Mid Staffordshire NHS Foundation Trust Fetal Movement

Document Sample
Mid Staffordshire NHS Foundation Trust Fetal Movement Powered By Docstoc
					Mid Staffordshire NHS Foundation Trust

DRAFT             Quality Report for consultation
Part One - Statement on Quality

This section of the Annual Report is a new requirement for 2009/10 and provides the
opportunity to demonstrate to patients, staff and the public how we have worked over the
past year to improve the quality of care we give to our patients.

There are three key elements in the quality of care delivered to patients:
    Patient safety
    Clinical effectiveness and outcome
    Patient experience

The beginning of the reporting year was marked by the publication in March 2009 of the
findings of the Healthcare Commission. Their investigation concentrated on the high
mortality rates in patients admitted to Stafford Hospital as emergencies and the assessment
of care provided to patients from April 2005-2008.

The then Trust Board accepted that significant improvements in its clinical services were
necessary and, when I joined the Trust in August 2009, a Transformation Programme
involving 107 activities was under way.

Since that time, a number of further improvements have commenced. Some have already
made an impact on patient care and others will take longer to achieve the standards that we
believe our patients deserve. The Trust is now working to Five Themes (outlined in the body
of this report). These themes capture the five most important areas of change that the Trust
needs to address, and everything we do is now being focussed on making these things

We have also been taking steps to ensure that structures and systems are fit for purpose.
The Medical Director has led on reviewing clinical governance procedures and ensuring that
the Trust has robust systems and processes. This includes supporting our staff and holding
them to account for patient care.

To improve care we felt it was essential to increase medical clinical engagement within the
Trust. The first steps were taken in 2009 to increase the clinical involvement in the newly
established Management Board and to help shape the strategic objectives of the Trust.

Each directorate is now led by a Clinical Director providing leadership and guidance to help
develop them into autonomous business units. With increasing time and development the
Clinical Directors will have budgetary responsibility and be accountable for the delivery of
clinical services. A Clinical Director development programme has been organised in
association with the University of Warwick and Aston University to ensure that they have the
skills and capabilities to effectively lead their directorates and influence the Board in its
strategic vision for the Trust.

The Medical Director meets the Clinical Directors monthly to discuss corporate and clinical
issues. The Trust‟s general surgical service has undergone strict review and re-configuration
during the year to ensure a safe service and is being remodelled to provide a sustainable

                                                                             Page 1 of 32
service for the future. This is to balance the desire to provide specialist care for patients and
the need for an emergency on call service.

Towards the end of this year Sir Robert Francis QC published his report into the care
provided by the Trust from 2005 to 2009. The stories told to him, and related in his report,
reinforce the importance of the work we are doing to ensure that the quality of care provided
by this Trust is always of the very best.

To the best of my knowledge the information in this document is accurate.

Signed …………………………………………..

Antony Sumara
Chief Executive                                      Date:

Part Two – Priorities for Improvement 2009/10

In identifying our improvement initiatives for 2009/10, we chose those priorities which would
have the maximum benefit for our patients.
    1. Patient Safety- Reducing our Hospital Standardised Mortality Ratio (HSMR)
    2. Clinical Effectiveness- Reducing hospital associated infections – C-Diff and MRSA
    3. Patient Experience- Improving patient care and respecting their privacy and dignity

Part Three of this report addresses the objectives that had been set for 2009/10 in our
2008/09 Annual Report.

1. Patient Safety

Reducing our Hospital Standardised Mortality Ratio (HSMR)

The HSMR is one indicator of healthcare quality that measures whether the death rate at a
hospital is higher or lower than you would expect.

Mortality ratios are calculated by an independent company, Dr Foster Intelligence, from
routinely collected hospital data. HSMR compares the expected rate of death in a hospital
with the actual rate of death. Dr Fosters Intelligence system looks at those patients with
diagnoses that most commonly results in death for example, heart attacks, strokes or broken

For each group of patients they work out how often, on average across the whole country,
patients survive their stay in hospital, and how often they die. Whilst, in itself, the HMSR is
not a single marker of the quality care, it is a useful barometer by which the Trust can
compare itself with other hospitals.

The HSMR is calculated by dividing the actual number of deaths by the expected number of
deaths, and multiplying this by 100. Generally speaking an HSMR below 100 means that the
Trust had fewer deaths than would be expected, given the types of cases treated. Trusts with
a rate above 100 will have had more deaths than would be expected.

The Trusts HSMR of 127 in 2006/2007 was the initial stimulus for the Healthcare
Commission to investigate the Trust in March 2008. The HMSR reduced to 116 in 2007/8
and significantly improved in 2008/9 at 90.9.

                                                                           Page 2 of 32
Page 3 of 32
The Table below shows the annual HSMR for the Trust from Jan 2005 to January 2010. The March 2010 position is not available at the time of
writing the report however it is expected that the HMSR will continue its downward trend.

                                                                     Page 4 of 32
How this was achieved

The Trust now thoroughly investigates every death which occurs in the hospital and
reports this to the Healthcare Governance Committee to give assurance to the Board
and to provide feedback to senior clinicians and senior managers.

During the year our emergency care directorate have worked extremely hard on
improving services for emergency patients and have implemented a new model of
emergency care for patients to ensure they get better, quicker and safer care.

The Trust uses the Dr Foster alerts system and unusual statistical results are
scrutinised and investigated. All serious untoward incidents are reported at several
different levels of the organisation and discussed at the Trust Board. All clinicians are
encouraged to review their own patient outcomes through the use of the Dr Foster
system and benchmark their performance to national standards.

Our clinical coding staff have worked hard to improve the quality and depth of the
coding of each clinical episode and we have also started to work with Patient Safety
First to learn more about leading edge safety methodology and embedding this
learning from Ward to Board level.

Clinical quality and patient safety is measured through a number of key performance
indicators seeking to improve patient experience and provide stretch targets to
improve the quality of care provided by the Trust.

2. Clinical Effectiveness

Reducing hospital associated infections – C.difficile and MRSA

We are totally committed in our responsibility to do everything we can to reduce
hospital associated infections as we know that these are of particular concern to our
patients and the community we serve.

We take infection control extremely seriously and we continue to work hard to
improve our standards of clinical practice. It is also very important that our hospitals
are maintained to the highest possible environmental hygiene standards.

While hospital cleanliness does play a part in tackling infection, it is simple and basic
personal hygiene that really makes all the difference in both prevention and control of
infection. It doesn‟t matter whether you are a member of staff, a patient or a visitor;
hand washing and/or hand decontamination is the single most important measure we
can all take to prevent the spread of infection in our hospitals.

Our Infection Prevention and Control team and our clinical ward and department
teams have done a fantastic job, resulting in a significant reduction in hospital
associated infections. MRSA bacteraemia cases have reduced by 67% during the
year with only 3 cases reported and C.difficile cases by 73% to 37 reported in the

How this was achieved

                                                                           Page 5 of 32
During the year all Trust staff, with the support of our patients and the public have
worked hard to reduce the number of infections. We have continued with our
„Cleanest Place in Town‟ campaign and have implemented many new practices to
help reduce the incidence and spread of infection. These new practices include:
     Increasing the number of audits of practice
     Increasing environmental cleanliness inspections
     Continued root cause analysis when infections occur
     Increased training of all staff
     The introduction of a refurbished and redesigned C Diff cohort ward.

3. Patient Experience

Improving patient care and respecting their privacy and dignity

Since the publication of the various reports staff have worked tremendously hard to
improve patient care Throughout the year our focus has been about putting our
patients first and this has already made a difference to patient care in our hospitals.

Every patient has the right to receive high quality care that is safe, effective and
respects their privacy and dignity. The Trust is committed to providing every patient
with same sex accommodation, because it helps to safeguard their privacy and
dignity when they are often at their most vulnerable.

How this was achieved

In addition to the achievements already detailed in section 2 (Operational
Developments Delivered) the Trust Board agreed a rolling programme of zero
tolerance targets to directly address concerns raised over patient care in the past.
Two of the targets that were successfully implemented during the year were antibiotic
prescribing audits to address issues related to C.difficile and nil by mouth audits to
address the inappropriate starving of patients prior to surgery.

