Commission for Health Improvement

NHS performance ratings Acute trusts Specialist trusts Ambulance trusts

2002 / 2003

Commission for Health Improvement

Finsbury Tower 103-105 Bunhill Row London EC1Y 8TG

Telephone 020 7448 9200 Text phone 020 7448 9292

www.chi.nhs.uk

ISBN 0-11-703253-0

www.tso.co.uk

PRA/0703/TSO/8000 9 780117 032538 NHS performance ratings Acute trusts Specialist trusts Ambulance trusts

2002 / 2003 Contents

Introduction 2 Acute trusts 4 Specialist trusts 6 Ambulance trusts 6 Primary care trusts 7 Mental health trusts 8 Learning disability trusts 9 Results for 2002 / 2003 10 Contacting CHI 11 Tables 12

This publication contains tables of performance information for acute, specialist and ambulance trusts. A similar publication includes performance information for primary care, mental health and learning disability trusts.

1 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Introduction The ratings incorporate key targets which cover Government priority areas, as well as a broader set of important indicators. This year, CHI has improved the transparency of the ratings methodology by Performance ratings for NHS trusts in England, covering the year ending March 2003 are the first to publishing in advance the indicator lists. CHI aims to bring this forward for the forthcoming year, to be produced and published by CHI, the Commission for Health Improvement. This year is also the give trusts more notice of the indicators against which they will be assessed. first in which primary care trusts and mental health trusts have received full star ratings. Star ratings for acute, specialist and mental health trusts also take into consideration CHI’s clinical CHI is the independent regulator of NHS performance. The Government is responsible for setting governance reviews. In future years this will be extended to include ambulance and primary care priorities which in turn determine the indicators relating to key targets. Other indicators have this trusts. In some cases, where a CHI clinical governance review is older, an assessment has been made year been designed by CHI and the Department of Health to reflect a wide range of performance of progress by the trust against the action plan agreed after the review. This updated assessment has issues, following consultation with the service and other stakeholders. been used in calculation of the star rating.

For the first time, the confirmed lists of indicators, and the technical specifications (or constructions) used to calculate them, were published in advance. Indicator lists for acute and ambulance trusts How does the NHS performance ratings system work? were published in December 2002, and for primary care and mental health trusts in March 2003. CHI is committed to extending this transparency by publishing indicator lists even earlier for the The NHS performance ratings system places NHS trusts in England into one of four categories: 2003 / 2004 year. trusts with the highest levels of performance are awarded a performance rating of three stars trusts that are performing well overall, but have not quite reached the same consistently high The ratings, together with the indicators used to calculate them, the thresholds and the standards, are awarded a performance rating of two stars methodology are published in full on the CHI website (www.chi.nhs.uk/ratings). This document trusts where there is some cause for concern regarding particular areas of performance are accompanies the internet publication, and summarises the star ratings and indicator scores for awarded a performance rating of one star each trust. trusts that have shown the poorest levels of performance against the indicators or little progress in implementing clinical governance are awarded a performance rating of zero stars The ratings and indicators provide people working in the NHS and the public with accessible and easy to understand information about the performance of local health services. Where a trust has a low rating based on poor performance on a number of key targets and indicators, this does not necessarily mean that a hospital is unsafe, does not contain some very good clinical services or that the staff are not working hard in often difficult circumstances. It does mean This publication that performance must be improved in a number of key areas.

Performance ratings for all acute trusts, specialist trusts and ambulance trusts in England with are A zero star trust is one which either fails against the key targets or is considered to have poor clinical covered in this publication. Primary care trusts, mental health trusts and trusts providing services for governance. people with learning disabilities are included in a similar publication. A three star trust is is one that does well on the indicators and, if a review has been undertaken, is Combined trusts, those which provide services in mental health as well as acute or primary care, are considered to have good clinical governance. star rated in both sectors (acute and mental health, or primary care and mental health). Each star rating is listed in the appropriate section. Role of clinical governance reviews in rating performance Summary reports are available on the CHI website for each type of NHS trust. Each one explains to local people and those responsible for leading and managing the trust how the trust has fared in the As last year, information from CHI's reviews is used in determining poorly performing (zero star) and ratings. The ratings tables allow trusts to compare their performance against others, so they can high performing leading (three star) NHS organisations. share good practice, and address weaknesses. Since beginning its work in 2000, CHI has published clinical governance review reports on most acute and specialist trusts, most ambulance trusts and some mental health and primary care trusts. A CHI Developments in NHS performance ratings clinical governance review assesses the trust across seven components of performance: risk management Over time CHI aims to develop performance indicators and ratings to enhance their accuracy as a clinical audit reflection of the patient experience. The method used this year to determine ratings is based on last research and education year’s approach, although there have been some changes to individual indicators and some patient involvement modifications to the methodology for calculating the star ratings. information management staff involvement education, training and development 2 3 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Each component is scored from I to IV. The indicators have been chosen to provide a balance across the clinical, patient, and capacity capability focus areas outlined below: After each review the trust prepares an action plan to address areas for improvement identified by the CHI report. It is agreed with CHI, and published. For trusts whose CHI clinical governance reviews Clinical focus are older (published before September 2002), CHI, with the support of strategic health authorities, clinical negligence has assessed progress against this action plan. Any significant improvements have been taken into death within 30 days of a heart bypass operation consideration in calculating the star rating. death within 30 days of selected surgical procedures emergency readmission to hospital following discharge For this year, clinical governance scores have not been incorporated into star ratings for ambulance emergency readmission to hospital following discharge for children trusts, who have only recently adopted clinical governance principles or for primary care trusts, in emergency readmission to hospital following treatment for a fractured hip recognition of their immaturity as organisations. CHI does intend to reflect clinical governance emergency readmission to hospital following treatment for a stroke assessments in next year’s star ratings. infection control procedures Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia: improvement score thrombolysis treatment time Acute trusts Patient focus All acute trusts have been assessed on their performance during 2002 / 2003 against a limited A&E emergency admission waits (4 hours) number of key targets and a larger number and range of indicators. Key targets are the most better hospital food significant factors in determining overall performance ratings this year. breast cancer treatment cancelled operations Key targets day case booking delayed transfers of care A&E emergency admission waits (12 hours) nine month heart operation waits cancelled operations not admitted within 28 days outpatient / A&E survey – access & waiting financial management outpatient / A&E survey – better information, more choice hospital cleanliness outpatient / A&E survey – building relationships Improving Working Lives outpatient / A&E survey – clean, comfortable, friendly place to be number of inpatients waiting longer than the standard outpatient / A&E survey – safe, high quality, coordinated care number of outpatients waiting longer than the standard paediatric outpatient did not attends rates total time in A&E patient complaints procedure two week cancer waits privacy & dignity six month inpatient waits Performance against targets is assessed in terms of whether the target has been achieved, whether thirteen week outpatient waits there has been some degree of underachievement or whether the target was significantly total inpatient waits underachieved. Trust performance is considered to be of concern if there are: waiting time for rapid access chest pain clinic a sizeable number of targets with some degree of underachievement a smaller number of targets against which there has been significant levels of underachievement Capacity and capability focus a combination of both data quality staff opinion survey Indicators junior doctors' hours The broader range of indicators make up a ‘balanced scorecard’ to refine the judgement on ratings. consultant appraisal This balanced scorecard approach allows a broad range of areas to be measured within a single sickness absence rate methodology. Trusts with high performance ratings therefore have to do well against a rounded set information governance of indicators. fire, health & safety

4 5 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Specialist trusts Primary care trusts

The ratings methodology for specialist trusts is similar to that for acute trusts. One of the key The ratings methodology for primary care trusts is similar to that for acute trusts, but balanced targets - two week cancer waits – and some individual indicators are only appropriate for some scorecard indicators grouped under unique headings reflect the responsibilities of these organisations individual specialist trusts. For instance two week cancer waits are not appropriate for specialist in public health improvement, and as providers of primary care and commissioners of primary and trusts, such as Moorfields Eye Hospital, which do not provide most cancer services. Similarly accident secondary care services. and emergency waits do not apply to specialist hospitals without A&E services. A trust rating is allocated on the basis of those key targets and indicators that are appropriate to the specialist trust Key targets concerned. access to a GP The indicators for specialist trusts are selected, as appropriate to the functions of the individual access to a primary care professional trust, from the list detailed for acute trusts. number of inpatients waiting longer than the standard number of outpatients waiting longer than the standard total time in A&E Ambulance trusts single telephone access - implementation plans four week smoking quitters The ratings methodology for ambulance trusts is similar to that for acute trusts except that the set Improving Working Lives of key targets and indicators is smaller, reflecting the particular range of services offered by financial management ambulance trusts.

