Quality Report

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SECTION 4:

Quality Report Statement on Quality Priorities on Improvement Statements of Assurance from the Trust Patient Safety Patient Experience Patient Outcomes Quality Overview Statements

108 What some of our Patients say about Us….

Whatever grade or occupation on

Castle Ward I was treated with non-judgemental, polite

professionalism. Both day and

night shifts standards to be remarkably credit worthy, it was

a pleasure being ill!

Source: Friends and Family Test survey

“In on Thursday, walking on Friday, home on

Saturday. Exactly the same excellent service I received when I had my left hip replaced

eighteen months ago. Friendly attentive staff in all departments makes a stay in this

hospital as pleasant as possible given the circumstances. Four weeks on I am feeling

great, pain free and walking up to 1.5 / 2.0 miles at a time. Thank you to the surgeon and all the staff in all the support teams!”

Source: NHS Choices Thanks to everyone at the unit for

my care during treatment for

breast cancer, they are all a credit

to the hospital, going the extra

mile to help when you’re worried or scared about what is

happening to you.

I would like to offer my thanks

Source: Friends for the prompt, courteous and effective treatment received in the Dermatology department at Warwick Hospital, following the referral from my GP at Shipston.

Source: NHS Choices

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Part 1: Chief Executive Statement on Quality

It is a great pleasure to introduce our Quality Report for the year ended 31 March 2014. Despite the reported pressures faced by the NHS as a whole, we have had a particularly successful year and one in which we can demonstrate further improvements in the quality of our services. Last year I reported that we had become much more focussed on local priorities, steered by our commissioners, Governors and Members and I feel that it is this focus which has led to our success.

We have continued to produce some of the best results in the Country in terms of staff and patient satisfaction. I have long held the view that staff satisfaction and engagement are important lead indicators for quality. Our staff are strong advocates for both our organisation and the care that we deliver to patients and service users. The correlation between this and patient satisfaction is very reassuring.

Last year we completed a national project funded by the Health Foundation to evaluate how improvements in ‘Acute Flow’ can reduce cost and improve quality. We implemented the final components of the project at the end of last summer. This was founded on the appreciation that high levels of occupancy affect patient safety. As the performance against the A&E target is a marker for overall hospital occupancy, we knew that improvements in this measure would be an indication of real improvements in safety and patient experience. So we have been delighted to see such positive results in both hospital and community settings. Our community services support all of the acute sites in the county. In the south of the county, where we run both hospital and community we have seen the full benefits of our integration. This resulted in us hitting the A&E target throughout the winter and holding improvements in hospital mortality and other further improvements in other quality markers, such as the ‘safety thermometer’.

Within this report you will see how we performed against the priorities that our local stakeholders identified. The remarkable reductions in hospital acquired infections and pressure ulcers that we saw in the previous year have continued and we have worked hard to ensure that all of our staff, clinical and non- clinical live our Trust values by delivering safe, effective, compassionate and trusted care.

The NHS continues to deliver more and more care to the people of this country, each year this not only grows in volume but also in complexity. We have seen more long term conditions, older, frailer patients and yet we face this against the challenge of increasing our productivity so that the NHS can continue to be affordable. This report, alongside our full Annual Report provides a balanced picture on how SWFT is meeting these challenges by not compromising quality. I hope that you are impressed.

I hereby state that to the best of my knowledge the information contained within the Quality Report is accurate.

Date: 21 May 2014 Glen Burley, Chief Executive

110 Part 2: Priorities for Improvement The Trust has 5 strategic goals listed below left. Each year the Trusts annual objectives are set and within these objectives, we have agreed 9 priorities for Quality improvement for next year, these are detailed below. We will report on their progress in our Quality Report next year.

Patient Outcomes To improve systems and processes to further reduce mortality rates Provide High Quality care Work with primary care to increase the level and quality of end of life care advance planning Provide more comprehensive 7 day services, increasing the availability Develop our Services of senior decision making clinicians

Patient Experience Improve patient meal experience Develop our People Improve patients experience with our booking processes Use the Patient Care Committee to drive user engagement

Patient Safety Provide a Sustainable Future Introduce a single point of access for community based care improving user experience Reduce agency nursing usage Revise team structures to increase clinical time Integrate our services

Last year we also agreed priorities for quality improvement please see Part 3 of this report to review these priorities and how we performed.

How these priorities were decided and why they are our priorities

We have sought the views of clinicians and managers about what quality looks like, how it should be measured and how to improve it. We ran a series of workshops on this subject during a leadership development programme for senior clinicians and managers at the Trust. There is a consensus that we should measure the three dimensions of quality - patient safety, clinical effectiveness and patient experience.

A number of engagement events have taken place including feedback from members, a SWOT(Strengths, Weaknesses, Opportunities and Threats) and PEST (Political, Economic, Social, Technology) analysis, workshops and a Governors Round table event. From this feedback the Chief Executive and the Executive Team agreed a long list of priorities for quality improvement based on what our staff and patients and stakeholders have told us. This list was developed into a questionnaire and was sent to 3,000 stakeholders of the Trust who were asked to vote on their top 3 priorities in the 3 dimensions of Quality. The stakeholder’s included the Trusts Board of Directors, Council of Governors, Management Board, Patient Forum, all staff and members of the Trust. A number of the initiatives identified are ongoing from the previous year as they remain high priorities for the Trust.

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How we measure, monitor and report Quality Our Board of Directors receive a monthly Integrated Quality Dashboard, Standards and Targets report from the Director of Nursing and Director of Operations that contain a broad range of performance measures including progress against the annual objectives and the quality priorities. The Board Assurance Framework provides assurance to the Board for delivery of all key objectives inclusive of our quality priorities. Each objective has a Lead Director that is accountable for the delivery of that objective. Our management and Governance Structure provide a mechanism for reporting progress against the priorities, for implementing change and assurance on risk.

As part of strengthening quality and visibility of the Board at ward and department level, the Board to Ward initiatives have continued throughout the year.

The Executive Team has adopted ward areas to visit on a regular basis to improve communication from Board to Ward. Many of the Executive team visit ward and department areas on a regular basis that is not recorded in the formal Board to Ward activity.

As part of these walkabouts patient safety, incidents, complaints and issues that impact on the quality of care are discussed. As a result of these discussions, action is taken by either the executive team or by the ward and department managers to ensure the quality of care.

We have introduced Quality dashboards at Board, Divisional and Service levels in the Trust with sets of key quality indicators as identified by the services. These will incorporate time-trend graphs and RAG (red, amber, green) rating against benchmarked standards.

High Level Committees

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High Level Committees

113 Statements of Assurance from the Trust

Review of Services

During 2013/14 South Warwickshire NHS Foundation Trust provided and/or sub-contracted 61 NHS services. The South Warwickshire NHS Foundation Trust has reviewed all the data available to them on the quality of care in 100 per cent of these NHS services.

The income generated by the NHS services reviewed in 2013/14 represents 91 per cent of the total income generated from the provision of NHS services by the South Warwickshire NHS Foundation Trust for 2013/14

Participation in Clinical Audits During 2013/14, 32 national clinical audits and 4 national confidential enquiries covered services that South Warwickshire NHS Foundation Trust provides. During that period South Warwickshire NHS Foundation Trust participated in 31 (97%) national clinical audits and 4 (100%) national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.

South Warwickshire NHS Foundation Trust’s clinical activity is as follows; The national clinical audits and national confidential enquiries that South Warwickshire NHS Foundation Trust was eligible to participate in during 2013/14 and The national clinical audits and national confidential enquiries that South Warwickshire NHS Foundation Trust participated in during 2013/14 are as follows. (See table 1) The national clinical audits and national confidential enquiries that South Warwickshire NHS Foundation Trust participated in, and for which data collection was completed during 2013/14 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. (See table 1)

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Clinical Audits activity (table 1)

National Clinical Audits that South National Clinical Audits that National Clinical Audits that Warwickshire Foundation Trust is South Warwickshire Foundation SWFT participated in and eligible to participate in 2013/14 Trust were eligible for and for which data collection participated in 2013/14 completed, % completion Children Neonatal Intensive and Special Care 9 100% Paediatric Asthma (British Thoracic 9 100% Society) Epilepsy 12 Audit (RCPH National 9 100% Childhood Epilepsy Audit) Diabetes (RCPH National Paediatric 9 100% Diabetes Audit) Acute Care Emergency use of oxygen (British 9 100% Thoracic Society) Adult community acquired pneumonia 9 100% (British Thoracic Society) Non Invasive Ventilation (NIV) – adults 9 100% (British Thoracic Society) Cardiac Arrest (National Cardiac Arrest 9 100% Audit) Adult critical care (ICNARC CMPD) 9 100% National Audit of seizure management 9 100% (NASH) National Emergency Laparotomy Audit 9 100% (NELA) Long Term Conditions Diabetes (National Adult Diabetes 9 Audit) includes National Diabetes 100% Inpatient Audit (NADIA) and National Pregnancy in Diabetes Audit (NPID) Rheumatoid and early inflammatory 9 100% arthritis Inflammatory Bowel Disease(National 9 100% IBD Audit) Bronchiecstatis (British Thoracic 9 100% Society) Chronic Obstructive Pulmonary 9 100% Disease (COPD) Elective Procedures Elective surgery (National PROM’s 9 100% Programme) Hip, knee and ankle replacements 9 100% (National Joint Registry) Cardiovascular Disease Acute Myocardial Infarction and other x N/A ACS (MINAP) Heart Failure (Heart Failure Audit) 9 100% Stroke National Audit Programme 9 100% (Combined Sentinel and SINAP) Cardiac arrhythmia (Cardiac Rhythm 9 100% Management Audit) Cancer Lung cancer (National Lung cancer 9 100% Audit)

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The reports of 12 national clinical audits were reviewed by the provider in 2013/14 and South Warwickshire NHS Foundation Trust is taking the following actions to improve the quality of healthcare provided. National Inpatient Diabetes Audit (NaDIA) Report (continuation from2012) Actions being taken following audit Implement nurse screening tool to be linked to nurse documentation for initial screening to be carried out by all. Roll out foot screening for completion by junior doctors for all patients with diabetes Snapshot audits commenced on the wards to identify the wards that are using the correct charts and following the guidelines with them, and to improve compliance on the wards that are not. Ongoing work surrounding insulin safety and prescribing still working on the introduction of insulin only prescribing chart. Rapid improvement programme for Diabetes to be rolled out across the trust and will include insulin safety involving prescribing and administration. Request has been made for insulin safety e-learning module to be made mandatory for all staff involved in administration and prescription of insulin. To re-launch the use of the hypo box and educate all trained staff on safe management and prevention of hypo glycaemia. Hypo-awareness week to be run by diabetes team. All wards to collect updated hypo-boxes and receive a hypo-education toolkit that will ensure full cascade training and compliance with the education delivered. All trained nurses to receive a small badge to wear on their uniform to demonstrate that they have received the training, aiming for 100% compliance throughout the trust. E-learning module to be made available to all on safe management of hypoglycaemia. Continue with 6 monthly link nurse study day, engage all link nurses in the rapid improvement program for diabetes care. Deliver snapshot training to link nurses to then cascade through the teams to ensure that education is reaching all nursing staff and improve the safety of patients in hospital with Diabetes.

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National Audit of Dementia Actions being taken following audit Presentation to Trust Board to engage Board members and consider dementia care as an agenda item.

Dementia training to be included in mandatory training for all staff and junior doctor inductions, supplemented by core principles of dementia care training.

Develop and implement standardised assessment scale for dementia assessment.

Audit current prescribing practices

Inclusion in care bundle, care pathway and training to improve understanding and prescribing practices

Implementation of adult mental health team providing 7 day a week cover with a standard of 24 hours to assess patients referred with dementia for behavioural and psychological symptoms of dementia and complex discharge planning.

Raise awareness within teams of the need to improve initiation of discharge planning within 24 hours via dementia champions, discharging planning teams and speciality medical teams. Include in care bundle.

Introduction of Dementia support manual supported by Local district Council and Arden Commissioning Support from The Carers Strategy and Ward resource folders.

Application to Learning & Development for funding to support a specific role to educate at clinic level to improve staff awareness, improve partnership working with cares, access to resources for support for carers and improve experience for patients with a dementia (12 month programme).

National Lung Cancer Audit (LUCADA) Actions being taken following audit

Ensure Clinical Nurse Specialist at UHCW is present for breaking of bad news.

All patients referred under the 2 week wait process should have a CT scan before appointment.

All PET scans should be recorded on the Somerset database.

Review results of 2013 national audit to ensure that the proportion of patients with 0-1 performance status (healthy patients with non small cell lung cancer advances stage) offered chemotherapy does increase as expected, in line with national benchmark average.

National Paediatric Asthma Audit Actions being taken following audit Use peak flow monitoring for over 5’s. Develop discharge planning sheet. Develop a written asthma management plan sheet. Remind all Consultants and Registrars of the need to follow up children with recurrent wheeze as per the national SIGN/BTS guideline.

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National Adult Asthma Audit Actions being taken following audit Discussion at Audit and Operational Governance Group on how the time from arrival to hospital to being given steroids could be improved. Investigate finding a written asthma action plan template and start stocking them, so that they can be used on the wards.

National Potential Donor Audit Actions being taken following audit Aim for 100% identification and referral of potential donors in a timely fashion. Increase Neurological Death Testing Rates to 100%. Improved network access for visiting SNODs. To maximise consent rates in line with NICE guidance and utilising best practice guidance ‘Approaching the families of potential organ donors’.

National Paediatric Pneumonia Audit Actions being taken following audit Presentation of the recent BTS guidelines in the department. Parents of patients discharged home should be given a patient leaflet on pneumonia.

National Diabetes Audit Actions being taken following audit Create a list of patients with no urinary albumin creatinine ratio recorded and update DIAMOND with the results accordingly. Intensification of lipid therapy based on cholesterol level in the clinic. Business case submitted and awaiting response from CCG for structured education for Type 1 Diabetes patients.

The reports of 97 local clinical audits were reviewed by the provider in 2013/14. These are a selection of actions from the local audits that will have a beneficial outcome on patient care:

To continue to deliver a brief synopsis of recognition and treatment of the acutely unwell patient on mandatory training. To gain an AIM (Acute Illness Management Course) license, this would allow delivery of a specific training course for Health Care Assistants. To include Automated External Defibrillation (AED) training within the mandatory “in hospital life support training – covering acute and community hospitals”. A laminated template will be displayed in each of the 3 surgeries, reminding the orthodontic staff to adhere to the 9 essential elements of correctly recorded clinical entries. Physiotherapists (SWATT) have been given power point slides to use in their classes and RCOA information booklet with information on spinal anaesthesia now goes out with date for operation. Patient information leaflet on DNACPR will be up loaded on to the intranet under the Resuscitation Service area. Policy on Managing Diabetes at School and School Care Plan developed An allergy focussed clinical history template should be produced for use with new patients. This methodical approach is anticipated to aid successful diagnosis and streamline care. It will also improve the quality of care of children with food allergy and allow dieticians to better inform the referring agents Further development of Dietetics website to include suggestions from the patient feedback where practical

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The outcomes of audits are reported to the relevant divisional Audit Operational Governance Groups (AOGGs) where action plans and progress is monitored. Quarterly progress is reported to the trusts Clinical Governance Committee.

Participation in Clinical Research

The number of patients receiving NHS Services provided or sub-contracted by South Warwickshire NHS Foundation Trust between 1 April 2013 and 31 March 2014 that were recruited to participate in research approved by a Research Ethics Committee was 903. Participation in clinical research demonstrates the Trusts commitment to improving the quality of care we offer and to making our contribution to wider health improvement.

South Warwickshire NHS Foundation Trust was involved in conducting 114 clinical research studies during 2013/14. Of these, 82 were supported by the National Institute for Health Research (NIHR) through its research networks, 100% were given permission by an authorised person within 5 days from receipt of a valid completion.

NIHR Portfolio Studies Number of Studies Percentage of Total Number of Patients Speciality Recruited Oncology 37 45.6 Neurology and Stroke 8 9.8 Musculoskeletal 7 8.6 Reproductive Health and Childbirth 5 6.2 Blood (Non-malignant haematology) 5 6.2 Diabetes 4 5 Paediatrics 4 5 Gastroenterology 4 5 Dermatology 2 2.5 ENT and Eyes 2 2.5 Congenital Disorders 1 1.2 Infectious Diseases and Microbiology 1 1.2 Cardiovascular 1 1.2

Non- Portfolio Studies Number of Studies Percentage of Total Number of Patients Speciality Recruited Educational (PhD, MSc etc.) 14 41.2 Other 11 32.4 Trust 6 17.6 Commercial 3 8.8

The Trust continues to partake in multi-centred studies supporting high quality research for the benefit of our patients. Our involvement in research has resulted in over 20 publications in the past 3 years, helping to improve patient outcomes and experience across the NHS.

Goals Agreed with Commissioners The key aim of the Commissioning for Quality and Innovation (CQUIN) framework is to support improvements in the quality of services and the creation of new, improved patterns of care. A proportion of South Warwickshire NHS Foundation Trust’s income in 2013/14 was conditional on achieving quality improvement and innovation goals agreed between South Warwickshire NHS Foundation Trust and NHS Warwickshire, through the Commissioning for Quality and Innovation payment framework (CQUINs). The value of income in 2013/14 conditional upon achieving quality improvement and innovation goals was

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£3,888,962. The value of income for the associated payment in 2013/14 is £3,220,962.

Some of the national CQUINs schemes proved challenging for the Trust these being Dementia and Friends and Family Test (FFT) within A&E. Whilst the Trust successfully rolled out FFT (patient experience survey) in line with the timetable and requirements stipulated by NHS England and was a success in Inpatient areas, it proved challenging in A&E. In light of the continuation of the FFT CQUINs for next year and the Trusts commitment to improve Patient experience, they will be further prioritised for delivery in 2014/15.

Indicator Name Expectations SWFT Status

Friends and Family Test – increasing the response rate in the acute inpatient and A&E areas A&E – Response rates Work on-going for 2014/15 Friends and Family Test – Delivery of Friends and Family roll-out for maternity services. Phased expansion

NHS Safety Thermometer – Reduction in the prevalence of pressure ulcers to 5.9. improvement

Dementia – Find, Assess, The proportion of patients aged 75 and over to whom case finding is Work on-going Investigate, Refer applied following emergency admission, the proportion of those for 2014/15 identified as potentially having dementia who are appropriately assessed, and the number referred on to specialist services.

Dementia – Supporting carers Ensuring carers feel supported. Provider must demonstrate that they have undertaken monthly audits of carers of people with dementia to test whether they feel supported and report the results to the Board.

VTE – Risk assessment 95% of all adult in patients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool.

VTE – Root Cause Analysis Root cause analyses carried out on hospital associated thrombosis.

Discharge and Flow Daily morning board rounds (defined as meeting on a ward involving consultant, junior doctors and senior ward nurse) occur for all patients 5 days per week.

Discharge and Flow Quality of Multi-disciplinary discharge meetings.

