Healthwatchsthelens.co.uk

Draft Quality Account 2015 – 2016
Front cover - DN: Maintain previous year's design for the front cover

Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font DN: Contents page to be reduced to main section headings only – left in draft for
ease of navigation
Contents
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 1. Section 1
1.1. Summary of quality achievements in 2015-16
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font
DN: Display as call out boxes?
Quality of services overall
 Caring rated as outstanding across the Trust, the best rating possible, by the
Care Quality Commission (CQC)  St Helens Hospital rated as outstanding
 Outpatients and Diagnostic Imaging Services rated as outstanding overall
 Trust rated as good overall  Ward quality accreditation tool rolled out across all general inpatient areas, namely the Quality Care Assessment Tool (QCAT)
Patient safety
 No never events since May 2013
 Patients consistently received above 98% new harm-free care, that is harm that has occurred whilst an inpatient in the Trust in 2015-16 reported via the NHS Safety Thermometer - outperforming neighbouring Trusts in this safety measure  48% reduction in falls resulting in moderate or severe harm, following the implementation of the falls strategy action plan in October 2015  Reduced the number of hospital acquired pressure ulcers compared to last year, with a 50% reduction in grade 3 and no grade 4 pressure ulcers  Reduced the number of Clostridium difficile infections, performing better than the  No hospital acquired methicillin-resistant staphylococcus aureus (MRSA) bacteraemia since September 2014  96.8% fill rate for registered nurses/midwifes

Patient experience
 Best in the UK for patient experience and shortlisted again for the forthcoming
awards by CHKS Top Hospitals  Best acute NHS Trust in England for the second year running in the Patient Led Assessments of the Care Environment (PLACE)  96.4% of inpatients would recommend our services as recorded by the Friends
Clinical effectiveness
 3rd best performer in England in the Sentinel Stroke National Audit Programme
following transformational changes to the service  Electronic modified early warning score (eMEWS) system went live to electronically record patient observations ensuring more effective treatment for patients at risk of deterioration  Cancer services seen as champions of the Electronic Holistic Needs Assessment (eHNA), for staff sharing best practice examples with other cancer hospitals nationally to improve individualised care plans for patients  First Department of Anaesthesia in the North West and 8th nationally to be awarded accreditation status by the Royal College of Anaesthetists Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font
Well-led
 Ranked in the top 100 places to work in the NHS in the Health Service Journal's
independent assessment in 2014 and 2015  Rated as the best acute Trust in the North West and the best non-Foundation Trust nationally in the latest staff survey  Scored the highest score for any acute hospital nationally for the question, "Are you happy with the quality of care you are able to deliver?" in the staff survey
Summary of 2015-16 awards

DN: Display as call out boxes?
The following staff and teams were recognised by external bodies for their outstanding contributions in their own professional areas of work:  Customer service excellence award for the Rheumatology Unit  Midwife, Joanne Price, won the prestigious Johnson's Baby Mums' Midwife of the Year Award 2015 for the North England region, at the Royal College of Midwives (RCM) Annual Midwifery Awards  Consultant, Tamara Kiernan, won the Liverpool and North West Surgical Society registrar prize for her work as Oncoplastic Fellow for Merseyside  Gary Barker, Specialty Lead Nurse, Sexual Health, was named the Gilead Sciences HIV Nurse of the Year at the National HIV Nurses Association's 17th Annual Conference  Jackie Burke, Healthcare Assistant, won the Michael McNally Mentor Award at the 12th Annual Cadet Award Ceremony  Julie Sanderson, Bereavement Midwife, was named North West Nurse of the Year at this year's North West Pride Awards, after being nominated by a bereaved parent who believes "every hospital should have a Julie"  Sexual Health team won first prize at the national Royal College of General Practitioners' conference for their poster presentation for services delivered to seldom heard communities, in partnership with the Addaction Service (drugs and alcohol service)  Finalist in the category of Education and Training in Patient Safety, in the national Patient Safety Awards, following the work in theatres to introduce safer systems based on Human Factors training  Maternity Bereavement Service shortlisted for the category of Best Hospital Bereavement Service Award at the Butterfly Awards  Ward 3C (trauma & orthopaedics) received an award for being an outstanding clinical placement for nursing students from Liverpool John Moores University. The Trust also celebrates success internally and hosted its 11th annual staff awards in July 2015 to celebrate the hard work and achievements of a number of staff and teams in providing excellent patient care. The annual awards and the employee of the month are important ways of recognising and rewarding the on-going dedication and commitment of staff throughout the year. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font

