012/13:

• 58 were non-commercial.


• 26 were commercial. RD&I continues to work as a member organisation with the Peninsula Comprehensive Local Research Network (PenCLRN) to ensure all studies are conducted in accordance with the Department of Health’s Research Governance Framework for Health and Social Care (2005, 2nd Ed.) and that clinical trials are conducted in accordance with the Medicines for Human Use (Clinical Trials) Regulations 2004 (MHRA) and subsequent amendments. Risk assessment and feasibility are conducted at an early stage in the approvals process. Systems for identifying delays in giving NHS permissions have been developed and we are working to a target of less than 30 days. The Trust continues to use the NIHR Research Passport System for streamlining approvals for external researchers. In the last year the Trust has sponsored innovative studies developed by Trust employees, such as the use of Nintendo Wii™ Sports for improving dominant arm function after stroke (Twist). The Trust has sponsored a study developed by the breast cancer surgical team investigating a novel approach to anaesthetic infusion for pain and shoulder function following mastectomy (Sublime). Dr Hayes Dalal and Dr Jennifer Wingham have received an NIHR grant to develop a home-based, nurse facilitated heart failure manual for patients with heart failure and their caregivers. Commissioning for Quality and Innovation (CQUIN) The CQUIN framework is a national scheme that incentivises providers and commissioners to work together to raise quality and develop innovative approaches to healthcare provision. It does so by making a proportion of providers’ income conditional on the achievement - or progress towards achievement – of jointly agreed goals. These are a mixture of nationally mandated and locally agreed quality improvement and innovation goals. CQUIN framework 2012/13 In 2012/13, for the first time, the CQUIN programme comprised two parts, reflecting the fact that our services are commissioned by two main commissioning organisations. The first was jointly agreed between RCHT and NHS Cornwall & Isles of Scilly (NHS CIOS) and the second between RCHT and the Specialised Commissioning Group (SCG). In both cases, the percentage of our income coming through the CQUIN route was 2.5%, an increase from the previous year’s figure of 1.5%. In our contract with NHS CIOS, just under £7 million was attached to our CQUIN programme. In our SCG contract, the figure was just under £0.25 million. Our performance against each goal is shown in our joint scorecard.


Royal Cornwall Hospitals NHS Trust CQUIN SCORECARD 2012/2013Yellow cells indicate paid milestones

Q1 Q2 Q3 Q4

1 Venous Thromboembolism (VTE)

Target 95% 95% 95% 95%

Actual 96.2% 97.2% 97.3% 97.5%

2 Patient Experience

Target >64.9

Actual 65.7

3 Dementia Awareness & Diagnosis

Improve awareness and diagnosis of dementia, using risk assessment, in an acute hospital setting. Daycases, electives, transfers and patients with LoS <72 hours are excluded.

Target 90%

Actual 99.3%

Target 90%

Actual 100.0%

Target 90%

Actual 100.0%

4 NHS Safety Thermometer

Target Q1 Q2 Q3 Q4

Actual 100.0% 100.0% 100.0% 100.0%

5 Avoidable Emergency Admissions

Target Q1 Q2 Q3 Q4

Actual

Target Q1 Q2 Q3 Q4

Actual 72.5% 75.4% 77.2% 81.3%

Target Q1 Q2 Q3 Q4

Actual 90.1% 88.7% 87.9% 83.0%

Target Q1 Q2 Q3 Q4

Actual

Target Q1 Q2 Q3 Q4

Actual

Joint working has been undertaken throughout the year, focussing on cardiology and respiratory pathways

We continue to provide a service through the two frailty specialist nurses close to the front door who integrate with the wider multi-disciplinary team there to assess, respond to immediate need if any safeguarding matters arise and to case manage key vulnerable patients the team's assessment highlights. They have established a set of KPIs that records their case management duties and a range of interventions. Their excellent work was recently acknowledged in the recent South West Dementia Care 2nd Stage Peer-Review.

Although collaboration with CPFT has continued, the CPFT Board has not supported its own team's business case for a new psychogeriatrician post. The effect of this has been to bring discussions to a halt whilst the CPFT team reviews its strategy.

5. Participate with CPFT in the design of an integrated RAID/ psychiatric liaison service linked to the Acute GP Service and a ‘mental health and well-being service’.

Quarterly submission of monthly-collected data on 4 outcomes (pressure ulcers, falls,urinary tract infection in those with a catheter, and venous thromboembolism). Each quarterly dataset must be complete.

1. With PCH, re-design 2 pathways that could be more appropriately managed by a Countywide Acute Care at Home team.

An improvement on the 2011 score is required in the CQC 2012 Adult Inpatient Survey composite indicator on responsiveness to personal needs. Maintenance of the 2011 score will trigger a 50% payment.

1. % of all patients aged 75 and over who have been screened following admission to hospital, using the dementia screening question.

2. % of all patients aged 75 and over, who have been screened as at risk of dementia, who have had a dementia risk assessment within 72 hours of admission to hospital, using the hospital dementia risk assessment tool.

3. % of all patients aged 75 and over, identified as at risk of having dementia, who are referred for diagnosis.

NA

TIO

NA

LN

AT

ION

AL

NA

TIO

NA

LN

AT

ION

AL

95% of all (eligible) adult inpatients are required to have a VTE risk assessment on admission to hospital, using the clinical criteria of the national tool.

LOC

AL

Progress against indicators relating to avoidable emergency admissions

3. Improve medicines management on discharge by reducing the number of TTA waits over 2 hours.

4. Ensure frail, elderly patients have personalised care plans with appropriate safeguarding and case management.

2. Access to recommended levels of therapy for patients receiving Early Supported Discharge for Stroke.


6 Avoidable Elective Admissions

Target 44% 46% 48% 50%

Actual 51.4% 60.3% 65.8% 62.6%

Target Q1 Q2 Q3 Q4

Actual 36.2% 43.5% 73.0% 82.0%

Target Q1 Q2 Q3 Q4

2 (b) Increase timeliness of e-discharge to cover 90% of discharges Actual 75.9% 89.5% 62.3% 70.1%

Q1 Q2 Q3 Q4

Actual

Target Q1 Q2 Q3 Q4

Actual

7 Quality Dashboards

Target Q1 Q2 Q3 Q4

Actual

8 Neonatal Intensive Care

Target 47% 50% 52% 54%

Actual 64.0% 89.5% 83.3% 90.0%

Target 60% 63% 68% 90%

Actual 94.4% 94.1% 100.0% 100.0%

9 Renal Replacement Therapy

Target Q1 Q2 Q3 16.5%

Actual 17.5% 16.4% 17.0% 17.5%

Target 20.0% 40.0% 60.0% 80.0%

Actual 31.8% 43.0% 90.5% 94.4%

10 Haemophilia

Target 42% 44% 46% 50%

Actual 56.0% 46.7% 46.7% 66.7%

A number of new telephone clinics have begun through the year, up to and including quarter 3. We are confident that we will submit quarter 4 data by the due date of 26 April

SC

G To increase the numbers of patients' data provided via the Haemtrack electronic monitoring system.

SC

G

9(a). To achieve a minimum 16.5% of dialysis patients (30 in total) receiving either peritoneal dialysis (including assisted automated peritoneal dialysis) or home haemodialysis.

9(b). To increase % number of CKD 5 and 4 patients (known to a nephrologist for 3 months and with progressive deterioration in renal function) to have a decision made regarding suitability for transplant.

SC

G

8(a). To achieve an increase in the % of low birth weight babies (<33 weeks) fed in part on mothers breast milk at final discharge.

8(b). To achieve an increase in screening to a target of 90% of babies with a birth weight of <1500g or a gestation of <32 weeks who undergo initial Retinopathy of Prematurity (ROP) screening whilst still an in-patient and screened ‘on time’ or within 7 days.

SC

G

To implement the routine use of clinical dashboards in - Radiotherapy - Renal Replacement Therapy - Cystic Fibrosis - Haemophilia - Neonatal Intensive Care

LOC

AL

1. Increase the number of terminations of pregnancy undertaken medically from a baseline of 42%.

4. Increase the number of patients receiving follow-up by means other than conventional face-to-face consultation.

Progress on indicators relating to avoidable elective admissions.