Key targets Indicators

category A calls meeting 14/19 minute target Access to quality services category A calls meeting 8 minute target emergency readmission to hospital following treatment for a fractured hip financial management substance misuse: percentage of GP practices in a shared care scheme Improving Working Lives sexual health: access to services for early unintended pregnancy level of 24 hour access to specialist mental health services A&E emergency admission waits (12 hours) Indicators twelve month heart operation waits delayed transfers of care Clinical focus access to NHS dentistry clinical negligence PCT survey – access and waiting thrombolysis protocols and procedures: training of paramedic staff PCT survey – better information, more choice PCT survey – building closer relationship Patient focus PCT survey – clean, comfortable, friendly place to be category B/C calls meeting national 14/19 minute target PCT survey – safe, high quality, coordinated care GP urgent calls meeting national 15 minute target prescribing of atypical antipsychotics patient complaints procedure Improving health Capacity and capability focus death rates from circulatory diseases, aged under 75 (change in rate) fire, health & safety death rates for accidents, all ages (change in rate) information governance death rates from cancer, aged under 75 (change in rate) sickness absence rate breast cancer screening staff opinion survey cervical screening flu vaccinations teenage pregnancy: conceptions below age 18 (change in rate) diabetes services baseline assessment CHD audit suicide audit

6 7 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Service provision Indicators emergency admissions (change in rate) emergency admission to hospital for children with lower respiratory tract (LRT) infections Clinical focus (change in rate) clinical negligence primary care management – acute conditions (change in rate) CPA systems implementation primary care management – chronic conditions (change in rate) psychiatric readmissions (adult) community equipment psychiatric readmissions (older people) patient complaints procedure suicide rate prescribing of antibacterial drugs prescribing rates for drugs acting on benzodiazepine receptors Patient focus staff opinion survey transition of care between adult services and OPMH GP appraisal transition of care between CAMHS and adult services sickness absence rate patients with copies of their own care plan fire, health & safety patient complaints procedure generic prescribing better hospital food privacy & dignity

Mental health trusts and community trusts that provide mental Capacity and capability focus health services missed outpatient appointments crisis resolution team implementation The ratings methodology for mental health trusts is similar to that for acute trusts. The exception is out of catchment area treatments (adults) in the choice of key targets and indicators, some variations having been made to reflect the out of catchment area treatments (older people) specialised range of services provided by mental health trusts. CAMHS service mapping data quality Key targets staff opinion survey junior doctors’ hours assertive outreach team implementation consultant appraisal CMHT integration sickness absence rate mental health minimum dataset implementation information governance number of outpatients waiting longer than the standard fire, health & safety Improving Working Lives hospital cleanliness financial management Learning disability trusts

The ratings methodology for trusts that provide services for people with learning disabilities is similar to that for mental health trusts. Learning disability trusts have been performance rated on the set of indicators applicable to mental health trusts, omitting those which do not apply to their services. A trust rating is allocated on the basis of those key targets and indicators that are appropriate to the learning disability trust concerned.

8 9 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Results for 2002 / 2003 Contacting CHI

A total of 599 star ratings have been awarded to 579 NHS trusts in England for their performance in The Commission for Health Improvement welcomes constructive feedback on its work. If you have a 2002 / 2003. Trusts which provide services in more than one sector have been given more than one comment or query about performance ratings, please contact: star rating. For instance an acute trust which also provides mental health services will have a star rating in the acute list and a star rating in the mental health list. Results for mental health trusts Commission for Health Improvement incorporate those for learning disability trusts. Performance ratings Finsbury Tower The overall results are as follows: 103-105 Bunhill Row 131 three stars London, EC1Y 8TG 258 two stars email: [email protected] 166 one star 44 zero stars To purchase additional printed copies of the 2002 / 2003 performance ratings publications please contact: For acute trusts, the results are as follows: 52 three stars TSO (The Stationery Office) 60 two stars PO Box 29 30 one star Norwich, NR3 1GN 14 zero stars telephone orders: 0870 600 5522 fax orders: 0870 600 5533 For specialist trusts, the results are as follows: email: [email protected] 10 three stars 9 two stars This booklet was published in July 2003. 1 one star 0 zero stars

For ambulance trusts, the results are as follows: 10 three stars 7 two stars 9 one star 5 zero stars

For primary care trusts, the results are as follows: 45 three stars 139 two stars 98 one star 22 zero stars

For mental health trusts (including learning disability trusts), the results are as follows: 14 three stars 43 two stars 28 one star 3 zero stars

10 11 12 Trust Lancashire Teaching Hospitals NHS King’s College Hospital NHS Trust James Paget Healthcare NHS Trust Homerton University Hospital NHS Trust Harrogate Health Care NHS Trust Guy’s and St Thomas' NHS Trust Gloucestershire Hospitals NHS Trust George Eliot Hospital NHS Trust Gateshead Health NHS Trust East Somerset NHS Trust NHS Trust Doncaster and Bassetlaw Hospitals Dartford and Gravesham NHS Trust Countess of Chester Hospital NHS Trust City Hospitals Sunderland NHS Trust Hospital NHS Trust Chesterfield and North Derbyshire Royal Calderdale and Huddersfield NHS Trust Burton Hospitals NHS Trust Bradford Teaching Hospitals NHS Trust (Teaching) NHS Trust Birmingham Heartlands and Solihull Hospitals NHS Trust Basildon and Thurrock University Trust District General Hospital NHS Barnsley Airedale NHS Trust Addenbrooke’s NHS Trust this information. mental health ratings report for by combined trusts; refer to mental health services provided These trusts do not include Acute trusts Organisation ^ n/a Data denotes a combined trust therefore also rated in mental health tables not applicable NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts a not available Rating ✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✶✶✶ ✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✶✶✶ ✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶ ✓ ✓ ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✶✶✶

A&E emergency admission waits (12 hours)

b Cancelled operations not admitted within 28 not provided/invalid data days

Financial management

Hospital cleanliness Key targets

Improving Working Lives

Number of inpatients waiting longer than the standard

✓ Key targets Number of outpatients waiting longer than the standard achieved

– Total time in A&E

✓ Two week cancer waits – underachieved n a aa23333234n/a33333355143335n/aaaaaa233 535334n/a4345524542355 254533 4n/a21333434 535423 313535135321533 223343 55133352332213533331 4321533533 132453n/a111211355355b 323453 43134333343312122333 4n/a3433333b 455532n/a5333344554551 333335 4n/a33133334 355343 4354533333 333323n/a35434345442324n/aaaaaa434 152443n/a333333354351b 323233 4n/a35333432 451334n/a444443553454b 343423 5n/aaaaaa235 445425 432323n/a44354335454314n/aaaaaa335 255241n/a2223223533435 324221 4n/a35333333 155533 335434n/a43333355353n/a35n/a32533433 533524n/a43333215544334n/aaaaaa43b 435424 33542153223213554453 232434 434334 5a31133333 235331n/a22311535444bb5n/a3553355b 532355n/a3333323543332 554323 5n/a33335433 542423 333242n/a34333431332534n/aaaaaa332 335341 n a 3223335344n/a33333535433234n/a33523233 323334 335332n/a54444455331234n/a13143432 442144 355353n/a54444335543324n/a25333535 333334 333333n/a34344335221214n/a33433431 533425n/a2222243534453 555132 2n/a32333333 453225 532434n/a45445435435n/a34n/aaaaaa531 Clinical 142434 negligence

Death within 30 days of a heart bypass operation

Death within 30 days of selected surgical procedures

✗ Emergency readmission to hospital following Clinical focus significantly underachieved discharge Emergency readmission to hospital following discharge for children