Discharge and Flow Reducing Internal Waits. Audits undertaken on wards linked to CQUIN 5a to quantify and evidence internal waits Discharge and Flow Development of 3 new criteria led discharge pathways. One in each of the following specialities: Cardiology, Gastroeneterology & Respiratory Medicine. End of Life (Acute Hospital) To participate in the national TRANSFORM programme for End of Life. 2 Year CQUIN Goal

Psychiatric Liaison (Training) Provider to ensure 90% of eligible staff are released for mental health awareness training.

Prescribing – Adherence to Adherence to Coventry and Warwickshire Area Prescribing Committee Formulary (C&W APC) guidance in secondary care.

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Discharge Communications 80% of patients discharged from hospital from A&E department, 75% of Notable progress all inpatient admissions and outpatient appointments in all specialties will made, have discharge/treatment summaries sent out to GPs electronically in Work on-going accordance with the agreed turnaround times. for 2014/15

Turnaround Times for Development of a standardised and consistent turnaround time of 7 days Radiology Reporting from the time of a plain X ray being taken to the time that the GP receives a copy of the relevant X ray report. 28 Days Length of Stay at Attainment of Average Length Stay of 28 days across Community wards Community Hospitals (+/- 3 days).

Community Services CQUIN Scheme

Indicator Name Expectations SWFT Status

Friends and Family Test – Phased rollout / alignment in domiciliary services

NHS Safety Thermometer Improvement. Reduction in the prevalence of pressure ulcers

Discharges from Integrated Teams will provide evidence of discharge planning in line with the Community Integrated levels of intervention care model. Teams

Improving Support for Improving Support for carers – Carer Awareness Training carers

Child in a Chair in a Day Provision of wheelchair services to ensure outcomes similar to those achieved by the best-performing providers of mobility services for children.

Further details of the agreed goals for 2013/14 can be found via this link http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf

Care Quality Commission

South Warwickshire NHS Foundation Trust is required to register with the Care Quality Commission (CQC) and is registered without conditions. Registration confirms that the Trust meets all regulations and standards stipulated by the CQC. It also confirms that the Trust is authorised to provide all registered services across all locations, registered under South Warwickshire NHS Foundation Trust. The CQC has not taken any enforcement action against South Warwickshire NHS Foundation Trust during the period of 1 April 2013 and 31 March 2014. South Warwickshire NHS Foundation Trust has participated in one unannounced ‘Review of Compliance’ carried out by the CQC during the period of 1 April 2013 and 31 March 2014 as follows;

Review of Compliance carried out on 26 February 2014

Following this inspection South Warwickshire NHS Foundation Trust was assessed as compliant with the CQC Essential standards and no enforcement actions were set by the CQC.

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What the CQC found when they inspected; Extracted from the CQC Inspection report

“We focused our inspection on the Maternity Unit within the South Warwickshire NHS Foundation Trust Hospital. We visited the antenatal clinic and antenatal assessment unit (AAU), the delivery ward, and the combined antenatal and postnatal ward called Swan Ward. We did not inspect the Special Care Baby Unit at this time. We spoke with eight women in the antenatal clinic, five women on the postnatal ward and two relatives. We also spoke with two doctors, the Head of Midwifery, the clinical governance midwife, the practice development midwife, the manager of the Electro-Bio Medical Engineering (EBME) department, six midwives, three support workers and a receptionist. The CQC found that people were involved in their care and encouraged to express their wishes and were treated with respect. One woman we spoke with told us, "I have had a lot of opportunity to ask about my surgery. Everything has been explained to me. I know exactly what is going to happen." Another told us, "I could ask any questions I wanted, I never feel rushed when I come here, even though it is sometimes very busy."

People commented positively on the care they received and we found that care and treatment plans were completed appropriately. Comments included, "You couldn't ask for a more caring hospital. They have arranged parking for me this week as I have to come in daily." Another person told us, "All the nurses are brilliant. It has been a wonderful experience. Everything had been explained to me beforehand as I was booked for surgery, so I knew what to expect." We found evidence of good information and support provided to women throughout their pregnancy, delivery and postnatal period. We found that there was enough suitable equipment available and there were good systems in place to ensure regular monitoring and maintenance of equipment.

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There were sufficient numbers of staff employed with the appropriate skills and qualifications to perform their roles. We found that staff had received ongoing training necessary to enable them to carry out their role effectively. We found that staff received regular supervision and training with opportunities to develop their career. There were systems in place to ensure that mandatory training and other essential training took place. One staff member told us, "We get good management support here. Management have a visible presence."

Overall the CQC Inspection was very positive, with all standards being met, however there were two areas which require improvement these are:

The patient experience and management of the Antenatal Clinic (ANC) Completion of all three sections of the WHO Safety Checklist.

The following improvement action plan has been developed in response to the comments from the CQC Inspection.

Improvement Action Plan in response to CQC Inspection Report – March 2014 Problem Action Progress Status observed Incomplete Audit of all procedures in obstetric Ongoing audit in progress 9 Ongoing WHO checklist theatre

Two WHO Letter sent to all midwives informing Letter sent to all midwives 9 checklists had them of their professional omissions responsibility to complete the WHO Checklist.

All staff made aware of the to the Maternity Newsletter 9 Guideline Senior staff meeting Letter sent to all Midwives

Performance management of Any midwives found to have not individuals found not to have completed the WHO Checklist to be 9 Ongoing completed the WHO Checklist performance managed

Long waits for Review of length of appointment Antenatal Clinic Manager appointed women times. 5/5/2014 – remit given to review 9 attending and improve the patient experience Antenatal Clinic Process for seeing women in in ANC with the DHoM Antenatal Clinic to be undertaken to 9 investigate how to improve the patient experience.

Antenatal Clinic Meeting with Medical Records Meeting to be arranged for week 9 appointments Manager and Antenatal Clinic beginning 26/5/2014 after ANCM double booked Manager to review process for has completed her Induction booking women into Antenatal Clinics. Programme and reviewed the processes currently in place within the ANC.

Increase the number of Consultant Two Obstetric Consultants Obstetricians to increase the number successfully appointed 1/5/2014. 9 of Antenatal Clinic sessions per week Will commence employment in August 2014 Concern raised To review the number of people ANCM appointed 5/5/2014 – remit 9 at the number present at each antenatal consultation given to review and improve the of people in the and ensure that only essential patient experience in ANC room at clinicians are present. consultation

123 Data Quality South Warwickshire NHS Foundation Trust submitted records during 2013/14 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. Please note; the results should not be extrapolated further than the actual sample audited

The percentage of records in the published data which included the patient's valid NHS Number was:

Admitted patient care 99.8% Outpatient care 99.9% Accident and emergency care 98.7%

The percentage of records in the published data which included the patient's valid General Practitioner Registration Code was

Admitted patient care 100% Outpatient care 100% Accident and emergency care 100%

Clinical coding During November 2013 South Warwickshire NHS Foundation Trust was subject to a Payment by Results inpatient coding audit carried out by CAPITA on behalf of the Audit Commission. Two hundred hospital provider spells were audited, half focused on accuracy of complications and co-morbidities for non-trauma orthopaedic procedures and the remaining half were emergency paediatric admissions with zero length of stay. A random sample was taken for the audit.

Audit Findings – Non-Trauma Orthopaedic Procedures The performance of the Trust, measured against the proportion of spells with an incorrect payment would place the trust better than average based on last year’s national performance. Provider Spells tested in sample 103

% spells changing payment 4% Pre audit commissioner payment £274,692 Post audit commissioner payment £274,764 Net change in payment – undercharge £72

Audit Findings – Emergency Paediatric Admissions with zero length of stay The performance of the Trust, measured against the proportion of spells with an incorrect payment would place the trust better than average based on last year’s national performance. Provider spells tested in sample 100 % spells changing price 6% Pre audit commissioner payment £60,009 Post audit commissioner payment £59,633 Net change in payment – overcharge £1,768

The final audit report made 3 recommendations to the trust: 1. Refresher training for complication and co-morbidity coding 2. Consistency in use of source documentation when coding, specifically the discharge letter that supports the coder to capture all relevant information for the current episode 3. Use all relevant clinical information when coding

These recommendations have been agreed and put into action by the trust.

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Information Governance – annual mandatory inpatient clinical coding audit NHS Information Governance requires an annual assessment of clinical coding based on methodology developed by the NHS Classifications Service. During March 2014 external clinical coding auditors undertook an audit of a random mix of 200 hospital provider spells across 3 chosen specialties: gastroenterology, cardiology, trauma and orthopaedics. Although the final audit report has not yet been received and approved, the initial audit results with regard to accuracy of primary diagnosis, secondary co-morbidities, primary procedure and secondary procedures are shown below. Last year’s results are also shown for comparison.

Initial Audit Results Information Governance Clinical Coding External Audit 12/13 Information Governance Clinical Coding External Audit 13/14 Primary Diagnosis 94.5% accuracy 97% accuracy Secondary Diagnoses 96.7% accuracy 96% accuracy Primary Procedure 97.8% accuracy 97% accuracy Secondary Procedures 98.1% accuracy 100% accuracy

The latest results confirm the consistency in the accuracy of clinical coding and that the Trust has maintained the highest level of attainment for the 2nd consecutive year for this Information Governance requirement.

Data Quality South Warwickshire NHS Foundation Trust will continue its work in improving data quality to ensure standards are continually kept high which in turn will help the performance and management of the activities of the Trust. It is essential that the Trust Data is complete, accurate and inputted in a timely manner to ensure support in providing patient care and helping the Trust to achieve performance targets. Data is continually monitored internally on a daily/ weekly basis and by the use of external dashboards provided by CHKS and The NHS Information Centre.

There is a monthly Data Quality Committee which has overall responsibility for helping to lead the improvement in the standard of Data Quality within the Trust. This is chaired by the Director of Finance and includes the Director of Operations, Associate Directors of Operations, General Managers, and Information team members. The Information Assurance Group feeds into this committee any issues arising that require further management and impetus.

The Director of Finance has sponsored a monthly Data Quality award, since April 2013, to showcase areas of excellence and to share good practice with the rest of the organisation. The award winners are chosen by the Data Quality team, to acknowledge good data quality, whether it is improvement or continued high performance. Award winners receive a certificate of achievement presented by the Chief Executive and Director of Finance, a large box of chocolates and publicity in Epulse.

The profile of Data Quality is now being more fully recognised as a key enabler for improvements to patient services and a slot on the Induction Training is now included for all new starters.

The Health and Social Care Information Centre (HSCIC) was set up as an Executive Non Departmental Public Body (ENDPB) in April 2013. The Trust was contacted by HSCIC regarding the overall good quality of the data we submit to the Shared Users Service (SUS). We were asked to provide some background information regarding the Data Quality procedures, checks and validations we have in place to ensure overall good Data Quality, so that they could share examples of best practice nationally.

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South Warwickshire NHS Foundation Trust will be taking the following actions to improve data quality: The next stage will include a widening brief to encompass assurance on the whole information and reporting process, of which Data Quality is the foundation. To ensure this momentum continues, the Data Quality team will arrange workshops throughout the year with clinical, administrative and operational staff and where specific work is required, and then individual DQ sessions will be arranged. The Data Quality Committee will continue to meet monthly and to continue to highlight areas of best practice and to share learning Trust wide, also to understand any issues which lead to risks of poor data quality and assist teams in resolving these.

It is envisaged that during the next six months the following will be achieved:

Trust-wide 95%+ same-day discharging on PAS. All transfers of consultant on PAS accurately and timely recorded and therefore minimal rework required to data Audit achievement of correct consultant for specialties Commence Data Quality workshops Further improvement in maternity data

Looking forward in regard to the Replacement PAS Programme, development is underway for a specific Data Quality Dashboard for the monitoring of the data cleansing programme taking place within the Data Quality and Data Migration workstream. This will ensure that the cleansing process will be completed on time and support a successful PAS/CPAS migration of data to the new solution.

Information Governance Information Governance is the way organisations ‘process’ or handle information. It covers personal information, i.e. that relating to patients/service users and employees, and corporate information, e.g. financial and accounting records. South Warwickshire NHS Foundation Trust Information Governance Assessment Report overall score for 2013-14 is 72% and was graded ‘satisfactory’ by the Information Governance Toolkit Grading Scheme. Information Governance is to do with the way organisations ‘process’ or handle information. It covers personal information, i.e. that relating to patients/service users and employees and corporate information, e.g. financial and accounting records. The Information Governance Toolkit is a performance tool produced by the Department of Health. It draws together legal rules and central guidance and presents them in one place as a set of information governance standards/requirements. Each Trust must undertake an annual assessment to identify and evidence its current level of compliance against these standards/requirements to see whether information is handled correctly and protected from unauthorised access, loss, damage and destruction; and, for this Trust, there were 45 standards/requirements in total (based on the law and central guidance). The toolkit rates organisations with either a ‘red/unsatisfactory’ score or a ‘green/satisfactory’ score. This year, to be graded as ‘green/satisfactory’ the Trust required a score of 72% or above and all 45 requirements achieving level 2 or above. Whilst the Trust is reporting a satisfactory score, it is conscious that it needs to give assurance that action continues to be taken, through the Information Governance Steering Group, to review, monitor and maintain the satisfactory score achieved and to ensure continual improvement in information governance generally. Reporting against core indicators Since 2012/13 NHS foundation trusts have been required to report performance against a core set of indicators using data made available to the trust by the Health and Social Care Information Centre (HSCIC). Performance against these core indicators can be found on page 184 of this report.

126 Part 3: Review of Quality Performance

We agreed 8 priorities for quality improvement for 2013/14 and these are detailed below;

In this section of the report we review performance against the priorities for quality improvement we agreed for 2013/14. As an integrated Trust providing both acute hospital based services and community services, this report covers progress across the Trust, unless specifically identified as either Acute or Community.

Patient Patient Patient Safety Experience Outcomes Implement an improved To improve patient safety Improve systems and food service for patients by achieving 95% harm processes to further free care using the Safety (Page 157) reduce mortality rates Thermometer Improve timeliness of (Page 164) (Page 128) discharge process for Patients (page 168) Implement an improved Fully implement frail appointment process elderly care pathway to To reduce the number of include dementia medication errors (page 173) screening & dementia (page 141) Put in place a new system for sensitive services booking and co-ordinating (Page 166) Community services (page 173)

Progress against achieving these quality priorities can be found on the page numbers indicated below each priority. If we have achieved the quality priority, a tick will be displayed. If a priority has not been achieved, a cross will be displayed.

127 Patient Safety Patient safety concerns everyone in the NHS, whether you work in a clinical or a non-clinical role. Every day more than a million people are treated safely and successfully in the NHS, but the evidence tells us that in complex healthcare systems things will and do go wrong, no matter how dedicated and professional the staff. When things go wrong, patients are at risk of harm. The effects of harming a patient are widespread. There can be devastating emotional and physical consequences for patients and their families. For the staff involved too, incidents can be distressing, while members of their clinical teams can become demoralised and disaffected. Safety incidents also incur costs through litigation and extra treatment.

Patient safety is a broad subject incorporating the latest technology such as electronic prescribing and redesigning hospitals and services to washing hands correctly and being a team player. Many of the features of patient safety do not involve financial resources; they involve commitment of individuals to practise safely. Individual doctors and nurses can improve patient safety by engaging with patients and their families, checking procedures, learning from errors and communicating effectively with the healthcare team.

Safety Culture A safety culture is one where safety is embedded in all activity, and where staff have a constant and active awareness of the potential for failure. At South Warwickshire NHS foundation Trust staff are able to acknowledge their mistakes, learn from them and take action to put things right.

South Warwickshire NHS Foundation Trust recognises the importance of encouraging a climate of openness in which all employees and other workers within the Trust can freely express their concerns without any fear of reprisal. This can contribute constructively to the development and continuous improvement of the Trusts services. As a result, if a member of staff raises such a concern the matter will be dealt with positively, quickly and reasonably.

As part of open and transparent working which is stipulated in a Whistle blowing policy, staff are encouraged to report incidents on the Trust’s electronic system. This permits both an effective risk management mechanism, and also empowers staff to report any malpractice they have evidenced. There will be no adverse consequences for a member of staff who raises a concern in accordance with this Policy unless the concern was raised with malicious intent. The Public Interest Disclosure Act 1998 (‘the Act’) makes it unlawful to dismiss, discipline or victimise a worker who ‘blows the whistle’ on criminal behaviour or other malpractice. The protection afforded by the Act applies to workers who follow the specific procedures laid down in the legislation in disclosing specific categories of malpractice. By following this Policy staff will be eligible for the protection set out in the Act.

Monitoring patient safety To ensure patient safety is at the core of the Trusts business, the following processes are in place;

Data is triangulated to all appropriate committees or groups as part of the reporting structure. National data regarding patient safety is validated by cross-checking against data released in the public domain by any governing health body. Board reports depict ward level performance where required to facilitate data and performance monitoring. Ward to Board dashboards have been introduced across the organisation which depicts ward performance against a multitude of quality and safety measures. Dashboards comprise of validated data and benchmarked against any national targets or Trust agreed targets.

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Quality Priority 2013/14 - Safety Thermometer

To improve patient safety by implementing the Safety thermometer and achieving 95% harm free care

The Safety Thermometer is a tool for analysing and reducing harm to patients. The Safety Thermometer survey records any harms which patients in a ward or team have suffered and is carried out on a specific date, every month. This focuses on four key areas, which have been identified by the Department of Health as areas of preventable harm; Falls – Records the severity of any fall that the patient has experienced within the previous 72 hours Pressure ulcers - Records the patients WORST old pressure ulcer and WORST new pressure ulcer Catheter-acquired urinary tract infection (UTI) – Records information about any UTI acquired whether the patient had a urinary catheterisation or a urinary catheter in place Venous thromboembolism (VTE) assessment, prophylaxis and treatment – Records whether the patient has had a VTE assessment completed and if applicable, the patient is receiving treatment The Safety Thermometer was introduced into the Trust during February 2012.The overall aim is to provide data from every patient on a given day each month, to include any patient in a hospital bed and any patient seen by a trained nurse within the community setting. The data is then collated in a central database and returned to the NHS Information Centre. The Patient Safety Team, Compliance Team and the Matrons have provided training to ward managers and professional Team Leaders throughout the year and have assisted with the data collection. Each area receives a copy of their data and are asked to complete an action plan to address areas where there are areas of concern. Each area must analyse their data, share with colleagues and develop interventions to improve their rate of harm-free care. The data is published monthly and available to the public. The Trust set a quality priority to achieve 95% harm free care in the Safety Thermometer. The trust has successfully achieved this 2013/14 quality priority! Rate of Harm Free Care 98 97 96 95 94 93

Percentage 92 91 90 89 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov 13 Dec-13 Jan-14 Feb-14 Mar-14

National SWFT

Data source: NHS Information Centre (NHSIC) data portal

Over the past 12 months the largest rate of harm was in connection with Pressure ulcers that are acquired from outside of the Trust where these patients may not be in receipt of healthcare provided were the Trust. Our performance is in line with the national performance and a notable improvement in performance can be evidenced. The safety thermometer has been successfully embedded across the Trust and its importance has been further evidenced by the achievement of 95% harm free care using the safety thermometer.