3. Participate in regional study of oesophageal doppler monitoring.

2. (a) Increase completion of e-discharge to cover 70% of discharges.

No regional study has taken place but, having benchmarked current practice we are confident that this technology has been introduced appropriately. A statement on our current position with regards to the use of this technology has been incorporated on our successful pre-qualification bid for the 2013-14 CQUIN scheme

A number of new telephone clinics have begun this year, as has the renal results review service. An activity baseline has been agreed as part of the AOP process for 2013-14

Once again this year, we have seen real benefits for patients arising directly from the focus on services that the CQUIN programme encourages. Amongst these are the following:


• We have sustained the significant improvement in venous thromboembolism (VTE) screening that we had achieved by the end of the previous year.

• Awareness, screening, diagnosis and treatment of dementia have all substantially improved after a concerted response to this challenging national goal.

• Use of the NHS Safety Thermometer has been implemented with great success, giving us valuable information about four avoidable harms to patients – pressure ulcers, falls, urinary tract infections from catheters and VTE.

• In Neonatal Intensive Care, our performances against both the breastfeeding on discharge and retinopathy of prematurity goals have been considerably in excess of the targets that we were set.

• In Renal Replacement Therapy, there has been a very significant increase in the number of patients in the target group who have had a decision made about their suitability for transplant.

Further details of the CQUIN scheme and the nationally mandated goals are available electronically at: http://www.institute.nhs.uk/worldclasscommissioning/pctportal/cquin CQUIN framework 2013/14 For 2013/14, the proportion of income linked to CQUINs will remain at 2.5%. New this year was the introduction of a set of pre-qualification tests that required us to demonstrate that we have made progress towards achieving the aims of Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS, the NHS Chief Executive’s report of December 2012 which set out a delivery agenda for spreading innovation at pace and scale throughout the NHS. As in 2012/13, there are 4 national CQUINs which will account for around 20% of the programme. These are:

1. VTE: in addition to maintaining our screening performance, we will now have a target to meet in respect of root cause analysis of a proportion of those admissions where patients experienced VTE.

2. Patient Experience : replacing the national patient experience survey, the new Friends and Family Test will be introduced into inpatient wards and the Emergency Department from April and into maternity wards from October.

3. Dementia: after spending much of 2012/13 developing the infrastructure to enable us to deliver this goal, we will continue to embed the FAIR process (Finding people with dementia, Assessing and Investigating their symptoms and Referring for support) into our hospitals.

4. Safety Thermometer: after the successful introduction of the Safety Thermometer tool, we will now be challenged to make targeted improvements related to the “4 harms”.


In addition to the national goals, the Trust will agree with both NHS Kernow and the SCG a range of other, local goals to complete the programme. How the NHS regulator, the Care Quality Commission, views the quality of our services

Registration with the Care Quality Commission Essen tial Standards of Quality and Safety

The Royal Cornwall Hospitals NHS Trust is required to register with the Care Quality Commission and its current registration status is unconditional. The Care Quality commission has not taken enforcement action against the Royal Cornwall Hospitals NHS Trust during 2012/13. Care Quality Commission Planned Review Visits The CQC carried out a responsive review of the Royal Cornwall Hospital on 23 May 2012 between 4pm and 8pm. This followed safeguarding concerns about the care of vulnerable people who may not be able to speak for themselves. Of the 5 outcomes assessed the Trust was found to be compliant with 4 and non-compliant with 1; Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs. The Trust immediately put in place actions to address the issue raised and was found to be compliant at a later inspection. The Trust then received a scheduled inspection by the CQC in November 2012. They visited 3 of the Trusts registered locations: Royal Cornwall Hospital, West Cornwall Hospital and Royal Cornwall Hospital Headquarters (this refers to the services we provide in the community for example outpatient appointments and x-ray departments at community hospitals). The CQC found the Trust to be compliant with all the outcomes assessed at all locations visited. NHS provider periodic review The CQC did not visit the Trust in 2012/13 as part of its periodic review programme. Data Quality The Trust’s Data Quality Strategy has been extended for a period of six months to allow a full review and update by the records specialist. The Data Quality Policy has been recently updated to reflect the organisational changes in reporting and managing the service and now includes corporate information systems as well as health information systems, this was following a recommendation from an internal audit review of data quality. The Trust Board receives assurance on data quality through the Trust’s Integrated Governance and Assurance Framework. The Data Quality


Assurance Group reports to the Information Governance Committee. This group performance manages data quality within the Trust by providing reports to Divisions and to the Information Governance Committee. The internal audit review of data quality commissioned by the Executive Sponsor, made five recommendations:

• Information Asset Owners to become more engaged and own their systems and information. Root cause analysis to be used when investigating targets not being met.

• Information Asset Owners to be identified for Maternity and Renal Systems

• Review resource levels in the Data Quality Team • Consider implementing an additional module to E-rostering to ensure

sickness management for clinicians is being monitored appropriately • Identify an Information Asset Owner for ESR and add to the data quality

dashboard for monthly reporting The Information Asset Owners have now taken responsibility and embedded monitoring the quality of the data held within their critical systems. Quarterly meetings continue with members of the Data Quality Assurance Committee. The Royal Cornwall Hospitals NHS Trust submitted records during 2012/13 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included the patient’s valid NHS number was:

• 99.6% for admitted patient care. • 99.8% for outpatient care. • 97% for accident and emergency care.

The percentage of records in the published data which included the patient’s valid General Medical Practice Code was:

• 100% for admitted patient care. • 100% for outpatient care. • 99.2% for accident and emergency care.

Information Governance Toolkit attainment levels

The Royal Cornwall Hospitals NHS Trust Information Governance Assessment Report overall score for 2012/13 was 72% and was graded Green. Clinical Coding Error Rate The Royal Cornwall Hospitals NHS Trust was subject to the Payment by Results (PbR) clinical coding audit during the reporting period by the Audit Commission. The error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were: Gynaecology accuracy

• Primary diagnosis - 97.3%.


• Secondary diagnosis - 97.9%. • Primary procedure - 91.8%. • Secondary procedure - 100%.

Within this section of the audit there was a 10.1% change in Healthcare Resource Group's (HRGs), this would have put the Trust in the worst performing 25% of Trusts compared to last year’s national performance. The Trust has a comprehensive clinical coding audit programme in place which includes individual coder audits, specialty audits, benchmarking audits and change process audits. All coding errors are fed back to clinical coders and where necessary further clinical coding training is carried out. Hip accuracy

• Primary diagnosis - 100%. • Secondary diagnosis - 97.7%. • Primary procedure - 97%. • Secondary procedure - 90.6%.

Within this section of the audit there was a 3% change in HRG's, this would have put the Trust in the best performing 25% of Trusts compared to last year’s national performance.


National Quality Indicators. Where possible the national data reflects acute trusts only. The value and banding of the summary hos pital -level mortality indicator (“SHMI”) for the trust

July 2011 – June 2012 October 2011-September 2012 The Royal Cornwall Hospitals NHS Trust considers that this data is as described for the following reasons

• The data is validated nationally, and • Correlates with the Trust’s internal data

The Royal Cornwall Hospitals NHS Trust has taken the following actions to improve this score and so the quality of its services, by continuing to review both national and local mortality data ensuring that appropriate actions are taken where indicated.

National Data RCHT

National Data RCHT average lowest highest average lowest highest

1.00 0.71 1.26 1.03 1.00 0.68 1.21 1.04

The percentage of patient deaths with palliative ca re coded at either diagnosis or specialty level for the trust July 2011 – June 2012 October 2011-September 2012

National Data RCHT


18.6 0.3 46.3 16 19.20 0.20 43.30 16.50

The trust’s patient reported outcome meas ures scores for groin hernia surgery – average health gain

The Royal Cornwall Hospitals NHS Trust considers that this data is as described for the following reasons


The Royal Cornwall Hospitals NHS Trust has taken the following actions to improve this score and so the quality of its services, by ensuring all PROMS data is reviewed by the relevant specialties and participating clinicians.

