quality account 2014-2015 - east surrey hospital...i reported in our last quality account that we...

Quality Account 2014-2015

Introduction ........................................................... x

Vision and values ............................................ x

What we do ............................................................ x

Culture champions ......................................... x

How we look at the safety and quality of our services .............................. x

Our safety and quality priorities.. x

Patient experience• Eliminate clinically inappropriate mixed

sex accommodation .................................................. x• Cleanliness .....................................................................x• End of life care ............................................................. x• Nutrition .......................................................................... x• Patient feedback ......................................................... x

Safety• Falls .................................................................................... x• Skin care .......................................................................... x• Safety thermometer .................................................. x• Dementia ........................................................................ x• Healthcare acquired infection ...............................x• Venous thromboembolism (VTE) ........................x• World Health Organisation (WHO) safer

surgery checklist .......................................................... x• Fractured neck of femur (hip) ............................... x• Patients admitted with stroke ...............................x• Access to services ....................................................... x• Incident reporting ....................................................... x

Clinical effectiveness• Mortality ......................................................................... x• Readmission to hospital ........................................... x• Reducing need for admission ............................... x• Enhanced recovery ..................................................... x• National Institute for Health and

Clinical Excellence (NICE) technology appraisals (TAs) ............................................................ x

• Amber Care Bundle ................................................... x• Safe and appropriate discharge arrangements• Mental health ...............................................................x• COPD Bundle ................................................................ x

ContentsStatutory declarations

• Review of services ......................................................x• Participation in clinical audit .................................. x• Participation in clinical research ........................... x• Goals agreed with commissioners...................... x• Care Quality Commission registration

and inspection ..............................................................x• Data quality ................................................................... x• NHS Number and GP practice Code Validity ....x• Information governance .......................................... x• Clinical coding .............................................................. x• Summary of hospital-led mortality indicator

(SHMI) and the percentage of deaths with palliative care coding .................................................x

• Patient reported outcome measures (PROMS) ....................................................x

• Responsiveness to inpatients’ personal needs ..............................................................x

• Percentage of patients admitted who were at risk of VTE ....................................................................... x

• Patient safety indicators ...........................................x• C.difficile infections ................................................... x• Staff recommendation of the Trust as a place

to be treated .................................................................x• Patients’ recommendation of the Trust as

a place to be treated ................................................. x

Staff awards and recognition ......... x

Our priorities for 2014-15 ......................x

Glossary ....................................................................... x

Appendices .............................................................. x

• Statement of our directors’ responsibilities..........x

• What our partners say ............................................. x

2 Quality Account 2014-2015 Contents 3

Quality Accounts are an important way for local NHS services to report on quality

and show improvements in the services they deliver to local communities and

stakeholders.

The quality of the services is measured by looking

at patient safety, the effectiveness of treatments

that patients receive and patient feedback about the

care provided.

NHS Choices

Thank you for taking an interest in our quality account, which is designed to give you information about how we assure our patients and their carers, our partners and commissioners and ourselves on the quality, safety and effectiveness of the services we offer.

It has been another year where we are proud to have maintained standards set nationally for access to services in the emergency department and to in-patient and operative care despite the challenges of more people than ever needing unplanned care.

It has been another year where we have met the standards set for us on patients suffering from healthcare acquired infection and the first year in our history where, although we reported a single MRSA contaminant at blood culture, we did not have a single MRSA blood stream infection. Every patient who contracts an infection related to hospital treatment has a story that is used to drive learning and improvement and this year the challenge is to reduce infections where there is a failing of care to an absolute minimum, a challenge we very much want to meet.

I reported in our last quality account that we had received a very useful and reassuring ‘mock’ CQC inspection provided by colleagues from many departments at Frimley Park NHS Foundation Trust. This was followed in June 2014 by a three day inspection of all our services by the Care Quality Commission themselves. This was a planned inspection and as well as reviewing much of the data related to our clinical performance and outcomes, it also met with patients, carers

Introduction

4 Quality Account 2014-2015 Introduction 5

and members of staff to gainan overall picture of the care we provide.

I was delighted that as a direct result of our strong clinical leadership and the commitment of staff across the Trust we were rated as ’good’ across all five inspection domains:

• safety• effectiveness• patient experience• access and responsiveness• well led

In addition, our end of life services were awarded ‘outstanding’.

This rating was a tremendous achievement and one we are very proud of - nonetheless we were told we could do more for patients attending our out-patient services, improve the availability of our medical notes and in relation to our medical secretary and PA workforce. In all of these areas we are advanced in delivering the improvements we are grateful to the CQC for raising.

We have had our best ever year for recruiting patients into clinical trials. The ability for patients to participate in research studies is a less widely publicised marker of quality of service - with many of the studies receiving national and local attention.

Studies suggest that as many as nine out of ten patients would be willing to take part and the challenge we face is identifying studies which are appropriate for us to take part in and asking patients whether they are willing to take part. Both of these aspects require an effective and hardworking research and development team and a willing and informed clinical workforce. We plan to build on last year’s success by working ever more closely with the Local Clinical Research network, which covers Kent Surrey and Sussex, so that we are thought of early when trials are looking for recruitment centres. We will also ensure that we support our research active staff to enable them to have time to spend with patients explaining studies.

We continue to be an associated university hospital of Brighton and Sussex Medical School and, in addition, this year we have become a member of Surrey Health partners. This initiative links clinicians and academics around central clinical themes (clinical academic groups) promoting research ideas, design and delivery to ensure the best care is available to patients. We have continued to be a member of the Kent Surrey and Sussex Academic Health Science Network (AHSN) and, as reported in this account, we have continued to perform well within their Enhancing Quality and Enhancing Recovery programmes. These programmes look at the frequency with which patients with certain clinical diagnoses receive specific quality interventions and drive safety and effectiveness of care. Looking forward, this year we will work with the AHSN to further strengthen our capacity to define quality for patient pathways and design and evaluate even more effectively the care we give.

Our journey towards Foundation Trust status continues. At the time of writing this introduction we have been referred by the NHS Trust Development Authority to Monitor, the Foundation Trust assessor and regulator. We are part of a final assessment undertaken by Monitor and we are pleased that at this stage we have recruited more than 10,000 members who have chosen to be involved and in the future plans of our organisation. In many ways, the most important advantage of being a Foundation Trust is having this proactive membership of people who have signed up as interested in how we deliver our services for them and the communities we serve. I am very grateful that so many people have taken this step and look forward to working with them this year to further improve the care we give.

Michael WilsonChief Executive

What we do

Surrey and Sussex Healthcare NHS Trust provides extensive acute and complex services at East Surrey Hospital in Redhill alongside a range of outpatient, diagnostic, day case and planned care at Caterham Dene Hospital and Oxted Health Centre in Surrey and at Crawley and Horsham Hospitals in West Sussex.

Serving a population of over 535,000 we care for people living, working and visiting east Surrey, north-east West Sussex, and south Croydon, including the towns of Crawley; Horsham; Reigate and Redhill.

East Surrey Hospital is the designated hospital for Gatwick Airport and sections of the M25 and M23 motorways. It has a trauma unit,

87,000

32,172 35,300 320,000

patients at our emergency department

In 2014-15 we saw more than

required emergency admission

were admitted at our out-patient clinics

which cares for seriously injured patients in partnership with the major trauma centres at St George’s University Hospitals NHS Foundation Trust and Royal Sussex County Hospital Brighton. East Surrey Hospital has 666 beds and ten operating theatres – along with four more theatres at Crawley Hospital in our day surgery unit.

We are a major local employer, with a diverse workforce of around 3,600 providing healthcare services to the community we serve.

The Trust is an associated university hospital of Brighton and Sussex Medical School.

In 2014-15 we had an income of £244m and we have delivered an increase in activity across the services we provide and in the number of people we have cared for:

There were We also saw

4,463birthspatients patientselective patients

6 Quality Account 2014-2015 What we do 7

• Dignity and respect: we value each person as an individual and will challenge disrespectful and inappropriate behaviour

• One team: we work together and have a ‘can do’ approach to all that we do recognising that we all add value with equal worth

• Compassion: we respond with humanity and kindness and search for things we can do, however small; we do not wait to be asked, because we care

• Safety and quality: we take responsibility for our actions, decisions and behaviours in delivering safe, high quality care

Our vision, Our values

Safe, high quality healthcare that puts our community first.

WESTSUSSEX

EASTSUSSEX

HORSHAM

MID SUSSEX

TANDRIDGE

CROYDON

REIGATE &BANSTEAD

MOLEVALLEY

CRAWLEY

KENT

GREATER LONDON

SURREY

East Surrey Hospital

CaterhamDene Hospital

Crawley Hospital

Horsham Hospital

First Community Health & Care

Sussex Community Trust

CSH Surrey

1 mile

I couldn't have had better treatment. All the staff were courteous and helpful. Really impressed with East Surrey Hospital.

8 Quality Account 2014-2015 Our vision, Our values 9

Our culture champions

Colin Pink, corporate governance manager,

updates us on the role of culture champions at Surrey and Sussex

Healthcare NHS Trust…

Putting our patients first and at the centre of what we do is key to enabling us to achieve our goal of moving from a ‘good’ organisation to an ‘outstanding’ one - making sure that everyone has quality, safety, productivity and patient experience as the cornerstones of their decision making.

In partnership with our staff, we have outlined the behaviours and expectations that explain what our organisational values look like in everyday practice and now we must strive to make sure they become part of the way we work, day in and day out.

To that end we have set up a network of culture champions who will help give us focus and visibility and help the organisation embed our culture in everything we do.

Chosen by the executive team and clinical chiefs our core group of culture champions are a mix of people - all bands, all divisions, all occupations - who are already role models for our values and behaviours. Their role is to help us to embed our values and behaviours by supporting our teams and staff:

• At an individual level to help colleagues understand our values and what it means for them, for our Trust and, most importantly, for our patients

• At a team level working with leaders to propose different ways in which our values can be communicated and integrated

• At a Trust level to create awareness and focus and support initiatives to integrate values and behaviours in our systems and processes - recruitment; induction, recognition

In collaboration with members of staff from across the organisation, we have developed a framework of ‘behavioural anchors’ that support our four key values:

• Dignity

• One Team

• Compassion

• Safety and Quality

The anchors provide all staff with a fair and transparent interpretation of what our values mean in day-to-day situations and will be become a powerful tool in challenging behaviours and setting appropriate expectations.

Changing the way we assess individual achievement and contributions to our organisation is one of the ways that we are creating focus to accelerate our journey to ‘outstanding’. A new style achievement review was developed during 2014/15, which replaces our existing appraisal system, has been designed to help us feedback and reflect each person’s contribution to our success.

Culture champions - living the

values

Our new achievement review process is different; it signifies a change in how contribution is reviewed by considering the extent to which people achieve their objectives in a way that reflects our values and behaviours.

To date this is making very positive changes to the Trust which, for example in our theatre team, can be seen in their development of team goals and beliefs and the use of behavioural questions in interviews for new staff.

10 Quality Account 2014-2015 11

How we look at the safety and quality of our services

Katharine Horner, patient safety and

risk lead, explains the background to how

we look at the safety and quality of our

services…

As we continue to grow and expand services we remain committed to improving and providing high quality safe and effective care to our patients and their families.

On a daily basis, teams across all wards and departments come together to discuss patient safety issues such as the number of patients who have a high risk of falling, the dependency of patients on the ward and any staffing issues. Each clinical division holds a monthly governance meeting to which safety concerns and risks are escalated.

The information contained within the scorecard covers a wide range of performance indicators for safety, clinical effectiveness, patient experience, performance and productivity and covers all services provided. This means that the sub-committees of our Board can focus on the right quality and safety priorities for patients.

The patient safety sub-committee provides an important interchange of information and experience for the teams responsible for ensuring that patients are safe. We recognise that incident reporting is only effective if the organisation learns lessons from the incidents that have occurred. We have continued to see incident reporting rates at a level that is consistent with a healthy incident and reporting awareness culture.