All wards and departments at Stafford and Cannock Chase hospitals have been
assessed against the 17 principles issued by the Department of Health for delivering
same sex accommodation. As a result the Trust Board has been able to declare that
the Trust is compliant with this standard.

Our Priorities for Improvement 2010/11 – The Trust’s Five Themes

In May 2009 the Trust began a programme of transformation aimed at putting right
the issues identified in the various reports. This programme has developed
throughout the year and in September 2009 the Trust launched its “five themes” as
the focus for improvement. Patients, public and staff representatives have been
involved in their development:

Theme one – Creating a culture of caring (Patient Experience)
   We always want to give personal and compassionate care. To do this we will
   make sure that patients are in clean beds, get the food and hydration they need,
   the pain relief they need and see friendly and helpful staff who always come if
   called. We expect patient dignity and privacy to be respected. We will also
   answer any questions the patient has and make sure that they are kept informed
   about their treatment.

                                                                         Page 6 of 32
Theme two – Seeing zero harm as our target by keeping patients safe (Patient
   We want to make sure that we are keeping every patient as safe as possible. So
   we will see that everyone gets the right treatment and medicine at the right times.
   learn from any mistakes we make, and follow the latest advice and guidance.
   Doing zero harm will be a priority for every member of staff.

Theme three – Listening, responding and acting on what our patients and
community are telling us (Patient Experience)
   We want to understand and act on what our patients and the community tell us
   about our staff and the services we provide. To do this we will make it easy for
   people to make comments and complaints, learn and change what we do as a
   result of what we are told, plus respond quickly to let people know what is

Theme four – Supporting our staff to become excellent; giving responsibility
but holding to account as well (Clinical Effectiveness)
   We want to have highly skilled, motivated and caring staff who are proud to work
   here. Everyone will get the training they need, we will have the right numbers and
   mix of staff and staff will be clear about the standards of behaviour and
   performance that are expected of them.

Theme five – Continuing to do what we need to do to satisfy our regulators
   We need to be sure that our regulators continue to get the information they need
   and that we continue to do what is required of us. So we will make sure that we
   put their guidelines and recommendations into practice and that we provide clear
   and useful information to show them what we have done.

Each theme is led by a “theme group” which is chaired by an Executive Director and
includes Non Executive Directors, Governors and patient representatives.

Bringing the five themes to life

The Trust is developing a “steering wheel” (the “wheel”) which is a set of promises to
patients, staff and regulators that will be used to improve performance on “getting the
basics right”. The promises are grouped by the Trust‟s five themes. The promises
address the basic issues that really matter:

      patients sleep in clean beds, get the right food and hydration, and are
       answered when they call
      We don‟t do any harm and learn from any mistakes
      We encourage comments while people are here and deal with complaints
       quickly and fairly
      Staff have all the training they need and every opportunity to develop
      Our regulators get the information they need to know that we are doing what
       is required of us

The wheel is how we will take the Trust‟s five themes forward and make sure that the
promises we are making to patients, staff and regulators in respect of each theme
are actually kept. Our Trust Board will receive a report on performance against the
wheel promises every month.

                                                                         Page 7 of 32
The concept of the wheel has been borrowed from Tesco, who are giving the Trust
advice on how they developed and use theirs. The wheel is currently being
developed and will be rolled out to every inpatient ward during summer 2010.

Monitoring progress against each of the promises will be managed through each
respective theme group meeting together with monitoring progress against each of
the outcome measures defined for each theme group as the key performance
indicators. Each group will also review progress on the series of activities agreed for
each theme group, delivery of which will collectively contribute towards achievement
of the outcome measures.

In cases where satisfactory progress is not being made then the respective theme
group will escalate issues for decision and resolution to Healthcare Governance
Committee (in the case of themes 1 to 3) and to Workforce Committee in the case of
theme 4.

Each theme group will also provide Trust Board with a summary of progress on a
monthly basis. Additionally, the Trust‟s Governors will also receive assurance both
through having representation on each theme group coupled with appropriate
reporting through to Council of Governors.

We have chosen the following quality indicators for 2010/11:

Indicators on Patient Safety for 2010/11

   Slips, trips and falls
    In 2009/10 there were a total of 884 reported incidents across the Trust. We aim
    to reduce this by half in 2010/11. We will produce a map locating incidents so that
    we can identify and address environmental hazards that may be contributing to
    the causes of those incidents. We will also ensure that all patients are risk
    assessed on admission and cared for appropriately. This indicator will be
    reported to out Board monthly via clinical dashboard monitoring.
   Every patient will have their medications checked by a pharmacist
    The most frequently reported types of medication incidents involve: wrong dose,
    omitted or delayed medicines, or the wrong medicine. The Trust is now fully
    staffed with ward pharmacists who will be proactively checking patients‟
    medications. We anticipate seeing a fall in medication errors as a result of this
   Venous thromboembolism (VTE)
    On 24 March 2010 the Department of Health published guidelines on the
    treatment of blood clots that can form in veins and prevent blood from circulating
    properly (which can cause fatal conditions, for example if a clot travels into a
    lung). We will implement these guidelines, which will reduce the number of VTEs
    taking place in hospital, and take part in the national programme to collect data in
    order to measure progress in respect of this.

Indicators on Clinical Effectiveness for 2010/11

   Number of cardiac arrests occurring outside ITU/HDU
    80% of cardiac arrests within hospital are preventable providing early intervention
    takes place. This indicator will be reported to our Board monthly via clinical
    dashboard monitoring.
   Observation chart completion

                                                                          Page 8 of 32
    In early 2010 the Trust began work with the Patient Safety First campaign looking
    at how to spot a deteriorating patient. We are now checking to see that
    observation charts are being fully completed on a weekly basis via our reporting
    on nursing indicators (please see below). This will ensure that deteriorations are
    spotted and addressed before a crisis occurs. Our Critical Care Outreach team
    will be monitoring that the correct escalations are being made.
   Statutory and mandatory training
    In September 2009 only 41% of staff had received their statutory and mandatory
    training. At the end of March 2010 88% of staff had attended the corporate
    statutory and mandatory training days. From April 2010 onwards we will be
    adopting a more detailed and comprehensive approach to reporting statutory and
    mandatory training, which will provide a more accurate analysis of compliance
    levels for the full range of mandatory training.

Indicators on Patient Experience for 2010/11

   Mystery shopper scheme
    We will work with patients about to come into hospital to identify how they would
    like to report on their experience and prepare them for doing that. This scheme
    will begin with elective patients, and, as the process is developed, it is hoped that
    more vulnerable patients may be able to discuss their experiences as well. This
    will be an additional assurance to the Board on the quality of our care and also
    form the basis for stories that will give potential patients an idea of what their
    hospital experience will be like.
   Nursing care indicators
    In early 2010 we developed patient “comfort rounds”; a system for ensuring that
    every patient‟s needs are checked and recorded every two hours and so ensuring
    that no-one goes without food, drinks, pain relief or access to toilet facilities.
    During 2010/11 we will continue to develop this system on the basis of patient
    and staff feedback to ensure that the quality of our nursing care is consistently
   Performance against 5 key questions on patient experience
    Professor Sir Brian Jarman has published work showing a statistical correlation
    between patient experience and mortality, with poor responses to 5 key questions
    being connected with higher rates of mortality. We will ask these 5 questions via
    our patient tracker system and report performance against them monthly to the
    Board via our clinical dashboard monitoring. In other words, good patient
    experience is directly linked to good outcomes. The five questions are:
             o If you had any anxieties or fears about your condition or treatment, did
                a doctor discuss them with you?
             o If your family or someone else close to you wanted to talk to a doctor,
                did they have enough opportunity to do so?
             o Did a member of staff explain the purpose of the medicines you were
                to take at home in a way you could understand?
             o Did a member of staff tell you about medication side-effects to watch
                for when you went home?
             o Would you recommend this hospital to your family and friends?