1.2. Statement on quality from the Chief Executive of the Trust

DN: CEO review/amend/approve
We are pleased to present the Trust's seventh annual Quality Account, which
reviews our performance and achievements over the past year, as well as outlining
our priorities for improving quality in the coming year.
Our mission is to provide high quality health services and an excellent patient
experience. Our vision to provide 5-star patient care remains the Trust's primary
objective so that patients and their carers receive services that are safe, patient-
centred and responsive, achieving positive outcomes every time. This continues to
be embedded in the everyday working practices of staff throughout the Trust and has
been recognised by a number of external organisations.
The vision is underpinned by the Trust's values, five key action areas and the ACE
behavioural standards of attitudes, communication and the experiences we create.
The vision and values are shown in the diagrams below:
St Helens and Knowsley Teaching Hospitals NHS Trust's Vision


St Helens and Knowsley Teaching Hospitals NHS Trust's Values

The Board, through its Quality Committee, oversees the delivery of the vision to achieve 5-star patient care by monitoring key performance indicators and by reviewing the delivery of the quality standards. One of the key ways of measuring the quality of services is through the regular inspections by the CQC, the independent regulator of health and adult social care services. 27/04/2016 Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font The CQC inspectors assess services against five key questions asking if services are:  Safe  Responsive to people's needs and We are delighted to report that the Trust was rated as outstanding for caring, with St Helens Hospital and our outpatients and diagnostics services rated as outstanding by the CQC following their comprehensive inspection. These are great achievements and demonstrate that the Trust is performing exceptionally well. Overall, the Trust was rated as good and noted to be one of the best Trusts inspected so far. The inspection took place during August and September 2015. A team of 52 inspectors, including doctors, senior nurses, pharmacists, trained lay members and CQC members visited the Trust, talked to patients, carers and staff and reviewed the services provided. The inspectors confirmed that patient safety and positive experiences were key priorities for the Trust and underpinned all aspects of service planning and delivery. In addition, they found that staff were fully engaged in the on-going development and implementation of the Trust's vision, values and behavioural standards. The CQC reported that they saw several areas of outstanding practice including:  The development of a pressure ulcer (PU) risk assessment tool used by the tissue viability nurses across the wards. This took into account the grade of the PU risk and a care plan was determined which included the equipment to be used for the patient  A pathway and coordinated approach for patients with additional needs to reduce the need for repeat procedures and to enhance the patient's experience  Staff were passionate about delivering high quality care and went above and beyond their usual duties to ensure children and young people experienced high quality care (Services for Children and Young People)  Feedback from children, young people and parents about their care was exceptionally positive  Excellent caring, respectful and compassionate interactions between staff, children, young people and their families, particularly in the outpatient clinics (Services for Children and Young People)  Positive interactions when staff were seeking consent (Surgery)  Improvements in the response times and access to timely treatment for a patient, by booking another follow-up appointment with the appropriate specialist if a critical or abnormal finding was detected on an X-ray by radiology staff The CQC did highlight areas for improvement within the Trust's Emergency Department (ED) in the responsive domain, as the Trust was not meeting the four- Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font hour access target or ambulance handover times, although, the Trust was amongst the best performing Trusts in the region. In Maternity Services some improvements were required in the safety, responsive and well-led domains. The CQC recognised that action was being taken to address these. Further work is on-going to embed the improvements via a robust action plan, which is monitored internally and external to the Trust. This year we have worked with our local Healthwatch organisations to improve accessibility and inclusivity of our services, particularly in respect of seldom heard groups within the community, shown in the progress achieved in meeting the agreed targets for the Equality Delivery System (EDS2) outcomes. In addition, we have continued to work closely with patients and carers during the year to ensure that they are able to influence changes made to our services. The Trust hosts a number of patient focus groups and has patient representatives on several Trust councils and steering groups. Healthwatch representatives are key members of the Patient Experience and the Patient Safety Councils which report to the Board's Quality Committee, ensuring effective representation in the oversight and governance structure of the Trust. Patients are able to present their experiences of the care received, in their own words, as a patient story at the start of our public Board meetings. This Quality Account details the progress we have made with delivering the priorities agreed last year and our achievement of national and local performance indicators, highlighting any challenges and the initiatives undertaken to work towards realising our vision of 5-star patient care. It also includes progress in delivering the plans set out in our Clinical & Quality and Nursing & Midwifery Strategies. It outlines our quality improvement priorities for 2016-17, which were widely consulted on seeking the views of staff, patient representatives and our commissioners. I am pleased to confirm that the Board of Directors has reviewed the Quality Account for 2015-16 and confirm that it is a true and fair reflection of our performance and that, to the best of my knowledge, the information contained within it is accurate. We hope that it provides you with the confidence that high quality patient care remains our overarching priority and that it clearly demonstrates the progress we have made. We recognise that our staff are our greatest asset and we acknowledge their professionalism, commitment and dedication as they work tirelessly to provide excellent care for our patients and their carers. On behalf of the Trust Board I would like to thank all staff who have contributed to what has been another successful and challenging year. Ann Marr Chief Executive St Helens and Knowsley Teaching Hospitals NHS Trust May 2016 Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 2. Section 2
2.1. About us
2.1.1. Our services