We were pleased to see an improvement in the 2014 National Staff Survey indicators:

• ‘percentage of staff reporting errors, near misses or incidents witnessed in the last month’ (KF13)

• ‘percentage of staff agreeing that they would feel secure raising concerns about unsafe clinical practice’ (KF15)

Both indicators are better than the national average. In addition for indicator, ‘Fairness and effectiveness of incident reporting procedures’ (KF14) the improved picture for 2014 placed us in the best 20% of Trusts in the country.

The hospital was clean and tidy and

the staff have all been wonderful, extremely

kind and caring.

12 Quality Account 2014-2015 How we look at the safety and quality of our services 13

Our safety and quality priorities

Patient experience

Eliminate clinically inappropriate mixed sex accommodationImprovement sought for 2014-15: We said we would continue to ensure there are no mixed sex breaches and enhance the privacy and dignity experience for all our patients.

• 2014-15 Performance rating ➜ Met

In 2014-15 we had no mixed sex breaches.

Improvements sought for 2015-16: To continue to ensure there are no mixed sex breaches and enhance the privacy and dignity experience for all our patients.

CleanlinessImprovements sought for 2014-15: Investment in new equipment to assist in a more streamlined cleaning regime and cleaning during the day rather than during the night to alleviate unnecessary noise for our patients.


New equipment has allowed us to provide a more streamlined cleaning routine. Our scheduled regular cleaning programme takes place during the daytime - we do not routinely clean during the night to ensure that our patients are not disturbed unnecessarily.

Improvements sought for 2015-16:To continue to maintain high standards of cleanliness and to ensure patients are not disturbed unnecessarily.

End of life careImprovements sought for 2014-15: The Trust’s End of Life Care Strategy (2011-2014) is due for renewal this year. This work will be taken forward via the End of Life Care Steering Group. We will continue to promote the use of, and audit, the newly introduced End of Life Care Plan. We will introduce a palliative care weekend service by expanding the nursing team by two whole time equivalent clinical nurse specialists.


Our end of life care strategy has been renewed for 2014-2017. The strategy has been reviewed and agreed by the end of life care steering group and at board level by the clinical effectiveness group and implementation is monitored via an action plan.

We have expanded the service provision from five days a week to include Saturdays and Bank Holidays since September 2014 and are working towards expanding this to a seven day service.

A two year pilot discharge liaison project has been launched by SASH and Marie Curie to aid hospital discharge for patients at the end of life to their preferred place of care.

Improvements sought for 2015-16: We will continue to audit end of life care via participation in the 5th National Audit of Care of the Dying Patient and internal audit of end of life care documentation. We will develop, introduce and embed the second version of SASH end of life care plan.

NutritionImprovements sought for 2014-15: We said we would continue to focus on implementing protected mealtimes and have an on-going audit to monitor progress and adherence to this initiative. We also said that we will introduce a new two week menu cycle and the dieticians and catering department have been working very closely to ensure this menu offers variety and continues to meet the nutritional standards for hospital catering. The new breakfast menu will include prunes and yoghurts at breakfast time following feedback from patients.


Our audits confirm good progress and that the two week menu cycle is proving popular with patients.

Improvements sought for 2015-16: We will continue to make improvements to protected mealtimes and our recent audits confirm good progress. The nutrition and hydration steering and the oral nutrition and hydration group will continue to monitor progress and we will continue to monitor feedback and make adjustments as necessary.

Patient experienceImprovement sought for 2014-15: We said we would encourage more senior frontline staff to respond directly to comments on Patient Opinion and that we would roll out the Your Care Matters programme to cover all patient pathways, build upon using it as a way to track performance and consistently respond to the comments we receive and strive to make improvements. We also said that we would

communicate the changes that we make to staff and our patients and their families and improve both admission and discharge patient literature.


Your Care Matters: Our bespoke patient feedback programme now covers the full range of different patient pathways and includes the Friends and Family Test as the first question. Patients are asked to take part in a short survey once they have experienced an episode of care. The programme is widely promoted across the Trust to both patients and staff and text reminders are also used to encourage participation. The survey gives patients the opportunity to commend staff for a job well done and also asks for any comments or suggestions on how the service might be improved. These staff commendations and additional comments are automatically emailed to key staff within the service. They are able to share positive comments and review additional comments alongside other sources of patient feedback such as PALS contacts, Patient Opinion and face to face interactions and make improvements where possible.

Changes that are made as a consequence of listening to our patients’ views are widely communicated using ward boards and digital screens across the hospital.

Improvements sought for 2015-16: We will continue to promote both staff and patient engagement with the Friends and Family Test and Your Care Matters and will make changes based on the feedback we receive. We will further broaden the way we seek feedback from the wider community through increased use of focus groups and wider consultation with stakeholder groups. We will continue to train our staff in customer care skills.

14 Quality Account 2014-2015 Our safety and quality priorities 15

Safety

FallsImprovement sought for 2014-15: We said we would improve data collection. The falls prevention team would start monthly falls clinics and develop routine monthly falls ward rounds to continue to reduce the overall number of falls and promoting good reporting and management processes. There is a goal to reduce the total number of falls by 25%.A 25% reduction is pragmatic for an organisation that is not an outlier for falls and considered by majority of staff as a stretch target. If delivered, this will result in a meaningful improvement in the safety of our patients.

• 2014-15 Performance rating ➜ Partially Met

We have started the monthly falls clinics and the weekly falls ward rounds. In addition, we also reconvened our falls prevention group in March 2014 to monitor trends and themes on falls. Patients are referred to our specialist falls nurse consultant, who joined us in year, and we have started ward staff teaching on falls prevention; conducted an audit on the use of falls care bundles for high risk areas;updated our Trust falls strategy and appointed falls champions.

We have also, working with our colleagues at the Kent, Surrey and Sussex Falls Collaborative and also with NHS England at a national level, assessed our current falls prevention practices/strategies per NICE guidance and participated in the first national in-patient falls audit by the Royal College of Physicians and the Falls and Fragility Fractures Audit Programme (FFFAP).We will also be participating in the largest research of its kind in the UK with regards to preventing injuries to older people through the provision of shock-absorbing flooring led by the University of Portsmouth.

2013/14 2014-15

Total falls 1049 1049

Falls with harm 315 314

Also, in 2014-15:

5.2%

The total number of patients who suffered no harm due to a fall has increased by

compared to 2013-14

21%

The number of patients who suffered major harms has

decreased by

50%There was a

reduction in the number of patients who suffered an extreme harm

29%

The total number of serious incidents due to a fall has also

decreased by

Improvements sought for 2015-16: We will continue to seek to achieve a 25% reduction in total falls and in harms caused.

Pressure damageImprovement sought for 2014-15: The number of patients affected by pressure damage is reported to the Trust Board at every meeting. We will reduce hospital acquired minor damage by 25% and have no hospital acquired major pressure damage.


We have continued to reduce hospital acquired minor damage by over 50% and we had no hospital acquired major pressure damage.

Improvements sought for 2015-16: Maintain our achievement of no hospital acquired major pressure damage and continue to strive to reduce hospital acquired minor damage.

Safety thermometerImprovement sought for 2014-15: We said that a specific maternity safety thermometer that was being piloted would be introduced and that the Trust would continue to engage with community services and clinical commissioning group chief nurses to ensure a joined up approach. The ‘new harms’ score is between 94.19% - 96.5% - the Trust has interrogated this data to allow it to identify areas for improvement.


The maternity safety thermometer has not yet been publishes and so we have been unable to introduce and implement.

Harm free (all harms) %

Harm free (new harm) %

April 2014 90.5 95.4

May 2014 92.8 97

June 2014 93.4 97.6

July 2014 90.8 95.3

August 2014 92.5 96.1

September 2014 92 94.5

October 2014 95 98

November 2014 93 96

December 2014 93 97

January 2015 93 96

February 2015 92 95

March 2015 92 96

Improvements sought for 2015-16: To maintain 95% average compliance with safety thermometer new harm metrics and increase average compliance to 97% throughout January to March 2016.

DementiaImprovement sought for 2014-15: We said that in order to ensure the most effective and significant engagement with local commissioning and care quality improvement initiatives, we would engage and commit to local commissioning intentions and care quality improvements. We also said that we would demonstrate a community facing mind-set and approach to dementia care, ensuring that the organisation is involved at the heart of efforts to minimise avoidable admissions, whilst maintaining a commitment to providing the highest standards of care for those who require inpatient admission and that we would actively seek feedback from carers of people with dementia about the care each individual receives and how well as an organisation we support the carer. We also said that we will disseminate and utilise this feedback in developing care delivery and where appropriate provide feedback and evidence to the carer demonstrating how their input has been successfully employed to make alterations and improve service provision.


We have been successful in ensuring that we have adopted a strong community facing approach to dementia care and are a key partner in local commissioning efforts to develop high quality dementia care. We have been central in efforts to develop high quality services which support a reduction in avoidable admissions and we continue to support the development of these services. We have also sought to solicit the views and opinions of carers of people with dementia to improve how we support them and this will continue to be a key feature of our aims going into 2015-16.


Improvements sought for 2015-16: We will continue to develop and build new pathways for both dementia and delirium which will be linked to the East Surrey Integrated Dementia Action Plan (ESIDAP) and to primary care and community pathways. Close involvement and support of the implementation of the ESIDAP will help in continuing to develop a community facing mind set, collaborative approaches to care and the avoidance of unnecessary admissions. We are committed to holding a number of carers’ focus groups to benchmark how well we support carers currently and at how we can improve. In-line with our commitment to the national Sign up for Safety pledge we will audit and benchmark our performance in the assessment and management of pain in dementia and undertaking an assessment of the knowledge and skills of staff to identify any training needs that can be met.

Healthcare acquired infectionImprovements sought for 2014-2015: We said that we will meet the Department of Health targets of no more than 29 patients who are affected by Cdiff, and will have no preventable MRSA blood stream infections. We also said that we would continue to analyse all cases and disseminate learning and that thefocus in the coming year would be to ensure that we identify patients with MRSA promptly with our screening programme and that we would prescribe and administer the MRSA suppression treatment in a timely way.


• Clostridium difficile* - 24 cases**

• MRSA blood stream infections - 0 (with 1 contaminant)

*The national maximum for all Trusts reporting cases of patients aged two years old or over during the reporting period was 121 minimum was 0

**This equates to 11.3 cases per 100,000 bed days

For the prevention of Clostridium difficile, there has been a continuing emphasis on antibiotic prescribing and improved timely risk assessment of all patients with symptoms of diarrhoea. There has been a continued focus on prompt isolation of affected patients. All cases of Clostridium difficile had full root cause analysis performed and the clinical teams fed these investigations findings back at divisional governance and taskforce meetings, so that learning could be spread throughout the organisation.

MRSA infections are more likely if a patient has intravenous lines, a urinary catheter, wounds, or if it is not known that they are a carrier. Over recent years there has been an overall reduction in MRSA blood stream infection, due to an enhanced focus on screening and the care of patients with intravenous lines and urinary catheters.

Learning: Each Clostridium difficile case was subject to a comprehensive investigation undertaken by clinical team in conjunction with the infection prevention and control team. In 2014-15 there were 24 Trust apportioned episodes of Clostridium difficile - 16 cases arose within the medical division and 8 in the surgical division; 19 patients had received an antibiotic post admission, all prescriptions being clinically justified. In four of these cases, although antibiotics were required, prescribing was not in line with Trust antibiotic policy (for choice, dose or duration). There were three episodes of probable cross-infection and there were no deaths directly attributed to Clostridium difficile infection.

Tackling Norovirus: Keeping the virus that causes vomiting and diarrhoea away from the hospital is a challenge every year. The virus spreads easily and causes huge disruption in all hospitals and schools, particularly over the winter. The whole health economy is working more effectively on Norovirus control, with planning meetings occurring in September of each year.

In October 2014, we organised a conference on Norovirus and invited our community partners

to join us to decide the best way to prevent and control the spread of the virus. Representatives from nursing and care homes, the ambulance service, Public Health England and other local NHS trusts all attended to discuss working together with us in seeking a common goal.