April 2009 - March 2010 April 2010 – March 2011

National Data RCHT


0.082 0.011 0.136 0.104 0.085 -0.020 0.156 0.078

The trust’s patient reported outcome measures score s for varicose vein surgery – average health gain (lower scores are bet ter) April 2009 - March 2010 April 2010 – March 2011

National Data RCHT


0.094 0.150 -0.002 0.092 0.091 0.155 -0.007 0.090


The trust’s patient reported outcom e measures scores for hip replacement surgery – average health gain April 2009 - March 2010 April 2010 – March 2011

National Data RCHT


0.411 0.287 0.514 0.376 0.405 0.264 0.503 0.411

The trust’s patient reported outcome measures score s for knee replacement surgery – average health gain


National Data RCHT


0.294 0.172 0.386 0.330 0.298 0.176 0.407 0.291

The percentage of patients aged 0 to 14; readmitted to a hospital which forms part of the trust within 28 days of being dis charged from a hospital which forms part of the Trust.

The Royal Cornwall Hospitals NHS Trust considers that this data is as described for the following reasons


The Royal Cornwall Hospitals NHS Trust intends to take the following actions to improve this score and so the quality of its services, by working together with the Cornwall Health and Social Care community to reduce hospital readmissions. *National average for all NHS Trusts in England. Lowest and highest figures relate to acute Trusts only


National Data RCHT


10.25* 0.00 22.93 9.97 10.15* 0.00 14.34 9.33

The percentage of patients aged 15 or over; readmit ted to a hospital which forms part of the trust within 28 days of bei ng discharged from a hospital which forms part of the Trust.

April 2009 - March 2010 April 2010 – March 2011 National Data RCHT

National Data RCHT

average lowest highest average lowest highest 11.61* 0.00 15.97 11.70 11.42* 0.00 15.33 11.21


The trust’s responsiveness to the personal needs of its patients. National In-patient results

2010 2011 The Royal Cornwall Hospitals NHS Trust considers that this data is as described for the following reasons


The Royal Cornwall Hospitals NHS Trust intends to take the following actions to improve this score and so the quality of its services, by listening and acting upon all patient feedback.

National Data RCHT


67.3 56.7 82.6 67.3 67.4 56.5 85.0 64.9

The percentage of staff employed by, or under contr act to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.

2011 2012 The Royal Cornwall Hospitals NHS Trust considers that this data is as described for the following reasons


The Royal Cornwall Hospitals NHS Trust intends to take the following actions to improve this score and so the quality of its services, by continuing with our Listening into Action initiative and improving the health and wellbeing of our staff. The Trust notes the low scores on this important indicator.

National Data RCHT


65 33 96 38 65 35 94 43

The percentage of patients who were admitted to hos pital and who were risk assessed for venous thromboembolism.

July – September 2012 October – December 2012 The Royal Cornwall Hospitals NHS Trust considers that this data is as described for the following reasons


The Royal Cornwall Hospitals NHS Trust has taken the following actions to improve this score and so the quality of its services, by continuing to ensure all our patients are risk assessed on

National Data RCHT


93.8 80.9 100.0 97.2 94.3 84.6 100.0 97.3


admission, including targeted action where performance is below 100%.

The rate per 100,000 bed days of cases of C.diffici le infection reported within the trust amongst patients aged 2 or over

April 2010 – March 2011 April 2011 – March 2012 The Royal Cornwall Hospitals NHS Trust considers that this data is as described for the following reasons


The Royal Cornwall Hospitals NHS Trust intends to take the following actions to improve this score and so the quality of its services, by reviewing antibiotic prescribing by both hospital doctors and GPs and compliance with all infection, prevention and control policies.

National Data RCHT


29.6 0 71.8 22.7 21.8 0 51.6 19.8

The number of patient safety incidents reported within the trust

April – September 2011 October 2011 – March 2012 The Royal Cornwall Hospitals NHS Trust considers that this data is as described for the following reasons


The Royal Cornwall Hospitals NHS Trust intends to take the following actions to improve this score and so the quality of its services, by continuing to encourage a reporting and learning culture within the organisation.

National Data RCHT


2676.47 88 8461 3335 2833.36 66 8778 3499 The rate of patient safety incidents reported within the trust

April – September 2011 October 2011 – March 2012

National Data RCHT


6.63 2.13 19.25 5.59 6.92 0.94 21.71 5.86 The number of such patient safety incidents that result ed in severe harm or death .


National Data RCHT



20.05 0 160 23 21.25 0 144 20 The percentage of such patient safety incidents that re sulted in severe harm or death .


National Data RCHT


0.79 0.00 7.01 0.69 0.82 0.00 3.58 0.57


PART THREE – REVIEW OF THE TRUST’S QUALITY PERFORMA NCE Patient Safety Obstetrics and Gynaecology Service Review The Trust published five independent reports on its Obstetrics and Gynaecology Service on 28 February 2013. The independent reports were commissioned following concerns about some of the treatment and care provided by one former Consultant - Mr K R Jones. The five independent reports were:

• The interim Independent Case Note Review of Mr Jones’ patients • Royal Cornwall Hospitals NHS Trust Organisational Learning Review • NHS Cornwall and Isles of Scilly Organisational Learning Review • Rapid Response Review commissioned by NHS South of England to

assess the current Obstetrics and Gynaecology service • Patients Association Review of recent patient experience in

gynaecology services Both the Chairman and Chief Executive of the Trust apologised unreservedly to the women affected. Martin Watts, Chairman (28 February Trust press release) “On behalf of the Trust I wish to unreservedly apologise to those women and their families for the pain, distress and anxiety caused by the practice of former Obstetrics and Gynaecology Consultant Mr Rob Jones. The Independent Organisational Learning Review commissioned by the current Trust Board confirms that concerns identified about some of Mr Jones’ practice should have been addressed with more vigour and urgency.” “We must fully acknowledge the mistakes made – apologise and learn from them – whilst also recognising the significant progress continuing to be made by our dedicated staff to secure better and safer care for the people of Cornwall and the Isles of Scilly.”

Lezli Boswell, Chief Executive (28 February Trust press release)

“I want to thank patients and staff who did speak out and raise concerns about the practice of Mr Jones. Their courage, persistence and candour has led to where we stand today.”

“The women who have spoken out have enabled other women to seek and receive the treatment and support they deserve from RCHT. I believe this is a significant moment for us and marks a challenge to change the culture of RCHT.”

“We will implement all of the recommendations from the independent reports and work tirelessly to rebuild trust and improve the services we provide.”


The interim Independent Case Note Review identified that in 2275 of the 2396 (94.95%) case notes reviewed there was no evidence of harm or need to recall women to clinic. 52 women (2.17%) under the care of Mr Jones were found to have suffered complications as a result of surgery - all of whom were already receiving follow up support and treatment. 69 women (2.88%) were felt to be at risk of harm either through failure to manage their case appropriately (1.88%) or because the quality of recording keeping did not permit the necessary assurances to be given (1%). 58 women have been recalled for clinical assessment and their outcomes will be known by the end of March 2013 when the final Independent Case Note Review will be published.

Lower Segment Caesarean Section Surgical Site Infec tion Surveillance (SSI) Surveillance of lower segment caesarean sections (LSCS) commenced in January 2012. Between January 1st and March 31st 2012 the data collected highlighted a Surgical Site Infection rate of 11.2%. This was compared to the national rate of 9.86% and despite the validity of this comparison (very few hospitals perform post-discharge surveillance and the more thoroughly this is performed, the more infections will be identified) a complete review of pre, intra and post-operative practice was undertaken. The following recommendations were made Pre operatively:

• Patient Education. • Shower before surgery. • If hair removal is necessary – clip do not shave. • Comply with antibiotic policy – antibiotics to be given 15 – 30 minutes

pre incision. • Skin prep – use 2% chlorhexidine and allow to dry rather than wiping

dry. Post operatively:

• Hydrofilm to be used rather than cosmopore as wound dressing choice. • Hydrofilm to be left insitu for a minimum of 48 hours. • Patient Education.