Emergency readmission to hospital following treatment for a fractured hip

Emergency readmission to hospital following treatment for a stroke

Infection control procedures

Methicillin Resistant Staphylococcus aureus (MRSA) bacteraemia: improvement score

Thrombolysis treatment time + CHI review 5 Focus areas ✓✓ Clinical governance progress against the trust action plan has been assessed

significantly above average A&E emergency admission waits (4 hours) significant strengths

Better hospital food

Breast cancer treatment

Cancelled operations ✓

many strengths Day case booking 4 above average Delayed transfers of care NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Nine month heart operation waits – strengths Outpatient / A&E survey – access & waiting Patient focus

3 Outpatient / A&E survey – better information, mm/yy more choice ✗ average significant areas of weakness

date CHI report published Outpatient / A&E survey – building relationships

Outpatient / A&E survey – clean, comfortable, friendly place to be 2

below average Outpatient / A&E survey – safe, high quality, coordinated care

Paediatric outpatient did not attends rates

– Patient complaints procedure n/a no CHI report 1 not applicable

significantly below average Privacy & dignity

Six month inpatient waits

Thirteen week outpatient waits

Total inpatient waits

Waiting time for rapid access chest pain clinic

Consultant appraisal Capacity & capability focus

Data quality

Fire, health & safety

Information governance

Junior doctors' hours

Sickness absence rate

Staff opinion survey 12/01+ 06/01+ 06/01+ 02/02+ 07/01+ 06/01+ 10/01+ 12/01+ 04/02+ 10/02+ 06/01+ 12/00+ 12/00+ 12/01+ 11/01+ 09/01+ 09/01+ 03/02+ 02/02+ 05/02 11/02 12/02 10/01

CHI review? CHI 13 ✓✓ ✓✓ ✓✓ ✓✓ ✓✓ ✓✓ n/a n/a ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Clinical governance NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus CHI

Acute trusts

These trusts do not include mental health services provided by combined trusts; refer to mental health ratings report for this information. Staphylococcus aureus Patient complaints procedure Privacy & dignity Six month inpatient waits Thirteen week outpatient waits Delayed transfers of care Nine month heart operation waits Outpatient / A&E survey – access & waiting Outpatient / A&E survey – better information, choice more Outpatient / A&E survey – building relationships Outpatient / A&E survey – clean, comfortable, friendly place to be Outpatient / A&E survey – safe, high quality, care coordinated Paediatric outpatient did not attends rates Total inpatient waits Total time for rapid access chest pain clinic Waiting CHI review? Clinical governance Better hospital food cancer treatment Breast Cancelled operations Day case booking Fire, health & safety Fire, Information governance Junior doctors' hours Sickness absence rate A&E emergency admission waits (4 hours) Consultant appraisal Data quality Staff opinion survey Staff Emergency readmission to hospital following Emergency readmission discharge for children to hospital following Emergency readmission hip for a fractured treatment to hospital following Emergency readmission for a stroke treatment procedures Infection control Clinical negligence Death within 30 days of a heart bypass operation Death within 30 days of selected surgical procedures to hospital following Emergency readmission discharge Methicillin Resistant score (MRSA) bacteraemia: improvement Thrombolysis treatment time treatment Thrombolysis Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard time in A&E Total week cancer waits Two A&E emergency admission waits (12 hours) A&E emergency admission Cancelled operations not admitted within 28 Cancelled operations not days Financial management Hospital cleanliness Improving Working Lives Working Improving

Luton and Dunstable Hospital NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a35133331 453334n/a221223454345b 15524209/02 ✓✓

Mid Staffordshire General Hospitals ✶✶✶ ✓ – ✓✓✓✓✓✓✓ 5n/a3513343b 332242n/a2223333522231 34452301/02+ ✓ NHS Trust

Morecambe Bay Hospitals NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a33333232 332333n/a5555533533335 33431212/01+ ✓

North Hampshire Hospitals NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ – ✓✓✓4n/a35333351 555441n/a3543353534412 23435307/02+ ✓

North Tees and Hartlepool NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a32233334 355434n/a4444432534325 24433309/01+ ✓✓

Nottingham City Hospital NHS Trust ✶✶✶ n/a ✓✓✓✓✓✓n/a ✓ 53313a3331 n/a5123433343533524323 43442401/02+ ✓

Peterborough Hospitals NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a34123233 435332n/a3433343533352 33523405/02+ ✓

Rotherham General Hospitals NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 5n/a31323534 433433n/a3324335543445 45232407/01+ ✓

Royal Bournemouth and Christchurch ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a31n/a33513 553452n/a3433333545333 24542305/02+ ✓ Hospitals NHS Trust

Royal Devon and Exeter Healthcare ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 5n/a45533433 45322344444433523223 54231410/01+ ✓✓ NHS Trust

Sandwell and West Birmingham ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/aaaaaa334 355233n/a2212214553433 31553301/02+ ✓ Hospitals NHS Trust

Sheffield Teaching Hospitals NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4331a33134 35344334433314534253 52235205/03 ✓

South Devon Health Care NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a35333333 353223n/a4443434534233 33534305/03 ✓✓

South Tyneside Health Care NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/aaaaaa315 553433n/a433542354353b 54341407/02+ ✓

Southampton University Hospitals NHS ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4351333333 23533233333343523253 33434312/00+ n/a Trust

Southend Hospital NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a23533531 535332n/a2322254523322 33435510/01+ ✓

Southern Derbyshire Acute Hospitals ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 5n/a31533334 455414n/a4444554533322 43333b01/03 ✓✓ NHS Trust

St Mary’s NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4353533332 23551331222212133353 2313b501/02 ✓✓

Stockport NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ –5n/a31233333 335424n/a3444333523355 51333203/02+ ✓

Taunton and Somerset NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ –4n/a34333313 351542n/a4544534542535 34534311/01 ✓

The Lewisham Hospital NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a43433332 13b543n/a1111111532222 33332402/02 ✓✓

University College London Hospitals ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4135533533 45543353443334533355 23434303/03 ✓✓ NHS Trust

University Hospital Birmingham NHS ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4331a33345 332553233333n/a4545455 43533402/03 ✓ Trust

Focus areas 5 significantly above average 4 above average 3 average 2 below average 1 significantly below average

Data Key targets Clinical governance n/a not applicable a not available b not provided/invalid data ✓ achieved – underachieved ✗ significantly underachieved ✓✓ significant strengths ✓ many strengths – strengths ✗ significant areas of weakness n/a not applicable

CHI review 14 ^ denotes a combined trust therefore also rated in mental health tables + progress against the trust action plan has been assessed mm/yy date CHI report published – no CHI report 15 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus CHI

Acute trusts

These trusts do not include mental health services provided by combined trusts; refer to mental health ratings report for this information. Staphylococcus aureus Patient complaints procedure Privacy & dignity Six month inpatient waits Thirteen week outpatient waits Delayed transfers of care Nine month heart operation waits Outpatient / A&E survey – access & waiting Outpatient / A&E survey – better information, choice more Outpatient / A&E survey – building relationships Outpatient / A&E survey – clean, comfortable, friendly place to be Outpatient / A&E survey – safe, high quality, care coordinated Paediatric outpatient did not attends rates Total inpatient waits Total time for rapid access chest pain clinic Waiting CHI review? Clinical governance Better hospital food cancer treatment Breast Cancelled operations Day case booking A&E emergency admission waits (4 hours) Emergency readmission to hospital following Emergency readmission discharge for children to hospital following Emergency readmission hip for a fractured treatment to hospital following Emergency readmission for a stroke treatment procedures Infection control Fire, health & safety Fire, Information governance Junior doctors' hours Sickness absence rate Clinical negligence Death within 30 days of a heart bypass operation Death within 30 days of selected surgical procedures to hospital following Emergency readmission discharge Thrombolysis treatment time treatment Thrombolysis Methicillin Resistant score (MRSA) bacteraemia: improvement Consultant appraisal Data quality Staff opinion survey Staff Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard time in A&E Total week cancer waits Two A&E emergency admission waits (12 hours) A&E emergency admission Cancelled operations not admitted within 28 Cancelled operations not days Financial management Hospital cleanliness Improving Working Lives Working Improving