Statements of assurance from the board

During 2009/10 Mid Staffordshire NHS Foundation Trust provided and subcontracted
58 NHS Services. The Trust supported a number of reviews of its services by
external organisation during 2009 and 2010 including:
     The Healthcare Commission,

                                                                           Page 9 of 32
       The Care Quality Commission
       Independent investigation conducted by Robert Francis QC
       Case Note review by South Staffordshire Primary Care Trust
       Royal College of Surgeons

As a result the Trust did not formally review any of its own services but supported the
reviews and developed action plans to implement recommendations to improve the
quality of care to our patients.

The income generated by the NHS services reviewed in 2009/10 represents 100 per
cent of the total income generated from the provision of NHS services by the Mid
Staffordshire NHS Foundation Trust for 2009/10. This is because the reviews of our
services over the past year have been comprehensive and wide-ranging.

National Clinical Audits and National Confidential Enquiries

During 2009/10 14 national clinical audits and 3 national confidential enquiries
covered NHS services that Mid Staffordshire NHS Foundation Trust provides.

During 2009/10 Mid Staffordshire NHS Foundation Trust participated in 12/14 (86%)
national clinical audits and 3/3 (100%) national confidential enquiries (of the national
clinical audits and national confidential enquiries which it was eligible to participate

The table below shows a full list of all the national (NCAPOP) audits and national
enquiries which the Trust was eligible to participate in and the participation status is
indicated. Where there was a required number of registered cases, this is also listed
in the table, along with the number and percentage of cases submitted.

Participation in National Clinical         Audits   (NCAPOP        list)   and    National
Confidential Enquiries 2009/2010

Audit title                             Participation     No               No.               %
                                                          required         submitted
Lung Cancer (LUCADA)                          Yes              *                             n/a
Bowel cancer (NBOCAP)                         Yes              *                             n/a
Mastectomy and Breast                         No
Oesophago-gastric (stomach)                   Yes              *                             n/a
Cancer – clinical
Cardiac Rhythm management                     Yes              *                             n/a
(Pacing/Implantable Defibrillators)
Heart Failure                                 No
Myocardial Ischaemia (MINAP)                  Yes              *                             n/a
Myocardial Ischaemia (MINAP) Data             Yes             20                 20          100
National Diabetes Audit                       Yes              *                             n/a
National Carotid Interventions Audit          Yes              *
– clinical **
National Stroke audit –                       Yes            n/a                             n/a

                                                                            Page 10 of 32
Falls and Bone Health -                       Yes            n/a                      n/a
National audit of Continence care –           Yes            n/a                      n/a
National audit of Continence care –           Yes            80            81         100
NCEPOD - Elective and Emergency               Yes            27            13         48
Surgery in the Elderly
NCEPOD - Parenteral nutrition                 Yes            20             9         45
NCEPOD - Acute Kidney Injury                  Yes            22            18         82

* for these audits, no particular number of cases was specified
** Information submitted via National Vascular Database

Other National audits in which the Trust participated 2009/2010

Audit title                               Participation      No       No        %
                                                          required submitted
National Comparative Audit of Blood           Yes            40       40        100
National Comparative audit of the             Yes            *                  n/a
Use of Red Cells in Neonates and
National      Mandatory      Advanced         Yes            *                  n/a
Orthopaedic         Surgical       Site
Surveillance audit
College of Emergency Medicine -               Yes           50        50        100
National audit of Fractured Neck of
College of Emergency Medicine –               Yes           50        50        100
National audit of Management of Pain
in Children
College of Emergency Medicine –               Yes           50        50        100
National      audit     of     Asthma
Parkinson‟s Disease Society – Audit           Yes            *                  n/a
of National standards relating to
Parkinson‟s Disease
British Thoracic Society – National           Yes            *                  n/a
Audit of Adult Asthma
British Thoracic Society – National           Yes            *                  n/a
Audit      of     Community-acquired
British Thoracic Society – National           Yes            *                  n/a
Audit of Paediatric Asthma
Saving Lives audit (Infection control)        Yes            *                  n/a
Royal College of Paediatrics and              Yes            *                  n/a
Child Health -
National Neonatal audit programme
Royal College of Radiologists –               Yes           50        42        84
National audit of adequacy, accuracy
and complication rate in image-

                                                                      Page 11 of 32
guided liver biopsy

* for these audits, no particular number of cases was specified

The reports of 10 national clinical audits and 2 national confidential enquiries were
reviewed by the Trust in 2009/2010 and the Trust is planning to take action as listed
in the table below.

National Audit and National Confidential Enquiry reports received 2009/2010
and actions taken

Audit title               Actions
National Audit Office -
                          1. Increase Outpatient Capacity to see new referrals for
services for people with
                            Rheumatoid Arthritis in less than 6 weeks - Business
rheumatoid arthritis July
                            case for New Consultant Clinical Lead, Divisional
                               Locum Consultant Started Nov 09
                               Business Case for substantive post to Trust Board –
                               May/Jun 2010

                             2. Monthly review of newly diagnosed Rheumatoid
                               Arthritis patients to enable tight control of disease –
                               Community Rheumatology Team & Consultant
                               Started additional adhoc appointments Nov 2009
                               Increased Clinical capacity – Apr 2010
                               Meeting with Primary Care Trust May 2010
                               To have additional nurse-led clinic slots – July 2010
                             3. Annual review of comorbidity – New Combined
                               clinics with Specialist Nurse and Clinician planned
                               from Aug 2010
                              Community Rheumatology          Team,     &   Consultant
                             4. Increase Capacity of Day unit (Space & Staff) to
                               deliver biologic treatments in a timely manner for
                               patients with active Rheumatoid arthritis despite
                               standard treatments and first-line biologics.
                              Day Unit Sister, Directorate Manager, Consultant
                               Interim Staff redeployment – Apr 2010
                          Interim Expansion of space – May 2010
                          Process mapping of capacity – May 2010
National Diabetes audit In order to improve control of patient‟s HbA1c and
2007/2008 (Paediatric)  reduce long-term complications :
                                    Review and increase number of eligible
                                      patients on insulin pumps
                                    Produce information and charts to assist

                                                                        Page 12 of 32
                                        patients/parent/carers to keep HbA1C in
                                        target by adjusting insulin

National Lung Cancer            Improve recording of data at MDT to improve
Audit Report 2009                the percentage of treatment plans input to the
                                 audit (currently 64%)
                                Increase number of patients having CT staging
                                 prior to bronchoscopy (target 90%) by
                                 discussion and reminders at MDT
National Sentinel Audit of      Diversion of all acute stroke patients to UHNS or
Stroke (Organisational)          Royal Wolverhampton Hospital from June 2009
                                Acute stroke patients to be admitted to Stafford
                                 when telemetry arrangements are in place (date
                                 to be arranged)
                                Development of early discharge team, linked to
                                 Community Stroke teams via Walsall Manor
                                 Community Stroke team) from end of June
                                Strengthening of rehab facilities on Fairoak ward
                                 and the Rehabilitation Day Unit at Cannock
                                 Chase Hospital from end of June 2009
                                PCT commitment to provide increased facility in
                                 the community for Stroke patients in need of
                                 palliative care/nursing home facilities from end
                                 of June 2009

Myocardial       Ischaemia      Individual cases where Barn Door thrombolysis
National Audit Project           times do not meet target to be reviewed monthly
                                 by team consisting of Emergency Department
                                 Consultant and Manager, Cardiology consultant,
                                 CAT team members
                                Focus on improving discharge medications by
                                 ensuring this is recorded accurately at the time
                                 of patient discharge and subject to monthly
                                 review at Cardiology Governance meeting
                                See also action plan for MINAP validation
Myocardial     Ischaemia
                                The CAT nurses to take overall responsibility for
National Audit Project –
                                 checking the quality of data collected for
Annual data validation
                                 individual patients on the wards from June 2009
study 2008
                                The Ward Receptionists to be trained to enter
                                 MINAP data onto Prism and for the data entry to
                                 be undertaken in real time as the patient is on
                                 the ward/discharged so that data is always up-
                                 to-date and any missing/query information can
                                 be quickly resolved to be in place by Sept 2009

National Bowel Cancer Actions identified through RCS review
National Audit of the
                           Appointment of fracture liaison nurse who will
Organisation of Services
                             run osteoporosis assessment clinics and also
for Falls And Bone Health
                             work closely with orthopaedics and elderly care
of Older People
                             by October 2009