129 Patient Safety Initiatives Medication Safety Thermometer In March 2014, the Trust joined the pilot scheme for the Medication Safety Thermometer and has started collecting data on a monthly basis.

As a point of care survey The Medication Safety Thermometer follows a three step process in order to identify harm occurring from medication errors. Data is collected on one day each month and enables wards, teams and the Trust to understand the burden of medication error and harm, to measure improvement over time and to connect frontline teams to the issues of medication errors and harm, enabling immediate improvements to patient care. Data can be used as a baseline to direct improvement efforts and then to measure improvement over time.

As part of the pilot, Data has been collected from 2 wards. The data has been submitted by the Trust to the NHS information Centre for initial review. Further to their review, the trust will receive further guidance to rollout the new initiative across the applicable areas. This will further strengthen the patient safety work that is part of the Trust’s key initiatives.

Patient Safety Newsletter The Patient Safety team has compiled a bi-monthly newsletter which is available to all areas. It includes examples of good practice, lessons learnt and changes in practice that occur as the result of an incident investigation. It will contribute to the feedback that staff receive from incident reporting, and demonstrate that reporting incidents does result in changes in practice for the benefit of patients.

Patient Safety Incidents Incident Reporting, Serious Incidents (SI) and Never Events

What is a Patient Safety Incident? A patient safety incident is any unintended or unexpected incident, which could have or did lead to harm for one or more patients receiving NHS care. Definition from the NPSA (National Patient Safety Agency)

The Trust’s Patient Safety Group has continued through 2013/14, and changed its title to the Patient Safety Surveillance Group. This group co-ordinates, supports and monitors the implementation of the associated work-streams. The group also monitors the implementation of patient safety alerts and provides assurance to the Clinical Governance Committee through the quarterly quality reports.

Incident Reporting The overall aim is to reduce incidents with harm and increase incident reporting in a fair blame culture. As per requirements stipulated by the NPSA, NHS organisations should have a centralised system for collecting data on patient safety incidents. This will enable organisations to analyse the type, frequency and severity of the incidents, and to use this information to improve systems and clinical care. For such systems to be effective, organisations need to encourage and support staff to report patient safety incidents. There are three types of incidents that should be reported: • Incidents that have occurred; • Incidents that have been prevented (also known as near misses); • Incidents that might happen.

Information from all these incidents and from risk assessments can flag up problem areas and lead to preventative strategies to protect patients. In line with NPSA requirements to have a centralised system for collecting data on patient safety incidents, the Trusts electronic incident reporting system, ‘Datix’ continues

130 to be the single reporting system across the organisation, since its implementation in November 2012. This electronic system enables real-time monitoring of incidents and prompt action.

Monthly reports are presented to each of the Divisional Audit and Operational Governance Groups, and a monthly patient safety report summarises the data collected and is presented to the Patient Safety Surveillance Group.

Serious Incidents A serious incident requiring investigation is defined as an incident that occurred in relation to NHS funded services and care resulting in:

the unexpected or avoidable death of one or more patients, staff, visitors or members of the public permanent harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention or major surgical/medical intervention, or will shorten life expectancy (this includes incidents graded under the NPSA definition of severe harm) a scenario that prevents or threatens to prevent a provider organisation’s ability to continue to deliver health care services, for example, actual or potential loss or damage to property, reputation or the environment a person suffering from abuse adverse media coverage or public concern for the organisation or the wider NHS

Serious incidents in healthcare are relatively uncommon, but when they do occur the NHS has a responsibility to ensure that there are systemic measures in place for safeguarding of people, property, NHS resources and reputation. This includes the responsibility to learn from these incidents in order to minimise the risk of them happening again.

During 2013/14 the reporting of Serious Incidents at South Warwickshire NHS Foundation Trust was as follows; Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Total SI 0 1 0 3* 0* 4* 1 0 2 3* 2 2 18 Maternity 3 0 2 5 3 1 1 1 1 1 0 2 20 MRSA 0 0 0 0 1 0 1 0 0 0 0 0 2 C. Diff 0 0 1 0 1 1 0 1 0 0 0 1 5 Inf Issue 1 0 0 0 0 0 0 0 0 1 0 0 2 P Ulcers 8 7 10 2 17 17 5 7 19 8 11 9 120 Total 12 8 13 10 22 23 8 9 22 13 13 14 167 Downgraded 3 2 1 1 3 6 0 1 3 0 4 4 28 Final 9 6 12 9 19 17 7 8 20 13 13 13 139 Data source: STEIS database (external), SORD database (external)

Following a thorough investigation of all serious Incidents, it may be deemed that the cause of the incident is not as initially recorded or reported, therefore the incident is then downgraded. For example; an incident initially reported as a pressure ulcer, may be downgraded to a moisture lesion following the trusts patient Safety investigation process.

At South Warwickshire NHS Foundation Trust, once the incident has been closed by the assuring Committee (Clinical Governance Committee), the lessons learnt are included in the Governance report for each of the Audit and Operational Governance Groups. Themes are monitored by the Patient Safety Team.

The actions arising from serious incidents are monitored by the Patient Safety team, and a quarterly report is reviewed by the Clinical Governance Group to ensure that actions are completed.

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Duty of Candour The Trust is required to demonstrate that a duty of candour has been applied to all serious incidents reported from April 2013. The Trust reports against the Duty of Candour for service users and their families and is part of our governance process and being open policy. Families should be informed by the Trust within 10 working days of a severe harm or death to a service user. This information has been made mandatory for all patient safety incidents. Duty of candour Performance Target Patient /Next of kin/carers were informed 100% 100% Relationship to patient was documented 100% 100% Person informing patient and / or NOK 100% 100% Method of informing patient / NOK: - Face to face 100% 100% - Not recorded 0% 0% Details of information given recorded 100% 100% Data source: SWFT Datix system (Internal incident reporting system)

Never Events Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Once an incident is categorised as a Never Event, the Trust follows a formal thorough investigation process to understand the root causes and to put actions in place to prevent it happening again in the future. During 2013/14, South Warwickshire NHS Foundation Trust has reported four Never Events. Following thorough investigations into the Never Events, the lessons learnt and actions required have been listed below;

Never Event Lessons learnt Progress

Wrong Site Surgery: The operator and Theatre team present (Scrub incorrect size practitioner and Surgeons Assistant) must 9All actions completed prosthesis inserted verbalise and agree that the prostheses requested have been appropriately selected, checked by the Operating Surgeon and Scrub Practitioner and are compatible before opening contents. As each component part of the total hip prostheses is implanted, the size will be written 9All actions completed clearly on the swab check board so that the operating team have a visual prompt for verification.

Staff education and training from the supplying company to ensure staff understand the 9All actions completed prostheses options and compatibility. Retained swab All doctors working within the maternity following normal service at SWFT should have a robust 9All actions completed vaginal delivery induction and orientation. Only x-ray detectable items should be in the delivery and suturing packs. 9All actions completed

All members of the multi-professional team must document that they have read and 9 All actions completed understood the Swab, Instrument and Needle Checking Procedure in Maternity Guideline.

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Maladministration of To amend the process for the infusion of potassium chloride potassium to ensure that: 9All actions completed solution Infusions of potassium are to be treated as a controlled drug and checked by two members of staff when preparing the infusion and when setting up and administering the infusion at the patient’s bedside.

Retained Swab The Medical Director to review the concerns raised related to Medical Staff 9All actions completed interpersonal relationships To re – circulate Theatre Services swab, needle and Instrument count policy to all 9All actions completed Theatre Staff. To discuss the lessons learned at the theatre services audit meeting 9All actions completed To share the lessons learned via letter / e mail correspondence with all Consultant / 9All actions completed Registrar . WHO Checklist – AMD`s to nominate an operating Consultant to champion the 5 9All actions completed Steps to safer surgery so that information and best practice, lessons learned from incidents can be disseminated via multi – disciplinary teams.

Global Trigger Tool The Patient Safety team review medical records on a twice monthly basis using the Global Trigger Tool methodology. This method identifies triggers during a patient’s hospital stay (e.g. blood transfusion). Once the reviewer has recognised a trigger, they then determine if this trigger has caused the patient any harm. The harm events range from temporary harm to contributing to patient’s death. See Categories below;

From our reviews harm events are predominantly in the first two categories E & F. This would appear to impact on the length of the hospital stay. The rate of harm identified through the note reviews ranges from 0% to 3.7%. The summary of triggers / harm events is as follows;

Data source: SWFT Patient safety dataset The majority of triggers relate to General care: - Readmission of patients within 30 days - Failure to respond to early warning score

The Trust has developed work streams to address these specific areas.

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NHS Litigation Authority Risk Management Standards

The NHS Litigation Authority (NHSLA) manages negligence and other claims against the NHS. The NHSLA helps to resolve disputes fairly, shares learning about risks and standards in the NHS and helps to improve safety for patients and staff. Participating NHS Trusts are assessed against the NHSLA Risk Management Standards. These are as follows;

Level Requirement South Warwickshire NHS Foundation Trust’s position Level 1 NHS Trusts are expected to have the process for managing risk described and documented in approved 9 Achieved policies Level 2 NHS Trusts are expected to evidence the process for managing risk is as described in the approved policies 9 Achieved Level 3 NHS Trusts are expected to demonstrate the process for The NHSLA are currently managing risk is working across the whole organisation. reviewing their Assessment process and assessments of all organisations have ceased until further notice.

South Warwickshire NHS Foundation Trust has successfully achieved and retained its Level 2 accreditation from the NHSLA for both Acute Standards and Maternity CNST (Clinical Negligence Scheme for Trusts). There have been no failures or breaches in compliance with the NHSLA standards in any other area.

134 Pressure Ulcers

Committed to our patients The Trust has continued in our determination to reduce the number of pressure ulcers that occur within the Trust. We have developed the following awards to issue to our Wards to celebrate their success;

BRONZE SILVER GOLD PLATINUM 50 days pressure 100 days pressure 365 days pressure 2 years pressure ulcer free ulcer free ulcer free ulcer free

We are pleased to announce that of our acute and community teams 16 teams have celebrated with Platinum awards and 19 teams have achieved Gold awards. In our community Teams 10 Teams have celebrated with Platinum awards and 1 Gold award. The team are planning an awards ceremony to be held in conjunction with the annual Pressure Ulcer Prevention Week.

A pressure ulcer (also known as 'bed sores', 'pressure sores' and 'decubitus ulcers') is an ulcerated area of skin caused by irritation and continuous pressure on part of the body. Pressure ulcers are more common over bony prominences (places where your bones are close to your skin) such as your heels, the lower part of your back and your bottom. There are various things that can increase your risk of developing a pressure ulcer - in particular, if your mobility is reduced for some reason and you are spending long periods lying in bed or sitting in a chair.

National Focus Over the past three years there has been a national increased focus on tissue viability services and pressure ulcer prevention. The National Patient Safety Thermometer has been instrumental in sharing success.

Pressure ulcers occur from long periods of uninterrupted pressure exerted on the skin, soft tissue, muscle, and bone. They are more frequently developed over a bony prominence such as the sacrum, the hip, or the heel. Of these two thirds occur in patients over 70 years of age. Treatment of pressure ulcers involves repositioning/removal of pressure source and good wound care. The prognosis for full healing of stage 1 and 2 pressure ulcers is good, however stage 3 and 4 pressure ulcers are much less likely to heal spontaneously even after months of treatment, and if healed they are often associated with scarring.

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Ambition 1 The Trust has built on the work that started with the Midlands and East Strategic Health Authorities Ambition 1 – to eliminate all avoidable pressure ulcers from the NHS by December 2012. The ambition required teams to take ownership of the problem and make sustainable changes to their reporting and practice to improve patient care and experience. The Trust embraced this challenge by showing commitment to achieving the ambition and providing our patients with excellence in clinical care.

Pressure ulcer prevention and management continue to form a significant proportion of the work of the Tissue Viability Service, this is provided by direct patient care and educating our staff in order to provide high quality care. The Tissue Viability Service saw an investment in staff in 2013 increasing the size of the team from 4 nurses to 6. This allowed the service to concentrate their efforts into pressure ulcer prevention and the embedding of the SSKIN bundle and Route Cause Analysis process. .

Data source: SWFT Datix system (Internal incident reporting system)

Improvements to monitoring Since the introduction of the electronic reporting system (Datix) in 2012 the team have been working throughout 2013 to develop the reporting system to ensure it captures the details and data that are required for both reporting purposes and improving patient care.

We continue to complete incident forms for all pressure ulcers this includes internally and externally acquired pressure ulcers. The reporting system has been fundamental in collecting enough information so that the information can be utilised to form the basis of the Root Cause Analysis (RCA) process, a process we carry out for all pressure ulcers. The incident reporting system forms the basis for the RCA for

136 all Grade 2 pressure ulcers, these are scrutinised by the Director of Nursing or Matron and are then determined to be avoidable or unavoidable. Grade 3 and 4 pressure ulcers are subject to a full RCA process. Once the RCA report has been completed the report is scrutinised at the Trusts Pressure Ulcer Review Group held monthly before being approved at the monthly Trust Patient Safety Surveillance Group.

The Trust reports Grade 3 and 4 pressure ulcers as serious incidents through STEIS. On a monthly basis, performance is reported via the Trust Integrated Quality Dashboard and at various patient safety forums to ensure widespread dissemination.

No of days since last Avoidable Pressure Ulcer 2013 14

700 600 500 400 No 300 200 100 0 ITU Guy 23hr CCU A&E Avon Oken Swan Mary Mary Castle Squire Hatton Malins Fairfax Farries Victoria Dugdale Nicholas Campion Beaumont Macgregor Charlecote Willoughby Wards

No of days since last Avoidable Pressure Ulcer 2013 14

700 600 500 400 No 300 200 100 0 EBH Arden Manor Rugby Feldon Alcester Stratford Warwick Camphill Bedworth Nicol Unit Kenilworth Rural North Leam CERT Leam/Southam Community Shipston/W'Bourne Data source: SWFT Datix system (Internal incident reporting system) and Tissue Viability Dataset

The graph above illustrates the number of days since the last avoidable Pressure ulcer reported in the acute setting.

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Screening Tool It has been recognised throughout the health economy that every contact with patients are an opportunity to provide health education. The team are in the final stages of developing a Traffic Light screening tool and referral pathway to detect and target non inpatients at risk of pressure ulcer development. The tool has been developed with the Multi Disciplinary Team (MDT) to assist them in identifying at risk patients and referring them to the most appropriate health care professional.

Education Tissue Viability and Pressure Ulcer Prevention training is mandatory for all clinical staff. This mandatory training encompasses pressure ulcer prevention, risk assessment, documentation and the use of pressure relieving equipment.

The team have developed an E Learning training package for pressure ulcer prevention that has been uploaded onto the Trust’s Electronic training system. This system is available to all Trust staff and can be accessed at home as well as within the Trust. The team receive quarterly reports regarding the uptake of this training.

Face to face training will continue throughout the Trust. Link Nurse Study days have continued to be well attended throughout the year. SKIN Bundle (Surface, Skin inspection, Keep me moving, Incontinence, Nutrition)

Prior to Ambition 1 being launched the Trust had already begun to develop a SKIN (acute) and SSKIN (community) bundle to improve the quality of care provided to our patients. The bundles focus on the essential care required to prevent pressure ulcers. As part of a documentation review within the Trust, it was decided to combine the Falls Challenge and Intentional Rounding with the SKIN bundle into one simple-to-use tool. In the acute setting a dedicated SKIN bundle implementation nurse was employed to support clinical areas in introducing the tool. In the community, due to overlap of community services a regional booklet was developed. The purpose of this booklet is to provide patients and carers with essential information to prevent pressure ulcers and provide contact details for support.

138 Infection Prevention South Warwickshire NHS Foundation Trust (SWFT) is proud of its strong commitment to reducing harm to patients, through both reducing rates of healthcare associated infections, and improving outcomes for those patients who have infections.

The Root Cause Analysis (RCA) process has continued to be rigorously applied by the Infection Prevention Team and their clinical colleagues, for the investigation of cases of Methicillin-Resistant Staphylococcus Aureus (MRSA), Clostridium Difficile (C.Diff) outbreaks, deaths where C. Diff has been certified as a leading cause of death and other outbreaks of infection. In addition, in 2013/14, we commenced a programme of formal RCA into every case of Trust-attributed C.diff. All such RCA findings and recommendations are presented to the Infection Prevention Board by the patient’s Clinical teams.

Clostridium Difficile (C.Diff) Over the last 7 years, we have learnt many lessons about sources of infection, root causes and the processes required to reduce infections. The level of success seen in recent years regarding the reduction in MRSA bacteraemias (bloodstream infections), has now been reflected in a significant reduction in rates of Clostridium Difficile (C.diff), thanks to the RCA process. A somewhat challenging C.diff target of a maximum of 24 cases was set for the Trust in 13/14. However, we are proud to report that this was successfully achieved with a total of 18 hospital- attributed cases of C.diff identified across both Community and Acute Trust services. This is a 42% reduction on the total number of cases identified in 12/13).)

Data source: SWFT Infection Prevention data

MRSA bacteraemia Methicillin-Resistant Staphylococcus Aureus (MRSA) is a bacterium responsible for several difficult- to-treat infections in humans.

In 2013/14, a “Zero-tolerance” approach to MRSA bacteraemia was introduced by the Department of Health. This means that any “avoidable” MRSA bacteraemias were deemed unacceptable. 1 SWFT-attributed MRSA bacteraemia was identified in 2013/14 (compared to 2 cases in 12/13). Root cause analysis and investigation proved that this case was not a “true infection” but were what is known as a “contaminated blood culture”. In effect, this meant that the patients did not have an MRSA bacteraemia infection. This was deemed an “Unavoidable” case.

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Data source: SWFT Infection Prevention data

Methicillin-Sensitive Staphylococcus Aureus (MSSA) Surveillance and monitoring of Methicillin-Sensitive Staphylococcus Aureus (MSSA) bacteraemias Rates of these remain low, however a total of 11 hospital-attributed MSSA bacteraemias were identified in 13/14 compared to 4 in 12/13. Of these 11 cases: 3 were due to underlying medical condition 2 were due to infected peripheral cannula 2 were due to infected feeding lines 2 were due to skin infections 2 were of unidentified sources

Actions to reduce MSSA bacteraemias are consistent with those associated with the reduction of MRSA bacteraemias i.e. improved intra-venous line care, a reduction in unnecessary cannulation and asepsis during wound care and surgery. In order to drive our rates of avoidable MSSA bacteraemias even lower, every case identified in 14/15 will undergo a detailed RCA, so that lessons can be learnt and practices amended Trust-wide.

Data source: SWFT Infection Prevention data

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E.coli bacteraemias 29 Trust-attributed E.coli bacteraemias were identified in 13/14, compared to 26 E.coli bacteraemias in 12/13. E.coli bacteraemias are quite common and usually associated with infections of the urinary tract. Actions to reduce avoidable E.coli bacteraemias are mainly associated with a reduction in the numbers of short-term urinaryyy catheters and excellent urinary catheter care.