West Dorset General Hospitals NHS ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a33333332 452233n/a43344325543n/a535223307/02+ ✓ Trust

West Suffolk Hospitals NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ –4n/a35533453 333333n/a3343353513353 42332310/02 ✓

Winchester and Eastleigh Healthcare ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a33333242 455132n/a3333353533222 23334501/02 ✓ NHS Trust

Wirral Hospital NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ –5n/a31133333 333443n/a4333322533235 35242307/02 ✓✓

Wrightington, Wigan and Leigh NHS ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 5n/aaaaaa335 451324n/a2333325532335 523322–n/a Trust

York Health Services NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4n/a45333343 335442n/a3543443513335 33534402/02 ✓

Aintree Hospitals NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 2n/a31n/a33415 255333n/a22233n/a1543335 35423308/01+ ✓

Ashford and St Peter’s Hospitals NHS ✶✶✓✓✗✓✓✓✓✓✓ 5n/a3554343b 452411n/a32222455335bb 42215310/01 – Trust

Barking, Havering and Redbridge ✶✶✓✓✓✓✓✓✓✓✓ 4n/a35533434 332142n/a1111132521342 33534107/01 – Hospitals NHS Trust

Bedford Hospitals NHS Trust ✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✗ ✓ ✓ 4n/abbbbb33b 453433n/a3333352523425 33343506/01 ✓✓

Blackburn, Hyndburn and Ribble Valley ✶✶✓✓✓✓✓✓✓✓✓ 4n/a31133132 335355n/a3223233545333 42423408/02 ✓ Health Care NHS Trust

Blackpool, Fylde and Wyre Hospitals ✶✶✓✓✓✓✓✓✓✓✓ 4331533235 435234n/a332333153435b 223512–n/a NHS Trust

Bolton Hospitals NHS Trust ✶✶✓✓✗✓✓✓✓✓✓ 4n/a32533334 152444n/a3333324523353 33332309/01+ ✓

Central Manchester and Manchester ✶✶✓✓✓✓✓✓✓✓✓ 4334543233 43b33423333312523433 33343301/02+ – Children’s University Hospitals NHS Trust

Chelsea and Westminster Healthcare ✶✶✓✓✓✓✓✓✓✓✓ 2n/aaaaaa434 35n/a333n/a2332215343432 15115402/02+ ✓ NHS Trust

County Durham and Darlington Acute ✶✶ ✓ n/a ✓✓✓✓✓✓✓ 4n/a31133334 532333n/a4334433324343 43323307/02+ – Hospitals NHS Trust

Ealing Hospital NHS Trust ✶✶ ✓ ✓ – ✓✓✓✓✓✓ 4n/a35532335 333111n/a111112253333b 35224208/02+ ✓

East Cheshire NHS Trust ✶✶✓✓✓✓✓✓✓✓–2n/aaaaaa43b 353213n/a3344353533133 42333203/03 –

East Sussex Hospitals NHS Trust ✶✶✓✓✗✓✓✓✓✓✓ 4n/a3433323b 433331n/a33223335322bb 53334202/02 –

Essex Rivers Healthcare NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 5n/a15533433 335135n/a2333353122233 34333310/02 –

Frimley Park Hospital NHS Trust ✶✶✓✓✗✓✓✓✓✓✓ 5n/a35333555 255341n/a23333n/a5533235 34435402/02+ ✓✓

Hammersmith Hospitals NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 533353343b 3353334322221313413b 32324304/03 ✓

Heatherwood and Wexham Park ✶✶ – ✓✓✓✓✓✓ – ✓ 4n/a33333131 235342n/a3322243554133 33524312/02 – Hospitals NHS Trust

Focus areas 5 significantly above average 4 above average 3 average 2 below average 1 significantly below average

Data Key targets Clinical governance n/a not applicable a not available b not provided/invalid data ✓ achieved – underachieved ✗ significantly underachieved ✓✓ significant strengths ✓ many strengths – strengths ✗ significant areas of weakness n/a not applicable

CHI review 16 ^ denotes a combined trust therefore also rated in mental health tables + progress against the trust action plan has been assessed mm/yy date CHI report published – no CHI report 17 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus CHI

Acute trusts

These trusts do not include mental health services provided by combined trusts; refer to mental health ratings report for this information. Staphylococcus aureus Patient complaints procedure Privacy & dignity Six month inpatient waits Thirteen week outpatient waits Delayed transfers of care Nine month heart operation waits Outpatient / A&E survey – access & waiting Outpatient / A&E survey – better information, choice more Outpatient / A&E survey – building relationships Outpatient / A&E survey – clean, comfortable, friendly place to be Outpatient / A&E survey – safe, high quality, care coordinated Paediatric outpatient did not attends rates Total inpatient waits Total time for rapid access chest pain clinic Waiting CHI review? Clinical governance Better hospital food cancer treatment Breast Cancelled operations Day case booking A&E emergency admission waits (4 hours) Emergency readmission to hospital following Emergency readmission discharge for children to hospital following Emergency readmission hip for a fractured treatment to hospital following Emergency readmission for a stroke treatment procedures Infection control Fire, health & safety Fire, Information governance Junior doctors' hours Sickness absence rate Clinical negligence Death within 30 days of a heart bypass operation Death within 30 days of selected surgical procedures to hospital following Emergency readmission discharge Thrombolysis treatment time treatment Thrombolysis Methicillin Resistant score (MRSA) bacteraemia: improvement Consultant appraisal Data quality Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard time in A&E Total week cancer waits Two Staff opinion survey Staff A&E emergency admission waits (12 hours) A&E emergency admission Cancelled operations not admitted within 28 Cancelled operations not days Financial management Hospital cleanliness Improving Working Lives Working Improving

Hinchingbrooke Health Care NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 4n/aaaaaa312 352333n/a43333n/a4533355 23253203/02+ –

Ipswich Hospital NHS Trust ✶✶✓✓✓✓✓✓✓✓–4n/a43333334 333333n/a45434321133n/a241213409/01+ ✓

Kettering General Hospital NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 5n/a3333333b 233242n/a43343345343b3 33214311/01 ✓

Kings Lynn and Wisbech Hospitals NHS ✶✶✓✓✓✓✓✓✓ – ✓ 4n/aaaaaa41b 433314n/a4344444533353 33322401/02+ – Trust

Kingston Hospital NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 4n/a35543235 333431n/a2322244532313 223333–n/a

Leeds Teaching Hospitals NHS Trust ✶✶ ✓ ✓ ✓ ✓ ✓ ✓ – ✓✓ 4451433353 23331332333323323313 33143208/02+ ✓

Mayday Healthcare NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 4n/a35533434 355133n/a2111124535335 42343109/01+ –

Mid Essex Hospital Services NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 2n/a35333333 532345n/a1332352133325 32142309/02+ –

Norfolk and Norwich University Hospital ✶✶✓✓✓✓✓✓✓✓✓ 5n/a45333331 333323n/a4444445532243 43323103/03 – NHS Trust

North Middlesex University Hospital ✶✶ ✓ ✓ ✓ ✓ ✗ ✓ ✓ ✓ ✓ 4n/a3333143b 335344n/a1111111552553 43332309/02+ – NHS Trust

North West London Hospitals NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 2n/aaaaaa455 232233n/a1111121522353 25215b10/01+ ✓

Northampton General Hospital NHS ✶✶ – ✓✓✓✓✓✓✓–5n/a34233333 152122n/a2322335522135 31433306/02 ✓✓ Trust

Northern Devon Healthcare NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 4n/ab34bb433 453433n/a5555533524351 43333403/02+ ✓

Northern Lincolnshire and Goole ✶✶✓✓✓✓✓✓✓✓✓ 4n/a33333232 432443n/a3233323545512 34223312/02 – Hospitals NHS Trust

Northumbria Health Care NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 4n/a31233314 335533n/a5445433534435 34333102/02+ ✓

Plymouth Hospitals NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 4bb4133333 23323323434341511432 14534310/01+ ✓