St Helens and Knowsley Teaching Hospitals NHS Trust is a medium-sized NHS Trust. It provides a range of acute and specialist healthcare services including inpatient, outpatient, maternity and emergency services. In addition, the Trust hosts the Mersey Regional Burns and Plastic Surgery Unit providing services for around four million people living in the North West of England, North Wales and the Isle of Man. The Trust has just over 780 inpatient beds and provides the majority of its services from two main sites at Whiston and St Helens Hospitals, both of which are new state-of-the-art, purpose built modern facilities that are well-maintained. Whiston Hospital houses the Emergency Department, the maternity unit, children and young people's service and all acute care beds. St Helens Hospital houses day-case and elective surgery, outpatients, diagnostic facilities, as well as rehabilitation beds and the dedicated cancer unit. The Trust provides outpatient and diagnostic services in a small number of other settings. The Trust Board is committed to continuing to deliver safe and high quality care. The Trust has had another successful year, despite the current financial challenges facing the NHS. There has been a significant increase in demand for its services, as the Trust continues to be one of the busiest acute hospital trusts in the North West of England. It has a good track record of providing high standards of care to its population of approximately 350,000 people across St Helens, Knowsley, Halton and South Liverpool, as well as further afield, which was recognised by the CQC. The number of patients attending the Emergency Department (ED) has continued to increase along with elective referrals from General Practice, patients attending the outpatients department and those receiving treatment as a day case patient. In the past year, the Trust saw:  65,782 inpatient admissions (an increase of 0.7%) (this is elective and non- elective admissions, excluding well babies)  3,902 births (an increase of 0.6% compared to the previous year's increase of  38,514 day-case patients (an increase of 10.8%)  103,940 ED attendances (an increase of 2.7%)  438,330 total outpatient attendances (an increase of 5.6%) 2.1.2. Our staff and resources
The Trust's annual budget for 2015-16 was £309 million. We employ more than 4,000 members of staff and we are the lead employer for the Mersey Deanery, responsible for 2,000 trainee specialty doctors, based in hospitals and general practice (GP) placements throughout Merseyside and Cheshire. The average staff Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font turnover rate in the Trust for 2015-16 was 9.34%, which is lower than the national rate of 9.46%. However, this overall rate masks variations between disciplines and the significant recruitment challenges within specific specialties and for specific roles, in particular: medical, nursing and scientific staff. The Trust is proactive in addressing these challenges, holding regular recruitment events and using international recruitment to ensure vacancies are filled. The Trust strives to meet the best standards of professional care whilst being sensitive and responsive to the needs of individual patients. Clinical services are organised within three care groups; surgery, medicine and clinical support, working together to provide integrated care. A range of corporate support services including human resources (HR), education and training, informatics, research and development, finance, governance, facilities, estates and hotel services, all contribute to the efficient and effective running of the two hospitals. 2.1.3. Our communities
The local population is generally less healthy than the rest of England, with a higher proportion of people suffering from a long-term illness. Many areas suffer high levels of deprivation. This has contributed to significant health inequalities among residents, leading to poorer health and a greater demand for health and social care services. Rates of obesity, smoking, cancer and heart disease, related to poor general health and nutrition, are significantly higher than the national average. 2.1.4. Our partners
We are continuing to work with stakeholders across the health economy to secure sustainable health care services for our local population. The Trust is working with its commissioners and provider partners to develop a five year Sustainability and Transformation Plan (STP) in accordance with the NHS national planning guidance. This plan will be submitted in June 2016. The Commissioners within the Liverpool City Region have formed a collaborative partnership and a Committee in Common to support decision-making. The Liverpool City Region is, therefore, the overarching STP footprint, but within this there will be more localised plans covering four Local Delivery Systems. Mersey Health and Social Care economy are broadly aligned, in that all partner organisations aspire to reduce urgent care demand and provide more services outside of hospitals. The Trust is working with partners within the economy to develop long term transformation programmes to deliver this aspiration, whilst at the same time securing sustainable and viable services. One of the key areas for attention is consolidating and integrating services, in particular care pathways for frail elderly patients across primary, secondary and social care, which are designed to reduce Emergency Department (ED) attendances and non-elective hospital admissions. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font The Trust is part of the Cheshire and Merseyside Paediatrics, Neonatal and Maternity Services Vanguard programme which is exploring new ways of working across the wider health economy. This will enable the sharing of best practice and resources, as well as leading to a reduction in the variation in outcomes between different units. This is an exciting new way of working to support the delivery of the NHS Five Year Forward View to achieve both clinical and financial long term sustainability for services. It is based on collaboration and integration of service models across traditional boundaries, where this will help to promote higher quality care. 2.1.5. Technology and information
This year the Trust has continued to deliver a portfolio of technological advancements to enhance patient safety and care. Working closely with teams of clinicians and nurses across the Trust, the Informatics Department have deployed an electronic modified early warning score (eMEWS) system. This system has replaced paper charts that required manual calculations of patients' observations with an automatic system, using iPads instead of paper. The system is faster and safer for patients with an automatic referral of a patient in the event of deterioration in their condition. It has already delivered significant time-saving benefits for clinical users of the system. This time can be re-invested back into patient care. The Informatics Department have also developed the eHandover application, to ensure the medical on-call referral process for patients admitted to the trust via emergency department (ED) is efficient, safe and transparent. Working closely with a team in the ED to develop the application, eHandover has replaced the manual process and is already proving to be an extremely useful tool for all teams involved in this handover process, improving the efficiency of the medical on-call referral process and minimising bleeps from ED to medical specialist-trainees and registrars. Informatics have also upgraded a number of existing Trust systems, including:-  Critical Care information system – to give better resilience of the system  Mortuary system – allowing the Trust to exchange information with Warrington  Trust-wide pager system - to enable more advanced monitoring and higher Trust systems and applications can only function effectively if the underlying infrastructure is secure, available and resilient. During 2015-16, the Informatics Department have also made significant improvements to the infrastructure that ensures staff and patients can access the right systems and information at the time they need it. We have:  Replaced the Storage Area Network (SAN) – enabling increased performance and capacity and higher availability of systems and data Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font  Commenced a project to deploy a new version of internet explorer web browser across the Trust – this is required for future projects in plan  Deployed Patient Wi-Fi – across a number of patient locations at St Helens  Developed the new Trust website – in collaboration with the Trust Communications Team, resulting in a more user friendly and up to date public website 2.2. Priorities for improvement