                                                                    Page 13 of 32
                                   By May 2010 to review the existing multi
                                    factorial risk assessment and interventions for
                                   To adopt validated exercise programme (Otago
                                    exercise) and home safety assessment for
                                    patients attending falls prevention programme at
                                    the day hospitals
                                   To review multi factorial risk assessment
                                    proforma and make necessary changes
                                   Develop systems to routinely monitor in- patient
                                    falls against bed days and to monitor
                                    implementation of falls policy by March 2010
                                  To review the existing orthogeriatric service and
                                   consider developing specialist orthogeriatric
                                   beds at Cannock hospital (Hollybank ward) by
                                   April 2010
National Audit Office - The Trust is compliant with all aspects of this audit and
Reducing        Healthcare no further actions required
Associated Infections in
Hospitals in England
College of Emergency
                                Proforma to be designed and then introduced to
Medicine           National
                                   dept by consultant team
Paracetamol       overdose
audit                           Poisoning to continue to be a topic at dept
                                   teaching with emphasis on delayed presentation
                                   – immediate and ongoing
                                   Poisoning to be presented at middle grade
                                    teaching with the perils of staggered overdose in
                                    particular – immediate and ongoing
                                   Re audit of topic after introduction of proforma

CEMACH        Obesity   in      Implementation of new CMACE/RCOG joint
pregnancy                       guideline :
                                „Management of women with obesity in pregnancy‟
                                March 2010
NCEPOD Adding Insult to              Make guidelines more readily available.
Injury                                  Hard copies to be made available on MAU
                                     Discussion with UHNS to provide joint rota to
                                        cover 24/7 cover to be progressed.
                                     Audit undertaken
NCEPOD Caring to the            An action plan is being developed on the
End                             recommendations

Local Clinical Audits

The reports of 50 local clinical audits were reviewed by the provider in 2009/10 and
Mid Staffordshire NHS Foundation Trust intends to take the following actions to
improve the quality of healthcare provided

Local clinical audits completed in 2009/10 and actions planned

                                                                        Page 14 of 32
Specialty       Audit topic          Actions
A&E             Shoulder
                                     By Consultant/Senior team
                Dislocation in
                A&E                        Introduction of pain stamp.
                                           Teaching at induction use of stamp and
                                            pain management (Sept 09).
                                           Introducing paperwork for use of sedation
                                            (Oct 09).
                                           Introducing procedure book in resus to
                                            capture times performed and method/staff
                                            involved (Oct 09)
A&E             Audit of
                                           A proforma to follow in tick box style to
                Management of
                                            ensure all patients are treated in a way
                Retention of Urine
                                            acknowledged as best practice –
                                            Emergency department consultant/ Urology
                                            consultant Jan 2010
                                           The proforma to be demonstrated, and best
                                            practice discussed as part of f2 teaching –
                                            Emergency Department consultants Feb
                                            2010 and then in every rotation

A&E             NHSLA - Record
                                           Coding and its importance now taught at f2
                Keeping (A&E)
                                            induction from Aug 2009 onwards –
                                            Emergency department consultants
                                           Including guidance for locum doctors to the
                                            dept – Emergency Department consultant

Acute Medical   Audit of COPD
                                           Business case for Ward- based NIV service
Unit            Patient
                                            at Stafford – Medical Division Management
                Admissions & NIV
                                            , Immediate
                                           ABGs to be performed on all admissions
                                            with COPD exacerbations
                                           Clear documentation in the notes whether
                                            the patient will be suitable for NIV and
                                            whether NIV will be the ceiling treatment
                                           Clear development of protocol and
                                            guidelines as outlined in the British
                                            Thoracic Society guidelines to include the
                                            requirement for ABGs and recording of
                                            patient suitability for NIV
Acute Medical   Audit of                   E-mail to be sent to Clinicians within
Unit            documentation of            Medicine to show results of the audit and
                Consultant Post-            highlight where documentation has been
                take Ward round             poor - Head of Division, Medicine - August
                on EAU                      2009
                                           Summary of results to be presented to
                                            Medical Division Governance meeting -
                                            Head of Division, Medicine - 15 September

                                                                 Page 15 of 32
                                       Requirement for full PTWR documentation
                                        and results of audit to be raised at Junior
                                        Doctor Induction - Head of Division,
                                        Medicine - 7 August 2009
All            VTE/ DVT
                                       Introduce National Risk assessment tool to
                                        the Medical EAU care pathway – Clinical
                                        Director, Emergency care ( end August 09)
                                       Ensure increased education in respect to
                                        VTE across both Medical and Surgical
                                        specialties via an educational program lead
                                        by the Practice Development team. Clinical
                                        Director Emergency care, Manager ( end
                                        Sept 09)
                                       Re-audit in 12 months. Clinical Director
                                        Emergency care
All            Medical                 Present Audit at Medical Grand Round to
               thromboprophylax         raise awareness of VTE prophylaxis – (FY1
               is audit                 2009 – 2010)
                                       Consultants to take a lead with regards to
                                        ensuring completion of VTE risk
                                        assessment on post take ward round
                                       Re-audit in 12 months
Anaesthetics   Antenatal
                                       Clinical lead to encourage all staff and
               information on
                                        trainees allotted for obstetric sessions to
               Labour Analgesia
                                        make sure the follow ups are carried out.
               and Anaesthesia
                                       Lead obstetric anaesthetist to communicate
                                        to staff on ward 9 not to discharge any
                                        obstetric patients before being reviewed by
                                        an anaesthetist
Anaesthetics   Knowledge of pre-
                                       Provide Surgical Directorate Manager with
               operative fasting
                                        agreed protocol so that it can be ratified at
               guidelines (Nil by
                                        the Surgical Governance Group in May
                                        2009 – Consultant Anaesthetist
                                       Email guidelines to everyone - Consultant
                                       Teaching sessions eg FY1/nurse study
                                        days, or at hospital induction - Pre-op
                                        department – achieved April 2009
                                       Flyer/poster for wards - Consultant
                                        Anaesthetist - Achieved April 2009
Anaesthetics   Percutaneous
                                       To improve documentation of the
                                        procedure - Consultant Anaesthetist within
                                        12 months
                                       Re-audit end of 2010

Anaesthetics   Single nurse
                                       Advancer Nurse Practitioner, Anaesthetics
                                        and Theatres to report to SMPG with
               scribing of
                                        proposal for change in practice on Surgical

                                                               Page 16 of 32
             Oramorph                 wards/Trust wide - 29/09/09
             10mg/5ml                If proposal accepted LBJ to lead on
                                      implementation Trust wide in liaison with
                                      SAP‟s, Matrons and Ward Managers -
                                      Implemetation by January 2010
Cardiology   Acute Coronary
                                     The cardiac chest pain pathway should be
                                      employed for all patients with possible
                                      acute coronary syndromes. Made that clear
                                      at the time of the presentation at Medical
                                      Grand rounds Jan 2010.
                                     Cardiology Consultant to contact
                                      Emergency care Clinical Director and
                                      manager to ask them to ensure that the
                                      pathway is easily available and used
                                      appropriately. - 21/02/2010
                                     Audit use of chest pain pathway for
                                      patients admitted to ACU - Project to be
                                      carried out with FY1 doctor during their
                                      April to July 2010 attachment to cardiology.
                                      Supervised by cardiology Consultant
Cardiology   Heart Failure           To reduce LOS, improve bed management
             2008                     processes to ensure more HF patients are
                                      under the care of Cardiologists/ Care of the
                                      Elderly Consultants
                                     Increase the number of newly-diagnosed
                                      patients having in-patient echo.
                                     Improve number of patients receiving
                                      information about condition
                                     Ensure daily weights for HF patients
                                     Improve monitoring for hyperkalaemia for
                                      pts on diuretics
                                     Improve completion of eTTO‟s
                                     Improved referrals to community HF
Cardiology   Angiography Care        Update CP as required – Angiography Unit
             Pathway Review           manager – June 2009
CCU          Critical Care           Improve awareness amongst nursing staff.
             Nutrition Audit          Cascade the results and recommendations
             (Nutrition - How         to all critical care nursing staff – Consultant
             soon we feed             anaesthetist
             patients following      Daily default nutritional order for all patients
             admission to             admitted to critical care unit - Consultant
             CCU)                     anaesthetist
Colorectal   Appropriateness         Presentation at monthly surgical audit
Surgery      of request for           meeting to inform clinicans of guidelines
             Colonoscopy              and improve adherence.
                                     A teaching session educating all junior
                                      doctors regarding the guidelines and the
                                      importance of its application should be
                                      arranged, to include Emergency
                                     Advertise the guideline via the trust
                                      intranet, and ensure copies are easily to