Poole Hospitals NHS Trust ✶✶ ––✓✓✓✓✓✓✓ 4n/a33133332 153152n/a4433434555435 23313406/01 –

Portsmouth Hospitals NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 4n/a31333331 133332n/a3223251532332 44312103/02+ ✓

Queen Elizabeth Hospital NHS Trust ✶✶ – ✓✓✓✓✓✓✓✓ 4n/a3553313a 233352n/a211212153343b 24223303/03 –

Queen Mary’s Sidcup NHS Trust ✶✶✓✓✗✓✓✓✓✓✓ 4n/a3553333b 235352n/a2332222524233 12352201/03 –

Queen’s Medical Centre, Nottingham ✶✶✓✓✓✓✓✓✓✓✓ 4n/abbbbb431 33b324n/a2212323533323 21433301/02 ✓✓ University Hospital NHS Trust

Royal Cornwall Hospitals NHS Trust ✶✶✓✓✗✓✓✓✓✓✓ 4n/a34433134 255343n/a455554252125b 32331302/02+ ✓

Royal Free Hampstead NHS Trust ✶✶ ✓ ✓ – ✓✓✓✓✓✓ 2a35533332 33232342321123531333 21323206/02+ ✓

Focus areas 5 significantly above average 4 above average 3 average 2 below average 1 significantly below average

Data Key targets Clinical governance n/a not applicable a not available b not provided/invalid data ✓ achieved – underachieved ✗ significantly underachieved ✓✓ significant strengths ✓ many strengths – strengths ✗ significant areas of weakness n/a not applicable

CHI review 18 ^ denotes a combined trust therefore also rated in mental health tables + progress against the trust action plan has been assessed mm/yy date CHI report published – no CHI report 19 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus CHI

Acute trusts

These trusts do not include mental health services provided by combined trusts; refer to mental health ratings report for this information. Staphylococcus aureus Patient complaints procedure Privacy & dignity Six month inpatient waits Thirteen week outpatient waits Delayed transfers of care Nine month heart operation waits Outpatient / A&E survey – access & waiting Outpatient / A&E survey – better information, choice more Outpatient / A&E survey – building relationships Outpatient / A&E survey – clean, comfortable, friendly place to be Outpatient / A&E survey – safe, high quality, care coordinated Paediatric outpatient did not attends rates Total inpatient waits Total time for rapid access chest pain clinic Waiting CHI review? Clinical governance Better hospital food cancer treatment Breast Cancelled operations Day case booking Fire, health & safety Fire, Information governance Junior doctors' hours Sickness absence rate A&E emergency admission waits (4 hours) Consultant appraisal Data quality Staff opinion survey Staff Emergency readmission to hospital following Emergency readmission discharge for children to hospital following Emergency readmission hip for a fractured treatment to hospital following Emergency readmission for a stroke treatment procedures Infection control Clinical negligence Death within 30 days of a heart bypass operation Death within 30 days of selected surgical procedures to hospital following Emergency readmission discharge Methicillin Resistant score (MRSA) bacteraemia: improvement Thrombolysis treatment time treatment Thrombolysis Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard time in A&E Total week cancer waits Two A&E emergency admission waits (12 hours) A&E emergency admission Cancelled operations not admitted within 28 Cancelled operations not days Financial management Hospital cleanliness Improving Working Lives Working Improving

Royal Liverpool and Broadgreen ✶✶✓✓✓✓✓✓✓✓✓ 4n/a31a3323b 331233n/a22222n/a25233n/ab52343202/03 – University Hospitals NHS Trust

Royal West Sussex NHS Trust ✶✶✓✓✗✓✓✓✓✓✓ 4n/aaaaaa33b 153353n/a344334253333b 31325503/02 ✓

Salford Royal Hospitals NHS Trust ✶✶ ✓ ✓ ✓ ✓ ✓ ✓ – ✓✓ 4n/a21a33434 455213n/a3443431542311 23423211/01+ ✓

Salisbury Health Care NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 4n/a35433232 253231n/a4443443534112 13212403/02+ ✓

Sherwood Forest Hospitals NHS Trust ✶✶✓✓✓✓✓✓✓✓–4n/a11333333 332313n/a3333331532435 33332210/01 ✓

South Tees Hospitals NHS Trust ✶✶ ✓ ✓ ✓ ✓ ✓ ✓ – ✓✓ 2331233134 253333n/a5544433533332 333324–n/a

South Warwickshire General Hospitals ✶✶✓✓✓✓✓✓✓✓–4n/a33333333 432423n/a3434353541323 45252203/02+ – NHS Trust

Southport and Ormskirk Hospital NHS ✶✶✓✓✓✓✓✓✓✓✓ 5n/a3533313b 335543n/a33333345133n/a534132202/02+ ✓ Trust

St George’s Healthcare NHS Trust ✶✶ ✓ ✓ ✓ ✓ ✓ ✓ – ✓✓ 433553335b 33133431122122132332 31424402/03 –

St Helens and Knowsley Hospitals NHS ✶✶✓✓✓✓✓✓✓✓✓ 4n/aaaaaa433 535432n/a3344423533223 32341305/02+ – Trust

Swindon and Marlborough NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 5n/a33333433 232431n/a3334331532415 35231b07/03 ✓

The Hillingdon Hospital NHS Trust ^ ✶✶✓✓✓✓✓✓✓✓✓ 2n/a3443353b 333131n/a2221232143152 33333b06/02+ –

The Mid Cheshire Hospitals NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 2n/aaaaaa133 335224n/a3333345533435 12222310/01+ ✓

The Newcastle Upon Tyne Hospitals ✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✗ ✓ ✓ 5331333433 43332344554433533235 54543302/02+ ✓✓ NHS Trust

The Royal Wolverhampton Hospitals ✶✶✓✓✓✓✓✓✓✓✓ 2a3313322b 333434n/a111222454323b 33353510/01 – NHS Trust

The Whittington Hospital NHS Trust ✶✶ ✓ ✓ – ✓✓✓✓✓–2n/a33433432 353331n/a1111142544523 22334401/02 ✓✓

University Hospital Of North ✶✶ ✓ – ✓✓✓✓✓✓✓ 5335133133 53224332233322521152 5b211203/02+ ✓ Staffordshire NHS Trust

University Hospitals Coventry and ✶✶✓✓✓✓✓✓✓✓–4331513333 23523212332312531331 42431309/01+ ✓ Warwickshire NHS Trust

Walsall Hospitals NHS Trust ✶✶ ✓ ✓ ✓ ✓ ✓ ✓ – ✓✓ 4n/a3133343b 455433n/a3233355533551 53432210/02+ –

West Middlesex University NHS Trust ✶✶ ✓ ✓ – ✓✓✓✓✓✓ 4n/a1553343b 352352n/a2121124533355 2b224302/02+ –

Barnet and Chase Farm Hospitals NHS ✶✓––✓✓✗✓✓✓4n/abbbbb121 235113n/a2221133511123 11224303/02+ – Trust

Barts and The London NHS Trust ✶✓– ✓✓✓✓ – ✓✓ 433353243b 33522411221213332352 32244310/01+ ✓

Brighton and Sussex University ✶ – ✓✓✓✓✓✓ – ✓ 43bbbbb233 251131n/a3332232522333 11334202/02 – Hospitals NHS Trust

Focus areas 5 significantly above average 4 above average 3 average 2 below average 1 significantly below average

Data Key targets Clinical governance n/a not applicable a not available b not provided/invalid data ✓ achieved – underachieved ✗ significantly underachieved ✓✓ significant strengths ✓ many strengths – strengths ✗ significant areas of weakness n/a not applicable

CHI review 20 ^ denotes a combined trust therefore also rated in mental health tables + progress against the trust action plan has been assessed mm/yy date CHI report published – no CHI report 21 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus CHI