The Divisional Manager, Tissue Viability Consultant Nurse and Wheal Fortune ward manager attended a meeting to discuss and action the recommendations. The SSI rate for April-June 2012 highlighted an improvement of 9.8% and between July and September 2012 the infection rate following LSCS was 3.5%. Due to such a considerable improvement it was decided that a further quarter of surveillance should take place to ensure consistency. An SSI rate of 2.8% showed a further decline from October to December.


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%SSI Rate Following LSCS 2012

Clinical Effectiveness Lung Cancer Services The Trust participated in the Improving Lung Cancer Outcomes Project (ILCOP), which is delivered by the Royal College of Physicians and funded by the independent charity The Health Foundation. ILCOP seeks to raise the standards of Multi-Disciplinary Teams (MDTs) by partnering them with other MDTs from two hospitals and enabling them to share their approaches and successes, and to identify solutions to their different challenges. This process – in which the team from Cornwall worked with colleagues from the Royal United Hospital Bath NHS Trust – identified four areas where changes have led to improvements:

1. The Trust made the case to secure additional lung Clinical Nurse Specialists (CNSs), meaning that more patients who have this important support from the very first stages of their patient journey, as well as during treatment and care. Patient satisfaction surveys show that patients hugely value this.

2. The Trust introduced a new technology – Endobronchial Ultrasound (EBUS) – which is used to take biopsies from the lung in a less invasive and safer way. Patients have the procedure as a day case, rather than coming in for surgery, reducing length of hospital stay. The unit is also evaluating the impact on histological confirmation and referral for treatment.

3. Specimens are now handed over in person to pathology by a clinical team member rather than sent via the central hospital portering system. Audit results show that this has improved communication and speeded up the time taken from biopsy to reporting, with results available in time for the MDT meeting almost without exception.


4. Improvements in the quantity and quality of data captured have been made thanks to ‘bouncers’. These people watch as data administrators input their data, during the MDT meeting and stop the MDT conversation if anything has been missed to enable the administrator to catch up.

The positive impact of the resultant service changes implemented during 2010 and 2011, are illustrated by the improvements in performance. National lung cancer audit results for Royal Cornwall Hospitals NHS Trust compared with respective national standard

In March 2013 MHP Health Mandate published “Quality at a glance - using aggregate measures to assess the quality of NHS hospitals”. MHP Health Mandate is a multi-award-winning specialist health policy and communications consultancy. The report focussed on the overall quality of NHS hospitals and the quality of lung cancer services. A number of sources were used to assess the quality of specific lung cancer hospital services:

• Waiting times for people referred with suspected lung cancer • The National Cancer Patient Experience Survey 2011/12 • The National Lung Cancer Audit 2012 • National Cancer Peer Review reports

RCHT was rated as the 2nd highest performing Trust for its lung cancer services. Junior Doctors in Training Postgraduate Medical Education is subject to rigorous quality checks and these take the form of an annual Deanery visit, annual General Medical Council (GMC) Trainee Survey, Local Education Provider visits from each Specialty School e.g. Medicine, Foundation, Surgery etc and end of placement trainee surveys. From these data streams an action plan is formulated for RCHT by the Peninsula Deanery and this plan is ratified by the GMC. The Director of Medical Education works in collaboration with the Divisional and Specialty leads in order to address action points that are coded on a red, amber and green basis. Sign off is by the Deanery and GMC, and is the measure by which the NHS Litigation Authority (NHSLA) ratings for supervision of doctors in training are recommended by the GMC for the Trust.


The GMC also reviews good practice at each Trust and in 2012 RCHT was commended for three areas of best practice; more than any other Local Education Provider in the Peninsula. Generic Skills – Good Practice Generic skills teaching is a six week rolling programme consisting each week of three hours of protected teaching time. In a small group of ten trainees, it focuses on areas of the Foundation Year 1 curriculum better taught in this setting. It covers the non-clinical professional attributes of ‘the good doctor’ as outlined in the GMC guide of this name. It also includes sessions on career planning, practical skills taught in the clinical skills laboratory by a clinical skills tutor, and acute care training using simulation. The sessions were initially started by Dr Cate Powell shortly after Foundation training was introduced nationally, and continue to be led by Drs Julie Blundell and Rachel Todd who are the Trust tutors for F1 training, and Dr Clare Moser who is the Clinical Skills tutor. We have been proactive in delivering teaching requested by the junior doctors and the trust, tailoring it to meet the requirements of the Foundation curriculum. Delivery of the teaching has been via mixed media, allowing maximum time for hands on practise on our models and manikins, and ample opportunity to ask questions. Trainees enjoy the sessions as they provide a relaxed and informal teaching environment away from the clinical setting. They also provide an opportunity to meet fellow trainees and to share and reflect on their clinical experiences. They have received excellent feedback from the trainees, in addition to very positive recognition by the Deanery and the GMC. Junior Doctors Management Group The Junior Doctors Group was established in 2010. Membership of the group includes representatives from human resources, postgraduate education, junior doctors at all levels, rota coordinators, British Medical Association (BMA) and medical staffing. The purpose of the committee is to inform junior medical staff of Trust, contractual and postgraduate education issues that impact upon them. It also allows the junior medical staff a voice at senior management level and gives the opportunity for a two-way honest feedback. Another initiative established in 2012 was ‘Team Talk’ delivered to junior medical staff twice monthly at the Postgraduate Centre. A Trust Board representative attends postgraduate education teaching sessions to give the junior doctors a presentation on current Trust performance and also to receive feedback from junior doctors about any concerns they have. We hope that this addresses a common concern raised by trainees, regarding the interface between NHS management and the delivery of patient care. This initiative has received positive feedback from the trainees. Simulation Training Over the past three years Simulation has been developed to deliver training for junior doctors in a classroom environment in the Postgraduate Education Centre. Approximately £250,000 of high fidelity simulation equipment has


been funded by the SHA and Deanery through successful bids to the innovation funds by Dr Cate Powell, Director of Medical Education and the education team. Over the past six months a highly successful and innovative pilot has been running, bringing simulation training to the point of care in the RCHT wards, clinics and operating theatres. Using high fidelity computerised patient manikins, scenarios that mimic potential emergency clinical situations are acted out in the clinical setting by the multi-disciplinary team. This type of training is likened to that received by pilots and has been shown to improve team working and communication, thus reducing potential errors and improving patient safety. 2000 hours of direct staff training has been delivered, and this project demonstrates that point of care simulation enables delivery of multi-professional training to nurses and Allied Health Professionals (AHPs) alongside doctors of all grades on the wards. Simulations have been run in 16 wards and clinical areas to date, including West Cornwall and St Michael’s Hospital, with plans to reach even more staff across the Trust. The project has met with great enthusiasm from all staff involved and momentum is growing rapidly as more staff members request to become involved. Strong governance pathways are becoming established, with training developed to address issues raised in critical incident reports. Feedback from simulations also ensures that potential patient safety issues are identified and addressed pre-emptively. The GMC have particularly commended the multi-disciplinary obstetric team training at the Royal Cornwall Hospital provided by an obstetric speciality clinical faculty on a monthly basis. Training in Obstetric Multi-Professional Emergencies (TOME) runs monthly and is currently provided for all clinical staff that care for the pregnant women of Cornwall and the Isles of Scilly. This includes hospital-based and community-based midwifery staff, maternity nurses, obstetricians, GP trainees and obstetric trainees, anaesthetists and anaesthetic trainees, operating department practitioners, paramedics, GPs and medical students undergoing clinical attachments on the Delivery Suite. The training fulfils the mandatory criteria for the multi-disciplinary obstetric team in the management of specified obstetric emergencies and has been recognised in the recent review (February 2013) by the Clinical Negligence Scheme for Trusts (CNST). The CNST assessment awarded Maternity Clinical Risk Management Standards at Level 3. Multi-disciplinary obstetric emergencies training is additionally recommended by the Royal College of Anaesthetists, Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives through the triennial CEMACH (Confidential Enquiry into Maternal and Child Health) and 2006-2008 CMACE (Centre for Maternal and Child Enquiries) reviews. Simulation team training is included as part of the TOME course and comprises multi-disciplinary groups undertaking two high fidelity scenarios; management of the collapsed mother and management of massive obstetric


haemorrhage, alternated with two low fidelity actor/staff-simulated scenarios for the management of cord prolapse and management of eclampsia and severe pre-eclampsia. The TOME simulation training programme in the Royal Cornwall Hospital has previously featured in the BMA publication Quality Time, December 2010. Dr Cathy Ralph described, at interview, how the significant contribution of dedicated multi-professional simulation training contributed to improvement and maintenance in provision of high quality care in the management of obstetric emergencies. The recent award of CNST Level 3 to Maternity Services at RCHT included acknowledgment of the positive impact of the TOME programme. Cornwall Vascular Unit