Data source: SWFT Infection Prevention data

Norovirus campaign Last year, the Trust experienced a large Norovirus outbreak, which was particularly challenging for the Trust. Following cessation of the outbreak, a programme of work commenced, targeted at implementing additional measures to help in any way possible in our fight against Norovirus outbreaks. Sadly, such outbreaks are inevitable due to the infectious nature of this bug, but we will always aim to reduce the impact of these outbreaks. As hand washing is key in removing viruses and bacteria from our hands, hand wash sinks were installed at, or near to, every ward entrance with clear signage at every sink encouraging staff and visitors to wash their hands on entering and leaving wards. In addition, a large communications programme was launched, which included a new “Virtual Nurse” positioned at the hospital entrance, delivering infection prevention messages to members of the public.

141 Medication Safety

Quality Priority 2013/14 - Medication incidents To reduce the number of medication errors

Achievements this year Improving medicines safety has been an on going priority for the Trust over several years. During the course of this year, the following achievements have been made; 9 The electronics incident reporting form has been improved to enable accurate reporting and analysis of medication incidents 9 Medicines policy and audit schedule revised 9 Medication incidents are reviewed and monitored closely at the medication safety committee 9 Development of the sepsis care bundle and implementation across the acute sector 9 Revised critical drug list and flow chart across acute and community settings to support nursing staff to know where and how to get critical drugs out of hours. 9 Improve the care; be diabetes aware’ Campaign has been launched 9 Revised and re-launched the good TTO guide 9 Audit of completion of good TTO guide has been undertaken 9 A review of the transfer checklist and policy to ensure patient drugs are included 9 An audit of the contents of the POD lockers has been devised 9 A revision of the bed space checklist to include POD lockers to ensure patient safety 9 The percentage of admitted patients having a full medicines reconciliation done by a Pharmacist and Pharmacy Technician (Medicines Manager) has increased to over 90% this year from a base of 79% 9 The Trust has increased non medical prescriber numbers this year

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9 A transcribing policy has been developed 9 Pharmacy services on Sundays have been trialled and have provided a level of service to high risk patients admitted or discharged over the weekend

The Trust continues to practise evidence based medicine, implementing NICE guidelines within 90 days of their publication, and maintaining a limited list of medicines approved for use in the Trust. We now achieve over 95% compliance with a formulary (preferred prescribing list) for medicines which are used in both primary and secondary care, up from a base of 75% the previous year, and compared to a target of 85% compliance.

Nurse Care Indicators (NCI) The Monthly NCI audits are a key element of measuring quality across the clinical wards. Over the last 12 months improvements continued across the Trust and by February 2014 overall compliance reached 96.9%, with all divisions exceeding the Trust target of 95%. The Elective Division and the Integrated Division continued to perform more favourably throughout the year having reached 97.1% and 98.8% respectively in February 2014. For the entire period from February 2013 to February 2014 the Integrated Division achieved in excess of 95%, and the Elective Division only dropped below 95% once which was in July 2013. The matrons continue to work with the Emergency Division Managers, because progress in this area has been slower. However, steady improvements have still been achieved and the most recent scores were 95.8% compared with 93.4% for the same period last year. Nursing Care Indicators OVERALL TRUST COMPLIANCE % Trust target 95%

96.9 96.8 95.60 96.1 95.9 95.9 91.5 95.3 95.40 95.3 94.80 94.3

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14

Data source: SWFT Nursing Care indicators data from Internal Compliance Department

The revised nursing documentation which was distributed at the beginning of February 2013, with all the current and relevant assessment tools and associated care plans in one booklet is well embedded in practice now. The Ward Managers continue to receive their results directly from the Compliance department on a monthly basis. The Compliance department and Matrons continue to monitor performance and discuss results regularly with the ward teams with the continued overall aim of maintaining good quality and safe outcomes for our patients.

143 Reducing Patient Falls in Hospital The causes of falls are complex and hospital patients are particularly vulnerable to falls because of medical conditions including delirium, cardiac, neurological or musculoskeletal conditions, or side effects from medication, or problems with balance, strength or mobility. Due to important changes in recent years to the management of patient falls in the Trust, we were fully compliant to the recommendations by NICE Clinical Guidelines 161: The Assessment and Prevention of Falls in Older People, prior to the publication in June 2013. As a result our falls, with injury rates have continued to decrease, with some months scoring record lows.

During 2013/14 we have: Developed a work stream programme, which includes bedside equipment, falls education, falls documentation, communication and more, to further improve the Trust inpatient falls strategy Participated in the Pilot National Audit of Inpatient Falls by the Royal College of Physicians Improved the investigations procedures following serious injury, leading to better learning outcomes Made further improvements to the reporting of circumstances of falls on the electronic incident reporting system DATIX, leading to better analysis of issues related to falls incidents and improved learning outcomes Improved the moving and handling procedures to transfer patients of the floor following a fall or cardiac arrest, using the Flat Lift Kit which was kindly funded by Warwick Hospital League of Friends Included Falls Awareness training into the Trust HCA induction programme

Next year, we will: Review falls risk assessment and care plan procedures following outcome of the Pilot National Audit of Inpatient Falls and local audit programmes of falls documentation and Root Cause Analysis Develop a falls awareness e-learning programme for inpatient and community areas Develop a new communication strategy to increase awareness of falls prevention with all staff in the organisation Provide wards and divisions with a tailored monthly or quarterly report detailing analysis of local falls incidents Continue to work with related work streams, such as dementia, pressure ulcer and nutrition

Data source: SWFT Falls Data

144 Patient Experience 96.3% of Inpatients would recommend South Warwickshire NHS Foundation Trust!! Our aim is to continually improve patient experience within the Trust. The Director of Nursing chairs the Patient Experience Group (PEG) and through this group a range of work is overseen, in all departments across the Trust. The PEG holds clinicians and managers to account for the patient experience in their area through direct reporting to the group. Each manager/clinician is expected to provide actions plans for improvement.

Friends and Family Test The Friends and Family Test (FFT) aims to provide a simple headline metric which can be a driver in recognising good practice and improvements in the provision of quality care received by NHS patients and service users.

The implementation of the FFT across all NHS services is an integral part of Putting Patients First, NHS England’s Business Plan for 2013/14 – 2015/16, and is designed to help service users, commissioners and practitioners.

Since April 2013, patients have been asked ‘How likely would you recommend hospital wards and A&E departments to their friends and family if they needed similar care or treatment’. This means every patient in these wards and departments is able to give feedback on the quality of the care they receive, giving hospitals a better understanding of the needs of their patients and enabling improvements.

Feedback since implementation Since the introduction of the FFT in April 2013 an impressive total of 10,351 patients have participated in the FFT and provided feedback on their experience. Based on the reviews that patients provide via the FFT about their treatment and stay at SWFT, we have maintained an average of 4.7 star rating out of a possible 5 stars.

Data source: Friends and Family Test data provided by iWantGreatCare

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What Patients have told us.. Since the introduction of the FFT at SWFT, 10.351 patients have participated in the FFT and provided feedback on their experience, their responses to the FFT question have been broken down by the categories;

Of the Inpatients who have participated since April 2013; 94% of inpatients patients are ‘Extremely likely’ or ‘likely’ to recommend SWFT 2.6% of inpatients stated that they are ‘Neither likely or unlikely’ to recommend SWFT 3.3% of inpatients stated that they ‘Don’t know’ as to whether they would recommend SWFT 0.1% of inpatients stated ‘Extremely unlikely’ to recommend SWFT

Of the A&E admissions who have participated since April 2013; 59% of patients are ‘Extremely likely’ or ‘Likely’ to recommend A&E department 40.5% of patients stated ‘Don’t know’ whether they would recommend A&E department 0.5% of patients are ‘Extremely unlikely’ to recommend A&E department

The FFT data is a powerful dataset available in the public domain and enables the public and patients to compare services across the healthcare economy, identify those who are performing well and drive others to take steps to improve. Data evidences that since the introduction of the FFT in April 2013 at South Warwickshire NHS Foundation Trust, a substantial proportion of our patients have participated in the FFT and provided valuable feedback on their experience. The trust has seen a notable increase in patients partaking in the survey with inpatient responses increasing from 22.9% to 58.7% (at its highest) and A&E 0.1% to 16.8% (at its highest). In addition to the notable response rate performance, since its implementation the Trust has achieved an average FFT score of 80, which is considerably higher than the national average of 63. This score is on par with last year’s performance which placed the Trust in the top quartile of NHS Trusts.

What some of our patients say about us:

‘Whatever grade or occupation on Castle Ward I was treated with non-judgemental, polite ‘Very happy ward, professionalism and…both day and night shifts almost a pleasure to standards to be remarkably credit worthy, it be in hospital! was a pleasure being ill!’ (Castle ward) (Beaumont ward)

‘ The level of care towards me and particularly vulnerable patients was very impressive’ (CCU)

'The care was ‘Hosts of 'I've never extremely good, an approachable people, been so cared excellent knowing what was for!' (Nicol atmosphere going on’ (A&E) created by staff. unit) Good team work.’ (Hatton Ward)

Data source: Friends and Family Test data provided by iWantGreatCare

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Emerging themes The free text comments are analysed by the Trust’s FFT Lead and the emerging trends since implementation have been summarised below;

Top 5 Positive themes: Patients receive clear explanations of their condition Cleanliness of wards/ bed areas Effective and promptness of staff Attentiveness to care Excellent atmosphere, friendliness of staff

Top 5 Negative themes: Slow to respond to call bells on ward Noise levels, especially at night Being moved around at night Communication between staff A&E waiting time – no real-time waiting time updates available

Actions to address Negative themes Whilst the highest proportion of comments received from patients is positive feedback, the negative feedback received as resulted in actions to be taken. This comprises of;

• Reinforcing the Night Charter: The Night Charter has been a successful campaign led by extremely proactive Trust staff, that aims to focus staff attention on improving patient experience overnight, by reducing noise and You said, disturbance in clinical areas and promoting a restful night’s sleep to assist We did recovery and improve patient outcomes. The matrons are also addressing the FFT feedback with the Night Charter team to review individual feedback received and to review the adherence to the Charter in those specific ward areas.

• Standard of call bells: As result of the call bells issue, a standard has been You said, implemented to ensure calls bells are answered within a specified We did timeframe. This will ensure a standardised approach and also allow monitoring of compliance.

• A&E to update waiting time board: Whilst there are boards in place to You said, provide waiting patients with waiting time indications, as result of feedback We did A&E staff have been informed to ensure that all information boards are updated to keep patients better informed.

Monitoring Patient feedback and improvements The Trust’s Patient Experience Group (PEG) is the dedicated forum where FFT reports are reviewed and scrutinised. The PEG holds clinicians and managers to account for the patient experience in their area through direct reporting to the group. With representation from each area, in line with groups schedule of business, each month a ward is required to deliver a presentation on their wards FFT performance and how the patient comments have been assessed. Any subsequent actions or service improvement actions taken are presented to the group. Each manager or clinician is expected to provide action plans for improvement.

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All comments from the FFT are distributed to each respective ward and each ward team is debriefed with performance at local meetings. Patient satisfaction performance is accessible to all patients with the aid of display boards on wards. Performance of patient experience measures is reported from ward to Board level through an integrated quality dashboard, on a monthly basis.

The Friends and Family Test data is available in the public domain and enables the public and patients to compare services across the healthcare economy, identify those who are performing well and drive others to take steps to improve. The FFT for acute in-patients and patients discharged from A&E became mandatory on 1 April 2013. In order to meet this national mandatory requirement, and to deliver the FFT survey requirements the Trust has contracted a third party patient organisation – iWantGreatCare (iWGC). The third party organisation has worked collaboratively with the Department of Health to ensure the methodology and reporting processes comply with requirements and legislations.

As part of our agreement with iWGC, the Trust receives a monthly management and ward report: Trust level report: This comprises include a summary of volume and feedback scores by ward by month, and easily identify top performers and outliers; Ward level report: This encompasses comparative scores across wards. Ward reports includes all free text comments provided by patients. Below is an example of a ward level report which informs the ward of their performance in relation to other participating wards. Smiley Face Cards Smiley face cards were introduced throughout the Trust in late 2011 to capture Patient feedback across the Trust.

During 2013/14 patients also have the opportunity to write a comment and attach their name and contact details should they wish to be contacted at a later date. To date we have had close to 6000 smiley face cards returned. Red and amber comments are followed up by the matron team and responsible line manager. The majority of red comments relate to delays in waiting times for appointments.

Red comments “Fine, apart from the excessively long wait for drugs once discharged. Very efficient pharmacy service” We have introduced the Home for Lunch initiative this year, which aims to ensure all our patients have everything ready for going home at lunchtime. “Meals could improve” We are currently reviewing our food services to see where we can make improvements. “Two hour wait! Doorway too narrow for wheelchair” The current Machen Eye Unit services have outgrown the building, and we are currently looking to update parts of the building and move some of the clinics nearer to patients’ homes. Amber comments “Very good. It's the waiting time that lets things down, and it pushes up car parking charges” “The staff are good but we feel appointment was unnecessary today for follow-up, because we could have been told information after the surgery, before discharge. Perhaps telephone appointments could be used instead for patients who don’t need to be examined and that would free up appointments for people who need to be seen”

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Green Comments “First class attention and caring - totally professional and a sense of humour - splendid!” “Everyone put me at ease and were very friendly. Cup of tea afterwards very welcome. Thanks to all.” “The service provided is of an excellent quality. Every team member appears highly qualified. They support one another and the patients.”

National Inpatient Survey A full copy of the CQC National Inpatient surveys 2013 In Patient Survey can be found here

Privacy and Dignity Privacy and Dignity remain high priority for the Trust. In 2007 we introduced 7 dignity promises in response to themes from patient surveys and complaints. As the promises were 5 years old and there had been a lot of change in the Trust, a further review was held in 2012 and changes were made as detailed in the promises below. This was important as the promises needed to apply to all of our patients – those in hospital and those in their own home.

We promise:

Not to allow language or other communications issues to become a barrier to understanding You will be introduced to the staff that are caring for you You will be called by a name of your choosing To respond to your questions promptly, or find someone who can Your privacy and modesty will be maintained at all times You will be treated in a courteous manner that respects equality, diversity and your human rights Our staff will deliver the highest standard of safe care and customer service

The Promises are presented to all new staff at Corporate Induction sessions held monthly and are displayed in all of our clinical areas. The training is delivered by the Matron team and explains the Trusts expectations and standards in relation to privacy and dignity.

We review the training we deliver to our staff yearly and are currently reviewing our communication training, this will enable us to deliver consistent excellent customer service. The training focuses on attitudes and behaviour whilst at work. The Practice development team deliver communications and customer service training to all newly qualified practitioners based on principles learnt from the British Olympic Games makers training. This new training is underpinned by the new National Nursing and Midwifery Strategy Compassion in Practice which focuses on the 6 C’s –

Care Compassion Competence Communication Courage Commitment (Jane Cummings Chief Nursing Officer 2012)

The Matron Team co-ordinate and lead an annual audit to ensure national privacy and dignity standards are achieved and maintained. An action plan has been developed and is currently being implemented. The audit confirmed that public and patient areas are consistently clean and well maintained and in addition, separate male and female toilet and washing facilities are clearly labelled and accessible. However, the main issue identified at this year’s audit was the inconsistent quality of curtains around patient bed areas. This finding was also supported by the Essence of Care benchmark reported by ward staff and where a problem has been identified, these curtains are currently being replaced. Ensuring all patients are treated with dignity and respect underpins the work of the Trust. The principles

149 are embedded across our working practices from the Board to Ward and can be demonstrated in the success we have achieved in our compliance to the single sex accommodation standards, delivering excellence in dementia care, our continued work with ‘Kissing it Better’, our Friends and Family Test results and National Inpatient Survey results. Many of our achievements are detailed later in this section.

In October 2013 we held the second Annual Nursing, Midwives and AHP Clinical Conference for South Warwickshire NHS Foundation Trust which was such a huge success.

The event saw colleagues coming to together from across the Trust to share truly inspirational stories and experiences. The event was opened by a patient with their story that challenged us to think differently about the care we provide. Throughout the day we heard presentations from staff and patients alike that were both thought provoking and inspirational. Presentations, speakers and posters were all of an exceptional standard interlinking the themes of gold standard, the 6Cs and personalised care in order to ensure that we continue to put compassion into Practice. The staff were provided with plenty of thoughts and reflections to work and motivate us throughout the year. This event wouldn’t have been the same without the patients and staff’s involvement, determination and drive to succeed.

Staff Experience The national Staff Survey was released in February 2014 and the results showed that the Trust made further improvements on last year’s already impressive results and like last year, the majority of the Trust’s responses were in the Top 20% of Trusts nationally. The survey which is produced annually by the Department of Health asks NHS staff a variety of questions about their opinions on the Trust they are employed by. The Trust significantly exceeded the national averageg when overall staff engagement was measured in the following areas: Staff motivation at work Staff recommendation of the Trust as a place to work or receive treatment Staff believing the Trust provides equal opportunities for career progression or promotion

Keyy findings from the reports also included: The Trust is above the national average for staff job satisfaction The Trust’s results for the percentage of staff feeling pressure in last 3 months to attend work when feeling unless was lower the national average (the lower the score the better) The Trust received lower results than the national average for the percentage of staff suffering work- related stress in last 12 months (the lower the score the better)

Response Rate The Trust’s response rate for the Staff Survey 2013/14 was 57% which is above the national average for acute Trusts in England.

Action plans The Staff Survey report contains a detailed breakdown of each of the Key Findings by Division and occupational staff group, which will allow us to produce targeted action plans to address areas of concern. Actions in response to this report will be incorporated into the Trust’s Workforce Action Plan

Promoting Normal Birth: The Trust’s Caesarean section rate fluctuated throughout the year, around the standard of 25%, at between 23% and 31%. Midwifery led clinics and beds continue to provide support for normal births, as does the policy of inviting all women who have had a Caesarean to attend a ‘vaginal birth after C section clinic’ to support them to have a normal birth, for their next pregnancy.

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In addition

A significant number of staff in the hospital and community have received comprehensive training in breast feeding.

The community service achieved level 2 accreditation during 2013/14 and acute service expects to be assessed for level 2 accreditation in the summer 2014

Audits are being undertaken to ensure that staff have the required knowledge and skills to support successful breast feeding in preparation for the Level 2 assessment. This will involve UNICEF BFI assessors visiting both the hospital and community midwifery setting to interview staff about their knowledge and skills. They will also interview women to ensure that they have been given a good standard of information in the antenatal period to enable them to make an informed choice regarding method of feeding.

The maternity department are pleased to announce the introduction of a tongue-tie division service in response to the needs of the local population. This is offered to babies between 48 hrs and 28 days of age who are born or reside in South Warwickshire. Mothers are reporting an instant improvement in attachment to the breast and a reduction in pain following this simple procedure. The expected benefit is that mothers will continue to exclusively breast feed for longer.