We looked at ways of avoiding admitting people with Norovirus symptoms, patient transport and the control of the illness in care and nursing homes. The Trust has seen a slightly higher level of activity compared to last year, in common with community settings. There were seven episodes of ward closures due to confirmed Norovirus throughout winter and spring. The focus of the coming year will be on cleaning standards, hand hygiene and the continued presence in wards by infection prevention and control nurses, to support the clinical assessment of patients with diarrhoea.

Improvements sought for 2015-16: We will meet the Department of Health objectives of no more than 15 patients who are affected by Clostridium difficile and will have zero preventable MRSA blood stream infections. We will continue to analyse all cases and disseminate learning.

For MRSA, the focus in the coming year will be to ensure that we continue excellent practice in the care of intravenous lines and urinary catheters. For the prevention of Clostridium difficile we will continue the high focus on antibiotic prescribing and ensure that hand hygiene and glove use is high on the agenda. There will also be a continued presence in wards by infection prevention and control nurses to support the clinical assessment of patients with diarrhoea.

Venous thromboembolism (VTE)Improvement sought for 2014-15: We said that the risk assessment will continue to be carried out on more than 95% of patients on admission and that the reassessment of risk will be highlighted through staff education, in line with NICE guidance. Also, that patient

information leaflets will be available to all admitted patients within the Trust, highlighting the risk of VTE and on-going preventative advice on discharge. We also said that a multi-disciplinary team would review any cases where a patient develops a venous thrombosis either whilst an inpatient, or within 90 days of discharge and that the numbers of such cases and whether care was sub-standard will be published within our Board performance papers.


Over the last year, 95% of patients looked after by us had a formal VTE assessment carried out on admission and recorded in the notes.

Improvements sought for 2015-16: To continue to develop the improvements achieved by the multi-disciplinary review of venous thrombosis.

World Health Organisation (WHO) safer surgery checklistImprovement sought for 2014-15: We said that we would continue to audit the quality of our safer surgery processes.


Improvements sought for 2015-16: We will continue to audit the quality of our safer surgery processes.

Fractured neck of femur (hip)Improvement sought for 2014-15: We said that we will maintain and further improve our best practice performance for hip fracture care and that we will aim to improve performance for time of admission to the hip fracture unit. We also said that we will look to improve our length of stay through collaborative multi-disciplinary working across the Trust and the community and that we hope to be able improve our follow-up data collection and reporting to achieve greater


Access to servicesImprovement sought for 2014-15: We said that we wanted to deliver the national standards for the emergency department (ED), referral to treatment (RTT) and cancer and, where possible, reduce waiting times for as many patients as possible.


Last year we saw an increase in the numbers of people treated by our emergency department (ED) from 82,000 to around 87,000 and against the national four hour access standard for the emergency department, 95.1% were admitted or discharged within four hours.

For the 18 week admitted pathway we treated 20,667 patients – 18,513 (89.6%) were treated within 18 weeks against the NHS constitution standard of 90%. There were 468 patients waiting more than 18 weeks for admitted treatment at the end of the year compared to 165, 12 months earlier.

Cancer access standards were achieved:

Surrey and Sussex Healthcare NHS Trust

Nationally set standard

Two week wait 93.15% 93%

Two week wait: breast symptomatic

93.7% 93%

62 day* 86.5% 85%

62 day screening 94.3% 90%

31 day first treatment

99.3% 96%

31 day subsequent treatment: surgery

100% 98%

31 day subsequent treatment: drugs

100% 94%

*Nationally this figure was not achieved

understanding of longer term outcomes for our hip fracture patients.


We have maintained very good access to theatres and to pre-op local anaesthetic blocks for pain relief. Tracking longer term outcomes beyond discharge was not routinely performed this year.

Fractured neck of femur: average length of stay

2010-11 2011-12 2012-13 2013-14 2014-15

19.2 19.7 21.3 20.5 19.6

Fractured neck of femur: % to ward within four hours

2010-11 2011-12

19.2 19.7

Improvements sought for 2015-16: Further improvements in pre-operative pain management and improved follow up for treated patients, in addition to an increased number of patients admitted to the ward within four hours; in-line with best practice standards.

Patients admitted with strokeImprovement sought for 2014-15: We said that we will continue to ensure quality by improving the performance in general and further improvement on scanning time although the target was met and to review stroke coding and mortalities for 2013-14. And that we would focus particularly on reinforcing ring-fencing to admit acute stroke patients to the Acute Stroke unit within four hours from presentation to hospital.

We also said that we would focus on improving clinical outcomes for patients who have had a stroke within 72 hours, follow-up assessment between four and eight months after initial admission and discharged with a joint health and social care plan.

• 2014-15 Performance rating ➜ Met/Partially Met

The Sentinel Stroke National Audit Programme (SSNAP) aims to improve the quality of stroke care by auditing stroke services against evidence based standards, and national and local benchmarks. SSNAP audit has five metrics:

• Metric 1: Stroke patients scanned within one hour of hospital arrival ➜ Met

• Metric 2: Stroke patients scanned within 24 hours of hospital arrival ➜ Met

• Metric 3: Percentage of patients admitted directly to an acute stroke unit within four hours of arrival to hospital ➜ Not Met

• Metric 4: Stroke - 90% or more time spent on stroke unit ➜ Partially Met

• Metric 5: Adjusted mortality for 2014-2015 ➜ Met

1: Stroke Patients scanned within one hour of hospital arrival

Jan – Mar 14 Apr – Jun 14 Jul – Sep 14 Oct – Dec 1451.9% 53.1% 57.8% 41.7%

2: Stroke patients scanned within 12 hours of hospital arrival


3: Percentage of patients admitted directly to an acute stroke unit within four hours of arrival to hospital


4: Stroke-90% or more time spent on stroke unit


5: Adjusted mortality for 2013-2014

2013-14 2014-15 (Apr – Dec)108.46 88.23

Improvements sought for 2015-16: To improve SSNAP audit performance to at least a ‘B’ rating. To work with commissioners on the community rehabilitation and re-enablement pathway.

Improvements sought for 2015-16: Our objective is to deliver the national standards for the emergency department (ED), referral to treatment (RTT) and cancer; being above the medial for national performance in all measurers and moving towards upper quartile for as many as possible.

Incident reportingImprovement sought for 2014-15: We said we would continue to improve the use of safety information at divisional governance level by increasing incident reporting rates whilst maintaining the percentage of harm, increasing the numbers of audits recorded that impact on patient safety and ensure that patient safety data is made more transparent for our patients and staff.


There is a steady increase in the numbers being reported on a monthly basis (with some fluctuations). The percentage of harm has remained broadly static over the year. We have robust processes in place to capture incidents. We have provided training to staff and there are various policies in place relating to incident reporting. We have identified that there scope for improvement in our incident report culture as we want to capture and learn from every incident.

Level of harm 2012-13 2013-14 2014-15

None to moderate 3775 4717 5737

Severe harm or death 55 37 39

Total 3830 4754 5776

Percentage of severe harm or death incidents

1.5% 0.8% 0.7%


My visit was an eye-opener. The patience, kindness and compassionate treatment of the bed-bound elderly patients both day and night staff, was truly exceptional. A shining example of the NHS - from start to finish.

Improvements sought for 2015-16: A key objective for the coming year is to improve trust-wide communication on safety issues to ensure that we improve dissemination of learning from incidents. We will further strengthen our incident investigation and processes for addressing safety issues throughout the organisation.

We will continue to improve the safety culture within the Trust by encouraging the reporting of low and no harm incidents. During 2015/16 we will be working with services to continue to support the development of service specific trigger lists. This will assist areas in accurately reporting incidents.

Amber Care BundleWe reviewed this priority following the trial at Guy’s and St Thomas’ Hospital and believed it was not appropriate to take forward at this time. However, we have reviewed our end of life care bundle internally and Surrey and Sussex Healthcare NHS Trust received an assessment of ‘Outstanding’ for End of Life Care as part of the Chief Inspector of Hospitals inspection in 2014.

Safe and appropriate discharge arrangements

We continue to focus on arrangements for safe and appropriate discharge to:

• To understand the effectiveness of the current integrated discharge processes/service Assess compliance with National Standards for Effective Discharge

• To determine any correlational links between compliance, non-compliance with standards and identify delayed discharge challenges attributed to a) SaSH b) the wider economy

• Stretch on 14/15 Safe and Timely Discharge CQUIN

• To determine opportunities for the development of a wider system integrated discharge processes

Mental healthDementia training: The training which is currently provided has been established based on and to comply with Health Education England requirements for Tier 1 Foundation Level Dementia Awareness training: (http://southwest.hee.nhs.uk/ourwork/dementia/tier1outcomes/) for acute providers.

In addition, Health Education Kent Surrey and Sussex (HEKSS) have agreed a local requirement for Tier 1 Training which is also met by the programme provided as mandatory for all Surrey & Sussex Healthcare NHS Trust staff.

The training programme is a 45 minute awareness raising session focussed at all patient facing clinical and non-clinical staff. It is currently provided exclusively as classroom based, face to face teaching, however a key objective for 2015/16 is to develop an e-learning module which can support greater numbers of non-clinical staff to undertake the training.

The current taught module covers the following key areas:

• The prevalence and consequences of dementia

• The nature of dementia as a condition

• Key signs and symptoms

• The difficulties faced by sufferers

• Subtypes and differences in sub types and distinction from other conditions

• Signposting to services

• Key clinical skills – such as empathy and communication skills

Staff feedback has been collected as part of the routine evaluation of all mandatory training.

COPD BundleWe continue to implement the British Thoracic Society chronic obstructive pulmonary disease discharge bundle:

• Patient reviewed by respiratory consultant before discharge

• Personalised self-management plan received before discharge

• Referral for pulmonary rehabilitation and point of contact for patient on discharge

• Advice on smoking cessation

• Assessment of depression by health and wellbeing, assessed using the Hospital Anxiety and Depression (HAD) Scale


Clinical effectiveness

MortalityImprovement sought for 2014-15: We said that we would continue to roll out our enhanced review of all patient deaths to ensure all divisions are using the electronic system for reporting deaths. Themes will then be identified by the mortality review group, which will provide assurance that learning happens to the Clinical Effectiveness Committee. We also said that we would seek to ensure that our mortality rate, as reported through Dr Foster Intelligence remains, ‘better than expected’ - investigating any mortality outlier alerts.


This year, the work of the mortality group has focussed on standardising reporting from speciality morbidity and mortality meetings and ensuring that discussions were taking place and divisional level around the findings at these meeting.

A template was rolled out at the end of last year and divisions now have regular updates on specialty morbidity and mortality meetings and The Trust Mortality Review will now begin to have divisional reports fed into it through 2015/16 where it will be able to look for any emerging themes and trends and instigate further reviews where applicable. The Group will also act as a forum for cascading learning from the divisional reports as well..

The mortality rates for the Trust have continued to improve this year with Dr Foster Intelligence reporting that as of the beginning of this year the Trust continued to have a ‘better than expected’ mortality rate when compared with the national average. The mortality rate, which includes any death within 30 days of discharge (Standardised Hospital Mortality Indicator) for the Trust is improved and remains slightly better than the national average and was classed as ‘as expected’.

No alerts on specific procedures or conditions were identified by the Care Quality Commission in their data on mortality as defined in the Intelligent Monitoring Report.

Improvements sought for 2015-16: The mortality group will increasingly look at categories of death, rather than just individual deaths and make recommendations through the clinical effectiveness committee to improve care.

Readmission to hospitalImprovement sought for 2014-15: We said that we will continue to improve on the changes made during 2013/14. There will be a clinical review of one month’s clinical readmission data and any lessons learnt will be implemented. Readmission performance is one of the main Key Performance Indicators reported to the Trust Board, Executive Board and Divisional Boards on a monthly basis.


The Trust formally reported a readmission rate of 7% which is less than half of the national average and indicates excellent performance.

Readmission data for one month was clinically validated jointly between hospital consultants and GPs to evaluate any alternatives to admission.

Improvements sought for 2015-16: Working jointly with the Clinical Commissioning Group’s (CCG) clinical teams we will audit readmissions for one month in Quarter 1 and act promptly on any agreed actions.