In the past year, vascular surgery has emerged as a new independent specialty distinct from its origins within general surgery. In 2005 the Royal Cornwall Hospital was the first hospital in the southwest to provide a separate vascular surgical service, with a dedicated on-call rota for emergencies, and it remains one of the few units to provide more than 50% of out-patient activity at outreach clinics throughout the county, designed to minimise inconvenience for patients. It has also led the region in the introduction of many new techniques and working practices over the last 15 years. However the geography and population of Cornwall is such that, in its present configuration, the vascular service deviates from the "ideal" configuration recommended by the Vascular Society of Great Britain and Ireland, despite its exceptional achievements in the following areas: Carotid Surgery Surgery to remove disease from the carotid arteries in the neck (carotid endarterectomy), is a key treatment in some patients suffering from strokes and transient ischaemic attacks ("mini strokes"). National recommendations advocate prompt referral and surgery following symptoms. As one of the final steps on the multidisciplinary stroke care pathway in Cornwall, the Vascular Unit provides a prompt service with rapid access to appropriate surgery and excellent patient outcomes. Comparative outcomes from the UK Carotid endarterectomy audit round 4 (2012), published by the Royal College of Physicians

Nationally agreed quality metric

Vascular Unit RCHT Southwest region average

Natio nal Average

Patients receiving Carotid surgery within 48hrs of referral to vascular surgery

17% 13% 15%


Patients undergoing carotid surgery within 14 days of referral to vascular surgery

90% 68% 65%

Patients undergoing carotid surgery within 14 days of initial symptom

72% 56% 49%

30 day stroke and death rate

2% 3% 2%

Aortic Aneurysms The Southwest Peninsula Abdominal Aortic Aneurysm (AAA) screening programme, hosted by the Trust, has been fully operational for 18 months, offering screening for aortic aneurysms to all men in their 65th year. A number of aneurysms have been detected by this programme and successfully treated at RCHT and Derriford Hospitals. The Cornwall Vascular Unit continues to develop its services to maximise the number of patients who can have their aneurysms repaired by keyhole surgery (EVAR), and at the present time over 70% of planned operations are undertaken by EVAR. There are also strong links with centres of excellence in Birmingham and London to provide access to keyhole surgery for the small number of patients whose aneurysms require more complex EVAR treatments. For a number of years the mortality rate following elective aneurysm surgery in Cornwall (currently 2.4%) has been below the 3.5% target set by the Quality Improvement Programme of Vascular Society as achievable for vascular surgical units in the UK by 2014. Varicose Veins Patients attending the hospital have had access to keyhole treatments for varicose veins since 2006, and most patients eligible for varicose vein treatments in Cornwall are now treated with endothermal ablation, which is a local anaesthetic, "walk in, walk out" treatment undertaken at West Cornwall and St Michael’s Hospitals. These treatments are not readily available to NHS patients in many parts of the country, although the National Institute for Health and Care Excellence (NICE) will recommend this as the first choice treatment for suitable varicose veins when it publishes its latest guidance on the management of varicose veins in July 2013. The Vascular service in Cornwall has been some years ahead of the rest of the country in bringing the most appropriate treatments to patients at RCHT. The future The aim of the vascular unit is to ensure that high quality, innovative, and clinically appropriate treatments continue to be available to the local population, and provided in Cornwall wherever possible. Our efforts in the immediate future will be concerned with ensuring that this aim is achieved to ensure that the RCHT remains a provider of high quality vascular surgical services.


Audiology Background The Audiology Service is based in Trelawny Wing at the Royal Cornwall Hospital within the Audiology and ENT (Ear Nose and Throat) Outpatients department. It is a joint Adult/Children’s service employing 39 staff and delivered around 30,000 outpatient spells in 2012/13. Staff are very much part of a wider multidisciplinary team comprising ENT, Aural Care, Hearing Therapy, Volunteers, Teachers of the Deaf, Social Workers for the Deaf and Hearing Impaired and Environmental Equipment Officers able to advise, provide and install assistive listening devices equipment as needed. This integrated approach is recognised as an area of excellence, allows for good communication between teams and personalised care for all patients accessing the service. The Audiology service is delivered across a wide variety of locations across Cornwall and the Isles of Scilly including schools, health centres and community hospital sites. A domiciliary and volunteer visiting service is also provided. Objectives achieved 2012/13 1. Improved Pathway for Children’s Hearing Service. GPs and other health professionals refer approximately 2000 children with suspected hearing loss to hearing assessment clinics (HACs) each year. Clinics run across the County at 17 community clinic venues providing a local, easily accessible service for families. Children are reviewed and a care pathway followed for:

• Newborn Hearing screen ‘at risk’ babies. • Initial hearing assessment from routine referral. • Monitoring of existing conditions. • Onward referral to other services e.g. ENT • Advice to parents regarding the detection and management of childhood

hearing loss and the effects on early language development. In June 2012 responsibility for HAC’s transferred from Child Health to the Audiology service, bringing together management of the whole hearing loss pathway for the first time. From the Newborn Hearing Screening Programme (NHSP), school screening and paediatric Audiology service through transition to Adult hearing services. Co-ordination of the pathway is already delivering family friendly improvements, which will continue into 2013/14 driving efficiency through rationalisation of appointments, and wider skill mix of teams. 2. Qualification of Adult Hearing Services under Any Qualified Provider (AQP). The advent of extending patient choice through the introduction of Any Qualified Provider (AQP) tender processes for Adult Hearing Services in 2012/13 presented a number of challenges and opportunities. Although already delivering the majority of service outcomes described in the AQP specification


further improvements in quality have been made to ensure the service is fully compliant with AQP. Main targets achieved:

• Shorter waiting times for Adult Hearing Services. o Maximum of 20 days from referral to assessment. o Maximum of 25 days from assessment to fitting. o Hearing aid follow-up after hearing aid fitting within 10 weeks.

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Adul ts waiting longer than 20 days for Assessment a nd 25 days for fitting of Hearing Aids

Assessment

Fitting

• Redesign of existing and development of new care pathways for

patients on an AQP pathway. • Development of new information reporting and data collection tools to

meet AQP monthly monitoring requirements. • Increased capacity for hearing aid follow-up with the introduction of a

new telephone follow-up service to start in 2013/14 for eligible patients to avoid patients traveling unnecessarily to hospital for follow-up.

• Consultation with staff to extend working hours to the weekend to improve access for patients.

• Registered with Improving Quality In Physiological diagnostic Services (IQIPS).

3. Audiology Service for West Cornwall Hospital (WCH). The creation of a new clinical area has seen the introduction of regular Audiology clinics to WCH. Clinics are currently running 4 days a week but will move to 5 days a week from 1 April 2013. Patients who historically have had to travel either to St Michaels Hospital or to the Royal Cornwall Hospital in Truro for hearing aid assessment, hearing aid fitting, maintenance and repair can now have this delivered locally providing care closer to peoples’ homes. The improved accommodation has also provided an excellent environment for the local children’s hearing assessment clinic which has now been moved from the Bellair clinic in Penzance.