Complaints The Trust is proactive in encouraging patient feedback, recognising that service user feedback, comments and complaints are effective measures of services delivered, what is needed to improve those services, changingg trends/demands and necessary learning. The information assists the Trust to: Recognise standards of service delivery and continue to ensure service improvement Understand the patient experience, perspective and expectations Identify any problematic areas Identify actions needed Monitor service requirements

Complaints are reported monthly to the Patient Experience Group and at each Divisional Audit and Operational Group. The reports include themes, areas, grading, outcomes and actions. The Divisions receive updates on the status of each month’s complaints until the complaint is closed, ensuring that each division remains aware of the complaints in their area.

The Parliamentary Health Service Ombudsman (PHSO) last year indicated that following the Francis inquiry they would be reviewing more cases referred. Six complaints received by the Trust were referred to the PHSO this year. Following initial review, three have to date been investigated by the PHSO. Of these, one is closed with no action. For another, the PHSO identified a failing in care and made recommendations, but upheld that these failings did not affect the patient’s outcome. For the third, the PHSO initially rejected the complainant’s claim for continued funding for footwear, but reversed their decision after an appeal. At the time of this report, any decision regarding the other three referrals has not been advised.

PALS and Complaints work together as part of the Patient Experience Team to ensure that complaints are dealt with proactively and appropriately to ensure that every effort is made to resolve complaints at local level where possible. Matrons continue to give close support to Complaints and PALS in order to assist with local level resolution, complaint responses and meetings.

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Comparison of complaints by month 30

2011/12 15 2012/13 10 2013/14 No. Complaints

0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Data source: SWFT Complaints data

90.5% of complaints were acknowledged within three working days. Eighteen complaints were acknowledged outside the 3 working days. There are a number of ways in which written complaints come into the Trust and this can lead to a delay in them reaching the Patient Experience Office and therefore meeting the 3 working days. Of the 184 complaints completed at 30 April 2014, 61% were responded to on or within 25 working days. To date 72 have been responded to after greater than 25 working days. Breaches of the 25 working day target are largely due to either the complexity of the complaints and/or delayed responses from staff involved in the complaint investigation.

No of 3 working Response Month complaints days > 25 days April 19 15 8 May 19 17 6 June 17 16 4 July 13 11 5 August 25 24 11 September 15 14 6 October 22 21 11 November 12 12 6

December 9 9 4

January 14 13 9 February 9 8 1 March 16 12 1 TOTAL 190 172 72 Data source: SWFT Complaints data

Complaints by Division Between April 2013 and March 2014, the number of complaints involving each division was:

Emergency 109 Elective 74 Integrated & Community 41 Support services 14

*Note numbers of complaints by division do not correlate to the total number of complaints received as they often relate to more than one divisional area.

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Main Concerns

The top five main concerns have been consistent in relation to the issues raised.

Main Concerns by Quarter 2013 - 14 40 35 30 25 20 Q1 15 Q2 10 Q3 5 0 Q4

Data source: SWFT Complaints data

Communication/Information 109 Clinical care 75 Nursing Care 59 Delay/wait to be seen 46 Staff Attitude 28 Data source: SWFT Complaints data

Lessons Learnt and Actions from Complaints To improve staff knowledge about the post fall immobilisation device, to remind staff that this information is included in the Post Falls Protocol. The device was taken to the ward to demonstrate clearly to all staff, its use and where the device is kept. Discussions held with Ambulance Transport Committee regarding the delay in an elderly patient being picked up and poor communication. Staffing levels changed on Victoria ward, a higher number of trained nurses to HCA and night rotation introduced. The Epidural Management Guideline to be updated & to include ‘The Association of Anaesthetists Guideline for Obstetric Anaesthesia Services’. Improve clarity and effectiveness of communication between staff by the introduction of a message book. Streamline the scheduling/allocation process to avoid patient visits being missed & to increase efficiency of team working & time management. (District Nursing)

Incident presented at A&E Morbidity Meeting to illustrate to junior clinical staff how an error occurred. Consultant reviewed x-rays with junior teams to ensure lessons learnt. (A&E) Local guideline for Obstetrics being re-written regarding contacting the paediatric team at patient admission.

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Patient Advice Liaison Service (PALS)

PALS is an independent and confidential advice and support service for patients and their relatives/friends. It offers the opportunity to raise concerns enabling appropriate intervention at an early stage. The service works closely with patients, relatives and staff to identify where the Trust can improve the patient experience.. The public expects a high level of service and where there is any concern this is not being delivered PALS can offer advice and support. Year Total Top Five PALS Contact Topics number of contacts 2012-13 2012/13 2056 2013/14 1547 369

252 247 197

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Clinical care decision Communication Property (lost/found) Outpatients Appts Discharge/transfer

Data source: SWFT PALS data

Examples of where PALS has supported and improved patient experience Where a concern is highlighted to staff, particularly where there has been a misunderstanding or miscommunication, encouraging small changes in individual practice to improve future patient care Liaison with appropriate staff to expedite appointment dates or follow up for diagnostic procedures where appropriate Assistance and support regarding discharge arrangements Assistance with housing/benefit claims Signposting to external agencies when additional help is required

Data source: SWFT Complaints data

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Non-Clinical Ward Moves The monitoring and analysis of non-clinical ward moves for patients continue with data being reported to the Patient Experience Group monthly. This reporting mechanism also includes a more detailed analysis of a sample of patients experiencing more than 3 moves on a quarterly basis. Patients are randomly selected from the higher numbers of moves and the healthcare records are reviewed to explore the indications, the times and the issues that arise from patients’ moves.

The matron team have continued to work with ward managers, their teams and the bed management team in an attempt to minimise the number of moves a patient experiences, which can result in disruption to communication and continuity of care. The concept of outlying patients with the Trust still exists due to capacity and demand however the developments of the Community Emergency Response Team (CERT) and the implementation of ‘Discharge to Assess’ (D2A) beds in nursing and residential homes has had a positive impact on length of stay and the need to transfer patients at their end of medical episode awaiting social or community health care to free up acute bed capacity. This year has seen a reduction of 1.3% of patients being moved more than 3 times. The average for the year is 3% however there was a dip in September 13 to 2.4% and a more significant dip to 1.8% in December 13.

This data is still analysed and reported to the Patient Experience Group (PEG) on a monthly basis. The quarterly patient story often reveals clinically indicated moves and moves in and out of the community hospitals. In the past 12 months the patient moves stories had not involved patients with a dementia and the most recent story illustrates that all ward transfers took place inline with the Night Charter principles.

Night Charter The Night Charter has been a successful campaign led by extremely proactive Trust staff, that aims to focus staff’s attention on improving patient experience overnight, by reducing noise and disturbance in clinical areas and promoting a restful night’s sleep to assist recovery and improve patient outcomes. In response to the National Patient Survey for SWFT (2010-2011), where noise at night had been identified as an issue for our patients, two night co-ordinators addressed the challenge with the support of a network of champions to improve experience overnight by raising awareness, reducing noise, minimising patient ward moves overnight, promoting good environmental maintenance and fostering a culture of supportive sleep for patients.

A working party was established in February 2012 which saw the launch of the Night Charter; a set of simple principles informing staff of how to achieve an improved service delivery overnight. This encompassed good housekeeping, clinical management systems and good practice quality standards. The working party continues to meet quarterly to review the application of the charter, challenge incidents raised overnight regarding patient experience and put into place actions to raise awareness and address specific issues. Their work is linked closely to the Friends and Family Test data analysis, the smiley face feedback processes, complaints and the national inpatient survey.

Some of the actions and quick fixes revolve around installation of silent closing bins in patient areas, enforcing the professional presentation policy, of rubber soled shoes, mobile telephone devices to prevent phones ringing unanswered for long periods disrupting patients sleep, challenging behaviours, ensuring hushed tones and minimising patient moves overnight.

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Same Sex Accommodation During the year the Trust has made a significant improvement in eliminating the numbers of patients who experienced mixed sex accommodation. We are able to report there have been no single sex breaches during 2013/14.

PLACE (Patient Led Assessment for the Care Environment). The programme is an annual self assessment process. Assessments would have normally been carried out in February 2013 for this Trust; however the process is changing for this year. It will now be known as PLACE (Patient Led Assessment for the Care Environment). The assessment calendar will now run from April to June and results will be issued in September/October time. We will be given six weeks’ notice of the week we have to hold the assessment in and scores will be reported the following week to the Information Centre. The scoring system has changed and will now be either a Pass, Qualified Pass or Fail for each area visited. Our team must be made up of at least 50% patient representation to staff ratio and a separate summary sheet will be completed by our Patient Representatives.

The actions and recommendations that came out of last year’s assessment have been implemented to ensure patient safety is not compromised.

The recent confirmed PLACE scores for 2013/14 This year’s PLACE assessment programme was carried out between April and June 2013, in which all 4 hospitals were assessed including the ward at Arden Court. The whole format for the assessment has changed with greater participation from our Patient Representatives/Governor, more in depth paperwork and a change to the scoring system. On all counts, if there was debate about the grade to be given on any area our Patient Representatives had the final decision. The week of the assessment was set by the The Health and Social care Information Centre 6 weeks in advance, we could then allocate the actual day.

Trust staff including a Matron and Hotel Services staff, together with the chair of our Patient and Public Forum attended a half day training session in Birmingham, we then trained all other members that were to take part in the assessments. This was well received and meant that everyone had a clear understanding of what was required on the day. This year there were 35 people involved over the 4 hospitals: 2 teams consisting of 2 patient representatives and 2 Trust members of staff for Stratford, Ellen Badger and Leamington Spa Hospitals including Arden Court and 5 teams for Warwick Hospital. We also placed an additional neutral person in each team to act as the scriber. Fundamentally the content was the same as in previous years with Cleanliness, Condition/Appearance and Maintenance (Environment) Privacy and Dignity, Hand Hygiene, Staff appearance, internal areas, External areas and Food but each section was more in depth with more elements having to be answered. A set of organisational questions on Food, Procurement, Buildings and Facilities, Privacy and Dignity and first impressions a) (as you walk on to the ward) and b) (when you had finished the assessment) had to be answered. The question on first impressions definitely made the team aware of the environment that they were walking into and fits with the 15 steps survey that the Trust are now carrying out. Once the assessment had been completed and before leaving each site our Patient Representatives were required to complete a summary paper to confirm that it was true reflection of the day and that Trust team members had not pressurised the outcome of the scoring. Action plans have been put together, some areas have already been visited where a fail was scored to see if any interim work could be carried out and these areas have been discussed with the Director of Nursing. Action plans have been distributed for the appropriate person to action and report back to Hotel Services. All plans will be RAG rated and will updated as work is complete, for any areas that will need a larger amount of money than we can fund through our PLACE monies these will be taken forward through other channels such as the Capital Committee.

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Summary of Scores Below is an overview of all scores for each hospital. Overall some 3000 elements were checked during this round of assessments, this year the official scoring system from the Health and Social Care Information Centre has been show in a thermometer format and that there is no pass or fail mark. This % is calculated by reference to the score achieved expressed as a % of the maximum score possible

Leamington Ellen Warwick Stratford Spa Badger Hospital Hospital Hospital Hospital

Cleaning Cleaning Cleaning Cleaning 94.19% 97.30% 97.15% 99.25%

Food and Food and Food and Nutrition Food and Nutrition Nutrition Nutrition 85.7% 79.72% 92.36% 91.61% Privacy and Privacy and Privacy and Dignity Privacy and Dignity Dignity Dignity 79.16% 90.45% 85.05% 90.94% Condition Condition Condition Condition appearance appearance apearance apearance maintainance maintainance maintainance maintainance 89.19% 93.85% 92.16% 93.40%

Data source: PLACE Assessment data

157 Nutrition and Hydration Nutrition is at heart of good health. To help us improve our food service, Patient surveys were carried out during the course of the year, to ascertain patient experience of the food at our hospitals. Surveys were distributed and completed by inpatients randomly selected across all wards.

Quality Priority 2013/14 - Patient food Improve the patient experience of food service

At all hospitals, choices on the patient menus have been changed to reflect comments received either after discussion with patients, from patient surveys or from discussions with ward staff. . All the hospitals have also retained the Gold Award for Food Hygiene and Safety awarded by Warwick District Council.

Catering, domestic, portering and security services are outsourced to an external service provider. These providers must ensure they meet our Trusts requirements and to ensure an excellent patient experience whilst in the care at any of our hospitals. The service provider until February 2014 was G4S, who are an established service provider and have achieved the British Standards UK accreditation - BSI 22000 for Food Safety and Hygiene last year.

From February 2014 the chosen supplier is AMEY.

Warwick and Stratford Hospitals On average 84% of in-patients felt the service they received was either excellent or good. For the period April 1st 2013 to March 2014, the chart below highlights the results for the catering surveys carried out at Warwick and Stratford Hospitals. In total 1000 responses were received within this period.

Percentage of patients who stated that the food service they received was EXCELLENT or GOOD 86 88 86 87 87 84 84 81 80 83 82 July May June April March August January January October February December November November September

Data source: Patient Meal satisfaction survey

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Leamington Spa, Ellen Badger Hospitals and Arden Court On average 95% of in-patients felt the service they received was either excellent or good.

For the period 1 April 2013 to 31 March 2014, the chart below highlights the results for the catering surveys carried out at Leamington Spa Hospital, Ellen Badger Hospital and Arden Court.

In total 379 responses were received within this period.

Percentage of patients who stated that the food service they received was EXCELLENT or GOOD 100 96 97 96 97 98 91 90 89 87 85 83 July May June April March August January January October February February December November November September

Data source: Patient Meal satisfaction survey

The Trusts Hotel Services Team and Matrons continue to focus on improving the overall patient meal experience. At Warwick Hospital the emphasise has been particularly around food temperatures with the focus on boosting the meal trolleys after the meals have been loaded just prior to the trolley leaving the catering department. This process has shown a heat retention benefit of around 4 -5C. We continue to monitor portion sizes and the quality of food provided to patients. We are working closely with Ward Managers and staff to improve the meal service delivery at ward level. Community hospitals introduced the use of the patient diet strips and notice boards and all staff including catering assistants received training on these. The boards were not successful on Campion Ward or for Chadwick Ward, at the Central England Rehabilitation Hospital, as different methods of communicating dietary needs are in place. Re -training for all healthcare cleaning staff in the use of the patient diet strips and notice boards above the patient’s beds was reviewed again during the year. Competent checks are carried out by the Contract Managers and Supervisors on an on-going basis. At all hospitals, some of the choices on the patient menus have been changed to reflect comments received either after discussion with patients, from patient surveys or from discussions with ward staff. The Nicol Unit at Stratford hospital is now using the same 3 week menu cycle as at Ellen badger and Leamington Spa Hospitals. This menu includes seasonal food changes. All the hospitals have also retained the 5* Award for Food Hygiene and safety awarded by Warwick or Stratford council.

Screening and Management of Malnutrition Dietetic and Nursing staff continue to actively support the Warwickshire Nutrition Pathway for hospitals and the community for patients who are malnourished or at risk of malnutrition. The pathway is based on the British Association for Parenteral and Enteral Nutrition (BAPEN) Commissioning toolkit - Malnutrition

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Matters: Meeting Quality Standards in Nutritional Care – A Toolkit for Commissioners and Providers in England. Key areas of work: Malnutrition Universal Screening Tool (‘MUST’) embedded across all wards and community teams in Warwickshire Oral Nutritional Supplement prescribing pathway in the hospitals continues Countywide referral criteria for Dietetic services Nutrition Screening and Assessment training – cascade training at ward level Auditing Nutrition Screening to meet requirements for Nurse Care Indicators and CQC Outcome 5

Objectives for the next 12 months: To improve training compliance for MUST as figures are currently 56.8% community staff and 39.6% acute staff To improve the compliance of MUST assessment and the correct implementation of care plans for ‘at risk’ patients, especially in the acute Trust

The Warwickshire Dietetic Service conducted an audit of the MUST tool within the hospitals across Warwickshire in 2013 and this concluded that the majority of patients had a MUST completed. However, only two thirds were filled out within 24 hours of admission. There were some other learning needs identified and it was recommended that the results from this audit should be shared with the ward managers and Nutrition Steering Committees as appropriate, who can feedback the results to the nursing staff.

Summary of audit results

Average % compliance NCI April – December 2013 In-Patients Integra Elective Emergency ted Is there a completed Nutritional Assessment (signed and dated) 93% 87% 98% If the patient is 'at risk' has a Care Plan, demonstrating nutritional support interventions, been completed? 57% 62.5% 91%

Community Teams Community Nutrition KPI Audit (November 2013) All patients who receive planned sequence of care 95% should be assessed for their risk using a recognised evidence based tools for developing a pressure ulcer, dehydration and malnourishment and falls Data source: SWFT Nutritional Assessment Quality KPI Audit

The Trust continues to encourage staff, friends and relatives, and volunteers to actively participate in enhancing the patient’s experience with regards to nutrition and hydration. The Productive Meal Service is well embedded resulting in the patients receiving hot food in a timely manner. In addition ‘Let’s do Lunch’ and ‘Tea for Two’ continue to be promoted across the Trust. Visiting times across the Trust have been expanded to include meal times to support ‘Lets do Lunch’ and encourage relatives and visitors to participate in mealtimes. Hotel Services and food service providers are working closely with nursing teams to look at alternate catering options with a view to delivering an improved patient service by the end of the year. The Trust also participates in a week long Nutrition and Hydration Awareness event, where the importance of good nutrition and hydration is highlighted by a series of events and activities across both acute and community hospitals.

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Specialist Nursing Services Palliative Care Team (Macmillan Service) This service is offered county wide and offers a series of interventions to address symptom control, advice and support for all professionals, patients and carers, signposting to specialist sources of help, support around the preferred place of death for a patient and bereavement services.

Work continues in the community to encourage the use of the supportive care pathway. The Community Palliative Care Team put an education programme in place for 2013 to support other professionals in end of life care.

The transforming end of life project commenced at Warwick Hospital in 2013 with the appointment of the project lead in October 2013. The aim of the project is to improve patient experience in relation to dignified end of life for patients, carers and families specifically related to advanced communication, symptom control and discharge planning. An advance care plan which includes Do Not Attempt Resuscitation order has been introduced across the county and was supported by a programme of education. Rapid discharge home processes have also been reviewed and are currently being trialled on Castle and Willoughby wards. Improvements will be incorporated and rolled out to all wards. An electronic Palliative care register is being developed as a countywide process and the Trust is helping to implement this. This will improve coordination and make patient’s wishes for end of life known to all staff they come into contact with. A new end of life personal care plan is being developed and will be ready for implementation early summer this year. An AMBER Care Bundle Facilitator is currently being recruited to work with staff to identify those patients for whom the outcome is uncertain. This will help put in place the details of advanced decision making. The whole programme is supported by a robust training plan, facilitation and support for staff in improving end of life care for patients. The two year programme will focus on 12 wards in year one and 12 in year two. The programme is also supported by the identification of 10 clinical champions who will attend quality at end of life care and assessment training (QELCA). This helps clinical champions to make changes at ward level quickly to improve care. The training commences in May 2014.