The Trust's priorities for 2016-17 are listed below with the reasons why they are
important areas for quality improvement. The views of a wide number of
stakeholders and staff were considered prior to the Board's approval of the final list.
The consultation included a survey that was circulated to staff, commissioners and
patient representatives, as well as placed on the Trust's website for public
participation. Also, Healthwatch members of the Trust's councils and our
commissioners were asked for their views on what should be included in the list of
priorities.
1. Reduce avoidable harm from falls, pressure ulcers and medication
incidents by 50% in the next 3 years
Rationale:
Patient safety remains a key priority for the Trust.
2016-17 will be the second year of the Trust's commitment to the three year Sign up
to Safety Campaign and the Trust remains focussed on continuing to reduce
avoidable harm to patients, with the aim to ‘get it right for every patient, every time'.
The key measures will be:
 Reducing the number of falls which result in moderate to severe harm by 50%
from 2013-14 baseline data  Maintaining a 50% reduction in theatre-related episodes of avoidable harm (measured against 2012-13 Human Factors service redesign data)  Reducing the incidence of Clostridium difficile and avoidable MRSA infections  Having zero tolerance to hospital acquired grade 4 pressure ulcers and continue to seek to further reduce harm from pressure ulcers at all grades by 5% in year  Reducing the incident of prescribing errors by 50% from 2013-14 baseline data  Improving the recognition and treatment of the deteriorating patient through technology and education  Introducing patient safety briefings at ward level This will be monitored by the Patient Safety Council and reported to the Quality
Committee.
2. To further embed the process for learning from incidents and complaints
Rationale:
Patients sometimes experience unintended physical or emotional harm, despite the
hard work of healthcare staff. The Trust remains committed to reducing harm by
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font strengthening Trust-wide and local learning from incidents and complaints and is proposing to keep this as a priority for the next year. This will be measured by:  Demonstrate a learning safety culture through increased reporting of incidents by  Improve on the timeliness of investigating and reporting serious incidents  Be in the top 20% nationally for reporting incidents within the reporting cohort in the national reporting and learning system (NLRS)  Improve timeliness of responding to complaints to meet the Trust target of 90% of complaints responded to within the agreed timescale  Implement a lessons learnt framework Trust-wide to increase the sharing of lessons learnt from incidents, complaints and claims
This will be monitored by both the Patient Safety and Patient Experience Councils
and reported to the Quality Committee.
3. Further reduce mortality of weekend admissions
Rationale:
In line with other trusts nationally, St Helens and Knowsley Teaching Hospitals NHS
Trust continues to experience higher than expected numbers of deaths for patients
admitted at the weekend and continues to strive towards reducing differences in care
across the days of the week.
This will be measured through hospital standardised mortality ratio (HSMR) data
from Dr Foster. Our first action to address this issue is to undertake detailed
analysis of the data to help identify the issues and to support the establishment of
targets for improvement going forward and help to determine a trajectory and
timeframe for achievement.
This will be monitored by the Clinical Effectiveness Council and reported to the
Quality Committee.
4. Earlier identification and initiation of appropriate treatment thus reducing
mortality due to sepsis for patients attending St Helens and Knowsley
Teaching Hospitals NHS Trust
Rationale:
Sepsis is a common condition associated with infection which, if not identified and
managed early, can lead to serious complications and death. Sepsis Trust quotes
that annually 37,000 patients die as a consequence of sepsis in UK alone. Sepsis is
one of the leading causes of death across all acute trusts in the country and at St
Helens and Knowsley Teaching Hospitals NHS Trust we are also faced with a similar
challenge. We admit between 15-30 patients every day with sepsis. The Trust is
determined to improve the management of sepsis and to reduce the number of
avoidable deaths due to sepsis.
This will be measured by:
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font  Increase screening from 30% of patients to 60% in next 12 months for all acute admissions including paediatrics  Increase antibiotic administration within first hour of presentation from 30% to 60% in next 12 months  Reduce length of stay by one day in next 12 months
This will be monitored by the Clinical Effectiveness Council and reported to the
Quality Committee.
5. To deliver 5-star care to patients admitted to hospital with an Acute Kidney
Rationale:
Acute Kidney Injury (AKI) is a sudden reduction in kidney function. In England, over
half a million people sustain AKI every year with AKI affecting 5-15% of all hospital
admissions. It is responsible for 40,000 excess deaths every year. Patients with AKI
are also subject to longer, more complex hospital stays with the annual cost of AKI in
England at more than £1billion.