                                                             Page 17 of 32
                                           hand in A&E, the Acute Medical Unit and
                                           all medical and surgical wards.
                                          Re-audit in 6 months
Dermatology   Osteoporosis
                                    All dermatologists treating Bullous Pemphigoid
              prophylaxis in
                                    patients from 01/06/2009 >65years with systemic
              patients on
                                    steroids are to
              systemic steroids
              for Bullous              a) confirm the diagnosis with histology and/or
              Pemphigoid                  immunofluorescence
                                       b) include the report in the notes
                                       c) document oral steroid and bone protection,
                                          sign and date in notes
                                       d) provide patients with an information leaflet.
                                    To be implemented from 1 June 2009 by all

Dermatology   Atopic Eczema               Specific history and examination document
              NICE CG57                    for all new patients with eczema.
                                          To be started in June 2009 – Dermatology
                                           Associate specialist
                                          All patients provided with BAD atopic
                                           eczema leaflet, including a link to the NICE
                                           guidance 2007 - Dermatology Associate
                                          Presentation of audit at Medical Division
                                           Grand Round 12 June 2009.
                                        Following interest in the subject of
                                           emollient use for atopic eczema from those
                                           attending the meeting, Dermatology
                                           Associate specialist supplied some
                                           guidance on the use of emollients and a
                                           link to the local formulary for circulation to
                                           all those who attended the Grand round
                                           (16 June 2009)
Dermatology   Timeliness of         No actions required – compliance evidenced
              Patient Diagnosis
              of Cancer to
              Patient's GP
Dermatology   Audit of use and
                                          Roll out nurse-led biologics clinics to all
              monitoring of
                                           dermatology consultants – Dermatology
                                           CNS - April 2010
              therapies in
              Psoriatic patients:         Await NICE update on IGRA testing (due
              April 2008 - March           2010) - Anne Ward - ?Feb 2010 – NICE will
              2009                         send us information when available
                                          Update Documentation sheet in keeping
                                           with revised BAD guidance 2009 - April
                                           2010, Consultant Dermatologist & CNS

Dermatology   Initiation of               To make department aware of NPSA
              methotrexate                 guidance requirements – Dermatology RN

                                                                  Page 18 of 32
               therapy for              – immediate
               psoriasis:              To make documentation “stickies” widely
               Compliance with          available in clinics at SGH and CCH -
               NPSA guidelines          Dermatology RN - immediate
Dermatology    Dermatology
                                         Staff meetings to disseminate findings of
               coding in the
                                          audit – Dermatology Senior O/P nurse,
                                          within 6 weeks
                                       Re-audit of coding, with breakdown of
                                          coding not obtained from this audit -
                                          Dermatology Senior O/P nurse, within 2
Dermatology    Management of     All clinicians are to :
               Bowen's disease   Maintain current standard of treatment , immediate

                                 All clinicians are to
                                       Follow up appointment for 6-12 month to
                                          monitor recurrence
                                       To document number of cycles in
                                       To document duration of freeze-thaw cycle
                                          and number in cryotherapy
                                       Patient information leaflet should be given
                                          on consultation

                                 By April 2010
Dermatology    Management of
                                       Discuss results with all members of the
               Squamous Cell
                                        skin team involved in the care of patients
                                        with SCC. GPSI, 29/1/10
                                       Ensure advanced communication skills
                                        courses are attended by skin team.
                                        Dermatology Cancer lead (within one year)
Dietetics      Record Card
                                       All dietitians to review results of audit and
                                        their own scores.
                                       All dietitians to review new Record Keeping
                                        Standard and take note of changes.
                                       All dietitians to aim to improve record
                                        keeping as necessary to meet the
Elderly Care   Audit of Trust
                                 Amend the Policy and FRASE form to add :
               Policy for the
               prevention and       1. Zero scoring option in sections on Medical
               management of           History, Medication, Sensory deficit to
               patient falls           ensure that the form can be visibly
                                       completed in each section for each patient.
                                    2. Specific section for recording score on
                                       admission to each new ward.
                                    3. Update policy – section 6.1.3 to ensure that
                                       patients are reviewed on admission &
                                       transfer to each ward, after a fall and
                                       during routine weekly checks.
                                 Persons responsible – Matrons (wards 10 &

                                                               Page 19 of 32
                                        Fairoak – end December 2009
                                        Amend Corporate Care planning documentation to
                                        include mobility.
                                        Person responsible – Matrons (wards 10 and
                                        Fairoak) - end December 2009
                                        Ward staff to be re-educated on correct procedure
                                        stated in Falls policy, particularly the importance of
                                        Medical review post fall and relatives being
                                        informed where appropriate.
                                        Person responsible – All Matrons - end January

Elderly Care       Effectiveness of
                                              Extend service to other wards -
                   service for
                                               Continence CNS and Community
                   Continence Pads
                                               Continence Nurse Team leader by March
                   from Hospital to
                                              To look at having the same pads in
                                               community and hospital - Continence CNS
                                               and Community Continence Nurse Team
                                               leader by June 2010
                                            Ensure Buffer Stock are available at both
                                               Stafford and Cannock Hospital -
                                               Continence CNS and Community
                                               Continence Nurse Team leader with
                                               immediate affect
Endocrinology      Use of               Audit demonstrated compliance – no actions
                   Radioactive iodine   required
                   in Thyrotoxicosis    Re-audit in 5 years
                   (RCP guidelines)
ENT                Diathermy
                                              To incorporate a theatre notes page for
                   settings for
                                               tonsillectomy with the power setting
                                               included - All ENT surgeons, immediate
                                              Re audit to make sure that the setting is
                                               being recorded – October 2010

Gastroenterology   Appropriate
                                              Flyer/ small poster for induction packs for
                   completion of
                                               new FY1 in August 2010.
                   request forms for         Presentation of audit results in Grand
                   upper GI bleeds            Round – Gastroenterology consultant
                                            FY1 teaching to include explanation of the
                                              forms, along with their importance to
                                              increase proportion of forms completed
                                              correctly - Gastroenterology consultant -
                                              Aug 2010
Gynaecology        Outcome of TVT       No problems identified, no actions required
Gynaecology        Patient              Medical practitioners should be encouraged to
                   satisfaction in      attach more importance to the issues of greetings,
                   Gynaecology          self-introduction, shaking of patients‟ hands,
                   Clinic               politeness as well as speaking audibly to patients

                                                                      Page 20 of 32
Inpatient     Management of
                                         Education of junior doctors regarding
Diabetes      Keto-Acidosis
                                          diabetic emergencies by means of ward
                                          rounds, tutorials by Metabolic dept staff,
                                         Update local electronic guideline - August
                                          2009 – Diabetes Staff Grade
                                         Education of patients by diabetes nurse
                                          specialists regarding 'sick-day rules' -
                                         Education of patients by diabetes nurse
                                          specialists regarding the importance of
                                          good compliance - ongoing
Neurology     Patients                   Feedback to staff responsible for
              discharged home             undertaking this procedure within one week
              with IV Cannula in          of audit results. To be undertaken by Day
              place (Stafford)            Unit Sister
                                         Ensure that future practice includes 100%
                                          compliance with regard to documentation in
                                          medical notes that information on the
                                          management of an IV Cannula at home
                                          has been given to the patient.
                                         Also that documentation that risks and
                                          benefits have been explained to the
                                        To be monitored by Day Unit Sister on an
                                          adhoc basis
Neuro-rehab   Rehab Day            Full compliance with guidelines – no actions
              Unit/Davy Unit       necessary
              patient therapy
              outing checklist
Obstetrics    Assessment of
                                   To be implemented by all clinical staff – immediate
              outcomes of
                                   and ongoing
              Reduced Fetal
              Movements                  Assess decreased fetal movement on first
                                          episode with no risk factors with CTG
                                         Assess decreased fetal movements on
                                          recurrent episodes with a risk factor with
                                          CTG and Ultrasound scanning
Obstetrics    Management of
                                         Use Trans-vaginal Scans as first measure
              Placenta Previa
                                          in all suspected placenta praevia patients
                                         Change in image modality – Manager,
                                          Superintendant Sonographer (Immediate