Acute trusts

These trusts do not include mental health services provided by combined trusts; refer to mental health ratings report for this information. Staphylococcus aureus Patient complaints procedure Privacy & dignity Six month inpatient waits Thirteen week outpatient waits Delayed transfers of care Nine month heart operation waits Outpatient / A&E survey – access & waiting Outpatient / A&E survey – better information, choice more Outpatient / A&E survey – building relationships Outpatient / A&E survey – clean, comfortable, friendly place to be Outpatient / A&E survey – safe, high quality, care coordinated Paediatric outpatient did not attends rates Total inpatient waits Total time for rapid access chest pain clinic Waiting CHI review? Clinical governance Better hospital food cancer treatment Breast Cancelled operations Day case booking Fire, health & safety Fire, Information governance Junior doctors' hours Sickness absence rate A&E emergency admission waits (4 hours) Consultant appraisal Data quality Staff opinion survey Staff Emergency readmission to hospital following Emergency readmission discharge for children to hospital following Emergency readmission hip for a fractured treatment to hospital following Emergency readmission for a stroke treatment procedures Infection control Clinical negligence Death within 30 days of a heart bypass operation Death within 30 days of selected surgical procedures to hospital following Emergency readmission discharge Thrombolysis treatment time treatment Thrombolysis Methicillin Resistant score (MRSA) bacteraemia: improvement Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard time in A&E Total week cancer waits Two A&E emergency admission waits (12 hours) A&E emergency admission Cancelled operations not admitted within 28 Cancelled operations not days Financial management Hospital cleanliness Improving Working Lives Working Improving

Bromley Hospitals NHS Trust ✶✓✓✓✓✗✓✓✓✓5n/aaaaaa234 133322n/a23212125243n/a513231b03/02 –

Burnley Health Care NHS Trust ✶✓✓– ✓✓✓✓ ✗✓ 5n/a33133222 433235n/a3223224522223 43443301/03 ✓

Dudley Group Of Hospitals NHS Trust ✶ ✓✓✓✓✓✓✓ ✗ –5n/a3533323b 231423n/a2222131544453 52433308/02 ✓

East and North Hertfordshire NHS Trust ✶✓✓✓✓✓✗– ✓ –4n/aaaaaa232 433343n/a333233452212b 11124b06/02 –

East Kent Hospitals NHS Trust ✶ ✓✓✗✓✓✓✓✓–4n/a31333533 431333n/a3223232522235 23323203/02 –

Epsom and St Helier NHS Trust ✶✓b ✗✓✓✓✓✓✓ 4n/a25533334 43bb31n/abbbbb43133323 43231408/01+ –

Hereford Hospitals NHS Trust ✶✓b ✓✓✓✓✓✓–4n/a35433233 133b42n/a43344315335n/ab35123103/02+ ✓

Hull and East Yorkshire Hospitals NHS ✶✓✓✓✓✓✓✗✓✓4331513452 3312341323233251231b 32243308/01+ ✓ Trust

Medway NHS Trust ✶✓✓– ✓✓✗✓✓✓4n/a351332a4 535b23n/a222233311345b 22331308/02+ –

Mid Yorkshire Hospitals NHS Trust ✶✓✓✗✓✓––✓✓ 4n/a3132351b 353124n/a3333423532231 23122207/02+ ✓

Newham Healthcare NHS Trust ✶✓✓✗✓✓✓– ✓✓ 4n/a33a32334 253244n/a11111n/a5541553 21343210/01 –

North Cheshire Hospitals NHS Trust ✶ ✓✓✗✓✓✓✓✓–4n/aaaaaa323 353333n/a3333331514425 3313b310/02 –

Oxford Radcliffe Hospital NHS Trust ✶✗✓– ✓✓✓✓✓✓ 4243533433 25314325444542534312 22335312/01 –

Pennine Acute Hospitals NHS Trust ✶ – ✓✓✓✓––✓✓ 4n/aaaaaa133 253223n/a223332254322b 53333212/01+ –

Royal Berkshire and Battle Hospitals ✶✓✓– ✓✓✓✓ ✗ –4n/a3333333b 155322n/a4333333122215 31344407/01 – NHS Trust

Scarborough and North East Yorkshire ✶✓✓✓✓✗✓✓✓✓2n/a3243314b 435322n/a4434442534131 33122111/01 – Health Care NHS Trust

Surrey and Sussex Healthcare NHS ✶✗– ✓✓✓✓✓ – ✓ 4n/a35333533 231221n/a2111234512433 12313207/02 – Trust

Tameside and Glossop Acute Services ✶ ✓ ✗✓✓✓✓✓✓✓ 5 n/a n/a b b n/a n/a 3 3 3 2 5 5 1 2 3 n/a b b b b b 3 4 5 4 2 2 5 3 1 3 3 3 1 1 03/02 – NHS Trust

The Princess Alexandra Hospital NHS ✶✓✓✗✓✗✓✓✓✓2n/a3554353b 333313n/a33232425324bb 33155103/02 – Trust

The Princess Royal Hospital NHS Trust ✶✓✓✗✓✗✓✓✓✓5n/a33133323 353554n/a3234343531435 333433–n/a

Trafford Healthcare NHS Trust ✶✓✓✗✓✗✓✓✓✓2n/a3553331b 333213n/a333332253312b 33331312/01+ –

United Lincolnshire Hospitals NHS Trust ✶✓✓✓✓✗✓✓✓✓5n/a33133332 332314n/a3334433533322 42223110/02 –

West Hertfordshire Hospitals NHS Trust ✶ ✓✓✓✓✓✓✓✓✗ 4n/aaaaaa251 352443n/a21222n/a2511233 11332109/02 –

Focus areas 5 significantly above average 4 above average 3 average 2 below average 1 significantly below average

Data Key targets Clinical governance n/a not applicable a not available b not provided/invalid data ✓ achieved – underachieved ✗ significantly underachieved ✓✓ significant strengths ✓ many strengths – strengths ✗ significant areas of weakness n/a not applicable

CHI review 22 ^ denotes a combined trust therefore also rated in mental health tables + progress against the trust action plan has been assessed mm/yy date CHI report published – no CHI report 23 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus CHI

Acute trusts

These trusts do not include mental health services provided by combined trusts; refer to mental health ratings report for this information. Staphylococcus aureus Patient complaints procedure Privacy & dignity Six month inpatient waits Thirteen week outpatient waits Delayed transfers of care Nine month heart operation waits Outpatient / A&E survey – access & waiting Outpatient / A&E survey – better information, choice more Outpatient / A&E survey – building relationships Outpatient / A&E survey – clean, comfortable, friendly place to be Outpatient / A&E survey – safe, high quality, care coordinated Paediatric outpatient did not attends rates Total inpatient waits Total time for rapid access chest pain clinic Waiting CHI review? Clinical governance Better hospital food cancer treatment Breast Cancelled operations Day case booking Fire, health & safety Fire, Information governance Junior doctors' hours Sickness absence rate A&E emergency admission waits (4 hours) Consultant appraisal Data quality Staff opinion survey Staff Emergency readmission to hospital following Emergency readmission discharge for children to hospital following Emergency readmission hip for a fractured treatment to hospital following Emergency readmission for a stroke treatment procedures Infection control Clinical negligence Death within 30 days of a heart bypass operation Death within 30 days of selected surgical procedures to hospital following Emergency readmission discharge Thrombolysis treatment time treatment Thrombolysis Methicillin Resistant score (MRSA) bacteraemia: improvement Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard time in A&E Total week cancer waits Two A&E emergency admission waits (12 hours) A&E emergency admission Cancelled operations not admitted within 28 Cancelled operations not days Financial management Hospital cleanliness Improving Working Lives Working Improving

Weston Area Health NHS Trust ✶✗✓– ✓✓– ✓✓✓4n/aabn/aaa132 233233n/a32322335224n/a515344312/01+ –

Whipps Cross University Hospital NHS ✶✓✓✓✓✓✓✗✓✓4n/a3353323b 333342n/a111111251135b 22443309/02+ – Trust

Worcestershire Acute Hospitals NHS ✶ – ✓✗✓✓✓✓✓–4n/a3533333b 231222n/a3333331522232 34332202/03 – Trust

Worthing and Southlands Hospitals NHS ✶ ✓✓✓✓✓✓✓ ✗✗ 4n/a35533342 333542n/a3333343521153 25354202/02+ ✓ Trust

Good Hope Hospital NHS Trust ✓ ––✓✓✗✓✗✓4n/a33523132 133111n/a3223222545251 33133311/02 –