This will be measured by:
 Delivery of a 4.7 day length of stay reduction for 25% of hospital-acquired AKI
population within two years using 2014-15 as a baseline  Delivery of the local Commissioning for Quality and Innovation (CQuIN) target for effective discharge communication for patients with AKI
This will be monitored by the Clinical Effectiveness Council and reported to the
Quality Committee.

6. Increase the percentage of e-discharge summaries sent within 24 hours to
Rationale:
In order to communicate the on-going treatment plan when patients are discharged it
is essential to share the relevant information in a timely and efficient manner,
particularly for patients with complex needs. This will ensure that patients' on-going
clinical care is provided effectively and will reduce the potential for readmission into
hospital.
This will be monitored by the Clinical Effectiveness Council and reported to the
Quality Committee.
2.3. Statements relating to the quality of the NHS services
provided by the Trust in 2015-16
The following statements are required by the regulations and they will enable comparisons to be made between organisations, as well as providing assurance that the Board has considered a broad range of drivers for quality improvement. 2.3.1. Review of services
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font During 2015-16 the St Helens and Knowsley Teaching Hospitals NHS Trust provided
and/or sub-contracted £260m NHS services.

The St Helens and Knowsley Teaching Hospitals NHS Trust has reviewed all the
data available to them on the quality of care in all of these NHS services.