Obstetrics    NHSLA - Record             To investigate non-compliance with the
              Keeping                     completion of neonatal records - Ward 9
              (Obstetrics) 2009           and labour ward managers - Immediate
                                          and ongoing
                                         To investigate downward trend in

                                                                Page 21 of 32
                                      documentation of the Diagnostic sections –
                                      Antenatal Screening Co-ordinator -
                                      Immediate and ongoing
                                     To investigate the downward trend in
                                      collection of basic information e.g. third
                                      stage, perineum - Delivery Suite manager
                                      and Matron, Maternity - Immediate and
                                     To investigate the lack of compliance with
                                      intrapartum and delivery action plans and
                                      documentation of lead professional –
                                      Supervisor of midwives and community
                                      team leads - Immediate and ongoing
                                     Monitor compliance with operative delivery
                                      sections in view of new continuous audit –
                                      Matron, Maternity and Clinical Risk Group -
                                      Immediate and ongoing
                                     Continue with the in house training
                                      programme – invite multi-professionals and
                                      consider the following trends:
                                          o Poor compliance with cord gases
                                          o Legibility, timing and dating of
                                              entries in the antenatal period
                                          o Poor        compliance      with     unit
                                              numbers/names and signatures on
                                                      Delivery Suite Manager - 3
Obstetrics   Low risk antenatal
                                     Deliver antenatal audit presentation to all
                                      community midwives – Supervisor of
                                      midwives - Dec 09
                                     Updated perinatal pregnancy records
                                      address some of actions. Incorporate
                                      changes re updated perinatal institute
                                      pregnancy notes into Trust guidelines –
                                      Supervisor of midwives - Dec 09
                                     Chlamydia screening to be incorporated
                                      into contraception/sexual health training
                                      package for all community midwives –
                                      Community Midwife - Commence Dec 09

Obstetrics   Documentation of
                                     Place handover sheets in a separate folder
                                      to the rota to ensure that it is not misplaced
                                      – FY1: complete
                                     Change the format of the sheet to have
                                      only one box for each time period; not
                                      giving and receiving boxes – FY1
                                     Raise awareness in each staff grade –
                                      FY1: done during presentation

                                                             Page 22 of 32
Obstetrics      Induction of              Implement change in the departmental
                Labour after pre-          practice in line with the recommendations
                labour rupture of          from NICE. Re-write the protocol and
                membranes                  disseminate information effective to all staff
                                           - (Ward Manager – ASAP)
                                         Re-audit in 3-6 months time against
                                           standards in guideline 15B but also
                                           including maternal and foetal outcomes -
                                           (Junior Doctor ~ July 2010)
Occupational    NHSLA - Record           Non-compliance with writing in black ink:
Therapy &       Keeping                    Reasons for non-compliance were clinically
Physiotherapy   (Occupational              valid and necessary. However, an
                Therapy&                   alternative method was agreed, and use of
                Physiotherapy)             symbols now means that entries can be
                                           written in black ink but clinical relevance is
                                           maintained.. Action completed.
                                         Abbreviations not written out in full when
                                           first used: Seniors will develop
                                           abbreviations lists specific to their clinical
                                           areas. A copy of this list will be dated,
                                           identified with the patient‟s details and
                                           attached to their notes. To be completed by
                                           September 2009.
                                         General lack of awareness of standards:
                                           Education sessions to be held with all staff
                                           to raise awareness of and compliance with
                                           standards, including issues of patient
                                           consent. Physiotherapist, to be completed
                                           by end July 2009.
Orthopaedics-   Patient Group        Standards met – no actions required
Elective        Directive audit on
                the use of
                Ranitidine (re-
Paediatrics     Paediatric
                                           Ensure all patients have eTTO‟s and follow
                                            up appointments –Consultant Paediatrician
                                            by 01/05/2010
                                           Quality of bowel prep impacted on insertion
                                            of colonoscope. Examine ways to improve
                                            this Consultant Paediatrician by 01/05/2010
                                           All patients to have pre-admission check
                                            (currently 94%) - Consultant Paediatrician
                                            by 01/05/2010
Paediatrics     Paediatric IBD
                                           To develop a Transition clinic for
                audit - care
                                            adolescents - Consultant Paediatrician,
                                            Paediatric nurse - 01/05/2010
                                           To develop a systemic annual review
                                            checklist - Consultant Paediatrician -
                                           Re-audit against guideline - Consultant
                                            Paediatrician - 01/05/2011

                                                                  Page 23 of 32
                                               Histology – seek improvement in reporting
                                                by attending joint meeting - Consultant
                                                Paediatrician - 01/05/2010
Therapy Services   Compliance with
                                         Wheelchair services managers investigating
                                         reasons for long delay in referral to assessment
                                         time and assessment to delivery time - 3 months
                   Standards Audit
Thoracic           Oxygen                      Introduce changes to the Trust prescription
                   prescribing                  chart (Respiratory Consultant - already
                                               Improve awareness among healthcare staff
                                                that oxygen is a medication that needs to
                                                be prescribed and monitored (Senior CNS
                                                Respiratory, Oxygen Champion – on-going)
                                               Consider adoption of the new British
                                                Thoracic Society Emergency Oxygen
                                                Guidelines with regards to Oxygen
                                                prescription and administration (Acutely Ill
                                                Patient Group - on-going)

Urology            Assessment of               Re-audit Post Biopsy Infection rates
                   incidence of                 Prospectively – Uro-Oncology Nurse –
                   infection/sepsis in          ASAP
                   prostate biopsy             Create patient questionnaire - Uro-
                   patients                     Oncology Nurse – ASAP
                                               Ensure all clinicians hand out
                                                questionnaires at patients OPA – once
                                                action 2 complete

Urology            Patients post               Specific slots made available on Monday
                   initial TURBT                morning lists and Urology Staff Grade
                   receiving single             Friday morning lists for patients requiring
                   installation of              first TURBT - All Team - one month
                   Intravescial                Improved communication with team and
                   Chemotherapy                 secretaries
                   (Mitomycin)                 Further liaison with chemotherapy unit as
                                                to the availability of slots - All team -
                                               House Officers to be made aware of the
                                                need of Mitomycin for these patients and
                                                how to book it - All team - ongoing as the
                                                rota changes
                                               Clearer indication at time of flexi in notes
                                                as to potential need for Mitomycin at
                                                TURBT to reduce the cancellation of
                                                already booked slots.All surgeons
                                                undertaking flexi, immediate action.
                                               Further liaison with chemotherapy unit as
                                                to the availability of slots
Urology            Patient Group
                                               PGD for Alprostadil to be renewed
                   Directive for
                   Alprostadil                 Audit and review 2 years - Urology
                   Injection                    Nurse Practitioner

                                                                      Page 24 of 32
                     (Caverjet) Re-

Clinical Research

The number of patients receiving NHS services provided or subcontracted by Mid
Staffordshire NHS Foundation Trust that were recruited during that period to
participate in research approved by a research ethics committee was 502.

