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Providing Services Across Cambridgeshire, Luton, Norfolk, Peterborough and Suffolk

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Providing Services Across Cambridgeshire, Luton, Norfolk, Peterborough and Suffolk 2014 – 2015 Cambridgeshire Community Services NHS Trust: providing services across Cambridgeshire, Luton, Norfolk, Peterborough and Suffolk Contents Part 1: Information about the Quality Account ........................................................... 2 Statement on Quality from the Chief Executive .................................................... 2 Statements from the Chief Nurse and Medical Director ....................................... 3 About the Quality Account ...................................................................................... 4 Part 2: Priorities for Improvement ............................................................................... 5 Quality Improvement Priorities for 2015-16 ........................................................... 5 Priority 1: .................................................................................................................... 6 Priority 2: .................................................................................................................... 6 Priority 3: .................................................................................................................... 7 Priority 4: .................................................................................................................... 7 Priority 5: .................................................................................................................... 7 Priority 6: ................................................................................................................... 8 Priority 7: ................................................................................................................... 8 Statement of assurance from the Board ................................................................ 9 1. Review of Services ............................................................................................. 9 2. Participation in clinical audits and national confidential enquiries ...................... 9 3. Participation in clinical research ....................................................................... 10 4. Use of the Commissioning for Quality and Innovation (CQUIN) Framework .... 12 5. Statements from the Care Quality Commission (CQC) .................................... 12 6. Data quality ...................................................................................................... 16 7. Information Governance Toolkit attainment level ............................................. 17 8. Improvements to Quality Governance .............................................................. 17 Part 3: Review of Quality Performance 2014-15 ....................................................... 18 3.1 Quality Improvement Priorities 2014-15 ........................................................... 18 Priority 1: Safety ............................................................................................... 18 Priority 2: Effectiveness .................................................................................... 20 Priority 3: Caring .............................................................................................. 21 Priority 4: Responsive ...................................................................................... 22 Priority 5: Well-led ............................................................................................ 23 3.2 Other Patient Safety Activity............................................................................. 24 3.3 Other Effectiveness Activity.............................................................................. 27 3.4 Other Patient Experience Activity ..................................................................... 28 3.5 Workforce Factors ............................................................................................ 31 3.6 Staff Innovation & Excellence Awards .............................................................. 34 3.7 Core Quality Account Indicators ....................................................................... 34 3.8 Quality Innovation 2014-15 .............................................................................. 37 Part 4: Statements relating to quality of NHS services provided ............................ 41 List of Trust Services ................................................................................................ 48 Cambridgeshire Community Services NHS Trust: providing services across Cambridgeshire, Luton, Norfolk, Peterborough and Suffolk Page 1 Part 1: Information about the Quality Account Statement on Quality from the Chief Executive Welcome to the 2014/15 Quality Account We are delighted to report that the Trust has achieved the vast majority of its quality, financial and performance ambitions and targets in the last 12 months. Highlights have included: . The Care Quality Commission rating our services ‘Good’ following an extensive inspection. 90% of the 9000 patients we surveyed expressing satisfaction with our services. Winning three multi-million pound contracts across the region during 2014-15, each for periods of up to five years bringing additional resources and security in to the Trust. Playing a vital role in enabling significant numbers of patients with increasingly complex needs to avoid hospital admissions or leave hospital earlier; particularly over the winter period when local hospitals experienced unprecedented pressures. Achieving a modest and planned operating surplus of £754,000 despite on-going financial constraints and ever-growing demands for our services, all of which will be ploughed back into improving services in the coming year. Staff rating the Trust best in the country compared to our peer community trusts in 11 of the 29 key findings areas of the national staff survey and in relation to staff engagement (and fifth best Trust in the country for staff engagement irrespective of the type of services provided). These findings were echoed by NHS Employers in partnership with the Health Service Journal, who identified the Trust as one of their Top 100 NHS Employers in 2014. Set out in this report are our priorities for improving quality in 2015-16. As you will read, we continue to set ourselves high ambitions. This report also reflects on achievements in 2014-15 in improving quality. We hope you will agree that much progress has been made. These achievements are the result of the outstanding commitment of our staff and we acknowledge and thank them for their amazing dedication. Nevertheless, there is more that we wish to achieve to improve the quality of our services and we have every intention of achieving the priority areas set out in this report. I can confirm on behalf of the Trust’s Board that to our best knowledge and belief the information contained in this Quality Account is accurate and represents our performance in 2014-15 and reflects our priorities for continuously improving quality in 2015-16. We are proud to provide high quality innovative services that enable people to receive care closer to home and live healthier lives. We hope the examples in this report demonstrate just some of the innovative ways we are supporting people across the east of England and improving their quality of life. Matthew Winn Chief Executive Cambridgeshire Community Services NHS Trust: providing services across Cambridgeshire, Luton, Norfolk, Peterborough and Suffolk Page 2 Statement from the Chief Nurse and Medical Director We are delighted to endorse this account of the work undertaken in the past year to not only deliver a safe and effective service but to strive always for improvement using best evidence. The Trust has maintained a high level of vigilance; shown by high quality incident reporting which enables learning, and year on year improvements in care; measured using the Safety Thermometer. Given significant operational changes in the past year this demonstrates a high performing and resilient clinical team where the quality of care is at the heart of their work, and this has further been endorsed by the outcomes of our staff survey. David Vickers Medical Director Mandy Renton Chief Nurse Cambridgeshire Community Services NHS Trust: providing services across Cambridgeshire, Luton, Norfolk, Peterborough and Suffolk Page 3 About the Quality Account What is a Quality Account? Quality Accounts are annual reports to the public from providers of NHS healthcare about the quality of services they deliver. The primary purpose of Quality Accounts is to encourage boards and leaders of healthcare organisations to assess quality across all of the healthcare services they offer. It allows leaders, clinicians, governors and staff to demonstrate their commitment to continuous, evidence-based quality improvement, and to explain their progress to the public. Our Quality Account is divided into the following sections: . Statements about our Quality from the Chief Executive, Chief Part 1 Nurse and Medical Director. Priorities for the Trust to improve the quality of our care during 2015/16. Part 2 . Statements about the quality of services provided by the Trust which also allow readers to compare us against similar organisations. A review of quality performance. This demonstrates how the Part 3 Trust has performed throughout 2014-15. Our Quality Strategy Our Chief Nurse is the Executive Lead for Quality across the Trust and is responsible for keeping the Board informed of Quality issues, risks, performance and good practice. We have developed a five year Quality Strategy which
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