The income generated by the NHS services reviewed in 2015-16 represents 100 per
cent of the total income generated from the provision of NHS services by the St
Helens and Knowsley Teaching Hospitals NHS Trust for 2015-16.
2.3.2. Participation in clinical audit

During 2015-16, 43 national clinical audits and 2 national confidential enquiries
covered NHS services that St Helens and Knowsley Teaching Hospitals NHS Trust
provides.
Please note: some audits are listed with one heading, however several individual
audits have been undertaken under each heading, as noted below:
 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) -
4 individual audits  Blood Transfusion Programme – 3 individual audits (participated in 2 audits)
 Falls And Fragility Fractures Programme (FFFAP) – 2 individual audits
During that period St Helens and Knowsley Teaching Hospitals NHS Trust
participated in 97% (28/29) national clinical audits and 100% of national confidential
enquiries of the national clinical audits and national confidential enquiries which it
was eligible to participate in.
The national clinical audits and national confidential enquiries that St Helens and
Knowsley Teaching Hospitals NHS Trust participated in, and for which data
collection was completed during 2015-16, are listed below alongside the number of
cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
2.3.2.1. Quality account audits/ascertainment rate
Rate Of Case
National Audits 2015-16
Diabetes (Paediatric) (Paediatric National Diabetes Audit (PNDA)) Procedural Sedation In Adults (College of Emergency Medicine (CEM)) Vital Signs In Children (Care in VTE Risk in Lower Limb (Care in Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Rate Of Case
National Audits 2015-16
Inflammatory Bowel Disease 4th BRS Rheumatoid and Early All Data Submitted Inflammatory Arthritis Emergency Use in Oxygen BTS Paediatric Asthma British Thoracic Society (BTS) National Emergency Laparotomy Audit (NELA) Diabetes (Adult) (National Diabetes Audit (Adult) (NDA (A)) National Comparative Audit of Blood Transfusion Programme (X3)  Blood Transfusion in Scheduled Surgery Audit  Audit of Red Cell  Lower GI Bleed Audit: Use of National Prostate Cancer Audit National Ophthalmology Audit Awaiting figures (National Bowel Cancer Audit from national centre Programme (NBOCAP)) Oesophago-Gastric Cancer Awaiting figures (National Audit Oesophago- from national centre Gastric Cancer (NAOGC)) Lung Cancer Awaiting figures (National Lung Cancer Audit from national centre (NLCA)) Adult Critical Care (Case Mix Programme) (Intensive Care National Audit & Research Centre (ICNARC)) Severe Trauma (Trauma Audit & Research Network (TARN)) Acute Coronary Syndrome or Acute Myocardial Infarction (Myocardial Ischaemia National Audit Project (MINAP)) National Cardiac Arrest Audit Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Rate Of Case
National Audits 2015-16
National Heart Failure (HF) (Awaiting 2014-15 national figures) Sentinel Stroke National Audit Falls And Fragility Fractures Programme (FFFAP)  Includes National Hip Fracture Fracture Liaison Service organisational audit Database (FLS-DB) Facilities and not eligible for National Joint Registry (NJR) Neonatal Intensive and Special Care (National Neonatal Audit Programme (NNAP)) Elective Surgery (National patient-reported April 15 – Feb 16 outcomes measures (PROMS) 79.6% (Provisional) Cystic Fibrosis Registry National Complicated Diverticulitis (CAD) National Confidential Enquiries
Rate Of Case
Gastro-Intestinal Haemorrhage Acute Pancreatitis Mental Care Health in Acute Hospitals
Confidential Enquiries across
the UK (MBRRACE-UK))
Maternal, Infant and Newborn -
Clinical Outcome Review Programme (Mothers and Babies - Reducing Risk through Audits Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font *The Diabetes National audit relies on direct data capture from electronic systems but St Helens and Knowsley Teaching Hospitals NHS Trust systems are currently paper based and therefore we have to submit a labour-intensive sample audit. 2.3.2.2. Trust participation in other national audits