Reducing need for admissionImprovement sought for 2014/15: We said that we would work with our health partners to ensure 40 community and 20 virtual hospital-at-home places are commissioned for the whole year. The newly established Urgent Care Pathway Board are reviewing a number

of pathways to reduce A&E attendances and provide alternatives to hospital admissions.


Improvements sought for 2015-16: We will continue to develop additional ambulatory care pathways. We will work with commissioners to further reduce acute length of stay and continue with discharge to assess and introduce discharge to assess in the emergency department.

Enhancing Quality (EQ)Improvements sought for 2014-15: We said that we will continue to further improve on our performance in the two pathways of heart failure and pneumonia whilst working with the Academic Health Science Network in new clinical areas of focus, including chronic obstructive pulmonary disease and acute kidney injury.


For heart failure and community acquired pneumonia, the teams have worked collaboratively across the network to make further improvements to the care of patients with these conditions. The Trust also began benchmarking data for acute kidney injury patients working on improving the identification and treatment of the condition.

Throughout 2014/15 the Trust has consistently remained as the best performer in the region for Heart Failure with over 90% getting all the required interventions when being treated at the Trust: (Graph 1)

For the pneumonia pathway, the whole region has seen their results improve over the year and there has been a significant reduction in the variation of care across Kent, Surrey and Sussex. The table shows the Trust around the average for the region although the variation between the top performing and bottom performing Trusts is just 10%. (Graph 2)

(Data period: January – December 2014. SASH = Trust J)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

South East Coast (ACS)

South East Coast (CQS)

South East Coast (ACS)

South East Coast (CQS)

Trust J

Trust H

Trust D

Trust A

Trust B

Trust E

Trust F

Trust K

Trust G

Trust I

Trust D

Trust K

Trust F

Trust A

Trust G

Trust B

Trust J

Trust I

Trust H

Enhancing Quality Performance Report Period: Jan 2014 - Oct 2015

Appropriate Care Score (ACS)Composite Quality Score (CQS)

Graph 1 - Heart Failure

Graph 2 - Pneumonia With CURB


For acute kidney Injury, the Trust is one of only five Trusts contributing to the benchmarking data and there remains significant variation between all Trusts. But coupled with the increased focus through this year’s commissioning for quality and innovation (CQUIN) standard, the Trust is refining its clinical pathways to improve on 2014-15 results through collaborative working with the network.

Improvements sought for 2014-15: The enhancing quality project remains within the CQUIN for the coming year; the Trust will continue to focus on further improvement for the coming year as well as looking to work with the Academic Health Science Network to establish new pathways for chronic obstructive pulmonary disease (COPD), fractured neck of femur and emergency laparotomy.

Enhanced recoveryImprovement sought for 2014-15: Having addressed our data collection methodology, we said that we would now seek to further increase the use of enhanced recovery whilst maintaining high levels of data completeness to demonstrate statistically significant improvements by improving our data collection methodology but also deliver a genuine increase in ER use within the division of surgery.


The enhanced recovery project team continued its focus on increasing the numbers of patients going through each of the pathways. The group was able to review the monthly reports on progress and focus effort on the parts of the pathway which were underachieving.

Enhanced recovery – orthopaedics

Clinical Area Measures

Numer-ator

Denomi-nator

2014 - 2015

2013 - 2014

Patient information on ERP

222 225 98.67% 90.98%

VTE_Prophylaxis

215 225 95.56% 94.27%

Antibiotics Prior

195 225 86.67% 97.94%

Epidural, Regional or Spinal Anaes

190 225 84.44% 92.97%

Early Mobilisation

197 225 87.56% 61.86%

Discharge advice

205 225 91.11% 93.56%

CQS 1,224 1,350 90.67% 88.16%

ACS 141 225 62.67% 51.80%

Enhanced recovery – gynaecology


Numer-ator

Denomi-nator

2014 - 2015

2013 - 2014


74 91 81.32% 73.11%

Antibiotics Prior

86 91 94.51% 97.48%

Hypothemia Prevention

88 91 96.70% 74.79%

Nausea and Vomatting control

85 91 93.41% 99.16%

Discharge advice

83 91 91.21% 94.96%

CQS 416 455 91.43% 87.90%

ACS 61 91 67.03% 52.94%

Enhanced recovery – colorectal


Numer-ator

Denomi-nator

2014 - 2015

2013 - 2014


57 67 85.07% 81.98%

Carbothydrates Given

66 67 98.51% 89.19%

IOFM Usage 50 67 74.63% 83.78%

Post Op Nutrition

47 67 70.15% 78.38%

Discharge advice

58 67 86.57% 72.07%

CQS 276 335 82.99% 81.08%

ACS 26 67 38.81% 36.94%

For the three benchmarked pathways, we improved its performance in delivering the key parts of each of the pathways with significant improvements in the orthopaedic and gynaecological enhanced recovery pathways. The Trust also ensured it met the minimum data completeness requirements.

Improvements sought for 2015-16: We will maintain and improve performance and commence pathways for breast surgery and caesarean section.

National Institute for Health and Clinical Excellence (NICE) technology appraisals (TAs)Improvement sought for 2014-15: We said that we would continue to ensure that we remain compliant with all published NICE Technology Appraisals that are applicable to the Trust. We also said that in order to gain further assurance where we require audit evidence to support Level 2 and 3 compliance, the pharmacy team will priorities a number of appraisals to be audited by the division this year.


We remain compliant for all TAs and this year we identified five appraisals which we wanted to focus our audits on, identified by the Chief Pharmacist. The following were chosen based on the following criteria:

TA 294: Aflibercept solution for injection for treating wet age related macular degeneration - now a choice of medicines, choice of locations, and is a growing activity so the Trust needs to ensure it is being used appropriately

TA 290: Mirabegron for treating symptoms of overactive bladder - a new drug, where the trust needs to ensure that the choice is appropriate within NICE guidance

TA 261: Rivaroxaban for the treatment of deep vein thrombosis and prevention of recurrent deep vein thrombosis and pulmonary embolism. Since it’s introduction there has been

a need for discussion on benefit and risks of treatment options with the patients. The audit is required to ensure this is properly recorded.

TA 265: Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours. A new high cost treatment, so the trust need to review the choice of patients.

TA 243: Rituximab for the first-line treatment of stage III-IV follicular lymphoma. Audit required to ensure doctors are using and documenting treatment criteria.

These were then added to the audit programmes of the relevant specialities a number were still ongoing at the time of writing the report. For TA 243, (Rituximab) the completed audit was used to assess whether all haematology patients treated with rituximab screened for hepatitis B surface antigen and anti-hepatitis B core antibody. Through the use of the audit tool, compliance was zimproved from 66% to 100% in the re-audit which completed in March 2015.

Improvements sought for 2015-16: Audits against NICE TA will be undertaken and be posted on audit intranet.


Statutory declarationsStatutory declarationsReview of servicesDuring 2014/15, Surrey and Sussex Healthcare NHS Trust provided 38 different acute services and eight specialised services to NHS patients (these numbers are based on the service specifications included in the contracts with Clinical Commissioning Groups and NHS England). We have reviewed all the data available to us on the quality of care in all of these services. The income generated by the NHS services reviewed in 2014/15 represents 100 per cent of the total income generated from the provision of NHS services by Surrey and Sussex Healthcare NHS Trust for 2014/15.

We have repeated the ‘Deep Dive’ programme which takes a detailed look at services at speciality level, seeking assurance and evidence that we are compliant with the five quality domains defined by the Care Quality Commission (CQC). The outcomes of these are reported to the safety and quality committee.

We continue to develop the quality programme to ensure inclusion of all services within this review. Divisions receive information on a monthly basis on patient safety, clinical effectiveness and patient experience for their areas. They report on their services at monthly governance meetings and to the executive committee for quality and risk and at performance reviews.

Participation in clinical auditClinical audit involves improving the quality of patient care by looking at current practice and modifying it where necessary. We take part in regional and national clinical audits. Sometimes there are also national confidential enquiries that investigate an area of healthcare and recommend ways to improve that area of healthcare.

During 2014-15, 30 national clinical audits and four national confidential enquiries covered NHS services that Surrey and Sussex Healthcare NHS Trust provides. During that period Surrey and Sussex Healthcare NHS Trust participated in 100% national clinical audits and 98% national confidential enquiries of the national clinical audits and national confidential enquiries in which it was eligible to participate.

The national clinical audits and national confidential enquiries that Surrey and Sussex Healthcare NHS Trust was eligible to participate during 2014-15 were:

This section details the information that

every NHS Trust must include in their Quality Account. We have highlighted an

explanation of the key terms at the start of

each topic.

Cases submitted % of cases submitted

Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) 133 72%

Bowel cancer (NBOCAP) 271 100%

Cardiac Rhythm Management (CRM) 577 100%

Case Mix Programme (CMP) - ICNARC 417 98%

Coronary Angioplasty/National Audit of PCI 100%

Diabetes (Adult) 100%

Diabetes (Paediatric) (NPDA) N/A

Epilepsy 12 audit (Childhood Epilepsy) Just commenced Just commenced

Falls and Fragility Fractures Audit Programme (FFFAP) N/A

Head and neck oncology (DAHNO) 26

Inflammatory Bowel Disease (IBD) programme 168 98.20%

Lung cancer (NLCA) 74.9%

Major Trauma: The Trauma Audit & Research Network (TARN) 100%

Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK)

National Cardiac Arrest Audit (NCAA) Began data collection March 2015

National Chronic Obstructive Pulmona 32 100%

National Comparative Audit of Blood Transfusion programme 100%

National Emergency Laparotomy Audit (NELA) 191 100%

National Heart Failure Audit 181

National Joint Registry (NJR) 409 100%

National Prostate Cancer Audit N/A

National Vascular Registry All data submitted via network

Neonatal Intensive and Special Care (NNAP) 100%

Non-Invasive Ventilation - adults - -

Oesophago-gastric cancer (NAOGC) 89 90%

Paediatric Intensive Care Audit Network (PICANet)

Renal replacement therapy (Renal Registry) N/A

Pulmonary Hypertension (Pulmonary Hypertension Audit) - -

Rheumatoid and Early Inflammatory Arthritis 308

Sentinel Stroke National Audit Programme (SSNAP) (Organisational) 395 99%

28 Quality Account 2014-2015 Statutory declarations 29

The national clinical audits and national confidential enquiries that Surrey and Sussex Healthcare NHS Trust participated in, and for which data collection was completed during 2013/14, are listed above alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Examples of improvements to care delivered by the clinical audit programme:

Audit of elective caesarean section bookings: women’s and children’s division. In response to higher than average caesarean section rates an audit of reasons for caesarean sections showed that best practice was not being followed when booking women for an elective procedure.

The Trust set up a specialist birth choices clinic (BCC) to counsel women who have had one previous caesarean section and any other reason which did not indicate a caesarean section as best practice for the delivery.

The birth choices clinic started in October 2012 and the audit showed a significant impact with a fall of the elective caesarean section rates from 17.8% in October 2012 to 6.9% in January 2013 and an average of 9.8% during 2013/14.

The audit demonstrated that the change in service and the implementation of the vaginal birth after caesarean (VBAC) pathway reduced the elective caesarean section rates in the largest group of women opting for a caesarean section. This audit is now a rolling audit, which monitors the elective caesarean section requests against the clinical outcomes to ensure compliance with the birth choices clinic pathway and maintain the elective caesarean section rate under the national rate of 10%.

Sepsis audit: medicine division. The introduction of the sepsis six bundle has been shown to reduce the relative risk of death by 46.6%, so the audit looked at compliance between April and June 2013.

To help build on the levels of compliance a drive to improve awareness including simulation training was implemented and a re-audit followed in May - July 2014. Overall compliance with the Sepsis Six improved between 2013 and 2014 - demonstrated by an increase in all domains. Average mortality at 30 days decreased between the two data sets from 38% to 18.9% with similar improvements for the length of stay for patients.