4. Hearing Therapy Team. The Audiology service also includes the provision of Hearing Therapy for patients with tinnitus or more complex hearing needs. The tinnitus service has been reviewed to reduce the number of DNA's and also to introduce a more robust outcome measure (Tinnitus Functional Index). There is close liaison with other agencies e.g. Adult Social Care, Hearing Loss Cornwall, West of England Cochlear Implant Programme, to ensure the best care for people with the most complex hearing needs. Key initiatives 2013/14

• Marketing of AQP service. • National accreditation for Adult Hearing Services. • Implementation of extended opening hours. • Review of DNA rates across Children’s Hearing Services. • Specialist commissioning Children’s Hearing Services and Implantable

Devices. • Service line costing and unbundling of tariff.

Laparoscopic Colorectal Surgery Bowel cancer is the third most common cancer in Cornwall with more than 350 people affected every year. This means that at any one time about 1,300 people living in Cornwall are being treated for the disease. Demand for the service is increasing both as a result of bowel cancer screening and 2 week wait referrals.

The Royal Cornwall Hospital achieves above National average results for the proportion of patients discussed at MDT (100%) and patients seen by a specialist nurse (99.7%). We do the most cancer operations in the Peninsula.


Cancer operations performed

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RCH Exeter Plymouth Torbay Barnstaple

All Colorectal cancers

Rectal cancers

Bowel cancer ranks second as a leading cause of avoidable cancer death in the UK accounting for 16,259 deaths in 2010 but the post-operative mortality at the Royal Cornwall Hospital is below the national average. The very latest laparoscopic (keyhole) surgery is undertaken at the Royal Cornwall Hospital. There are six specialist colorectal surgeons all of whom are experienced in laparoscopic surgery. Laparoscopic bowel resections are undertaken in state of the art dedicated laparoscopic theatres. In the National Cancer Patient Experience Survey (2011/12) Royal Cornwall Hospital staff scored above the national average in many areas: on giving a complete explanation of purpose of test, what was involved in the test, written information about the test, a complete explanation of the results in an understandable way, written information on their type of cancer and about the operation, taking patients views into account and being able to discuss worries with staff, staff working well together, ensuring patients did not feel that they were a set of cancer symptoms, and taking part in cancer research. Comments made include:

“The doctor who operated on me was very careful” “The Surgeon and Specialist Care Nurses were very good. They always had the time to help with queries.” “I am very happy with the way I have been looked after by all Hospital Doctors and Nurses and would like to thank Treliske Hospital and the Cornwall NHS. Thank you.” “Everyone involved in my cancer treatments and care were well informed and knew exactly what was going on and were easy to contact.”


To promote bowel cancer awareness in conjunction with a National campaign 3 nurses from the specialist bowel ward and a Consultant Colorectal Surgeon undertook radio interviews, published newspaper reports and trust press releases, gave talks and met with various organisations including Lions, Rotary Club, University of the 3rd Age (U3A) and Cornwall County Council. They raised more than £15000 through their fundraising events all of which went toward the charity Beating Bowel Cancer. The Royal Cornwall Hospital actively participates in research contributing to many clinical trials. In addition the department has contributed to research through presentations and publications at regional and international meetings. Bariatric and Metabolic Surgery Obesity is a serious health issue in Cornwall as it is in the rest of the UK. Half the population are overweight and 30% are obese. Obese patients are at greatly increased risk of a range of illnesses including diabetes, hypertension, heart disease, joint failure, breathing difficulties and cancer. These illnesses cost the NHS over £5 billion per year. At any age the mortality rate of obese patients is double that of the non-obese population and their life expectancy is reduced by an average of 9 years. Most overweight people try to control their weight by dieting and lifestyle measures, and some patients are treated by their GP’s with medication. Unfortunately, for most obese patients with a Body Mass Index over 35 these measures are unsuccessful. For patients above 18 years of age whose Body Mass Index exceeds 40, or those with a Body Mass Index over 35 who have developed medical illnesses linked with obesity, bariatric surgery is the only treatment likely to be successful. Bariatric and Metabolic surgery describes a number of procedures intended to help patients lose weight, and more importantly to cure conditions linked to obesity such as Type 2 Diabetes and high blood pressure. The most common operations performed are the Gastric Band procedure, the Roux-en-Y Gastric Bypass procedure and the Gastric Sleeve Procedure. Gastric Bypass Operation Gastric Band Operation

These operations are performed in specially commissioned dedicated bariatric surgery units. In July 2009 the Medical Weight Management and Bariatric


Surgery Service was commissioned and established at the Royal Cornwall Hospitals NHS Trust. The team includes specialist nurses, dieticians, surgeons and anaesthetists to provide complete care for these patients. All operations are performed by keyhole surgery in newly installed purpose built state of the art laparoscopic theatres. Around 100 – 150 operations are performed annually. Two surgeons perform operations, and the service is to be expanded with the appointment of a third surgeon later this year

The results following this surgery at RCHT are very impressive, and match those achieved elsewhere in the world. Patients having a gastric band have lost 49% of their excess weight within 30 months after their operation. After gastric bypass operations patients have lost 70% of their excess weight within a year.

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Gastric Band Ga stric Bypass

Excess Weight Loss after Bariatric Surgery


Similarly impressive results have been achieved in resolving the medical conditions of obese patients: 92% of diabetic gastric bypass patients had their Type 2 Diabetes cured within 3 months of surgery. 47% of diabetic gastric band patients had their Type 2 diabetes cured 6 months after surgery. Marked improvements or cure of other obesity related conditions including arthritic joint pain, high blood pressure, high cholesterol levels or breathing difficulties were also achieved. As a result of bariatric surgery our patients have a much better quality of life and life expectancy, and the demands placed upon the NHS have decreased markedly. Patient Experience National Accident and Emergency (A&E) / Emergency D epartment (ED) Survey During 2012, a questionnaire was sent to patients who had attended an NHS A&E / ED during January, February or March 2012 in England. Responses were received from 406 of the Trust’s patients. The Trust’s scores compared to other NHS Trusts Score Theme Comparison with other Trusts 9.2/10 Travel by ambulance

6.2/10 Reception and waiting

8/10 Doctors and nurses

7.9/10 Care and treatment

8.1/10 Tests

8.1/10 Hospital environment and

facilities

6.2/10 Leaving the ED Department

6.5/10 Overall views on experience


The department reviewed the survey results in full and identified a number of actions including linking in with other initiative already underway:

• The rebuild of the Emergency Department (ED) as part of the Clinical Site Development Plan (CSDP).

• The Listening into Action (LIA) ED workstream. National Inpatient Survey Between September 2013 and January 2013 a questionnaire was sent to patients who had been admitted as an inpatient during June, July or August 2012 for each NHS Trust in England. Responses were received from 436 of the Trust’s patients. The Trust’s scores compared to other NHS Trusts Score Theme Comparison with other Trusts 8.1/10 The Emergency / A&E

Department

9.3/10 Waiting list and planned admissions

7.7/10 Waiting to get to a bed on a

ward

8.1/10 The hospital and ward

8.6/10 Doctors

8.1/10 Nurses

7.5/10 Care and treatment

8.3/10 Operations and procedures

7/10 Leaving hospital

4.9/10 Overall views and experiences

The Trust has worked hard to improve the experience of our patients resulting in improved scores for 8 out of the 10 question areas.


We will be concentrating on the following themes in 2013/14: • Admission through the Emergency Department. • Improving ward environments. • Emotional support and communication with patients. • Discharge processes.

Early Supported Discharge (ESD) for stroke The initial ESD pilot began in November 2011 covering West Cornwall. Following the success of this pilot the service continued and was commissioned to cover the whole county with the East team in operation from August 2012. The new county-wide service facilitates early discharges from hospital for patients with mild to moderate symptoms post stroke and provides specialist stroke rehabilitation (Occupational Therapy, Physiotherapy and Speech and Language Therapy) in the home environment. Rehabilitation is focussed around patient specific goals and can be provided for up to 6 weeks. The service comprises two teams, one in the East and one in the West of the county. Referrals are accepted from the acute stroke unit at Royal Cornwall Hospital and the community stroke rehabilitation units in Bodmin and Camborne. The NHS Accelerating Stroke Improvement (ASI) Programme set a target of 40% of stroke patients to be supported by ESD services on discharge from hospital. Since August 2012 when both ESD teams became operational we have supported an average of 42% of stroke patients. The graph illustrates the estimated bed days saved by the service over the year with an average of 3 bed days saved per patient.