Commissioning for Quality Innovation

A proportion of Mid Staffordshire NHS Foundation Trust income in 2009/10 was
conditional upon achieving quality improvement and innovation goals agreed
between Mid Staffordshire NHS Foundation Trust and any person or body they
entered into a contract, agreement or arrangement with for the provision of NHS
services, through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2009/10 and for the following 12 month period
are available on request from Jonathan Pugh, Information Services Manager, 01785
886853 or jonathan.pugh@midstaffs.nhs.uk

The Trust agreed five goals with South Staffordshire Primary Care Trust with a
monetary value of £600,000 conditional upon achieving the quality improvement and
innovation goals during 2009/10. The Trust achieved the following goals and will
receive £386,000:
     End of Life - Percentage of all deceased patients on the Liverpool End of
        Life Care Pathway
     Ambulance Handover - Percentage of patients transported to Trust by
        ambulance and handed over within 15 minutes of arrival.
     Stroke – Percentage of patients admitted for stroke who had an appropriate
        diagnostic imaging test within 24 hours of admission

The Trust partially achieved the goal for the assessment by a senior grade doctor
(Consultant, Staff Grade or Specialist Registrar) of major cases (as defined by
Payment by Results Guidance) within 30 minutes of arrival and as a result will not
receive £64,000.

The Trust failed the data requirement goal to provide timely and robust data on a
monthly basis for contract monitoring meetings and as a result will not be paid

Care Quality Commission (CQC) Registration

Mid Staffordshire NHS Foundation Trust is required to be registered with the CQC
and must meet set standards which cover important issues for patients such as:

      Treating people with respect
      Involving them in decisions about care
      Keeping clinical areas clean
      Ensuring services are safe

The Trust‟s current registration status is conditional and has the following conditions
on registration:

                                                                        Page 25 of 32
1. The Trust must ensure its procedures for managing patients admitted as
emergencies are implemented by 1 April 2010. Evidence must be available to
demonstrate this from 1 April 2010.

Reason for this condition: The Trust is in breach of regulation 9 („care and welfare of
people who use services‟) as follows: The Trust has declared itself to be non
compliant with regulation 9 at the time of application and has provided action plans to
demonstrate how it intends to become compliant by 31 March 2010. The
implementation of its procedures for managing patients admitted as emergencies will
support the delivery of timely care and treatment that meets the needs of
individual service users.

2. The Trust must ensure that governance and audit systems to assess and monitor
the quality of service provision are in place across all services by 1 April 2010.
Evidence must be available to demonstrate this from 1 April 2010.

Reason for this condition: The Trust is in breach of regulation 10 („assessing and
monitoring the quality of service provision‟) as follows: The Trust has declared itself
to be non compliant with regulation 10 at the time of application and has provided
action plans to demonstrate how it intends to become compliant by 31 March 2010.
The governance and audit systems will enable the Trust to determine the quality of
the service provided and manage any risks.

3. The Trust must ensure that all medical equipment in use is in full working order
and that a maintenance programme is in place by 1 April 2010. Evidence must be
available to demonstrate this from 1 April 2010.

Reason for this condition: The Trust is in breach of regulation 16 („safety, availability
and suitability of equipment‟) as follows: The Trust has declared itself to be non
compliant with regulation 16 at the time of application and has provided action plans
to demonstrate how it intends to become compliant by 31 March 2010. The
maintenance of medical equipment will minimise the risk of failure and poor
performance which may impact on the quality of care to those using the service.

4. The Trust must ensure that clinical staff who use medical equipment have been
trained and are competent to operate that equipment by 1 April 2010. Evidence must
be available to demonstrate this from 1 April 2010.

Reason for this condition: The Trust is in breach of regulation 16 („safety, availability
and suitability of equipment‟) as follows: The Trust has declared itself to be non
compliant with regulation 16 at the time of application and has provided action plans
to demonstrate how it intends to become compliant by 31 March 2010. The correct
training and support of staff will minimise risk to those using the services.

5. The Trust must have a system in place by 1 April 2010 to ensure that the numbers
of nursing staff available are sufficient to meet the needs of the patients. Evidence
must be available to demonstrate this from 1 April 2010.

Reason for this condition: The Trust is in breach of regulation 22 („staffing‟) as
follows: The Trust has declared itself to be compliant with regulation 22 at the time of
application. However, the Trust reported an overall nursing staff deficit of 11% at the
end of January 2010. Furthermore, the Trust has recently undertaken a
review which indicates that its establishment figures may not be sufficient to meet the
dependency levels of patients on all the wards. The Trust is actively recruiting to its
establishment figures and it is anticipating that the full complement of nursing staff

                                                                          Page 26 of 32
will be employed by 1 April 2010. It is also repeating the review referred to above
which should give the Trust further results for consideration. It is important that the
nursing staff levels are sufficient to ensure quality of service and minimise risk to
those using the service.

6. The Trust must ensure that there are systems in place by 30 June 2010 for the
supervision and appraisal of staff, and for the keeping of proper records of that
supervision and appraisal. Evidence must be available to demonstrate this from 1
July 2010.

Reason for this condition: The Trust is in breach of regulation 23 („supporting
workers‟) as follows: The Trust has declared itself to be non compliant with regulation
23 at the time of application and has identified a need to provide systems for
supervision and appraisal to support learning and development. The Trust has
provided action plans to demonstrate how it intends to become compliant by 30 June
2010. The implementation of supervision and appraisal systems will ensure that staff
are supported and competent to carry out their role.

The CQC has not taken enforcement action against Mid Staffordshire NHS
Foundation Trust during 2009/10.

Of the 16 regulations relating to quality and safety, the Trust declared that it was not
compliant with five regulations, and in January our action plans were provided to
address the shortfalls in these areas.

The Trust Board confirmed at its March 2010 meeting that it was compliant with
regulations 9,10,16,22 and will be compliant with regulation 23 by June 2010.

CQC Periodic Reviews

Mid Staffordshire NHS Foundation Trust is subject to periodic review by the CQC and
the last review was on 7th July 2009 with follow-up visits in October and November
2009 against the hygiene code. The unannounced inspections during 2009 were to
ensure that we were following guidance on how to protect patients from infection. For
this inspection they evaluated four duties of the hygiene code.

The report noted the following:

“When we inspected the Mid Staffordshire NHS Foundation Trust on 7 July 2009, we
found no evidence that the Trust has breached the regulation to protect patients,
workers and others from the risks of acquiring a healthcare-associated infection. Of
the 18 measures we inspected, we had no concerns about 17. For one measure, we
found areas for improvement and made a recommendation to the Trust.

On 16 October, we visited the Trust to gain assurance that it had implemented this
recommendation. In November 2009, we had additional correspondence with the
Trust to gain further evidence”

Our overall judgement: When we followed up, we found no evidence that the Trust
has breached the regulation to protect patients, workers and others from the risks of
acquiring a healthcare-associated infection.”

Mid Staffordshire NHS Foundation Trust has been inspected and provided evidence
to give assurance that the regulation was not being breached.

                                                                         Page 27 of 32
CQC Investigations and Review

Mid Staffordshire NHS Foundation Trust has participated in special reviews or
investigations by the CQC relating to the following areas during 2009/10.

A Healthcare Commission report published in March 2009 detailed their findings from
an investigation of the Trust‟s Mortality rates for emergency patients. The CQC
undertook a six month review of progress following the report and this was published
in the autumn of 2009. The progress report highlighted that in the first six months the
Trust had made steady progress against its key priorities.

It was very positive that the majority of patients who spoke to the CQC when they
visited the Trust in September said that they were happy with the care they were

[Note: at the time of writing the CQC are carrying out their 12 month review of the
Trust. Feedback from this review will be inserted if it is received in time for the
publication of this Quality Report].

Hospital Episode Statistics

Mid Staffordshire NHS Foundation Trust submitted records during 2009/10 to the
Secondary Uses service for inclusion in the Hospital Episode Statistics which are
included in the latest published data. The percentage of records in the published

- which included the patient‟s valid NHS Number was:95.80% for admitted patient
care; 95.80% for outpatient care; and 95.30% for accident and emergency care.

- which included the patient‟s valid General Practitioner Registration Code was:
100% for admitted patient care; 100% for outpatient care; and 100% for accident
and emergency care.

(data rounded to two decimal places)

Information Quality and Records Management

Mid Staffordshire NHS Foundation Trust‟s score for 2009/10 for Information Quality
and Records Management (assessed using the Information Governance Toolkit) was
82% (Version 7).