161 Working with others to improve Patient Experience

Our core purpose is to provide high quality NHS healthcare services that meet the needs of our patients and the population that we serve. In order to help us improve quality, we work with stakeholders and partake in various initiatives.

Stratford and Warwick Hospitals Patient Forum One key programme is the work with the Stratford and Warwick Hospitals patient Forum. It is now four years since the Patient Forum was established as an independent body by the trust with the vision to improve the patient experience at our hospitals. The role of this independent Patient forum is to: - Monitor and review the services provided by the Trust for patients - Ascertain the views of patients, users and carers - Prepare and carry out a published work plan for each year - Make regular reports and recommendations to the Trust based on the work plan and the views of patients and the public Patient Forum’s work plan for 2013/14 Cleanliness Inspections - Continue with a programme of full inspections each year of wards and departments. The inspections will include aspects of privacy and dignity for patients. Food Matters - Monitoring and audit of protected mealtimes, the red tray scheme, belt to service, ordering of meals and wastage. Pharmacy Matters - Monitor the impact of electronic prescribing and follow up on any other medication issues. Inform Visitors about the Forum - Update Forum Notice Boards. Updates and other steps to be developed. Establish Liaison with All Wards- Members to become known to ward managers and visit allocated wards as appropriate. CHIEF (Community and Hospital Information Exchange Forum) - A continuing programme of two-hour meetings every other month with one topic chosen by the meeting and one by the Trust. Emergency Patient Pathway including Ambulatory Pathway, Second Phase - to investigate the Patient Experience in these areas of the hospital. Stratford Hospital Development - to monitor developments. Leamington Spa Hospital - to monitor developments. Ellen Badger Hospital - To monitor the patient experience. Appointments - To monitor progress in improving the appointments process including data on rescheduled appointments and patient "no shows". Discharge Process, Pathway into Community - To investigate the process and patient satisfaction. End of Life Care - To investigate procedures in place to care for patients who are reaching the end of life. This will include examination of the implementation of the Liverpool Pathway which is under examination by the NHS. The forum has compiled an annual report which provides a review of the work carried out during 2012/13, This can be obtained from the Stratford and Warwick Hospitals Patient Forum by contacting the Trust.

Kissing it Better Kissing it Better’ is about sharing simple healthcare ideas. It is also about harnessing the energy of the most dynamic groups in a local community and inviting them to use their specialist skills to make a difference to the care of patients and their carers within hospitals and care homes.

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We have been working with ‘Kissing it Better’ for the past year, the scheme has involved harnessing the energy of the local schools and colleges and inviting them to use their specialist skills to make a difference to the care of patients. By making small changes we can create a positive patients experience in hospital. This year we have had students from a number of schools and colleges visiting the hospital and making a difference. Hair and beauty students visit once a week and provide a pampering session for our older patients. We have some students that sing popular songs when they visit the wards and departments; we recognise that music therapy is especially beneficial for people living with a dementia. Patients also really enjoy having short stories and poems read to them. Health and Social care students have started a voluntary long term placements with us, this enables them to obtain valuable work experience but also gives an opportunity for the students to talk to patients and take part in Tea for Two, a scheme where we encourage our staff to sit and enjoy a cup of tea and a chat with a patient that may not be having any visitors.

‘The Fifteen Steps’ challenge Quality from a patient’s perspective- the type of care you can expect to receive on entering any clinical area is identified within the first fifteen steps. The challenge helps us to gain an understanding of how patients and service users feel about the care provided and what gives them confidence. It can also help organisations to understand and identify the key components of high quality care that are important to patients, services users and carers from their first contact with a care setting.

The purpose of the 15 Steps Challenge is:

to help staff, patients, service users and others to work together to identify improvements that can enhance the patient or service user experience to provide a way of understanding patients’ and service users' first impressions more clearly a method for creating positive improvements and dialogue about the quality of care

A working party made up of Patient Forum members, executives, clinicians, non clinical and Foundation Trust Members visited the acute wards using the following four questions:

1) Is it welcoming?

2) Is it safe?

3) Is it caring?

4) Is it organised and calm?

We wanted to ensure that the environment and culture is customer focused, patients are seen as people first, illness second. Supporting staff to empower and encourage patients to be involved in their care and strengthening partnerships for public participation and engagement.

Having completed the wards 15 steps feedback there were lots of positive experiences and so these were put it into a picture 'woordle' together with some narrative and recommendations. It needed to be quick and easily digested as it is for staff information and staff areas only, the idea being to take from it key words and emerging themes on how the ward 'felt'/ initial impressions.

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164 Patient Outcomes Hospital Mortality Rates Quality Priority 2013/14 - Mortality To improve systems to further reduce mortality rates

In the last year, our overall mortality rates remain within the average range for NHS Trusts in England. A variety of mortality indicators have been developed, which use different methods to adjust for differences in age, gender, time range and palliative care coding. Trends for SWFT are similar on all these measures. Overall, rates are downward. Mortality rates have been described as, “A smoke alarm” which should always be checked even if the site of the problem is thought to be already known. A variety of mortality indicators have been developed, which take in to account patient factors such as whether an admission was emergency or elective, age, gender, diagnosis when first admitted to hospital, important co-morbidities, whether receiving palliative care, and the relative affluence of the area where the patient lived. Trends for SWFT are similar on all these measures. In the last year, our overall mortality rates remain within the average range for NHS Trusts in England.

What we have done We monitor trends in overall mortality, and discuss contributing factors at our monthly Mortality Surveillance Committee. The Committee is chaired by the Trust’s Medical Director, and has external representation from the local Clinical Commissioning Group and the Local Area Team. The Committee initiates work relating to patient mortality. For example, it has commissioned a report to look at whether mortality rates are higher in patients admitted at the weekend and found that there is no increase. We also monitor mortality rates within specialties at the Mortality Surveillance Committee. We compare well in most areas. Reports on the mortality within each speciality are produced and each month, the speciality lead presents a response to the Committee. Where mortality rates for specialties are high compared to the previous year or with peers, we have undertaken specialty mortality reviews, and developed comprehensive action plans, leading to reductions in mortality rates. The Trust also receives monthly data from CHKS which compares mortality rates by condition with other similar sized organisations. If the Trust is identified as having a higher mortality rate for a specific condition, a further review of this group of notes is conducted to ensure that appropriate treatment was given. Mortality data is discussed monthly at the Trust Mortality Surveillance Committee,

Mortality reviews The Trust sets a standard for all individual deaths to be reviewed and we have introduced new systems to support compliance with this standard, as well as making participation in mortality reviews part of Consultant job plans and an essential requirement for revalidation. Any areas where patient care may be improved identified by these reviews are widely shared within the Trust and actions taken. We have strengthened oversight of mortality reviews thorough our Audit and Operational Governance Groups which report monthly to the Mortality Surveillance Committee. The Audit and Operational Governance Groups and the Mortality Surveillance Committee report to the Clinical Governance Committee on a quarterly basis, which reports to the Trust Board of Directors. Mortality figures are reported to Trust board on a monthly basis in the Integrated Quality dashboard.

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Data source: CHKS Data

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Summary Hospital-Level Mortality Indicator (SHMI)

SHMI is the ratio between the actual number of patients who die following a treatment at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.

It covers all deaths reported of patients who were admitted to acute, non-specialist trusts and either die while in hospital or within 30 days of discharge.

The data used to produce the SHMI is generated from data the Trust submits to the Secondary Uses Services (SUS), linked with data from the Office for National Statistics (ONS) death registrations, to enable capturing of deaths which occur outside of hospitals. Additional contextual indicators are also published alongside the SHMI to add some context to the interpretation of the SHMI.

South Warwickshire NHS Foundation Trust’s latest SHMI value for the 12 months June 2012 to June 2013 is 1.05 which is “as expected”.

How to use the SHMI

The SHMI requires careful interpretation, and should not be taken in isolation as a headline figure of trust performance. The SHMI is an indication of whether individual trusts are conforming to the national baseline of hospital-related mortality. Mortality within a trust is described as being either “as expected”, “lower than expected” or “higher than expected”. All trusts are encouraged to explore and understand the activity which underlies their SHMI from their own data collection sources.

Care of Patients with a Dementia Quality Priority 2013/14 - Dementia Fully implement frail elderly care pathway to include dementia screening & dementia sensitive services

For the year 2013/14 the focus has been placed on embedding the evidence based care bundle derived from ‘The Delivering Excellence in Dementia Care in Acute Hospitals’ project based on the composite module of New Cross Hospital, Royal Wolverhampton NHS Trust and the annual National Audit of Dementia Care and Anti-psychotic Prescribing. It provides support and signposting for carers and relatives of people living with dementia and measuring their experience of the support they have received. It also secures funding to enhance the inpatient environments on the Warwick site to improve signage and identification of areas to support people living with dementia whilst they are in hospital.

The project team called the Dementia and Elderly Care Action Alliance (DECAA) led by the Trust’s clinical lead for dementia, has been instrumental in the implementation of the care bundle, supported in practice by the dementia champion network. The care bundle supports the use of the getting to know the person concept, utilising the Alzheimer’s Society’s ‘This is me’ document, adopting the ‘Butterfly Scheme ©’ endorsed by the Department of Health (DH) which aims to support a person with dementia in an unfamiliar environment by the recognition and application of a specific care response from all Trust staff. It also empathises the need for nutrition and falls assessment and appropriate care planning and the expectation to review any established anti-psychotic medication and prescribe with caution under specialist advice. Establishing engagement with the person living with dementia and their family onto the Butterfly Scheme© provides the opportunity to support carers and signpost them to dementia literature, services and websites or portals. As part of this year’s Commissioning for Quality & Innovation (CQUIN) schedule, we have established a system for measuring the support carers have experienced, working collaboratively with the DH to measure carers support and the success of the care bundle. The number of responses has been low, since we launched the postal survey in November 2013 but the detail of information allows us to

167 review our processes and practices, celebrate success and address areas of concern. The focus on dementia awareness training and been maintained and is delivered across many forums including our contract staff, with our greatest success having achieved the recognition of the mandatory requirement for all Trust staff to have dementia awareness training. It is now an integral element of the training programme for annual mandatory training.

Following this year’s Patient Led Assessment of the Care Environment (PLACE) inspections, we have secured some funding to improve some of the inpatient areas within the acute site. We have worked with a nationally accredited, dementia friendly signage company and are in the process of modifying 5 of our acute wards to become more dementia friendly, with clear, pictorial signs, for bays and bathrooms, orientation boards and floor graphics to support safe mobilisation.

168 Process to Improve Care for Emergency Medical Admissions Quality Priority 2013/14 - Discharge process Improve the timeliness of the discharge process for Patients

The Trust has been working on improving the timely access to care for patients admitted as a medical emergency for a number of years. There are 4 principles for the redesign of the service that have been implemented which have enabled patients to be treated and discharged rapidly.

Assess before Admission Early Access to senior clinicians Standardised care processes in hospital wards Discharge to Assess model of care

What we have achieved… Assess before Admission 9 We have developed an ambulatory emergency care clinic 7 days a week which is located alongside our medical assessment unit. Patients are referred to the clinic by GP’s or by the A&E department if they are safe to be cared for in a non-bedded environment. 9 GP’s have access to discuss patients with a consultant acute physician 7 days a week. 9 Our Community emergency response team (CERT) provides a 2 hour response to any patients in the community who is referred to them – 7 days a week.

Early access to senior clinicians 9 We have invested in our A&E consultant staff so that they are on site 7 days a week and provide on-call cover 24/7. 9 We have invested in our team of consultant acute physicians so that they are now on site 7 days a week providing consultant led care for all emergency patients. 9 We have developed a specialist frailty assessment unit for older patients admitted as an emergency with care provided by a multi-disciplinary team of old age specialists. 9 There is on the day access to all our specialist teams on weekdays.

Standardised care process is hospital wards 9 All medical wards now have a consultant of the week model to ensure continuity of patient care. 9 We have set a standard that all diagnostic tests will be completed within 24 hours of request. 9 We have implemented standardised Board and ward rounds in all our wards and set expected date of discharge with patients so they can plan for going home with their families. 9 We have implemented nurse-led discharge for patients with specific diagnoses or after surgery.

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Discharge to Assess 9 We have developed three ‘Discharge to Assess’ pathways for patients who cannot be discharged home without support – so that no patients should have to stay in hospital for assessment of their on-going needs. These pathways support patients at home, in community hospitals and in temporary residential and nursing homes. 9 There is a ‘trusted assessment’ process in place so that hospital staff can restart packages of care for patients and refer to reablement services without a social worker needing to be involved. 9 Over 150 patients a month are now seen in the ambulatory emergency clinic and 75% are discharged home on the same day. 9 We have avoided the admission of over 20 patients a week through the CERT team response to patients at home. 9 Nearly 50% of patients admitted as an emergency are now discharged home within 48 hours. 9 Over 95% of patients referred for a specialist opinion or diagnostic test are seen within 24 hours of referral. 9 Length of stay for patients admitted as an emergency has reduced by over 1 day 9 The Trust had met the A&E target for admitting or discharging 95% within 4 hours

Improving the Discharge Pathway Improving the discharge process for patients remains one of the Trust’s key priorities. Evidence shows that often, frail elderly patients are unable to make the right decision about their future long term care when they are in hospital, still recovering from an acute illness or accident. The Trust has focused on developing a number of discharge pathways with partnership organisations in order to provide integrated health and social care services, to enable patients to receive the right care, at the right time in order to make an informed choice and receive a better outcome.

What we have done and achieved Implemented a further 2 discharge pathways from the ‘Discharge to Assess’ (D2A) model. Embedded the electronic Common Assessment Tool (eCAT) that delivers ‘trusted assessment’ between health and social care as ‘normal business’ following on from last year’s success. Audited the quality of Multi-Disciplinary Team (MDT) meetings at the acute site of South Warwickshire NHS Foundation Trust.

Discharge to Assess (D2A)

Discharge to Assess (D2A) is a transformation project that builds on local developments designed to move care closer to home for patients and reduce unnecessarily prolonged acute hospital stay. It is a multi- agency project working with the Local Authority (Warwickshire County Council) and South Warwickshire Clinical Commissioning Group (CCG). There are 3 patient discharge pathways:

Pathway 1 - For patients who can directly return home with additional support from either the Community Emergency Response Team (CERT), part of Intermediate Care or Reablement, provided by Warwickshire County Council. This pathway is already in place and working well, and on average 30 patients are referred for these services via the electronic Common Assessment Tool (eCAT) and discharged per week.

Pathway 2 - For patients who cannot be discharged directly home, but have the potential to do so, if given a further period of additional rehabilitation and assessment. Patients requiring this level of support are offered a number of settings away from the acute hospital, in accordance with their level of care needs.

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Pathway 3 – This is for patients, often with multiple complex needs and where Continuing Health Care (CHC) eligibility is a possibility. Patients are discharged to one of three commissioned nursing care homes in order to recuperate and are assessed for CHC eligibility in an environment appropriate to their health and social care needs.

A pilot commenced in July 2013, which has subsequently extended to June 2014, to implement discharge pathway 2 and 3. On behalf of the CCG, 30 beds were commissioned by the Local Authority in 3 nursing care homes including Dementia specialist care to allow South Warwickshire patients a period of recovery, therapy and further assessments for up to a maximum of 6 weeks. A service specification was drawn up exclusively for this pilot for the 3 care homes to ensure that patients received ‘enablement’ as opposed to care more traditionally given in such settings. Both discharge pathways are for patients over the age of 18 years, although predominantly relate to the frail and elderly, including those with a cognitive impairment. The only exclusions are patients requiring a restart in care packages, and some specialised pathways including ‘end of life’ care.

Patients are given information and formal consent is sought prior to discharge to either pathway to one of the 3 care homes. South Warwickshire NHS Foundation Trust provides case management for each patient on both pathways.

All patients on both pathway 2 and 3 are discussed at a weekly Multi-Disciplinary Team (MDT) meeting at the relevant nursing care home. The MDT incorporates a General Practitioner (GP), the care home manager, senior nurse at care home, Discharge Co-ordinator and therapists from South Warwickshire NHS Foundation Trust’s Community and Integrated services division, as well as a designated social worker from the hospital social care team.

To date, since the pilot commenced, approximately 150 patients have entered pathway 2 and 3; the majority of which have been pathway 3. This is as anticipated, in view of the fact more people are being discharged directly home from the Trust through pathway 1 or by accessing other discharge routes, as well as transferring to Community Hospitals for further rehabilitation.

D2A Beds - Total Number of Patients Discharged from Acute Trust to Pathway 2 and 3

26% Patients discharged to Pathway 2 Patients discharged to 74% Pathway 3

Data source: Discharge to Assess dataset

During the pilot, 24% of suitable patients refused to be discharged onto pathway 2 or 3. The main reason attributed to this was found to be geographical location, rather than the nursing care home being an interim placement. This is an area for future consideration through the evaluation of the D2A pilot in the forthcoming months.

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A total of 94 patients have been discharged from the pathways. Patients on pathway 2 were enabled and predominantly went home with support either from CERT or Reablement (Pathway 1). A small minority, were discharged to a permanent residential care home setting.

D2A Beds - Number of Patients Discharged from Pathway 2 & Destination 7% Patients discharged directly home from Pathway 2 Patients discharged into 93% 24 hour care home from Pathway 2

Data source: Discharge to Assess dataset

In contrast to this, patients on pathway 3 were discharged mainly to permanent 24 hour care, either residential or nursing; with some requiring specialist Dementia care homes; with a small minority returning home with long term support/care packages.

D2A Beds - Number of Patients Discharged from Pathway 3 & Destination

Patients discharged 17% directly home from Pathway 3 Patients discharged into 24 83% hour care home from Pathway 3

Data source: Discharge to Assess dataset

The qualitative feedback so far indicates that the continuity of discharge planning by the Trust across acute and nursing home settings, benefits patients, families, primary care and the Local Authority. Equally the continuity of discussion around clinical management plans and ‘ceiling of care’ with patients and families , including the transferable DNAR sleeve for patients, has ensured that patients receive the right information to make informed decisions about future treatment as well as reduce the likelihood of unnecessary readmission to the Trust. Patients have benefitted from having a further period of assessment outside the hospital setting; as some results have shown patients that have experienced challenging behaviours or Delirium in the acute hospital have settled once in the right environment with the right support, and given the right amount of time. Equally, some patients that haven’t displayed challenging behaviours in the acute hospital, have exhibited these whilst on the pathway; as they have recovered it is likely they have returned to their pre admission status, and therefore it is likely they would have been discharged to the wrong setting if they had gone directly from the acute hospital, rather than onto pathway 2 or 3. Patients and families have indicated that these pathways have allowed the opportunity to return home rather than enter

172 residential care prematurely; as well as more time to make long term decisions about their future care. Professor David Oliver from the Kings Fund recently visited the Trust and one of the care homes involved in the D2A pilot for pathway 2 and 3, to see some of the integrated care being developed and implemented to improve the quality and continuity of services for older people.