A poster presentation of this audit at the recent Kent Surrey Sussex Academic Health Science (KSS AHSN) Awards ceremony saw this audit awarded best poster prize in a competition judged by Sir Bruce Keogh.

Mouth Care Matters audit: surgery division.An original audit focussed on whether patients who are hospitalised for more than 24 hours had a mouth care assessment carried out and if a mouth care assessment was carried out and daily mouth care and mouth care supportive measures were in place. The topic was picked up from a complaint and also during the recent Care Quality Commission (CQC) inspection and was conducted in February, both looking at case notes, and a survey of staff.

With poor compliance, training has been rolled out across the organisation including awareness campaigns around the importance of maintaining mouth hygiene for patients. The training package has now been successfully introduced in the Trust and significantly has now received regional funding by KSS to roll out across the south-east. It was also a recent topic at the Patient Safety Executive.

The hospital was clean and tidy and

the staff have all been wonderful, extremely

kind and caring.


Our performance in delivering research as measured against the National Institute for Health Research (NIHR) national performance metrics is strong with increases in both the number of different research studies for patients to engage with and numbers of patients recruited to studies.

Our strengthening relationship with the pharmaceutical industry is enabling us to offer our patients access to the newest treatments within clinical trials. The Trust supported the recruitment of patients to 45 different high quality studies – ten of these studies were pharmaceutical industry sponsored studies.

In 2014-15, we recruited 760 patients to participate in research approved by a research ethics committee.

Participation in clinical researchClinical Research involves gathering information to help us understand the best treatments, medication or procedures for patients. It also enables new treatments and medications to be developed. Research must be approved by an ethics committee.

The key reason for our commitment to research is to improve clinical treatments, care and outcomes for our patients. We want to offer our patients the opportunity to be involved in research activities in order to improve patient experience and enable them to benefit from improved health outcomes.

Our key priorities are to:

• Increase number of patients participating in research studies

• Increase number of high quality National Institute for Health Research (NIHR) Portfolio research studies open at our Trust.

• Maintain our high quality research management processes and enhance performance in project delivery

• Develop our infrastructure, staff and facilities, to support research

• Become a preferred partner for the pharmaceutical research industry and increase our research income from commercial contracts

We have highlighted research activity in four different areas of the organisation:

• Anaesthetics

• Urology

• Dermatology

• Paediatrics

Anaesthetics Our clinicians are able to develop their own research ideas into research protocols bringing new ideas and solutions into clinical practice for the benefit of patients. Designing research protocols which enhance personal knowledge and education in our clinical teams allows us to provide higher quality clinical care.

Dr Matthew Mackenzie, consultant anaesthetist, successfully secured funding from the Association of Anaesthetists of Great Britain and Ireland (NIAA) for his study: ‘Simulation Aided Assessment of a Clinical Algorithm’ within the anaesthetics department.

The study utilised the Newman Simulation Suite, at East Surrey Hospital, and sought to examine the use of emergency protocols of relevance to anaesthetic practice by inviting members of the anaesthetic department to manage a simulated emergency situation on a high-fidelity mannequin.

The benefit to staff participants was that they were provided with personal updates in the emergency management of anaesthetic related complications listed as core continuing professional development (CPD) topics by the Royal College of Anaesthetists, which meant that the research provided relevant clinician training.

The research will also provide an overall contribution to the development of national emergency protocols in the future.

Urology Opening a new national trial has allowed the urology team to offer some of our intermediate risk bladder cancer patients access to a potentially advanced treatment.

The new study is exploring the benefits of giving hyperthermic (heated) mitomycin compared to current standard treatment, mitomycin at room temperature. It is thought that hyperthemic mitomycin will prove to be a superior treatment due to increased absorption by any remaining cancer cells at a higher temperature and therefore improve disease free survival.

Since the trial started, the urology team have recruited nine patients to date and remain the second highest recruiter nationally, the highest being the lead site. Of these nine patients, four have received hyperthermic mitomycin.

32 Quality Account 2014-2015

Number of studies open to

recruitment

382012-13 5 6162013-14 40 5 506

2014-15 45 11 771

Number of pharmaceutical

industry studies*

Number of research

participants

*Included within total number of studies open figure

Statutory declarations 33

At all times I have been treated with respect, great care and fully informed. I am pleased that I was asked to take part in the research.

34 Quality Account 2014-2015

Jack ChampDermatology patient

PaediatricsParticipation in clinical trials can provide increased support for families and young children at the early stages of managing newly diagnosed medical conditions.

A study for newly diagnosed diabetic children aged 7 months to 15 years began at Surrey and Sussex Healthcare NHS Trust in September 2012. Families recruited to the study are randomised to receive either insulin by continuous infusion via a pump or standard intermittent injections, to see which is more effective in the management of diabetes in babies, children and young people.

The randomised treatment must be started within 14 days of diagnosis and all patient education, which ordinarily may normally take up to three months to deliver must be completed within that 14 day timeframe.

Families recruited to the study are then supported during an intense 12 month follow up which tracks the course of their normal diabetes management and logs all interventions and clinical episodes. Quality of life, control of blood glucose and costs are all documented.

Whilst the treatment itself does not actually change at all the study provides an opportunity to acquire a pump very early from diagnosis which can be a big asset. Initially, families can find the thought of the randomisation quite daunting but getting so much educational input early on helps them to understand the condition and to quickly develop skills to support their child.

Dermatology researchOne of the key ways of offering new treatments to our patients is through participation in clinical trials. Incorporating clinical trial research activities into clinical practice can also encourage new ways of working which lead to improved models of patient care.

In 2011, the dermatology department introduced a new way of working to help accommodate a small Clinical Research Network psoriasis study. This change has had a significant, long-term impact on research engagement and patient care. Dedicated psoriasis clinics are run on a monthly basis where patients can be reviewed in a 'one stop shop'.

In addition to promoting research activity, the changes have promoted more individualised, holistic care for patients and streamlined the review process for patients. Research participation has been integrated into the clinical pathway for patients with psoriasis which has maximised recruitment potential for studies and allowed the team to take on more complex, clinical trials.

Running clinical trials allows us to offer opportunities to have new treatments and the reassurance of additional follow up visits with a consultant dermatologist, specialist nurse and research nurse which promotes a positive patient experience. One of our research participants, Jack Champ, 73, from West Sussex, pictured with Nwando Onugha, lead dermatology nurse, describes his experience:

Statutory declarations 35

Goals agreed with commissionersClinical Commissioning Groups (CCG) hold the NHS budget for their area and decide how it is spent on hospitals and other health services. This is known as commissioning - East Surrey, Surrey Downs, Crawley and Horsham & mid Sussex CCGs are the four main commissioners of our services. They set us targets based on quality and innovation.

A proportion of our income in 2014-15 was conditional on achieving quality improvement and innovation goals agreed between Surrey and Sussex Healthcare NHS Trust and any person or body we entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation (CQUIN) payment framework.

Further details of the agreed goals for 2014-15 and for the following 12 month period are available on request from: [email protected]

Care Quality Commission registration and inspection

The Care Quality Commission (CQC) regulates and inspects health organisations across England. Surrey and Sussex Healthcare NHS Trust is required to register with the Care Quality Commission and its current registration status is ‘registered without conditions’.

The Care Quality Commission did not taken enforcement action against the Trust during 2014-15.

Surrey and Sussex Healthcare NHS Trust has not participated in any special reviews or investigations by the CQC during the reporting period.

Care Quality Commission report Everyone at Surrey and Sussex Healthcare NHS Trust has a huge commitment to safety, quality and providing care and compassion and this focus on excellence was endorsed in 2014-15 by the Care Quality Commission (CQC) team of doctors, nurses and senior NHS managers who completed an inspection in May 2014.

Their report, published in August, by the Chief Inspector of Hospitals focused on five key questions about the healthcare services we provide, are they:

• Safe

• Effective

• Caring

• Responsive to people’s needs

• Well-led.

Thanks to the hard work of our staff, we achieved a ‘Good’ rating across the board in all five areas - to put this context nationally at the time of the most recent (31) inspections only four other Trusts achieved an overall ‘Good’ rating and only two of these were green in all domains. This puts us amongst the best in the country for the quality of services and the CQC said that our staff should be extremely proud of what they have achieved.

The report highlighted several areas of outstanding and good practise, including:

• End of life Care achieved an ‘Outstanding’ in the responsiveness category

• The excellent care and facilities on the midwife-led birthing unit and the neonatal intensive care unit

• The pre-assessment clinic at Crawley Hospital, which has been extended in the evening in response to feedback and local demand

• Staff focus groups: best attended – more staff than they had seen in any other Trust

• Clear ambition across the Trust to be the best – from catering staff through to the Chair

• Staff willingness to go the extra mile and work together to meet individual pastoral needs

• Strong desire to be clinically-led

• Large number of specialist nurses with a strong focus on learning and development

The report recommended some areas where improvements could be made – the majority of which were in our out-patients areas. These included a need to ensure adequate capacity to meet demand and improvements to the quality of service including waiting times and cancellations.

We have made significant progress in addressing these points - the refurbishment of the out-patients department at East Surrey Hospital and improvements to seating and signage; the opening of the Earlswood Community Diabetes and Endocrine Centre and the involvement of our patients in focus groups to help us to gather feedback and to co-design and shape the service as we plan for the future, are just some of the ways we have moved forward and focused on putting people first. We know that this will help us to improve the experience we provide for our patients and also for the teams involved.

The inspectors said our staff were the most engaged out of all of the Trusts they had visited and we know this makes a real difference to patient experience and care. They also said they would be very proud to work here and would want their family and friends to be cared for here which is a great endorsement of everyone’s efforts and commitment.

I am very proud of our staff – this is their story and I am glad their talent, hard work and dedication has been recognised. The report also makes for reassuring reading for the community we serve and shows our commitment to safety and quality.

Last rLast ratateded

6 August 2014

Overallrating

SurrSurrey and Sussex Healthcarey and Sussex Healthcare NHSe NHSTTrustrust

ArAre sere servicviceses

Safe? GoodGood

Effective? GoodGood

Caring? GoodGood

Responsive? GoodGood

Well led? GoodGood

The Care Quality Commission is the independent regulator of health and social care in England. You can read ourinspection report at www.cqc.org.uk/provider/RTP

We would like to hear about your experience of the care you have received, whether good or bad.

Call us on 03000 61 61 61, e-mail [email protected], or go to www.cqc.org.uk/share-your-experience-finder

Inadequate Requiresimprovement

Good Outstanding

Michael WilsonChief executive

Last rLast ratateded

6 August 2014

Overallrating

SurrSurrey and Sussex Healthcarey and Sussex Healthcare NHSe NHSTTrustrust

ArAre sere servicviceses

Safe? GoodGood

Effective? GoodGood

Caring? GoodGood

Responsive? GoodGood

Well led? GoodGood

The Care Quality Commission is the independent regulator of health and social care in England. You can read ourinspection report at www.cqc.org.uk/provider/RTP

We would like to hear about your experience of the care you have received, whether good or bad.

Call us on 03000 61 61 61, e-mail [email protected], or go to www.cqc.org.uk/share-your-experience-finder

Inadequate Requiresimprovement

Good Outstanding


Data qualityData quality measures whether we record patients’ NHS and GP numbers in their notes as well as ethnicity and other equality data.

The chief operating officer has overall accountability for the quality of data provided to the Trust Board and executive committee.

The Trust has a data quality strategy which describes the agreed strategic actions to improve data quality.

The information team meets regularly to discuss data quality and provides regular updates to the information governance steering group on the completeness and validity of data available to the Trust.

We have a data quality team that is responsible for the day to day management of data quality. The team undertakes national data quality checks, reviews the challenges from the Clinical Commissioning Groups (CCGs) and checks clinical coding daily. The data is also checked externally by Indigo 4 Services Limited, who provide services to a range of NHS organisations.

The internal audit plan for 2014/15 – 2015/16 includes review of data quality and Information governance. Internal audit also carries out audits of systems that provide narrative on elements of data quality, such as Board assurance framework reviews and financial feeder system audits. Internal Audit will make recommendations to improve systems where potential is identified, these recommendations are developed into actions which are managed locally and ultimately monitored by the audit and assurance committee.