Payment by Results

Mid Staffordshire NHS Foundation Trust was subject to the Payment by Results
clinical coding audit during the reporting period by the Audit Commission and the
error rates reported in the latest published audit for that period for diagnoses and
treatment coding (clinical coding) were:

Primary Diagnosis: 16.2%

Secondary Diagnosis: 11.1%

Primary Procedure: 21.5%

                                                                          Page 28 of 32
Secondary Procedure: 16.5%

The results of this audit should not be extrapolated further than the actual sample
audited as results will vary depending on which actual case notes are subject to

The areas reviewed in this audit were:

Theme: Paediatrics: 0% errors in Primary Diagnosis, 0% errors in Secondary
Diagnosis, 14.1% errors in Primary Procedures, 21.8% errors in Secondary

Specialty: General Medicine: 7.1% errors in Primary Diagnosis, 0% errors in
Secondary Diagnosis, 33.0% errors in Primary Procedures, 11.4% errors in
Secondary Procedures

Sub-Chapter: HRG QZ-Vascular procedures and Disorders: 30.4% errors in Primary
Diagnosis, 11.4% errors in Secondary Diagnosis, 22.1% errors in Primary
Procedures, 10.6% errors in Secondary Procedures

HRG: HB55C-Minor Hand Procedures for non-trauma Category 2: 0% errors in
Primary Diagnosis, 1.7% errors in Secondary Diagnosis, 6.7% errors in Primary
Procedures, 28.6% errors in Secondary Procedures

The results of the audit were reviewed and discussed with the Finance Director, the
Associate Director of Corporate Governance and the Clinical Coding Service and
Data Quality Manager. Agreement was reached for a Programme of Work to Improve
Data Quality in MSFT to be undertaken immediately to address the causes of the
errors in the audit. This action will be agreed with the executive team and progressed
through the Patient Data Quality Group (PDQ). Further actions as recommended by
the auditors will be discussed and agreed at the audit closure meeting to be held with
the PCT.

Part Three – Other Information
In our 08/09 Annual Plan we gave quality objectives for 2009/10 as follows: Patient
Safety; reduction of harm from drug administration, care of the deteriorating patient:
Patient Experience; work of the Patient Experience Group: Effectiveness of Care;
work of the Clinical Outcomes Group and becoming a pilot site for Connecting for
Health Clinical Dashboard Pilot Programme.

Timescales for publication of that report precluded us from addressing the full impact
of the HCC report into the quality of care at this Trust. During the first six months of
09/10, as we began to address the issues raised by the HCC report (and those by
Professor Sir George Alberti and David Colin-Thome that followed), our priorities
altered leading to the emphasis on the work described in Part Two of this Report.
Therefore the objectives listed above have not been addressed in the way originally
envisaged. An update is provided below:

   Reduction of harm from drug administration: ward pharmacy staff have now been
    recruited and are in post. Every patient‟s medications are now checked to ensure
    frequencies/dosages are correct.
   Care of the deteriorating patient – The Patient Safety First campaign carried out
    two workshops at the Trust on 14 January and 10 March on this topic. They were

                                                                          Page 29 of 32
    attended by a mixture of doctors, ward staff and clinical governance staff. As a
    consequence we will be using a simple “chart checker” to ensure observations
    are made correctly and consistently.
   Work of the Patient Experience Group – has been focused on improving the
    complaints process and developing better information for patients on how to feed
    back their views (see below).
   Work of the Clinical Outcomes Group – This became the Patient Safety Group as
    part of the restructuring of Trust governance in November 2009. The group is
    now focusing on supporting our “Zero Harm” theme.
   Pilot site for Connecting for Health Clinical Dashboard Pilot Programme – work is
    progressing on this ward level patient information system.

Also addressed during 2009/10

Complaints Handling
The investigation and independent reports published during the year highlighted that
the Trust‟s complaints handling policy and practice needed urgent revision in order to
properly address the concerns raised by patients and their loved ones. Changes to
the policy were approved by the Board on 25 March and this will be reviewed during
2010/11 to ensure that the policy keeps abreast of developments. Examples of the
practical changes being made include making earlier contact with those that raise
concerns and holding meetings with hospital staff. Changes are also being made to
the way the Trust runs its Patient Advice and Liaison Services to ensure that it
provides excellent customer care and meets the needs of our patients and visitors.

To cope with the increased number and complexity of the complaints received, many
of which relate to care and treatment issues in previous years, the Complaints Team
have needed additional resources. This has included the appointment of two new
administrative staff in late 2009 and we now also have a new interim Complaints

Following the publication of the Healthcare Commission report, the opportunity was
given to patients or their relatives to request an independent review of case notes.
South Staffordshire Primary Care Trust took over responsibility for the review of over
200 sets of case notes and a formal report is anticipated during 2011.

The Trust takes all complaints seriously and acts on all issues that are raised,
ensuring problems are resolved quickly. As a consequence of a formal investigation
into concerns raised by a patient, actions are identified and these are also now
shared with the patients or their relatives by means of reassuring them that standards
are being improved.

The total number of complaints raised in 2009/10 was 555 in comparison to 368
in 2008/9 and 339 in 2007/8. 174 of the complaints received during 2009/10
related to care provided in previous years. Each complaint has been broken
down into themes and issues detailed in the table below. Complaints may
include more than one issue or theme therefore the total number of complaints
will not be the same as the total number of issues/themes.

 Complaint Issue/Theme issues          2009/2010     2008/2009     2007/2008
Admissions, discharge and transfer         81            43            48
Aids, appliances, equipment and            22             0             8

                                                                       Page 30 of 32
premises etc
Appointments, delay/cancellation           102            31             6
Appointments, delay/cancellation           18             12            35
Staff Attitude                             117           68            50
All Aspects of Clinical Care               348           373           257
Nursing Care                               67            14            13
Communication/Information to               158           77            67
Consent to Treatment                        2             8             0
Complaints Handling                         0             0             0
Patients property and expenses              7             3             1
Patient privacy and dignity                60            21            22
Personal records                           16            12             1
Policy and decisions of the Trust           9             0             0
Failure to follow agreed procedures        15            11            10
Transport                                   2             0            16
Hotel Services (including food)            36            13            16
Other                                       4             0             4
TOTAL                                     1064           686           554

During 2009/10 of the 555 complaints received there were six complainants that
advised that they had approached the Parliamentary and Health Service
Ombudsman for a second stage review. Of these complaints three were upheld and
the Trust was asked to investigate further, two cases were not upheld and therefore
closed and one case remains open.

Performance against National Core Standards

The Trust is not fully compliant with the core standards for better health. For 2009/10
the Trust felt unable to self certify that the following 7 sub core standards (out of a
total of 44 sub core standards) were compliant in the Mid Year declaration made in

       C1a Healthcare organisations protect patients through systems that identify
       and learn from all patient safety incidents and other reportable incidents, and
       make improvements in practice based on local and national experience and
       information derived from the analysis of incidents.

       C4b Healthcare organisations keep patients, staff and visitors safe by having
       systems to ensure that all risks associated with the acquisition and use of
       medical devices are minimised.

       C5d Healthcare organisations ensure that clinicians participate in regular
       clinical audit and reviews of clinical services.

       C7a&c Healthcare organisations apply the principles of sound clinical and
       corporate governance and C7c Healthcare organisations undertake
       systematic risk assessment and risk management.

       C9 Healthcare organisations have a systematic and planned approach to the
       management of records to ensure that, from the moment a record is created
       until its ultimate disposal, the organisation maintains information so that it

                                                                        Page 31 of 32
       serves the purpose it was collected for and disposes of the information
       appropriately when no longer required.

       C11b Healthcare organisations ensure that staff concerned with all aspects
       of the provision of healthcare participates in mandatory training programmes.

       C14c Healthcare organisations have systems in place to ensure that patients,
       their relatives and carers are assured that organisations act appropriately on
       any concerns and, where appropriate, make changes to ensure
       improvements in service delivery.

In March 2010 the Trust has declared we are now compliant with all these standards
except C11b which is planned to be achieved by June 2010.

Annex – Statements from primary care trusts, Local Involvement Networks and
Overview and Scrutiny Committees

[Note: To be completed once feedback has been received]

                                                                      Page 32 of 32

Shared By:
Description: Mid Staffordshire NHS Foundation Trust Fetal Movement