‘Trusted Assessment’ – eCAT Following on from the successful pilot last year (January – March 2013), the eCAT (electronic Common Assessment Tool) has now been fully deployed as the supportive tool that delivers a ‘trusted assessment’ between health and social care practitioners across acute and community services. As the goal for the majority of patients within hospital is to return home, the eCAT is currently utilised for patients requiring a supported discharge home with either Intermediate Care (The Community Emergency Response Team - CERT) or Reablement (D2A - Pathway 1).

Although the services for this pathway were already in place, the eCAT has reduced duplication of information that should be gathered as part of assessment at home, rather than in hospital. This has led to a reduction in the overstatement of needs that often occurs when a patient is assessed in an unfamiliar environment, at their most vulnerable.

This new improved way of working has equally streamlined the referral process, by removing the social care assessment in hospital to determine if a patient was suitable for Reablement, as whilst Intermediate Care has historically received direct referrals from health teams, Reablement had not. This direct referral has reduced a prolonged length of stay for this specific group of patients.

The eCAT embedded as ‘normal business’ has resulted in strengthening new relationships between the organisations, shared working practices and opened up a dialogue to encourage blended care, that previous cultural barriers inhibited. This has resulted in both services providing a degree of flexibility by ‘bridging the gap’ as an interim measure for each other, when capacity is an issue, to ensure the patient has a timely discharge home. On the 31 March 2014, a refined version of the eCAT was launched in conjunction with the implementation of this tool to the North of the county, at George Eliot hospital.

Quality of MDT meetings The Trust recently audited the quality of all Multidisciplinary Team (MDT) meetings at the acute site (25/11/13 – 20/01/14), as these are crucial in dedicating uninterrupted time to discharge planning, especially for frail, elderly patients who often have multiple co-morbidities and complex transfer/discharge needs.

A total of 9 wards were evaluated to determine if the MDT meetings were operating on a weekly basis and consistently add value as part of the discharge process. The findings verified that all 9 wards have pre planned, consistent, weekly MDT meetings and representation by the core membership, as the quorum of 65% of the membership attending to be of value, was achieved 97% of the time. The core membership includes Consultant, ward nurse, Discharge Co-ordinator, allied health professionals and a social worker. Attendance by individual members of the MDT ranged from 76% to 100%; with Consultants and Occupational Therapists (OT’s) achieving 100% throughout the audit to social care attending 76% of the meetings. It was evident social care attendance had dramatically improved in comparison to a previous audit whereby only 28% of MDT meetings had a social care representative. Some of this improvement may be attributed to the implementation of the various new discharge pathways and trusted assessment within D2A, which has released capacity and reduced some of the work traditionally associated with social care colleagues in the acute Trust.

It was clear that these regular MDT meetings contribute in determining patients accessing the right discharge route and pathway in a timely fashion, through the representation of health and social care colleagues, who often have more specialist knowledge and understanding of local services. This was apparent during the audit, as although there was a good understanding of pathway 1, the other 2 pathways were not as clear to all members of staff. This is something the Trust will need to clarify and reiterate through a number of communication mediums, if the decision is to fully embed these pathways as a normal process once the evaluation of the pilot has been completed.

173 Continuous improvements… Quality Priority 2013/14 - Booking appointments Implement an improved appointment process

We set 2 targets for improved booking processes;

•Past performance: 3% + of all OPD appointments cancelled at short notice short notice • Target set of 2% cancellations • Year to date performance: 1.7%

• Past performance: Over 8% of appointments rescheduled Rescheduling of • Target set of 6.5% appointments • Year to date performance: 6.1%

We have developed a project to integrate our in-patient and out-patient booking teams based around specialties – so that the team can meet the needs of patients and clinicians as a ‘one stop shop’. Improving the patients experience is an aim of this work and will be monitored through Trust patient surveys.

81% of our patients said their appointment have not been changed against a national benchmark of 78% (source: OPD Survey).

Transformation Programme What is the Transformation Programme and why was it developed?

Quality Priority 2013/14 - Community Services Put in place a new system for booking and co-ordinating Community services

Following the integration of Community Services with South Warwickshire NHS Foundation Trust (SWFT) in April 2011 and collaborative working in the North of the county, SWFT aims to reduce the overlap between hospital and community services and strengthen collaborative working with primary care.

The vision of integration is to deliver quality locality based community health services, responsive to patients needs through a skilled workforce, productively serving the local population with dignity and care. There are currently 8 areas being reviewed and developed within the Transformation Programme as detailed overleaf:

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What has the Transformation Programme achieved and what are the benefits to patients? The information below gives a flavour of some of the transformational work taking place under the Programme:

Care of Older People - What are our goals? - To develop Integrated Health Teams to include Urgent Response to enable us to support patients in crisis at home to prevent admissions to hospital where possible. - To arrange an assessment and on-going support for patients at home in the immediate period following a hospital stay to promote earlier discharges. - Provision of a Comprehensive Geriatric Assessment undertaken within 24 hours of patient arriving at Warwick Hospital, 7 days per week.

What are the benefits to patients? What have we done so far? Next steps Where appropriate, patients’ health In the North of the County - needs supported by Community Through the introduction of the CERT Team, George Review of Services Services allowing them to remain in Eliot Hospital saw a reduction of the length of stay for at Ellen Badger their usual place of residence patients, cutting at least 1 day off their average. Hospital and scoping thereby maintaining their based on the Nicol independence. Community Services teams were enlarged to be able to Unit and Arden Ward receive more referrals to ensure patients can be treated model. Where admission to hospital is in their own home rather than staying in hospital necessary, clinical teams will (Increase of 133% to Intermediate Care Services, 30% Development of a ensure patients are supported to to Virtual Ward). CERT response in return home at the earliest possible the East of the opportunity thereby reducing their In the South of the County - county in conjunction length of stay in hospital. On the Nicol Unit: with UHCW, Rugby Refurbishment to Nicol Unit has delivered an enhanced St Cross Hospital Reduced likelihood of readmission healing environment with positive feedback received and Coventry to hospital. from patients and staff. Community Services.

Partnership working will ensure that More patients are being seen, on average an increase patients receive quality, seamless of 32% and the average length of stay has reduced care. from 28 days to 19 days.

Improved patient experience and An audit on the use of sedatives prescribed has seen clinical outcomes. much less use of sedatives and anti-psychotic drugs. Patients receiving these reduced from 60% of patients to 25%.

South CERT: Direct referrals from GPs to CERT Team has seen a dramatic increase, these means that significantly more patients are cared for at home rather than having to be admitted to hospital. This has helped by freeing up capacity for patients who are in need of a hospital stay.

Arden Court: In March 2014, the decision was taken to relocate this service within the main hospital site. to meet the needs of the patients who require some additional support prior to going home following a hospital stay, or require a little more support than can be provided in their own home so that they do not need to be admitted to an acute hospital setting.

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Long Term Conditions - What are our goals?

To develop services for patients with a long term condition (e.g. Diabetes, Respiratory Disease, Heart Conditions) to help them to have healthy active lives and reduce the need to come in to hospital.

We are currently scoping the work that is required across a numbers of organisations including health, social care, mental health and voluntary and private sector organisations to make this a truly joined up system.

Musculoskeletal – What are our Goals?

To make it easier to access Orthopaedic services and to make the way that the patient travels through the system more consistent.

What are the benefits to What have we done so far? Next Steps patients?

Patients access the right The Knee, Shoulder, and Foot Auditing that the new pathways treatment, in the right place, at the and Ankle Pathways have been are being used. right time. jointly reviewed and redesigned Review to make sure that by Consultants, GPs and duplication of diagnostics and Reducing duplication in the Clinicians and have been agreed. unnecessary follow-up system, including diagnostics. These have been communicated appointments are reduced. Improved patient experience and through a number of forums to Patient feedback to be collected clinical outcomes. ensure that everyone is using to ensure changes have delivered them to make the process the an improved patient experience. same whoever you see.

There has been a review of the Orthotics Service. A robust triage, review and discharge process has been implemented to ensure that patients receive the service closer to home in community settings and where possible a shift from bespoke insoles to off the shelf insoles and creating a “one stop shop” for patients.

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Stroke Services What are our goals?

To enhance the quality of care along the pathway to ensure care is delivered to meet or exceed nationally recommended standards Patients receive the A National Stroke Service review is being carried out, Strategic stroke review right care, in the right so we are working closely with the Midlands and East completed and place, at the right time. lead to ensure that the pathway redesign aligns with .communicated. local and national requirements. CareWhat delivered are the closerbenefits to What have we done so far? BusinessNext Case steps finalised home. to patients? A number of working groups have been set up to to develop stroke review and redesign patient flow along the pathway, services including an Reduced lengths of stay service delivery models, staffing and resource, enhanced team in the in hospital. communication and strategic impacts. community to support patients to be Better clinical outcomes. The organisation is developing a business case discharged safely and based on the local review and ensuring that this earlier and to develop Ability to self-manage aligns with the recommendations of regional review longer term health conditions and service specification for Stroke Services. rehabilitation needs in thereby increasing the community. independence.

Confirmation of resource required to deliver agreed pathways of care.

To work with partners in acute, community, social care and voluntary sectors to develop an Integrated Hospital and Community Service that is consistent, effective, seamless and communicated.

Ambulatory Care Pathways – What are our Goals? To be able to see patients in an emergency clinic to assess them to reduce unnecessary hospital admissions To be able to treat patients with identified conditions i.e. cellulitis, blood clots in a clinic or community setting or their own home rather than them having to stay in hospital Follow-up Reduction Plan – What are our Goals? To remodel our outpatient services to deliver a more efficient appointment booking system To meet the targets to see patients within the national guidelines of 18 weeks

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What are the benefits to What have we done so far? Next steps patients? The provision of a quality and On-going review of long waiters Whole system change to needs driven outpatient service. to understand why patients are outpatient services to improve Outpatient appointments waiting a long time for their access and waiting times. available within the required appointments. Capacity to see new patients timescales. Identification by specialty of within the 18 week target due to The ability to be fast-tracked pathway changes to improve the released capacity. back in to the system if system and meet the needs of appropriate. the patient and organisation.

The changes to patient pathways through the transformation work undertaken so far have created different requirements for community and hospital based staff. The aim of the Workforce Integration projects is to develop community services to deliver care that is universal, integrated and easier to access through ‘Integrated Teams’

Integrated Health Teams: ‘right care, right place, right time, first time’

Elements that will make up an integrated team:

Long Term Conditions Team Long term condition teams have now been integrated into all teams throughout Warwickshire. The focus remains on managing patients with one or multiple long term conditions in the community through an integrated health care pathway. The main aim of this element of the team is to prevent unnecessary hospital admissions but also work with colleagues to promote a safe and timely discharge for patients from acute hospitals. The teams are engaged in the development of a self-care model of health supporting and teaching patients about their individual conditions. This allows individuals to monitor their own health care status. However, when there is significant exacerbation of the symptoms the long term conditions element of the team are able to respond quickly to provide a clinical management plan to treat patients in their own homes. Surveys have suggested this leads to better outcomes for patients, increasing quality of life outcomes in terms of their own management of their long term conditions.

Urgent Response –Community Emergency response Team (CERT) Urgent response is available in all Integrated Health Teams. It provides a rapid response rehabilitation service at short notice, including nursing and therapy to enable people to stabilise from an acute episode that might otherwise have resulted in an acute hospital stay (step up care) or following acute hospital treatment (step down care). This element of the service helps prevent unnecessary hospital admission and also facilitates safe early discharge from a hospital environment.

Urgent response sits within the intermediate care element of the team and can undertake assessment of needs within 2 hours of initial referral. This consists of a range of Intermediate Care components such as enabling, rehabilitative and treatment services in community and residential settings to improve a patient’s independence. The patient is then transferred to the appropriate service within 72 hours.

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Urgent Response (CERT) flowchart

Intermediate Care Element of an Integrated Team Intermediate Care is available within each integrated team across the county. This consists of community based multi-disciplinary rehabilitation team providing a range of service responses for a maximum of 6 weeks. The aim of this element of the team is to facilitate the transition to functional independence so that patients can return to or remain in their usual place of residence. This can avoid unnecessary admission to hospital, and support discharge from hospital allowing patients to complete their rehabilitation and recovery at home or within a defined residential setting.

Nursing Element of an Integrated Health Team Community Nursing is a key element in the Integrated Health Team and deliver a wide range to

180 support within patients own homes and clinic bases. They deliver wound care, palliative and end of life care, continence and skin care. Also intravenous anti biotic therapy can now be delivered in a community setting. Leg Ulcer clinics have also been developed which are locality based within community settings

The Community Children’s Nursing Team (CCNT) The service continues to grow as it responds to the increased need for delivery of skilled complex/technological nursing care in any setting outside of the hospital. Our objectives continue to focus on reducing hospital admissions, facilitating early discharge from hospital for children with life changing and life limiting conditions, ensuring high quality safe care for children with complex care needs and ensuring that the views of the children, young people and their families are continually used to shape our service. Over the past few months a number of surveys have been carried out using the EleLites secured by children’s services. All feedback has been very positive from users.

Through successful partnership working with Coventry University’s research department, funding has been secured for three years to run focus groups and explore patient experience. Three focus groups have been run so far and have been very successful. A second Christmas party for the children in both Coventry and Warwickshire CCNT services is planned following the excellent evaluation last year. Again, through excellent partnership working across Coventry and Warwickshire our Consultant Nurse, the Clinical Education Lead along with her counterpart in Coventry launched e-competencies in April 2012. They are now being used nationally and have transformed teaching of all grades of staff in the care and management of children and young people with complex healthcare needs.

2013/14 has been a very busy year for paediatric palliative across both Coventry and Warwickshire, our lead nurse and consultant have continued to raise the profile through updating the national Together for Short Lives care pathways. Both CCNT’s were successful in becoming one of only four areas across England collecting palliative care data for the Department of Health. The aim of this national project is to gather data which will enable better understanding of the resources and costs of children and young people’s palliative care across England. This information will help to inform the Department of Health on the development of a classification that categorises and costs the different levels of support needed, creating a national funding system based on a per –patient tariff.

Partnership working continues with our colleagues in the local authority Integrated Disability Service (IDS). Following the successful funding in 2010 of two of our band 3 support workers, the IDS have funded a further support worker to work alongside their staff, to deliver a short break service to children and young people across Warwickshire. Funding for this very valuable service has been secured for a further year. In a recent local authority Ofsted report the staff from our service were highly commended.

Community Nursing This service is available across the county and provides nursing care to people within their own home (including residential care) or within specialist community clinics. This service is predominantly for patients who are housebound. Community nurses are currently assigned to work with specified GP Practices or work within identified geographical boundaries. The service delivers: End of life care Tissue viability Bladder and bowel management

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Nutritional support Long term conditions support IV Therapy in the Community setting All Band 6 and 7 Community Nurses who hold a caseload have been trained in the delivery of Telehealth following a successful pilot of this tool in the North Virtual Ward who now 19% of their patients using Telehealth as part of their planned care.

Family Nurse Partnership (FNP) The Family Nurse Partnership (FNP) is a preventative programme offered to first time young mothers, aged 13-19 years. The same family nurse works with families from early pregnancy up until the child is two. The programme's primary focus is the future health and well being of the child and mother. Family nurses have backgrounds in midwifery and health visiting and they receive supplementary training to equip them for their new role.

There have been a total of 108 clients enrolled to the service and caseloads are now full. Occasionally spaces arise in case loads due to attrition and we target the youngest and most vulnerable to these places wherever possible. During the recruitment phase of the programme, the target was to enrol 75% of eligible clients and the team achieved 76%.

90% of clients have additional needs such as mental health problems, leaving care, unstable living arrangements and learning difficulties. So far 9 clients have left the programme – 5 have moved out of the area and 4 have become inactive (decided to leave the programme). The fidelity goal for attrition is 40%; Warwickshire’s attrition rate is 9%. All the Family Nurses are fully resourced and have completed the pregnancy and infancy training, motivational interviewing techniques and post natal depression training. There is one further training day in March, 2012.

Learning from FNP has been shared with other services such as health visiting and school nursing; and client and agency feedback about the service has been good.

School Nursing In March this year we held a conference for school nursing at Dunchurch Park Conference Centre in Rugby, called “Celebrating Success”. Wendy Nicholson, Professional Officer for the Department of Health (DH) attended. It was timely that she came as the document “Getting it right for children, young people and families” was launched. She was impressed with the work going on in Warwickshire. She invited us to send in examples of good practise as she is collating examples from across the country. All these examples if chosen will go on the DH school nurse site and C4EO site.

We have a nurse working with Wendy at the DH looking at a young carers pathway for school nurses. One of our practice teachers from the south of the county was chosen by Wolverhampton University to be in a promotional film about school nursing as a career. We introduced a child protection health assessment last year following findings from a serious case review in Gateshead. School Nurses now see the child or young person who is subject to a child protection case conference to search for health needs. It is now embedded in practice. Many school health leads from around the region have been interested in using the assessment.

We secured funding for two members of staff to develop their teaching interests further and become practice teachers. They have just completed the course. In school nursing now we have four practice teachers.

School Nurse Assistants offer smoking cessation to young people in schools. They have seen many young people over the year. We now receive payment from the quit smoking service which will go

182 towards resources for the teams. Staff attended training put on for them specifically from the quit smoking service around advocacy and promotional branding. Due to the fantastic work that the team provide all year round, staff have been invited to attend briefings on next year’s quit smoking campaign. We were very fortunate to secure bespoke training from the Family Planning Association for staff who deliver sex and relationship education in schools. Partners from Respect Yourself have paid for two groups to go on the training which can be accredited from Staffordshire University.

Productive Community Services continues in school nursing teams. All bases will have had 5’s training and will have applied that to their areas. We have set up a focus group to look at projects that can be standardised across the county.

Health Visiting (HV) The Health Visiting Service in Warwickshire has continued to improve and embed changes as detailed in the Health Visitor Implementation Plan (DH, 2011). As an Early Implementer Site in taking this vision forward we are now in a position of helping other trusts to follow suit.

As a service we are now offering the new core offer to all families to include: Community, Universal, Universal Plus and Universal Partnership Plus. This is outlined in our new leaflet for parents and includes the 'Healthy Child Programme (DH, 2009). We will have full coverage of this programme by April 2015 as the number of Health Visitors increases and the caseload numbers reduce. We continue to closely audit antenatal visits to parents and are collecting case studies to demonstrate the difference these are making to families.

Strengthening the ‘Partnership Agreement’ between Midwives and Health Visitors across the health economy aims to improve communication and this is a key piece of work for the Trust. Strengthening further elements of the Healthy Child Programme (HCP) has also been a focus during this last year. We are currently undertaking two pilots. One to improve the two to two and a half review working with partners, specifically at incorporating the Early Years Foundation Stage summary. This project is being led by the Department for Education and Department of Health and Warwickshire is a project partner. We have been awarded £9,000 by the Department of Health to support the project development. A second pilot is looking at the nine month review in introducing the Ages and Stages Social and Emotional tool to identify babies with any attachment/speech and language difficulties early. We celebrated 150 years of Health Visiting in 2012, with the format of a conference attended by well regarded national speakers, families, health visitors and partners. This was very well evaluated.