Isle of Wight Healthcare NHS Trust ^ ✓✓✗✓✓✓✗ ✓–4n/a33333233 335554n/a4435443114125 23323311/01+ –

Maidstone and Tunbridge Wells NHS ✗✓✗✓✓– ✗✗✓4n/a3533333b 132322n/a323224311233b 23213312/02 – Trust

Milton Keynes General Hospital NHS ✗✓✗✓✓✓– ✗✓2n/a1323323b 233133n/a1112233131512 43412210/01 ✓ Trust

North Bristol NHS Trust ✓✓✗✓✓✗✓ – ✓ 4n/a35333334 233322n/a333333351321b 42443205/02+ ✓

North Cumbria Acute Hospitals NHS ✓✓✗✓✗✓– ✓✗ 4n/a33333233 333132n/a5434441523221 43333102/03 – Trust

Royal Shrewsbury Hospitals NHS Trust ✓✓✗✓✗✓✓✓–5n/a53333433 335345n/a4555543533453 41343303/02 ✓

Royal Surrey County Hospital NHS Trust ✗ b ✗✓✓✓✓ ✗✓ 5n/a35533212 332b21n/a23322355233n/a221315410/01 –

Royal United Hospital Bath NHS Trust ✗✓✗✓✓✗– ✗✓4n/a5555313b 152353n/a3333342513112 23323111/01 –

South Buckinghamshire NHS Trust – ✓✗✓✓✓✓ ✗ –4n/a35333332 235532n/a3333323534233 33124311/02 ✓

South Manchester University Hospitals ✗ b ✗✓✓– ✓✓✓4bbbbbb23b 232124444543235341bb 23412206/02 – NHS Trust

Stoke Mandeville Hospital NHS Trust ✗ b ✗✓✓✓✓ ✗✓ 4n/a3533323b 135b43n/a44544525332bb 13115312/02 –

United Bristol Healthcare NHS Trust ✗ ✓✗✓✓✓✓ – ✓ 4434533233 1512332344332453212b 34334409/02 ✓

University Hospitals of Leicester NHS – ✓✓✓✓✗✓✗✓4331133234 33233421222233541322 42233202/03 ✓ Trust

Focus areas 5 significantly above average 4 above average 3 average 2 below average 1 significantly below average

Data Key targets Clinical governance n/a not applicable a not available b not provided/invalid data ✓ achieved – underachieved ✗ significantly underachieved ✓✓ significant strengths ✓ many strengths – strengths ✗ significant areas of weakness n/a not applicable

CHI review 24 ^ denotes a combined trust therefore also rated in mental health tables + progress against the trust action plan has been assessed mm/yy date CHI report published – no CHI report 25 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus CHI

Specialist trusts

These trusts provide specialist acute services. They have been performance rated on the set of indicators applicable to acute trusts, omitting those which do Staphylococcus aureus not apply to their services. Patient complaints procedure Privacy & dignity Six month inpatient waits Thirteen week outpatient waits Fire, health & safety Fire, Information governance Junior doctors' hours Sickness absence rate Delayed transfers of care Nine month heart operation waits Outpatient / A&E survey – access & waiting Outpatient / A&E survey – better information, choice more Outpatient / A&E survey – building relationships Outpatient / A&E survey – clean, comfortable, friendly place to be Outpatient / A&E survey – safe, high quality, care coordinated Paediatric outpatient did not attends rates Total inpatient waits Total time for rapid access chest pain clinic Waiting Consultant appraisal Data quality Staff opinion survey Staff CHI review? Clinical governance Better hospital food cancer treatment Breast Cancelled operations Day case booking A&E emergency admission waits (4 hours) Emergency readmission to hospital following Emergency readmission discharge for children to hospital following Emergency readmission hip for a fractured treatment to hospital following Emergency readmission for a stroke treatment procedures Infection control Clinical negligence Death within 30 days of a heart bypass operation Death within 30 days of selected surgical procedures to hospital following Emergency readmission discharge Thrombolysis treatment time treatment Thrombolysis Methicillin Resistant score (MRSA) bacteraemia: improvement Number of inpatients waiting longer than the standard Number of outpatients waiting longer than the standard time in A&E Total week cancer waits Two A&E emergency admission waits (12 hours) A&E emergency admission Cancelled operations not admitted within 28 Cancelled operations not days Financial management Hospital cleanliness Improving Working Lives Working Improving

Birmingham Women's Health Care NHS ✶✶✶ n/a ✓✓✓✓✓✓n/a ✓ 5 n/a n/a 1 n/a n/a n/a 3 a n/a n/a 5 n/a 4 5 5 n/a 3 3 4 3 4 n/a 5 5 5 5 3 n/a b 2 3 5 4 4 3 12/01+ ✓ Trust

Clatterbridge Centre for Oncology NHS ✶✶✶ n/a n/a ✓✓✓✓✓n/a n/a 4 n/a n/a a n/a n/a n/a 3 a n/a n/a 3 5 n/a n/a n/a n/a 4 5 5 4 5 n/a 4 5 5 5 5 b 5 4 5 1 3 3 5 03/02+ ✓ Trust

Great Ormond Street Hospital for Children ✶✶✶ n/a ✓✓✓✓✓✓n/a n/a 4 n/a n/a n/a 5 n/a n/a 5 3 n/a n/a 3 n/a 2 2 5 n/a n/a n/a n/a n/a n/a 3 4 5 4 3 4 n/a 3 4 3 4 3 4 5 03/03 ✓✓ NHS Trust

Liverpool Women's Hospital NHS Trust ✶✶✶ n/a ✓✓✓✓✓✓n/a ✓ 5 n/a n/a 3 n/a n/a n/a 3 a n/a n/a 5 n/a 3 3 n/a n/a 5 3 5 5 4 2 4 5 5 5 4 n/a 5 4 5 5 5 2 2 11/01+ ✓

Moorfields Eye Hospital NHS Trust ✶✶✶ n/a ✓✓✓✓✓✓n/a n/a 5 n/a n/a 1 n/a n/a n/a 3 a n/a n/a 5 n/a 5 5 5 n/a 3 3 3 3 2 n/a 3 5 5 5 3 n/a 5 2 4 3 5 3 1 03/02+ ✓

Nuffield Orthopaedic NHS Trust ✶✶✶ n/a ✓✓✓✓✓✓n/a n/a 4 n/a n/a 5 n/a n/a n/a 5 a n/a n/a 3 n/a 2 4 4 n/a 3 4 4 3 3 n/a 4 5 2 1 5 n/a 5 4 2 3 5 5 4 06/03 ✓

Papworth Hospital NHS Trust ✶✶✶ n/a ✓✓✓✓✓✓n/a ✓ 2 3 n/a 3 n/a n/a n/a 5 1 n/a n/a 3 b 3 4 5 4 5 5 5 5 5 n/a 3 5 4 5 3 n/a 5 3 3 3 2 5 5 05/02+ ✓✓

Royal Liverpool Children's NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 4 n/a n/a n/a 4 n/a n/a 3 4 n/a 4 3 n/a 4 3 5 n/a n/a n/a n/a n/a n/a 3 4 5 4 3 4 n/a 5 5 3 3 4 2 3 09/02 ✓

The Queen Victoria Hospital NHS Trust ✶✶✶ n/a ✓✓✓✓✓✓n/a ✓ 4 n/a n/a 4 n/a n/a n/a 4 3 n/a n/a 5 1 3 5 5 n/a 5 5 5 5 5 4 5 5 3 4 3 b b 3 5 5 5 3 5 02/03 ✓✓

The Royal Marsden NHS Trust ✶✶✶ n/a ✓✓✓✓✓✓n/a ✓ 2 n/a n/a 3 n/a n/a n/a 3 3 n/a n/a 5 3 5 5 n/a n/a 5 5 5 5 5 5 4 5 5 5 2 n/a 3 5 5 5 2 3 5 11/02 ✓✓

Birmingham Children's Hospital NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 2 n/a n/a n/a 3 n/a n/a 3 3 n/a 4 5 n/a 3 1 5 n/a n/a n/a n/a n/a n/a 3 2 5 5 4 4 n/a b 3 5 1 3 5 3 10/02 –