NHS Number and GP Practice Code validitySurrey and Sussex Healthcare NHS Trust submitted records during 2014-15 to the Secondary Users Service for inclusion in Hospital Episode Statistics, which are included in the latest published data. The percentages of records in the published data are:

NHS Number compliance

In-patient Out-patientEmergency

department (ED)

Total

Valid 105,337 445,64 85,969 636,954

All 105,848 446,476 87,276 639,600

% 99.5% 99.8% 98.5% 99.6%

GP Practice Code

In-patient Out-patientEmergency

department (ED)

Total

Valid 105,537 444,297 86,385 636,219

All 105,848 446,476 87,276 639,600

% 99.7% 99.5% 99.0% 99.5%

Information governanceInformation governance means keeping information about patients and staff safe.

Surrey and Sussex Healthcare NHS Trust’s Information Governance Assessment Report score for 2014-15 was 72% and was graded ‘satisfactory’. The report was finalised and submitted on 31 March 2015. Of the 45 requirements within the assessment, 37 were scored at level two; and eight at level three.

Action plans will be updated in order to sustain and improve upon these scores during 2015-16. Our aim is to improve our compliance year on year and a key element in achieving this is ensuring that all staff receive annual training and regular updates relating to information governance. All information governance risks are added to the Trust risk register and reported in-line with the Trust risk management policy.

During 2014-15 no serious untoward incidents were reported to the Information Commission’s Office.

Clinical coding Clinical coding is the translation of medical terminology as written by the clinician, to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format which is nationally and internally recognised. The process is bound by National Standards issued by the Health and Social Care Information Centre (HSCIC). The mechanism for receiving payment is called Payment by Results (PbR).

The Information Governance clinical coding Audit (IG Audit) in 2014-15 looked at 200 finished consultant episodes (FCEs) for accuracy of both diagnosis and treatment:

IG clinical coding audit 2014-15

Primary diagnosis correct 91.50%

Secondary diagnoses correct 94.80%

Primary procedure correct 95.72%

Secondary procedures correct 96.24%

These accuracy levels mean the Trust achieved Level 2 in the Information Governance Assessment Requirement 11-505 for 2014-15.

Improvement aims for 2015-16: We will continue to train two new trainee coders using the clinical coding Standards Course and help our experienced coders work towards accreditation by supporting them to sit the National clinical coding Qualification (NCCQ). Our aim is to continue to deliver 100% coded activity at post-inclusion ensuring no loss of income to the Trust due to uncoded or miscoded episodes. The depth of coding is steadily increasing - 5.8 diagnosis codes per FCE and we will continue to work with clinicians to ensure coding accurately reflects clinical diagnosis. On-going training programmes for clinical coders are planned for continuous professional development.

We are keen to have on-going clinical engagement in all aspects of coding more so in mortality coding as the data impacts the trusts performance figures. The long-term plan is to set up divisional coding leads to liaise with the clinical leads of those particular divisions which in turn will improve both mortality and morbidity coding.

Summary of hospital-led motality indicator (SHMI) and the percentage of deaths with palliative care codingSHMI is a hospital-level indicator, which provides a summary reporting of mortality (deaths) at trust level across the NHS for England. The SHMI is the ratio between the actual number of patients who die following treatment at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated here. It covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge.

SHMI values for each trust are made available along with bandings indicating whether a trust’s SHMI value is ‘as expected’ or otherwise.

The bandings are:

1 – where the Trust’s mortality rate is ‘higher than expected’

2 – where the Trust’s mortality rate is ‘as expected’

3 – where the Trust’s mortality rate is ‘lower than expected’


Our SHMI compares favourably to the national average of 100% as it is lower at 93.07% (6.93% less than average) which was an improvement on our position from the previous year.

Improvement aims for 2015-16: We will seek to continue to improve our mortality through full participation in the Dr Foster process of actions in response to alerts and by working with external partners to ensure seamless care between primary and community and secondary care.

Summary of hospital-led mortality indicator 2014-15

Trust value 0.9307

Trust banding 2

Lowest (national) 0.5966

Highest (national) 1.1982

Percentage of deaths with palliative (end of life) care coding

As reported in last year’s

Quality Account

October 2013 – September

2014

Trust 0.9307 34.3

Lowest (national) 2 0

Highest (national) 0.5966 49.4

Average (national) 1.1982 25.44

The percentage of elective admissions resulting in a death occurring either in hospital or within thirty days (inclusive) of discharge for the period Oct 13 – Sept 14 was 0.2% (Range 0.2-7.8)

The percentage of non-elective admissions resulting in a death occurring either in hospital or within thirty days (inclusive) of discharge for the period Oct 13 – Sept 14 was 3.7% (Range 1.2-5.9)

Some patients are admitted to our care and die while with us, or within a short period of time after discharge. For some of these patients their nearness to death is recognised, either because of the terminal nature of their illness or because all curative and life prolonging treatment options have

been exhausted. In this case, end of life care or palliative care can provide symptom control. We recorded 34.3% of our deaths as palliative, or end of life care, which is just above the national average. This represents an increase from last year which came from the introduction of a palliative care weekend service allowing us to more accurately record patients requiring palliative care and reflects a trend nationally for more accurate identification of patients. The large range in the table above also reflects the differing patient populations of different hospitals in England.

Patient reported outcome measures (PROMS)Patient Reported Outcome Measures (PROMs) assess the quality of care delivered to NHS patients from the patient perspective. Currently covering four clinical procedures, PROMs calculate the health gains after surgical treatment using pre- and post-operative surveys.

PROMs measure a patient's health status or health-related quality of life at a single point in time, and are collected through short, self-completed questionnaires. This health status information is collected from patients through PROMs questionnaires before and after a procedure and provides an indication of the outcomes or quality of care delivered to NHS patients. The most recent data available shows:

2012/13 Eligible episodes

Trust average

health gain

Groin hernia * 432 *

National average 0.087 0.085

Hip replacements 0.440 249 0.434


Knee replacements 0.255 242 0.321


Varicose veins * 102 *


* Data suppressed due to small numbers. No data = no figures to report.

Single index measure which ranges from 0 to 1, where 1 is the best possible state of health.

Percentage of patients readmitted within 28 days of dischargeThere is a national expectation that patients who are admitted for episodes of care should not need to be readmitted soon after they are discharged. The Trust uses the Dr Foster quality monitoring tool as part of its reviews of readmissions - this tool shows a 28 day readmission rate based on latest data published on the Health and Social Care Information Centre: Compendium of Population Health Indicators.

2010/11 2011/12

Under 16s 10.39 11.31

Average (national) N/A N/A

Adults and over 16s 9.83 11.47

Average (national) 11.04 11.08

Responsiveness to inpatients’ personal needsThis indicator is calculated as the average of five survey questions from the national inpatient survey which is carried out each year. Each question describes a different element of the overarching theme - responsiveness to patients’ personal needs.

The questions are:

• Were you involved as much as you wanted to be in decisions about your care and treatment?

• Did you find someone on the hospital staff to talk to about your worries and fears?

• Were you given enough privacy when discussing your condition or treatment?

• Did a member of staff tell you about medication side effects to watch for when you went home?

• Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?

Responsiveness to inpatients' personal needs

2012/13 Inpatient

survey

2013/14 Inpatient

survey

Trust value 74.2 74.3

Lowest (National) 68 66.8

Highest (National) 88.2 88.2

For the 2014 inpatient survey we were ranked as 123rd among trusts in England in these categories - we will continue to work to improve our patients’ experience.



National average


rank orderQ1 – As a place to work

78% 62% 20th

Q2 – As a place to work

76% 61% 27th

Q4 – As a place to work

74% 62% 33rd

Q1 – As a place to receive care

89% 76% 42nd


90% 77% 36th


88% 77% 41st

Response rates:• Q1 response rate for Surrey and Sussex

Healthcare NHS Trust was 22% against a national average of 14%

• Q2 response rate for Surrey and Sussex Healthcare NHS Trust was 10% against a national average of 12%

• Q4 response rate for Surrey and Sussex Healthcare NHS Trust was 14% against national average of 13%

Percentage of patients admitted who were at risk of VTEIn 2014-15, we said that the risk assessment will continue to be carried out on more than 95% of patients on admission and that the reassessment of risk will be highlighted through staff education, in line with NICE guidance. Also, that patient information leaflets will be available to all admitted patients within the Trust, highlighting the risk of VTE and on-going preventative advice on discharge. We also said that a multi-disciplinary team would review any cases where a patient develops a venous thrombosis either whilst an inpatient, or within 90 days of discharge and that the numbers of such cases and whether care was sub-standard will be published within SASH Board performance papers.


Over the last year, 95% of patients looked after by us had a formal VTE assessment carried out on admission and recorded in the notes.

Improvement aims for 2015-16: We will move to 95 of patients having their ongoing VTE risk assessed at discharge

Patient safety incidentsThese are incidents reported to the National Reporting and Learning System (NRLS) where the Trust has failed to provide ‘harm free care’.

The Trust incident reporting system is web-based and available on every Trust computer at each hospital site - this has increased our ability to report and respond to safety incidents at pace. It has also facilitated the ability to track trends in safety incidents within the organisation more readily so that we can target our improvement work. Risk management training is included in the mandatory training programme. The risk management team provide ad hoc bespoke training to clinical teams on risk management which includes the reporting of incidents.

C.difficile infections We said we would have no avoidable Trust acquired MRSA blood stream infections (zero tolerance), and no more than 29 patients affected by Clostridium difficile diarrhoea.

2014-15 Performance rating: Clostridium difficile - 24 cases


2014-15 Performance rating: MRSA blood stream infections- 0 (with 1 contaminant)


Patients’recommendation of the Trust as a place to be treatedThe Friends and Family Test in our inpatient wards and emergency department is well established. The most recent figures show the percentage of respondents who are ‘extremely likely’ or ‘likely’ to recommend Surrey and Sussex Healthcare NHS Trust as:

Inpatient wards

Date Surrey and Sussex Healthcare NHS

Trust

National average

April 2014 97.4% 93.9%

May 2014 97.1% 94.2%

June 2014 98.0% 94.1%

July 2014 98.1% 94.2%

August 2014 98.2% 93.8%

September 2014 86.7% 93.5%

October 2014 96.7% 93.7%

November 2014 97.0% 94.7%

December 2014 94.7% 94.5%

January 2014 95.7% 94.2%

February 2014 96.9% 94.5%

March 2014 94.2% 94.7%

Emergency department

Date Surrey and Sussex Healthcare NHS

Trust

National average

April 2014 97.9% 86.5%

May 2014 97.7% 86.0%

June 2014 98.0% 86.1%

July 2014 98.7% 86.3%

August 2014 97.9% 87.5%

September 2014 97.5% 86.4%

October 2014 95.3% 86.8%

November 2014 96.4% 87.4%

December 2014 92.7% 86.2%

January 2014 95.8% 88.1%

February 2014 97.1% 87.9%

March 2014 94.7% 86.9%

Our Emergency Department was in the top 10% of all Trusts for Q4 and we exceeded the Commissioning for Quality and Innovation (CQUIN) target response rate in both inpatients and ED patients for Q4.

Staff recommendation of the Trust as a place to be treatedThe Staff Friends and Family Test is conducted in Q1, Q2 and Q4 - the National NHS Staff Survey takes place in Q3. Figures show the percentage of respondents who are ‘extremely likely’ or ‘likely’ to recommend Surrey and Sussex Healthcare NHS Trust as:

Treated with total dignity and professionalism.


I have to say that I was overwhelmed by the care provided by the NHS at East Surrey hospital. They were so helpful, kind, loving, compassionate and professional. They saved my wife's life and I can't thank them enough.

Staff awards and recognition

Providing high quality patient care and sustaining high levels of service provisions would not be possible without the professionalism, dedication and commitment of our staff.

Our patients and their relatives and friends regularly let us know just what a difference our staff have made to them through a range of feedback options designed to meet the needs of the people we care for.