Bed Days Saved

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Apr-12 Jun Aug Oct Dec Feb


NICE Stroke Quality Standard 10 states that ‘All patients discharged from hospital who have residual stroke-related problems are followed-up within 72 hours by specialist stroke rehabilitation services for assessment and ongoing management’. Since April 2012 97% of stroke patients discharged with ESD have been seen at home within 72 hours, of this figure 88% have been followed up within 24 hours. The ESD service works closely with the Short Term Enablement and Planning service (STEPs) run by Cornwall Council. The STEPs teams provide re-enablement packages of care. Collaborative working across agencies allows earlier discharges from hospital and facilitates greater improvements in the patient’s functional independence. On discharge from the ESD service 61% of patients who originally received a STEPs package do not require a long term package of care. The ESD service aims to provide 45 minutes of therapy for a minimum of 5 days a week in line with the NICE Stroke Quality Standard 7. For 2012/13 the service has been 81% successful in providing therapy for 45 minutes or over.

81%

12%

7%

Therapy Provided

45 Minutes and Over

Less Than 45 Minutes

Required but Not Delivered

Feedback on the service from patient and carer satisfaction questionnaires has been positive;

“I am a lot more mobile. I am a lot more confident doing things and am a lot happier.” “I feel that the ESD team have been extremely supportive, helpful and informative. They have been very attentive to [my relative’s] needs and


have interacted with him well. He always looked forward to their visits and will miss the team.” “Absolutely outstanding care – really impressed by [the] team’s professional attitude.”

Young Peoples takeover event in Sexual Health

As part of the National Children’s and Young people’s takeover day initiated by the National Children’s Commissioner, Sexual Health involved young people in service change and design. Seven young women students from St Austell College attended from 10 am to 3pm.

Aims of the day • For a group of young people to experience and then comment on the

patient journey. • For us to discover how we can improve the service for young people. • For young people to gain an insight into how services run and are

improved.

They spent most of the morning experiencing the patient journey from initial call to getting an appointment through to receiving a positive result.

Following this they participated in a number of activities to ascertain their views and ideas for the service.

The feedback on their experience in the clinic was positive • Staff attitude, knowledge and respect for them was high. • Language used and explanations given was at the correct level. • The overall experience was ‘comfortable, friendly, relaxed’. • They were given choices and enabled to make decisions.

Suggestions for improvement were

• More community awareness of services offered. • Better information available on the ‘clinic experience’ or ‘what to expect’. • The waiting area and initial ‘coming into the building’ was the only

experience that was daunting, we discussed ways of improving that i.e. music, screens, décor, magazines.

Feedback relevant to other organisations

• Need for increased relationship and sex education in schools. • Prefer to have ‘professionals’ delivering sexual health messages in

schools & colleges. • Outside of the clinic there is a general lack of clear information on

contraception, enjoying sex and what is normal. The suggestions and feedback are being used to improve our service and community awareness. Feedback relevant to other services has been shared with a positive response. Partnership work is underway to increase awareness


of services offered for young people, vulnerable groups and those who are hard to reach.

Involvement and Stakeholder Engagement As an aspirant NHS Foundation Trust we are increasingly looking to our membership as the focus for engagement and involvement and integrating this work with Patient Ambassadors and speciality patient groups. Public membership is now at 5,241 and the staff membership is at 5,255 (20 opt out members). The target for public members by December 2013 is 10,000 which will give a full membership of over 15,000 members including staff. To support this target there is a Membership and Engagement Committee which has been created by the Shadow Council of Governors. Their first meeting will be in May 2013 and will debate the strategy and plans for membership recruitment and engagement initiatives. Due to Governor elections, training and support, there has been limited recruitment activity. This will continue from April 2013 including a new membership leaflet distribution and recruitment activity using outpatient appointment information. The Governors held their first Shadow Council of Governors meeting on 7 March with a training day on 14 March. There has been an improvement in member involvement as a new monthly bulletin has been created which is emailed to all members along with links into health interest areas, recruiting the following numbers for hospital groups:


Group Interested Bowel Cancer Patient Group 1 Beathe Easy Group 4 Cancer Patient Network 3 Cardiac Patient Group 7 Dermatology Patient Group 3 Diabetes Patient Group 7 Hospital Radio Volunteering 5 Mermaid Patient Group 3 Patient Ambassadors 9 Prostate Cancer 1 RCHT Volunteering 8 Readers Panel 7 Research 3 Stepping Stones Patient Group 0 Learning Disability information 4 In addition there is a new reader’s panel in which members can confidentially read and improve hospital information, ranging from leaflets to website content. They have worked on the membership leaflet, an easy read version of this leaflet, a children’s questionnaire and the readers panel recruitment leaflet itself. To continue improving the engagement with the membership there are a number of projects being developed such as the bedside folder, health talks for members, Royal Cornwall Hospital open day and Governor engagement activity. The Trust has continued to enjoy excellent working relationships with both Cornwall and Isles of Scilly Local Involvement Networks (LINks). As well as responding to formal and informal requests for information, Trust staff have participated with various task groups including safe hospital discharge arrangements from West Cornwall Hospital to the Isles of Scilly by plane now that the helicopter service has been discontinued. During the past year LINks have been focussing on the transition from LINks to Healthwatch which took place on 1st April 2013. The existing LINk staff hope that the newly appointed Board of Directors for Healthwatch will wish to continue with the joint health and social care meetings. These meetings proved to be of value in providing a more joined up approach to health and social care priorities and issues that matter most to the people of Cornwall. In line with the Trust’s 5 year rolling strategic plan, the Patient Experience Group meets on a monthly basis to oversee the implementation of the Patient Experience and Public Involvement Strategy. Part of the strategy involves the recruitment of Patient Ambassadors; twelve Ambassadors were recruited and trained in December 2012. These Ambassadors are working closely with the Divisions to support them in various projects which benefit from patient and public involvement; for example: looking at streamlining the patient’s journey through Clinical Imaging departments making it more logical and time saving;


involvement in the Clinical Site Development Plan and the move of acute services to Trelawny wing; involvement in changes to patient areas within the Theatre and Anaesthetics Division; membership of the Patient Information Group and the Readers Panel, reviewing all patient information to assess clarity and accessibility. The Child Health department is currently recruiting young people from schools to become Patient Ambassadors; they will be looking at the patient environment, patient surveys and menus. The department is also involved with the ‘Kinda Magic’ project which aims to ensure that as many voices of people, who in the past, have found it hard to contribute to patient experience feedback (e.g. those with cognitive and communication impairment, learning disability and young children) are included in surveys that get reported to the Trust Board. Alongside this is the exploration of mechanisms that ensure feedback is heard at the right level and responded to. An example of involving children and young people in service change and design was the ‘Takeover day’ held on 23rd November. Young people from two primary schools and the 6th form of Camborne Academy worked on changes to the menus, the patient experience feedback form and the décor of the children’s’ unit. The young people involved have now met with the relevant managers involved and any changes made are being fed back to the young people and their teachers. Statements from Healthwatch, Health Overview and Sc rutiny Committees and Clinical Commissioning Groups Kernow Clinical Commissioning Group Kernow Clinical Commissioning Group is pleased to have the opportunity to comment on the Quality Account 2012/13 for the Royal Cornwall Hospitals Trust (RCHT), and welcomes the approach the Trust has shown in developing and setting out its plans for quality improvement. There are routine processes in place with RCHT to agree, monitor and review the quality of services throughout the year covering the key quality domains of safety, effectiveness and experience of care. The Quality Account presents an overview of a wide range of quality improvement work being undertaken. We are particularly pleased to see the Boards commitment to quality as demonstrated through the Board work on the Listening into Action Programme. We welcome the Trust Boards commitment to implement the recommendations of the five review reports in respect of Gynaecology, published February 2014. The report presents a fair reflection of progress in 2012/13 and we can confirm the information presented in the Quality Account appears to provide a balanced account which is accurate and fairly interpreted, from the data collected. In terms of the performance against the 2012/13 CQUIN goals the indicators were achieved in full. We note the positive improvements Royal Cornwall Hospitals has made in:


• Meeting the Infection Prevention and Control standards • Recognition of the work in the Improving Lung Cancer Outcomes project • The GMC commendation for three areas of best practice in junior

doctors training Kernow CCG looks forward to working with the Trust throughout the year to deliver high quality services to patients, especially:

• Patient Safety • working with partners to identify and prevent the admission of high risk

patients to hospitals • improving the discharge experience reducing unnecessary discharge

delays • the focus on the CARE campaign • the focus on staff wellbeing

We are pleased to see that the priorities chosen for 2013/14 have been identified with key stakeholder involvement. Kernow CCG would wish the Trust to focus on these areas although not selected as a priority:

• Improving patient experience through the single point of access and reducing ambulance delays

• It is good to see the work undertaken to reduce harm to patients through the implementation of the national safety thermometer and is therefore disappointing that the Trust has requested a reduced target from the national recommended 50% reduction in relation to pressure ulcers

• Delivering the action plans for improvement in Gynaecology services following the review report of February 2013

• Developing and delivering action plans for improvement in cancer services in response to the Cancer Services Peer Review report

Cornwall Health and Adults Overview and Scrutiny Co mmittee During the consultation for this Quality Account, Cornwall Council was in a pre-election period prior to the 2013 local elections. Whilst the election has now taken place there is to be a new Council governance structure which will include alterations to the health scrutiny function. In the period April 2012 to April 2013 the Health and Adults Overview and Scrutiny Committee has regularly scrutinised Royal Cornwall Hospital Trust. This scrutiny will be undertaken by the new Health and Social Care Scrutiny Committee in the future municipal year. It is expected that Royal Cornwall Hospital Trust will be required to report to the Health and Social Care Scrutiny Committee, its progress against the stated future priorities for quality improvement and performance indicators contained within this Quality Account.


Healthwatch Cornwall Do the priorities of the provider reflect the priorities of the local population? Healthwatch Cornwall is alarmed to see that the number of ambulances waiting over 30 minutes at RCH is the highest it has been for 2 years. This is particularly alarming considering the measures that the Trust has put in place to ease patient flow. Furthermore, Healthwatch Cornwall notes from the April 2013 Board report that 4791 patients spent more than four hours waiting at either the Royal Cornwall Hospital or West Cornwall Hospital, which sits above the RCHT standard of seeing 95% of patients within the four hour time frame. Recent patient feedback given to Healthwatch Cornwall reflects these figures with patients having to wait too long to be seen. Discharge and the flow of patients remains a priority for Healthwatch Cornwall, as it was for its predecessor, LINk in Cornwall as it remains one of the most prominent issues which patients tell us about. Last year, LINk in Cornwall recommended that RCHT monitor the quality of discharge as perceived by patients and carers (not just by themselves) and should contribute to work on a cross-agency basis, with an agreed measure of quality in this area. Healthwatch Cornwall would like to see further detail on how quality of discharge will be measured. Healthwatch Cornwall would like to echo LINK’s previous statement, particularly in light of the Overview & Scrutiny Committee’s recent Discharge Enquiry Day and its emphasis on cross-agency working. Healthwatch Cornwall would recommend that there is a member of staff who has the overall responsibility of patient flow, as discharge is frequently delayed or the quality of discharge suffers without having someone responsible. Healthwatch Cornwall would like to see more detail around the reasons for the difficulty in getting patients triaged, and the delayed ambulances. Likewise, further detail around the areas of improvement would be welcomed. Healthwatch Cornwall is pleased to see the re-launch of the “When will I go home?” booklet, which was developed and championed by LINK in Cornwall. However, Healthwatch Cornwall would like to see clearer measures of how discharge is monitored. Regarding pages 55-57 of the account on Patient Experience, Healthwatch Cornwall (like its predecessor LINk in Cornwall) wishes to contribute to development of the methodology that RCHT adopts to measure patient experience. We have asked to have discussions about the Patient Survey and its content so that statutory providers are collecting patient feedback in a standardised way. We note that Patient Related Outcome Measures (PROMs) are in use in parts of the Trust, although this does not appear to be referred to in the Quality Accounts. Patient opinions should be sought (1) by asking questions that have been agreed in advance by the widest possible group of people, including


Healthwatch Cornwall, and (2) by looking at ways of collecting data that allow patients time for reflection on their experience, perhaps after discharge and the completion of their course of treatment. This might include electronic means (for example the Meridian programme, currently in use in CPFT). We at Healthwatch Cornwall look forward to contributing to this process, which, when coordinated with consumer views from across the health and social care services, will assist the Health and Wellbeing Board in its task of influencing the commissioning of services that patients truly value, and in whose design patients will feel they have played a part. Is the Quality Account clearly presented for patients and the public? Healthwatch Cornwall finds the Quality Account to be presented in an attractive easy to read style and explains information in a way that will be accessible to the public, with abbreviations explained. Isles of Scilly Health Overview and Scrutiny Commit tee The Isles of Scilly Health Overview and Scrutiny Committee welcomes the opportunity to contribute to these Quality Accounts. We would like to see continued work to improve the patient experience of discharge from mainland acute settings back to the islands. Work needs to be done in individual wards to ensure knowledge of the particular circumstances relating to travel and accommodation for patients from the islands. The work to ensure appointment flexibility for islanders has improved pathways for patients and this must continue particularly in the light of travel disruption over the last winter. Continued commitment to transport issues from the Trust is welcomed. In order to overcome some of these issues the islands would like to see better take up of technology for consultation and assessment. We would like to see greater commitment to the pilot project set up by local health partners. We believe that technology can improve patient experience and is a more efficient use of resources. We would also like greater engagement with the Trust in strategic thinking about how to maximise the total health and care resources on the islands to commission and provide the best services for islanders. Formalised feedback from the appointed Governor will be critical to ensure consistent and constructive dialogue with the Trust.

Healthwatch Isles of Scilly Thank you for forwarding your Quality Account. It is a comprehensive and informative document and will provide a useful reference in the coming year. We are pleased to see that improving the discharge experience for patients continues to be a priority. RCHT’s Patient Transport Service worked closely with IOS Council and Link4Scilly in 2012 on a number of travel and transport issues and was instrumental in reviewing and reorganising procedures after the cessation of the helicopter service. Their knowledge and understanding of


our particular transport needs is a valuable resource and one which we would like to see all ward staff refer to in discharge planning. Healthwatch Isles of Scilly has been able to take forward LINk’s good working relationship with the Trust and we continue to raise issues directly with key contacts in the organisation. We are looking forward to re-establishing our Medical Travel-IOS joint working group and the Joint Liaison Group co-chaired with Healthwatch Cornwall. IOS involvement with RCHT has been further strengthened by the election of a Foundation Governor and the appointment of a Patient Ambassador. Trust response to comments from third parties The Trust is grateful to stakeholders and third party organisations that helped to shape our Quality Account for 2012/13 We will continue to work with our colleagues in health and social care to reduce ambulance handover delays and the length of time patients wait to be seen in the Emergency Department. Rebuilding of the Emergency Department is underway with completion of the first two phases expected in late July. This includes additional trolley bays and a dedicated Paediatric treatment area to improve the flow through the department and the resulting patient experience. A procurement process is underway for an electronic solution for capturing patient experience e.g. touchscreen kiosks which we aim to have in place by the end of March 2014. Statement of Directors' Responsibilities in Respect of the Quality Account The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulations 2011 and 2012 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements). In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

• the Quality Accounts presents a balanced picture of the Trust’s performance over the period covered;

• the performance information reported in the Quality Account is

reliable and accurate;

• there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice;


• the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance.

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account. By order of the Board


Independent Auditors’ Report





Documents

ROYAL CORNWALL HOSPITALS NHS TRUST QUALITY … · Peninsula Trauma Network 9 Improved pathway for Glaucoma patients 10 Patient Experience 11 Quality of discharge including information