Christie Hospital NHS Trust ✶✶ n/a ✓✓✓✓✓– n/a – 4 n/a n/a 5 n/a n/a n/a 4 3 n/a n/a 5 5 5 1 4 n/a 5 5 5 4 5 n/a 3 5 4 3 4 n/a b 3 5 3 4 4 5 07/02 –

Royal Brompton and Harefield NHS Trust ✶✶ n/a ✓✓✓✓– ✓ n/a ✓ 4 3 n/a 2 n/a n/a n/a 2 3 n/a n/a 3 n/a 3 2 5 3 5 4 5 3 5 n/a 3 5 3 5 3 5 3 3 3 3 1 5 5 03/03 ✓

Royal National Hospital for Rheumatic ✶✶ n/a n/a ✓✓✓✓✓n/a n/a 4 n/a n/a b n/a n/a n/a 5 a n/a n/a 3 n/a n/a 1 n/a n/a 5 2 4 5 3 n/a 1 5 5 5 3 n/a 5 3 4 2 5 4 4 04/03 – Diseases NHS Trust

Royal Orthopaedic Hospital NHS Trust ✶✶ n/a ✓✓✓✓✓✓n/a n/a 4 n/a n/a 5 n/a n/a n/a 4 a n/a n/a 5 n/a 5 3 4 n/a 1 2 2 4 3 n/a 3 5 5 3 3 n/a 5 3 3 5 5 4 5 03/03 –

Sheffield Children's NHS Trust ✶✶✓✓✓✓✓✓✓✓✓ 2 n/a n/a n/a 1 n/a n/a 2 a n/a 5 5 n/a 5 3 5 n/a n/a n/a n/a n/a n/a 2 3 5 4 3 3 n/a 3 3 5 4 4 5 4 09/02+ –

The Cardiothoracic Centre - Liverpool ✶✶ n/a ✓✓✓✓✓✓n/a ✓ 2 b n/a 3 n/a n/a n/a 1 3 n/a n/a 3 n/a 4 1 2 3 5 4 5 5 5 n/a 3 5 4 5 4 n/a 5 4 5 3 2 2 3 01/03 – NHS Trust

The Royal National Orthopaedic Hospital ✶✶ n/a ✓✓✓✓✓✓n/a n/a 4 n/a n/a 5 n/a n/a n/a 2 3 n/a n/a 3 n/a 2 2 5 n/a 3 4 4 2 3 4 4 5 2 2 2 n/a 3 2 1 1 4 3 3 02/02+ ✓ NHS Trust

Walton Centre for Neurology and ✶✶ n/a ✓✓✓✓✓✓n/a n/a 4 n/a n/a 5 n/a n/a n/a 3 3 n/a n/a 5 n/a 2 4 3 n/a 4 3 5 5 4 n/a 5 5 3 1 5 n/a 2 3 4 2 3 3 4 03/03 – Neurosurgery NHS Trust

Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS ✶ n/a ✓✗✓✓✓✓n/a n/a 5 n/a n/a 4 n/a n/a n/a 2 a n/a n/a 5 n/a 4 2 5 n/a 3 3 5 5 4 3 4 5 1 1 2 n/a 5 1 1 2 5 3 1 01/02 ✓✓ Trust

Focus areas 5 significantly above average 4 above average 3 average 2 below average 1 significantly below average

Clinical governance ✓✓ significant strengths ✓ many strengths – strengths ✗ significant areas of weakness n/a not applicable

Data Key targets CHI review 26 n/a not applicable a not available b not provided/invalid data ✓ achieved – underachieved ✗ significantly underachieved + progress against the trust action plan has been assessed mm/yy date CHI report published – no CHI report 27 NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts NHS performance ratings 2002 / 2003 – acute trusts, specialist trusts, ambulance trusts

Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus Organisation Rating Key targets Clinical focus Patient focus Capacity & capability focus

Ambulance trusts Ambulance trusts Category A calls meeting 14/19 minute target Category A calls meeting 8 minute target Category A calls meeting Financial management Lives Working Improving Clinical negligence and procedures: protocols Thrombolysis training of paramedic staff Category B/C calls meeting national 14/19 minute target GP urgent calls meeting national 15 minute target Patient complaints procedure health & safety Fire, Information governance Sickness absence rate opinion survey Staff Category A calls meeting 14/19 minute target Category A calls meeting 8 minute target Financial management Lives Working Improving Clinical negligence and procedures: protocols Thrombolysis training of paramedic staff Category B/C calls meeting national 14/19 minute target GP urgent calls meeting national 15 minute target Patient complaints procedure health & safety Fire, Information governance Sickness absence rate opinion survey Staff

Bedfordshire & Hertfordshire Ambulance ✶✶✶ ✓ ✓ ✓ ✓ 433333534 Sussex Ambulance Service NHS Trust ✶✓ ✗ ✓ ✓ 433233112 & Paramedic Service NHS Trust

West Yorkshire Metropolitan Ambulance East Anglian Ambulance Service NHS ✶✶✶ ✓ ✓ ✓ ✓ 433342224 ✶ –––✓ 2223421b2 Trust Service NHS Trust

Lancashire Ambulance Service NHS ✶✶✶ ✓ ✓ ✓ ✓ 534555543 Dorset Ambulance Service NHS Trust ––✓✗453343323 Trust

North East Ambulance Service NHS ✶✶✶ ✓ ✓ ✓ ✓ 434325533 Essex Ambulance Service NHS Trust ✓✗– ✗ 44335b331 Trust

Hampshire Ambulance Service NHS Royal Berkshire Ambulance Service ✶✶✶ ✓ ✓ ✓ a454 342353 ––✓✗222312534 NHS Trust Trust

Tees East and North Yorkshire South Yorkshire Metropolitan Ambulance ✶✶✶ ✓ ✓ ✓ ✓ 553223333 ✓ – ✗✓424233221 Service NHS Trust Ambulance Service NHS Trust

Staffordshire Ambulance Service NHS ✶✶✶ ✓ ✓ ✓ ✓ 445453233 Wiltshire Ambulance Service NHS Trust ––✓✗212323b32 Trust

Surrey Ambulance Service NHS Trust ✶✶✶ ✓ ✓ ✓ ✓ 443434455

Two Shires Ambulance Service NHS ✶✶✶ ✓ ✓ ✓ ✓ 433435444 Trust

Westcountry Ambulance Service NHS ✶✶✶ ✓ ✓ ✓ ✓ 5b3 423444 Trust

Cumbria Ambulance Service NHS Trust ✶✶ – ✓✓ ✓ 433533334

East Midlands Ambulance Service NHS ✶✶ ✓ ✓ ✓ ✓ 421133442 Trust

Gloucestershire Ambulance Service ✶✶ ✓ – ✓✓445511332 NHS Trust

Greater Manchester Ambulance Service ✶✶ ✓ ✓ ✓ ✓ 4b3 435343 NHS Trust

Oxfordshire Ambulance NHS Trust ✶✶ – ✓✓ ✓ 432233232

Warwickshire Ambulance Service NHS ✶✶ ✓ ✓ ✓ ✓ 234552345 Trust

West Midlands Ambulance Service NHS ✶✶ ✓ ✓ ✓ ✓ 5b2 224333 Trust

Avon Ambulance Service NHS Trust ✶ ––✓✓421232323

Hereford & Worcester Ambulance ✶✓ ✓ ✓ ✗ 244345313 Service NHS Trust

Isle of Wight Healthcare NHS Trust ✶✓ ✓ ✗ ✓ 425331355 (Ambulance)

Kent Ambulance NHS Trust ✶✓ – ✓✓213315133

Lincolnshire Ambulance & Health ✶✓ ✓ ✓ ✗ 525441431 Transport Service NHS Trust

London Ambulance Service NHS Trust ✶ ––✓✓531125235

Mersey Ambulance Service NHS Trust ✶ – ✓✓ ✓ 44213b323

Data Key targets Focus areas 28 n/a not applicable a not available b not provided/invalid data ✓ achieved – underachieved ✗ significantly underachieved 5 significantly above average 4 above average 3 average 2 below average 1 significantly below average 29