Your Care MattersWe receive around 1,000 responses a month to our Your Care Matters patient feedback survey. Patients are encouraged to take part and can do so on-line, by using a Freephone number or, for some services, completing a paper copy.

Patient OpinionPatient Opinion is an an independent website that provides an online option for patients to tell their story about their experiences and about the level of care they have received.

In the past 12 months 346 patients have told their story and their comments were viewed more than 67,100 times.

Comment posted on Patient Opinion

Comment posted on Patient Opinion

The nursing staff were helpful and kind and at each stage introduced themselves and explained the tests and procedures.

44 Quality Account 2014-2015 Staff awards and recognition 45

Behind the Scenes Employee of the Year Nalani Ruberoe, medical records clerk

Nalanie was recognised for being hard working, kind and helpful and for always going the extra mile to ensure that the patient is always having a positive experience.

Compassion (individual ward) Dr Jane Preston, dental officer

Jane was nominated for the level of compassion she shows patients and her colleagues – making everyone feel valued and special as she not only listens to their concerns but goes out of her way to help them.

Compassion (team award) Angela Main; Julie Anthony; Lisanne Eagle; Caroline North; Sue Munn; Dr Naomi Collins and Christina Probert, palliative care team

The team was recognised as promoting excellent patient care, dignity and compassion to all in, sometimes very difficult circumstances and for providing support for healthcare professionals at the trust, offering not just education and advice but importantly emotional support for those who need it. They inspire others to care for those at the end of their life, with dignity and respect.

Annual staff awardsEvery day of the year our staff are responsible for delivering high quality care to the communities we serve and we know just how much the people they care for appreciate their compassion and commitment through the feedback we receive. Each year we make sure that we celebrate this hard work and dedication at our annual Staff Awards of Excellence.

Over 100 staff were nominated in 11 categories for our 2014 awards along with those recognised for long service – the winners in each category were:

Innovation and Service Improvement: Samantha Shale, senior occupational therapist

As a result of her investigation in to the sensory needs of patients with dementia Samantha introduced a number of sensory items on to her ward. Showing colleagues how these could be used to

distract or stimulate patients resulting in a ward that has a calmer, dementia friendly feel.

Frontline Employee of the Year Sandhya (Sandy) Blakey, ward manager

Sandy was recognized for her dedication and commitment to putting patients first and improving patient care and also for looking after relatives and staff. One of her collegaues wrote: "She's

always ready to listen to each and every one of us. The reason we work so well as a team is due to her excellence in leadership." This was also recognised in our recent CQC inspection.

Frontline One Team

Michelle Cudjoe; Denise Newman; Adaline Smith; Janice Blythman, maternity matron team

This team was nominated for making a truly inspirational difference in delivering a safe service and developing our maternity services into something that the Trust is really proud of. They have worked exceptionally well as a team and achieved many notable successes:

Behind the Scenes One Team Diane Mintrim; Hilda Williams; Lesley Harmer, medicalstaffing team

The team were recognised for their sustained commitment, dedication and organisation in the smooth running of clinical staffing - particularly the new intake of junior doctors joining the Trust. This attention to detail was noted by many of the junior doctors, who said it was one of the most organised inductions they had ever had.

Your Care Matters – improving the patient experience Lynne McDowell, staff nurse

Lynne has received a number of SenSASHional commendations through Your Care Matters

feedback from patients. One patient wrote: "She was always so positive and friendly. Always so patient with everyone in our bay - she showed an interest in each and every one of us and was

reassuring, calm and confident in her care."

Dignity and Respect Chatardharry Bissonauth (Krit), nursing assistant

Krit was praised for his exceptional manner in nursing patients and for going out of his way to ensure each and every one of his patients is looking their very best every day. Most of his patients know

him by name and ask for him to attend to their needs - a real testament to how they value the care that he offers.

Safety and Quality Debbie Cawston, senior radiographer

Debbie works remotely and she was recognised for bringing consistency to the X-ray department at Horsham and her ability to meet the challenges of remote working and her expert delivery of both

clinical and non-clinical aspects of her role means that there are frequent health and safety audits, exceptionally infrequent incidents, zero serious incidents and low waiting times.

Volunteer of the Year Gordon Thomson, volunteer

A veteran of the trust, Gordon has volunteered with us for 22 years – he is loyal, supportive, generous, diplomatic and kind and greatly respected and appreciated and was recognised for his reliability, dedication, commitment and hard work.

46 Quality Account 2014-2015 Staff awards and recognition 47

Our priorities for 2015-16

In this account we have detailed our areas of focus within the topics of patient experience, safety and experience and outlined what we intend to achieve in 2015-16.

To enable us to define our priorities for the coming year we have shared our account with our:

• Board

• Clinical chiefs of service

• Lead clinicians

• Assistant directors of operations

• Senior nursing staff

• Divisional teams

• Members

We have also shared this account with:

• Healthwatch (West Sussex & Surrey)

• Clinical Commissioning Groups

• West Sussex Health & Adult Social Care Select Committee (HASC)

• Surrey Health Scrutiny Committee & Surrey County Council Quality Account Reference Group

Emerging priority areas:All our quality improvement work will be based on benchmarked quality performance through locally generated metrics and those provided through accepted agencies (Dr Foster, national and regional data sets) based on the Trust’s five strategic objectives:

SO1: Safe – Deliver safe services and be in the top 20% against our peers

SO2: Effective – Deliver effective and sustainable clinical services within the local health economy

SO3: Caring – Ensure patients are cared for and feel cared about

SO4: Responsive – Become the secondary care provider for the catchment population

SO5: Well led – Become an employer of choice and deliver financial and clinicalsustainability around a clinical leadership model

Priorities for 2015-16Our priorities for 2015-16 will include:

Sign Up to SafetyFive pledges in the sign up to safety plan; put safety first, continually learn, honesty, collaboration and support.

1. Identify, evaluate and implement patient safety systems that look to enhance the quality of our care by increasing the chances of the initial signs of a deteriorating patient being acted on appropriately.

2. Seek to improve the Trust’s systems for identifying and managing pain specifically with patients who have a diagnosis of dementia.

3. Ensure that the Trust is compliant with the statutory responsibility regarding Duty of Candor.

4. Learn from COPD EQ pilot and seek to identify and share learning across South East Coast over the 3 year period of the pilot.

5. Help people understand why things go wrong and how to put them right.

National Patient Safety Collaborative

Likely to be based on five scoping events

1. Pressure ulcer

2. Safe discharge and transfer

3. Culture and leadership

4. Medication errors

5. Sepsis

Commissioning for quality and innovation (CQUINS)• All National projects – Sepsis, Acute Kidney

Injury, Dementia, Urgent Emergency Care: ‘Reducing the proportion of avoidable emergency admissions to hospital’ and ‘Improving diagnoses and re attendance rates of patients with mental health needs at A&E’

• All NHS England projects – not yet released

• Local CQUIN for Ward Accreditation

• Local CQUIN for discharge pathways

• Local CQUIN for participation in the Academic Health Science Network Enhancing Quality and Recovery programme

Mouth care for frail elderly• Mouth Care Matters initiative, funded by

Health Education England, led by the Surrey and Sussex Healthcare NHS Trust dental team

• four additional four dental nurse practitioners who will work across the hospital to support and provide extra training for our nursing and ward teams as they care for our patients

• improving the oral health of the people we care for, especially older patients will also have a positive impact on their general health and well-being too

Waiting times• Reduce our waiting times for elective care to

achieve and maintain a position that is higher than the National average

• Improve the process and timeliness of patient

discharge from ITU beds to wards

Outpatient servicesPatient experience improvements defined in the Care Quality Commission (CQC) action plan.

Virginia Mason Programme and safety• Review the possibility of starting the Trust

on a safety journey guided by the principals established by the Virginia Mason Hospital (or similar depending on position)

• Establish our Patient Safety Executive

• Establish a series of anaesthetic standards to be adopted by all anaesthetists

NutritionReview training on Malnutrition Universal Screening Tool (MUST) with a focus on improvement. Improve compliance for protected meal times; provide more support for patients who need help with eating and further develop menus and food choices for patients with specific needs.

Quality Goals linked to achievement reviewsContinue to embed the setting of personal goals that effect quality of service for all staff.

2014-15 priorities to be retainedWe will retain key priorities from the 14/15 Quality Account and continue to improve all priorities.

48 Quality Account 2014-2015 Our priorities for 2015-16 49

Glossary

Acute TrustA Trust is an NHS organisation responsible for providing a group of healthcare services. An acute Trust provides hospital services, for example, Surrey and Sussex Healthcare NHS Trust. But not mental health hospital services, which are provided by a mental health Trust.

Audit CommissionThe Audit Commission regulates the proper control of public finances by local authorities and the NHS in England. The Commission audits NHS trusts to review the quality of their financial systems. It also publishes independent reports that highlight risks and good practice to improve the quality of financial management in the health service, and, working with the Care Quality Commission, undertakes national value-for-money studies. Visit: www.auditcommission.gov.uk

Board (of Trust)The role of the Trust’s Board is to take corporate responsibility for the organisation’s strategies and actions. The chair and non-executive directors are lay people drawn from the local community. The chief executive is responsible for ensuring that the Board is empowered to govern the organisation and to deliver its objectives.

Care Quality CommissionThe Care Quality Commission (CQC) is the independent regulator of health and social care in England. It regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations. Visit: www.cqc.org.uk

Clinical auditClinical audit measures the quality of care and services against agreed standards and suggests or makes improvements where necessary.

Clinical Commissioning GroupClinical commissioning groups are predominantly GP-led groups of local healthcare professionals that commission the local health services for their catchment population, based on the needs of the patient population.

CommissionersCommissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. Clinical Commissioning Groups are the key organisations responsible for commissioning healthcare services for their area. They commission services, including acute care, primary care and mental healthcare, for the whole of their population with a view to improving the health of their population.

Commissioning for Quality and InnovationHigh Quality Care for All included a commitment to make a proportion of providers’ income conditional on quality and innovation, through the Commissioning for Quality and Innovation(CQUIN) payment framework.

Community servicesHealth services provided in the community, for example health visiting and podiatry (footcare).

Department of HealthThe Department of Health is a department of the UK government but with responsibility for government policy for England alone on health, social care and the NHS.

Foundation TrustA type of NHS Trust in England that has been created to devolve decision-making from central government control to local organisations and communities so they are more responsive to the needs and wishes of their local people. NHS Foundation Trusts provide and develop healthcare according to core NHS principles – free care, based on need and not on ability to pay. NHS Foundation Trusts have members drawn from patients, the public and staff and are governed by a board of governors comprising people elected from and by the membership base.

Hospital Episode StatisticsHospital Episode Statistics is the national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere.

National Institute for Health and Clinical ExcellenceThe National Institute for Health and Clinical Excellence is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. Visit: www.nice.org.uk

National patient surveysThe National Patient Survey Programme, coordinated by the Care Quality Commission, gathers feedback from patients on different aspects of their experience of recently received care, across a variety of services/settings. Visit: www.cqc.org.uk

NHS ChoicesThe first port of call for the public for all information on the NHS.

NHS Information Centre

The NHS Information Centre is England’s central, authoritative source of health and social care information. Acting as a ‘hub’ for high quality, national, comparative data for all secondary uses, they deliver information for local decision makers to improve the quality and efficiency of frontline care. Visit: www.ic.nhs.uk

ProvidersProviders are the organisations that provide NHS services, for example Surrey and Sussex Healthcare NHS Trust.

RegistrationFrom April 2009, every NHS Trust that provides healthcare directly to patients must be registered with the Care Quality Commission (CQC).

ResearchClinical research and clinical trials are an everyday part of the NHS. The people who do research are mostly the same doctors and other health professionals who treat people. A clinical trial is a particular type of research that tests one treatment against another. It might involve either patients or people in good health, or both.

50 Quality Account 2014-2015 Glossary 51

Appendices

Appendix A: Statement of our directors’ responsibilities Commissioners

The content of this report was agreed with the Trust’s Executive Team, Senior Clinical Staff (Executive Committee for Quality & Risk), the Safety and Quality Committee and the Trust Board. Our priorities for quality improvement in 2014/15 are based on our Quality Strategy and follow consultation through our clinical divisions with staff, and with our other stakeholders, including patients and their carers.