The service received a 'rapid appraisal' from Sustain (commissioned by the Cluster SHA) this November. The three day review involved staff members from all levels being interviewed, the final report showed no areas of concerns and some areas of note to which progress has already been made. The report was described as “exceptional”.

We are working closely with our commissioners in ensuring the growth of Health Visitors is reached as outlined in the Operating Framework. We have increased the number of Health Visitor students by 900%.

183 Quality Performance Overview

This section of our quality accounts provides information on our compliance with national standards and targets and locally derived targets not covered elsewhere in the Quality report.

NATIONAL KEY PERFORMANCE TARGETS 2013/14 Financial Year Achievement

TARGET Target Actual Achieved (y/n) Cdiff (In-Hospital) 24 18 Y

MRSA (Post 48hr) 6 1 Y

Cancer 31-Day (all subsequent cancer treatments): Surgery 94% 98.40% Y

Anti-cancer drug treatments 98% 100% Y

Cancer 62-Days National Screening Programme 90% 95.50% Y

Cancer 62-Day (2Week Wait Ref to treat, all cancers) 85% 82.1% N

Referral to Treatment Times – admitted (90% within 18 weeks) 90% 88% Achieved in Q4

Referral to Treatment Times - non-admitted (95% within 18 weeks) 95% 96% Y

Referral to Treatment Times - open pathways (92% within 18 weeks) 92% 93% Y

Cancer 31-Day (Diag to treat, all new cancers) 96% 99.10% Y

Cancer 2 Week Wait all cancers (Urgent GP Referral) Y 93% 94.70% Cancer 2Week Wait (Symptomatic Breast) N 93% 92% A&E max wait time of 4hrs from Arrival to Discharge 95% 95.20% Y

Compliance with requirements regarding access to healthcare for people with a learning difficulty Y

Community care - referral to treatment information - Allied Health Professionals 50% 55.90% Y

Community care - referral information - Allied Health Professionals 50% 94.70% Y

Community care - activity information Allied Health 50% 91.20% Y Professionals

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From local Trust data From Health and Social Care Information Centre Time period for Most recent Worst Indicator most Best result National 2013-14 2012-13 results for result recent nationally average Trust nationally Trust results The value and banding of the summary Not Not Not Not hospital-level mortality indicator (“SHMI”) 1.05 1.04 1.05 traceable o traceable on traceable traceable on for the trust for the reporting period; and NHSIC NHSIC on NHSIC NHSIC

The percentage of patient deaths with The Trust considers that this data is as described for the following reasons: palliative care coded at either diagnosis or -The Trust acknowledges that these percentages are within the expected range. specialty level for the trust for the The Trust has taken the following actions to improve these percentages, and so the reporting period. quality of its services by: -Working closely with the specialist palliative care team. -Improving access to the expertise of the palliative care team and recording their input accurately. Readmitted to a hospital which forms part 1.0% 1.0% Not available Not Not available Not Not available of the trust within 28 days of being on NHSIC available on NHSIC available on NHSIC discharged from a hospital which forms on NHSIC on NHSIC part of the trust during the reporting period. % of patients aged 0-15 readmitted within 28 days Readmitted to a hospital which forms part 5.5% 4.9% Not available Not Not available Not Not available of the trust within 28 days of being on NHSIC available on NHSIC available on NHSIC discharged from a hospital which forms on NHSIC on NHSIC part of the trust during the reporting period. The Trust considers that this data is as described for the following reasons: % of patients aged over 15 -Since the national published figures (across) are considerably historical, we have looked at readmitted within 28 days our recent data and in 2012/13 the overall Trust average for all ages groups is XX% which compares to our peer group of similar hospitals of 6% (from CHKS). Trust intends to take the following actions to reduce this percentage, and so the quality of its services by: -Continuing to expand and develop the Acute Medicine and Acute Surgery service by employing more senior decision makers in the initial assessment units, for longer, some unnecessary/avoidable admissions are prevented Continuing to develop the community virtual ward service. More proactive, risk based management of virtual ward patients is already having an effect on avoidable admission reduction The trust’s patient reported outcome measures scores for— 0.097 0.139 0.097 April 2012- Not available Not 0.789 (i) groin hernia surgery, 0.046 0.093 0.046 March 2013 on NHSIC available on 0.083 (ii) varicose vein surgery, 0.294 0.412 0.294 NHSIC 0.351 (iii) hip replacement surgery, and 0.259 0.292 0.259 0.409 (iv) knee replacement surgery, during the reporting period. The Trust considers that this data is as described for the following reasons: -The Trust acknowledges the results vary across the four procedures; for Groin Hernia surgery it is below average, for Varicose Vein surgery it is above average and for Hip and Knee replacements it is in the region of the national average. With regards to Groin Hernia we have noted that 94% of patients said that their problems are better now when compared to before the operation and 87% of patients describe the results of their operation as excellent, very good or good. The Trust has taken the following actions to improve these scores, and so the quality of its services by: -The Trust regularly monitors and audits the pre- and postoperative healthcare of all patients. Surgical operative outcomes are consistently of high quality and safety, with excellent patient satisfaction for these procedures. The health gains that PROMs measure are of a more generic nature and are not exclusively linked to secondary healthcare provision and will need the consideration of a health economy-wide group to influence, comprising GPs, community services, social services, welfare benefit services and Public Health.

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Responsiveness to inpatients’ personal Not needs (Source: national NHS inpatient 6.3 6.2 6.3 2013 7.5 3.0 provided survey) by NHSIC The Trust considers that this data is as described for the following reasons: National data published confirms that South Warwickshire NHS Foundation Trust is in the best performing 20% of Trusts The Trust has taken the following actions to improve these scores, and so the quality of its services by: Setting Patient Experiences as Priority for 2014/15 and reporting back on developments and achievements in the next Annual Quality report. Percentage of staff who would recommend 3.89 3.83 3.89 the provider to friends or family needing Not a Not a Not a 2013 4.25 Not 3.68 care Source: national NHS staff survey percentage percentage percentage available The Trust considers that this data is as described for the following reasons: National data published confirms that South Warwickshire NHS Foundation Trust is in the best performing 20% of Trusts The Trust has taken the following actions to improve these scores, and so the quality of its services by: National data published confirms that South Warwickshire NHS Foundation Trust is in the best performing 20% of Trusts The percentage of patients who were Not Not Not Not Not admitted to hospital and who were risk Average Average: available on availabl available availabl available assessed for venous thromboembolism 95.1% 93.3% NHSIC e on on NHSIC e on on NHSIC during the reporting period. NHSIC NHSIC The Trust considers that this data is as described for the following reasons: Performance is on-par with national data published and is as expected. The Trust is pleased to note that it is above the national average in undertaking these risk assessments due to, in particular, the work of a dedicated specialist nursing team and the promotional work they undertake on this important topic The Trust has taken the following actions to improve these scores, and so the quality of its services by: -Continuing the educational sessions with each junior doctor intake -Continuing with a variety of promotional activities to staff and patients -Implementing the use of technology to assist in the recording of the risk The rate per 100,000 bed days of cases of 10.724 17.683 Not available Not Not Not Not C.difficile infection reported within the trust on NHSIC available available available available amongst patients aged 2 or over during the on NHSIC on NHSIC on NHSIC on NHSIC reporting period. The Trust considers that this data is as described for the following reasons: In 2012/13 there were 31 cases of C-Diff with 175310 occupied bed days. (All wards in the Trust except for SCBU, Swan & Delivery Suite). This calculates to a rate of 17.683 per 100,000 bed days. In 2013/14 there were 18 cases of C diff last year and there were 167,842 occupied bed days (all wards in the Trust except for SCBU, Swan & Delivery Suite). This calculates to a rate 10.724 per 100,000 bed days. The Trust has taken the following actions to improve these scores, and so the quality of its services by: -Reviewing in detail all cases to see what lessons can be learned to prevent further cases -Introducing more intensive cleaning methods and expanding their use -Improving the guidance to clinicians on the prevention and treatment of C.diff. The number and, where available, rate of Total of 6183 Total of 3533 Total of 2729 April Not Not Not patient safety incidents reported within the incidents, incidents, incidents, 2013 available avail on available trust during the reporting period, and the Of which Of which Of which To Sept on NHSIC NHSIC on NHSIC number and percentage of such patient 1.7% 1.1% 1.2% 2013 safety incidents that resulted in severe Resulted in Resulted in Resulted in harm or death. severe severe severe harm/death harm/death harm/death The Trust considers that this data is as described for the following reasons: As organisations that report more incidents usually have a better and more effective safety culture, the Trust is pleased to note it has higher than average reporting rates for one of the reporting periods specified. The Trust has taken the following actions to improve these scores, and so the quality of its services by: - Continual raising of awareness of what constitutes as an incident and how to report. -Continual improvement of quality investigations and learning. -Reviewing the severity coding of all incidents to ensure accuracy and consistency of reporting. Please refer to the Patient safety section of the Quality report for reporting rates and the initiatives taken to encourage reporting.

186 Glossary AHP Allied Health Professional BAPEN British Association for Parenteral and Enteral Nutrition BFI Baby Friendly Initiative BSI British Standards Institution CARE Care, Attitude, Responsiveness and Environment CCG Clinical Commissioning Group CCNT Community Children’s Nursing C.Diff Clostridium Difficile CERT Community Emergency Response Team CHC Continuing Healthcare Checklist CHKS Caspe Healthcare Knowledge System CQC Care Quality Commission DECAA Dementia and Elderly Care Action Alliance DoH Department of Health eCAT electronic Common Assessment Tool E.Coli Escheria Coli EOL End of Life FNP Family Nurse Partnership HCA Healthcare Assistant HCAI Healthcare Associated Infection HCP Healthy Child Programme HIA Higher Impact Action HV Health Visiting LTC Long Term Condition MDT Multi-Disciplinary Team MRSA Methicillin-Resistant Staphylococcus Aureus MSSA Methicillin-Sensitive Staphylococcus Aureus MUST Malnutrition Universal Screening Tool NICE National Institute for Health and Care Excellence NIHR National Institute for Health Research

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NHLSA National Health Service Litigation Authority NPSA National Patient Safety Agency PALS Patient Advice Liaison Service PEAT Patient Environment Action Team PEG Patient Experience Group PHSO Parliamentary Healthy Service Ombudsman PLACE Patient Led Assessment for the Care Environment RCA Root Cause Analysis SHA Strategic Health Authority SHMI Summary Hospital-Level Mortality Indicator SSKIN Surface, Keep Moving, Incontinence, Nutrition/Surface, Skin Inspection, Incontinence, Nutrition SSI Surgical Site Infection STEIS Strategic Executive Information System SWFT South Warwickshire NHS Foundation Trust UHCW University Hospitals Coventry and Warwickshire UTI Urinary Tract Infection VW Virtual Ward WCC Warwickshire County Council

188 Stakeholder Feedback: Warwickshire County Council’s Adult Social Care and Health Overview and Scrutiny Committee with Stratford-on-Avon District Council, Warwick District Council and Warwickshire Healthwatch

Response on behalf of the Quality Accounts Task and Finish Group (TFG) set up by Warwickshire County Council’s Adult Social Care and Health Overview and Scrutiny Committee with Stratford-on-Avon District Council, Warwick District Council and Warwickshire Healthwatch. This commentary is formally presented on behalf of these organisations, who volunteered their time and expertise to the process.

The new approach developed in 2012 towards Quality Accounts to develop a more meaningful outcome focussed process has been strengthened this year. The TFG has welcomed the opportunity to work with SWFT over the past six months to consider the implementation of the Priorities on Improvement identified in the previous QA, to work with SWFT on identifying their priorities for the next year and to comment on the 2013/14 Quality Account (QA). To this end, the TFG are supporting SWFT to use their QA as an ongoing tool for improvement and developing this approach for scrutiny to continue to use the QA as a tool for identifying areas that need to be considered by the overview and scrutiny committee in more depth. The Group have challenged SWFT, over the year, to make the experience of patients and staff central to their priorities for QA, and to ensure that QA priorities are locally driven and focussed on outcomes rather than national or CQUIN targets, which the Trust are already performance-monitored against. The QA document is well presented and easy to read and understand, and does focus strongly on the voice of the patients and staff. This approach was confirmed in visits the TFG made to the Trust, which included the opportunity to visit a number of wards and to speak to staff on duty. The TFG welcomed the opportunity to put forward suggestions for QA priorities for the next year, which were based largely on the evidence gathered by Healthwatch and scrutiny in their dealings with the Trust and its patients. Some of the TFG’s suggestions have been included in the QA (End of Life Care, You Said We Did approach) and this highlights the level of engagement this work has achieved. The TFG would like future QA documents to illustrate what success looks like for each of the priorities. An important role for overview and scrutiny in the future is to ensure the integration of health and social care services. The QA demonstrates that SWFT is committed to this agenda, working with social care as well as community and voluntary sector services. Concerns with some aspects of the maternity services were raised by the TFG, and the QA includes the CQC inspection report of these services. This will be an area for monitoring over the next year.

Quality Priorities – looking back and looking forward The Group welcome the improvements that have been achieved, particularly in the work done with pressure ulcers, reducing falls and infection prevention. It is unfortunate that despite an improved food service for patients being identified as a priority for 2012/13, that this is still being highlighted as an issue for patients, and is again a ‘Patient Experience’ priority. The TFG look forward to working with SWFT over the next year to monitor progress against the priorities that have been identified and the patient experience more generally.

189 Stakeholder Comments: NHS South Warwickshire Clinical Commissioning Group

Following our review of the South Warwickshire NHS Foundation Trust Quality Account we are pleased to state that this provides an honest representation of the work the Trust has undertaken to improve the quality of its services during 2013/14.

NHS South Warwickshire Clinical Commissioning Group (as lead commissioner for the South Warwickshire NHS Foundation Trust contract) continues to work in partnership with the Trust with the aim of ensuring that service users, carers and their families receive excellent care and treatment throughout their healthcare experience, whether this is in the acute sector or in community services. During 2013/14 the Trust has continued its programme of transformation of patient pathways, seeking to achieve integrated service provision across acute and community services, as appropriate. Inpatient experience of care (as demonstrated by response rates and scores in the national Friends and Family test) continues to be high. A&E response rates however, continue to be a challenge and further work is underway to ensure better completion of the survey and more representative scores in this service. The Friends and Family test was successfully rolled out to Maternity Services during the latter part of 2013/14 and 2014/15 will see a further roll-out of the test to Outpatient Departments and a number of a community services. Given work undertaken as part of the Commissioning for Quality and Innovation (CQUIN) scheme during 2013/14 the Trust is well placed to deliver this in the community setting.

Infection Control was a challenging area for the Trust during 2012/13 and therefore a priority for action during 2013/14. We are pleased to say that revised infection control policies, which included early ‘lock down’ of wards affected by vomiting and diarrhoea, appeared to pay dividends during 2013/14 with much lower Norovirus levels and significantly less impact on operational activities. Despite a challenging reduction during 2013/14, the Clostridium difficile targets were met and the only MRSA bacteraemia assigned to the Trust was the result of a contaminant. Performance against stroke targets improved during the course of the year but our attention has now turned to cancer waiting times where diagnostic waits, the two-week wait for breast symptoms and the 31 and 62 day cancer waiting time targets continue to be an area for improvement. The CCG is developing a joint action plan with the Trust to tackle issues across primary and secondary care in this regard.

Following a poor start to the year, the A&E target of 95% of patients being seen within 4 hours of arrival was achieved by year end. Referral to Treatment (RTT) targets at specialty level, whilst showing continued improvement, remain a challenge in terms of delivery. Following the success of the Urgent Care working group in tackling the A&E target we have recently established with the Trust a similar group for Elective Care to jointly tackle scheduled care targets such as Cancer and RTT. Whilst performance against maternity services key performance indicators is generally good Caesarean section rates are higher than we would like and we are planning further work to review the reasons for these in 2014/15, as well as the actions to address them, as appropriate.

Some of the national and local CQUIN schemes proved challenging for the Trust in terms of delivery in 2013/14, particularly those on dementia and discharge communications. In view of the local priority of these they will be further prioritised for delivery in 2014/15.Patient Safety remains a joint priority. Given the never events at SWFT during 2013/14 the CCG undertook a review visit in December 2013 specifically to look at Serious Incident reporting and management procedures. Whilst we were happy with the governance in place, the review did identify the need for further staff training in some areas in respect of serious incident reporting.To conclude, we are content that the information in this account is accurate and has been discussed in detail during our monthly Clinical Quality Review meetings. The priority of quality within the Trust is evident from the report and we are encouraged by the Trust’s continued openness in discussing quality matters of concern and the actions being taken to address these. There is strong evidence that the vast majority of patients are happy with the services they receive and feel able to raise matters of concern with the Trust, if required. The CCG’s recently introduced GP feedback system enables us to feedback key themes emerging from patients who have recently experienced care at SWFT, whether positive or negative, and further supports our insight into patient experience at the Trust.

We look forward to a further year of collaboration to drive forward our shared aim of improving the quality of services for our local population.

190 2013/14 Statement of Directors Responsibilities in Respect of the Quality Report

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation of the Quality Report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

The content of the Quality Report meets the practice; requirements set out in the NHS Foundation Trust Annual Reporting Manual 2013/14 and that The data underpinning the measures of the content of the Quality Report is not performance reported in the Quality Report is inconsistent with internal and external sources of robust and reliable, conforms to specified data information including: quality standards and prescribed 106 definitions, is subject to appropriate scrutiny Board minutes and papers for the period April and review and the Quality Report has been 2013 to March 2014 prepared in accordance with Monitor's annual Papers relating to Quality reported to the reporting guidance (which incorporates the Board over the period April 2013 to March Quality Accounts regulations) (published at 2014 http://www.monitor.gov.uk/sites/default/files/publi Feedback from the commissioners dated 08 cations/FTARM2013-14March2014.pdf) as well May 2014 as the standards to support data quality for the

Feedback from Governors dated 16 April 2014 preparation of the Quality Report (available at www.monitor.gov.uk/sites/all/modules/fckeditor/pl

The trust's complaints report published ugins/ktbrowser/_openTKFile.php?id=3275) under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 14 May 2014 The directors confirm to the best of their knowledge and belief they have complied The National outpatients survey 2013/14 with the above requirements in preparing the

The National inpatients survey 2013/14 Quality Report - By order of the Board

The National staff survey 2013/14

The Head of Internal Audit's annual opinion over the trust's control environment dated Signed: 21 May 2014 (Director of Finance, South Warwickshire NHS Foundation Trust) CQC quality and risk profiles 2013/14

The Quality Report presents a balanced Date: 21 May 2014 picture of the NHS Foundation Trust's performance over the period covered;

The performance information reported in the Signed: Quality Report is reliable and accurate; (Chief Executive, South Warwickshire NHS Foundation Trust) There are proper internal controls over the

collection and reporting of the measures of Date: 21 May 2014 performance included in the Quality Report,

and these controls are subject to review to confirm that they are working effectively in

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Limited Assurance certificate to the Council of Governors and Board of Directors of South Warwickshire NHS Foundation Trust

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193