The report has been reviewed by:

• Crawley, Horsham, Mid Sussex Clinical Commissioning Group

• East Surrey Clinical Commissioning Group

• Surrey Downs Clinical Commissioning Group

• Surrey Health Scrutiny Committee

• West Sussex Health and Adult Social Care Select Committee

• Healthwatch Surrey

• Healthwatch West Sussex

They have been invited to review the report and their comments are included.

Statement of directors’ responsibilities in respect of the Quality AccountThe directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011).

In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

• the Quality Account present a balanced picture of the trust’s performance over the period covered

• the performance information reported in the Quality Account is reliable and accurate;

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

• the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review

• the Quality Account has been prepared in accordance with Department of Health guidance

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

By order of the Board

25 June 2015Chair

25 June 2015Chief Executive

Appendix B: What our partners say

Crawley, Horsham and Mid-Sussex, East Surrey and Surrey Downs Clinical Commissioning Groups

Thank you for giving Crawley, Horsham and Mid-Sussex, East Surrey and Surrey Downs Clinical Commissioning Groups the opportunity to comment on your Quality Account for 2014/15.

The CCGs have reviewed the Surrey and Sussex Healthcare NHS Trust Quality Account and can confirm that the quality account complies with the guidelines and demonstrates progress against its priorities identified for 2014/15. The Quality.

Account provides information across the three areas of quality: patient safety, patient experience and clinical effectiveness and highlights an on-going commitment to the improvement of the quality of care.

Performance against 2014/15 prioritiesThe CCGs agree that the report is comprehensive and although mainly reflecting the good work that the Trust has done, it is in fact balanced with areas where improvements are required.

With regards to patient safety we are pleased to note that the organisation has done well to maintain reductions in Falls, Major hospital acquire pressure damage and Healthcare Acquired Infections. In particular, the section on Healthcare Acquired Infections clearly highlights how the processes put in place have enabled the Trust to successfully reduce the number of hospital acquired infections.

We have also considered that there were areas of strength within the accounts, namely that the accounts clearly show how the organisation has set its future priorities for quality. We note specific improvements made on environmental cleanliness and nutrition. The investments in the new cleaning equipment as well as the introduction of the 2 week menu cycle and dieticians show a real commitment to improved patient experience.

Also noteworthy, is the Trusts performance in the Friends & Family Test as evidenced by high rating on a national level. We particularly welcomed the inclusion of patient’s feedback and staff recognition within the accounts.

The Trusts performance in reducing readmission rates is also to be noted.

Priorities for 2015/16Rather than selecting new priorities, the organisation has sought improvements on existing priorities from 2014/15. The CCGs support the priorities for 2015/16 which appear appropriate in this context, and it is encouraging to note that the organisation acknowledges the areas where further improvements are required. However, a full evaluation of the priorities for 2015/16 was limited as draft version was incomplete and we have not been able to evaluate the ones not included. The document could be strengthened by consistently including the improvements for all areas.

ConclusionThe Trust continues to make sustained progress with its improvement priorities within the context of continued whole system challenges, in particular around demand and workforce issues.

We believe that the Quality Account captures the good work that the Trust is doing and outlines the quality aspirations for 2015/16. The CCGs consider the priorities outlined for 2015/16 appropriate and look forward to reviewing progress at the regular Quality conversations throughout the year.

52 Quality Account 2014-2015 Appendices 53

Healthwatch West SussexIntroduction

As the independent champion for health and social care for patients across West Sussex Healthwatch (HWWSx) are pleased to be invited to comment on Surrey and Sussex Healthcare NHS Trust (SaSH) draft Quality Account (QA) for 2014-15.

We note that the Care Quality Commission (CQC) has awarded a “Good” rating to the Trust with some areas reported as “Outstanding”. The CQC did identify a need to improve outpatient services and communication with patients, therefore, we are delighted to see a clear focus on patient engagement embedded in the proposed priorities for 2015/16. We await with interest the report on Responsiveness to Patient Personal Needs.

The Trust is commended for using a variety of tools to elicit patients’ views and experience. However evidence of actions taken as a result are not included in the QA for 2014-15.

Our commentary not only reflects the content of the Trust’s draft QA but is also drawn from patient experience as recorded in our Client Relationship Management (CRM) system.

HWWSx received both positive and negative comments from patients.

In summary:

Positive

• Staff - A number of patients praised the nursing and midwifery staff at Horsham, Crawley and East Surrey Hospitals

Negative

• Delays in treatment - including not hearing back about treatment/repeated cancellation and postponement of appointments/information lost or incorrect.

• Discharge - inadequate arrangement and lack of follow up care.

• Treatment - condition not taken seriously or condition not resolved

• Safety and hygiene - particularly in East Surrey

and Horsham hospitals

• Staffing – poor attitude, inconsistency of consultant and general staffing levels

Further anonymised details can be supplied if required.

Safety Reported improvement 2014/15

• HWWSx welcome the reduction in hospital acquired infections and pressure damage. An improvement in access to services addresses a number of issues reported to us. The use of the WHO Safer Surgery checklist can only lead to improvement in surgical practice.

Priorities for 2015/16

The Trust is to be commended in recruiting a falls champion and working towards timely treatment for fractured neck of femur using the research based FNF care pathway.

Maternity services at the Trust are recognised as offering high quality care which is supported by the Maternity Safety Thermometer now rolled out across Kent, Surrey and Sussex.

We have been made aware of national concern around stroke, therefore, HWWSx is pleased to see the Trust is introducing SSNAP standards.

Serious incidents and near misses are a source of learning and we welcome the Trust’s renewed focus on disseminating this to staff. We would wish to see evidence of this included in the Quality Account.

Effectiveness Reported improvement 2014/15

HWWSx congratulate the Trust in reducing the readmission rate and the need for admission through partnership working with community providers.

We would expect all Trusts to be compliant with NICE guidance, to take part in the National Clinical Audit Programme and Confidential Enquires and hope to see evidence of improved outcomes over time.


Data quality and accuracy of coding are a major issues for all healthcare providers. We are pleased to note that the Trust is reviewing these areas.

We welcome the priority of a seamless care pathway between primary/secondary care as it will address some of the issues reported to us.

Patient experience Reported improvement 2014/15

As the independent patient’s voice we commend the Trust in its efforts to hear directly from patients and carers and offer more information on their services. We would wish to see continued evidence of improvements made as a result of patient feedback in the 2015-16 QA.


HWWSx very much welcome the inclusion in the QA of increased patient feedback through focus groups and a Customer Care programme to support the philosophy of patients at the heart of care. The development of Cultural Champions will assist staff and ensure that individuals with protected characteristics receive equal access and an improved experience of care from the Trust.

Conclusions from the service user perspective As an organisation representing patient interests, viewing evidence of service improvement is of primary importance to us.

HWWSx commends the Trust for their stated aim of putting the patient at the heart of their care. A commitment to high quality, safe care with a view to continuous improvement is welcomed.

We congratulate the Trust on the improvements achieved as identified in the QA 2014-15 report but would wish to see a more outcomes focused approach in the future with clear evidence of actions taken as a result of meaningful patient engagement.

A significant number of West Sussex residents’ access healthcare at various Trust sites. We now welcome the recently introduced formal opportunity for engaging with the Trust’s Quality Nurse Lead and hope this continues throughout 2015-16 and to work together on the development of the Quality Account.

HWWSx looks forward to building an open, transparent and mutually respectful relationship with the Trust to support continuous improvement in the delivery of healthcare for all patients.

Surrey Health Scrutiny Committee

The Committee is grateful for the opportunity to comment on the Surrey & Sussex Healthcare NHS Trust (SASH) Quality Account

following regular meetings with both the Medical Director and Director of Quality & Nursing throughout the last year.

• Two Members of the Committee are responsible for oversight of the Trust’s quality and have scrutinised this year’s account and wish to put on record the following comments:

• The Committee noted the high quality of care provided by SASH and that it achieved a good inspection outcome from the Care Quality Commission.

• The Committee welcomed the fact that SASH had met 70% of their targets, with the remainder being partly met.

• The Committee welcomed the action that the Trust was taking in relation to working with partners to increase dementia and stroke awareness and welcomed the fact that the trust had a lead champion for the target areas. However, the full data was not available for stroke care – a partially met performance which meant the committee could not fully scrutinise performance in this area.

• The Committee welcomed the actions being


West Sussex Health & Adult Social Care Select Committee (HASC)

Thank you for offering the Health & Adult Social Care Select Committee (HASC) the opportunity to comment on Surrey and

Sussex Healthcare NHS Trust’s Quality Account for 2014-15.

HASC is pleased that clinicians are now key in managerial decision-making and that external benchmarking is used to measure all aspects of safety, clinical effectiveness and patient experience.

The ‘Your Care Matters’ programme and the Patient Opinion website are important and have provided ways for patients to give vital feedback to the Trust.

HASC welcomes the move towards more transparency as a result of recommendations in the Francis Report and also the reconfiguration of staff ward ratios.

Finally, we look forward to hearing whether or not the Trust achieves Foundation status.

taken to improve quality to an even greater level to achieve a better result at its next CQC inspection.

• The Committee welcomed the further focus on screening and IV line/catheter hygiene to achieve zero attributable cases of MRSA and the emphasis on root cause analysis of all incidents of C. difficile which, together with appropriate antibiotic prescribing and hygiene practices, has kept incidences below the targeted maximum.

• The Committee welcomed the introduction of mouth care assessments for in patients

• The Committee regrets that amongst the items where the data was unavailable for the draft were two important areas: firstly safe and appropriate discharge and secondly mental health as problems with provision in both areas have occurred across Surrey. The Committee notes that SASH had committed to a planned discharge programme and would expect to assess progress in implementation and analysis of factors hindering progress such as difficulties with patient transport services.

• The Committee noted that other NHS trusts tend to include references to complaints and, whilst noting that the SASH would be limited by the regulator, advised that they would welcome a section on complaints in the quality account.

• The Committee noted this year’s objective for improvement to encourage more senior frontline staff to respond directly to comments on Patient Opinion and roll out the Your Care Matters programme to cover all patient pathways, building upon existing performance measurements and to consistently respond to the comments they receive and strive to make improvements.

• The Committee will continue to work closely with the Trust and looks forward to continued improvements in 2015/16.

How to contact usSurrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust provides emergency and non-emergency services at:

East Surrey HospitalRedhillSurrey RH1 5RHTelephone: 01737 768511

Surrey and Sussex Healthcare NHS Trust provides non-emergency services at Crawley Hospital which is managed by NHS Property Company.

Crawley Hospital CrawleyWest SussexRH11 7DHTelephone: 01293 600300

We also provide a number of services at four community sites:

Caterham Dene Hospital Church RoadCaterhamSurrey CR3 5RATelephone: 01883 837500

Horsham HospitalHurst RoadHorshamWest Sussex RH12 2DRTelephone: 01403 227000

Oxted Health Centre10 Gresham RoadOxtedRH8 0BQTelephone: 01883 734000

Surrey and Sussex Healthcare NHS TrustTrust HeadquartersCanada AvenueRedhillSurrey RH1 5RHTelephone: 01737 768511Email: [email protected] www.surreyandsussex.nhs.uktwitter: @sashnhs


The Patient Advice and Liaison Service (PALS) focuses on improving services for NHS patients. It aims to:

• advise and support patients, their families and carers

• provide information on NHS services

• listen to your concerns, suggestions or queries

• help sort out problems quickly on your behalf

You can contact PALS by:

• telephone: 01737 768511 x 6922 or 6831 (for all sites)

• e-mail: [email protected]

• writing to: PALS, c/o East Surrey Hospital, Redhill, Surrey RH1 5RH

Need help or advice?

This information is available in other languages and formats including audio tape, large print and Braille. For further information please contact PALS (Patient Advisory Liaison Service) on 01737 231958 or email: [email protected]

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