Audit Title
Data collection
completed
National End of Life Care Society For Acute Medicine Benchmarking Audit (SAMBA) Audit Of Enhanced Recovery Programmes in Lower Limb Joint Replacement 1st National Audit Of Inpatient Falls 2015 Bliss Baby Charter Audit Tool National Diabetes Foot Care Audit (NDFA) National Audit Of Dementia: Pilot Project Of Feasibility For Community Hospital Mastectomy Decisions Audit: A Multi-Centre, Population Based Audit National Audit Of Dementia Recording The Impact of Acute Kidney Injury Following Major Gastro-intestinal Surgery (STARSURG) Implant Breast Reconstruction Audit (IBRA) National 3rd Corrective Jaw Treatment Audit Head and Neck Oncology RACPC Audit Programme
The reports of 30 national clinical audits were reviewed by the provider in 2015-16
and St Helens and Knowsley Teaching Hospitals NHS Trust has taken and intends
to take the following actions to improve the quality of healthcare provided:

Inpatient Falls Audit
Following recommendations from this audit an extensive action plan has been
produced which includes the implementation of a revised Falls Prevention Strategy;
a Strategic Falls Group has been formed to oversee the implementation of this
strategy and to performance manage the associated actions contained in the action
plan.

End of Life Care Audit
The results of the audit report will be discussed at the EOLC Steering Group and a
formal action plan will subsequently be produced.
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Parkinson's UK Audit
The Trust will review the advanced care planning pack, give advice regarding
financial benefits available for patients, review the Parkinson's clinic assessment
questionnaires and establish the support available from Speech & Language
Therapy Team (SALT).

National Dementia Audit: Following first and second audit
The pathway for patients with suspected dementia forms part of the Dementia
Commissioning for Quality and Innovation (CQuIN) target and, therefore, this
standard is monitored and reported to the commissioners. The Trust's Datix system
is now set up to allow for identification of patients with cognitive impairment. In
addition, the Trust is developing the frailty service, which includes patients with
dementia. A Frailty Unit was established in November 2014 and the frailty nurses
now see patients in the Emergency Department (ED) and the Medical Assessment
Unit (MAU).
A prompt for mental health diagnosis is included in the discharge summaries for the
Frailty Unit and Intermediate Care Unit and the frailty discharge summary will be
implemented across the Older People's wards over the next 12 months.
Carer Support workers proactively identify carers of inpatients in Whiston and St
Helens hospitals. The Carer Policy ensures there are clear guidelines regarding
involvement of carers and information sharing.
Therapy assessments are available on request for all patients and referrals can be
made for geriatric and psychiatric assessment. The assessment of nutritional status
includes recording of weight. In an effort to improve social interaction at meal times
and during the day, some wards encourage patients to eat their lunch at a table with
other patients in their bay. The volunteer project on 3alpha improves social
interaction for patients who have had a hip fracture.
The Trust has a delirium prevention care plan in place.
All the Older People's wards on the 5th floor of Whiston hospital have been adapted
and are dementia-friendly. Dementia-friendly cubicles have been established within
the ED. A capital bid has been submitted for dementia-friendly adaptations to the
Frailty Unit.
Dementia awareness training is mandatory in the Trust and Mental Capacity Act
training is soon to be mandatory. The Trust is meeting all the training levels required
by the Dementia CQuIN.
UK Inflammatory Bowel Disease Audit (IBD) - 4th Round
Appointment of 2 new IBD Nurse Specialists since round 4 of IBD audit, all inpatients
are being reviewed by IBD nurse specialists. Parenteral iron therapy offered for
patients with iron deficiency anaemia who are intolerant or nonresponsive to oral
iron. Endoscopy treatment unit receives all referrals for the same and is able to
action, as per patient choice.
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Initial Management of the Fitting Child Audit (CEM)
Epilepsy advice leaflets reviewed and sourced, which are now available in
Paediatrics & ED and given out on discharge.

Sepsis Audit (CEM)
Sepsis Pathway has been implemented, Stretcher Triage and Triage Nurse Training
has been completed.
Paracetamol Overdose Audit (CEM)
Following the audit 2 new pro forma have been introduced; for use in initial
assessment by nursing staff and Medical staff. Teaching sessions have been
completed.

National Audit of Seizure Management in Hospitals (NASH2) - Emergency
Department
New epilepsy referral pathway should improve follow-up for all patients presenting
with seizures.
National Paediatric Diabetes Audit (NPDA) 2012-2013
Issues around child and adolescent mental health services (CAMHS) identified and a
Clinical Psychologist is now employed and in place. Data capture has been
improved and International Classification of Diseases (ICD) codes are now within the
system, with patients identified and the data updated. Monthly validation is
undertaken to ensure data accuracy prior to submission. The Trust participates in
this National Audit annually.
Trauma Audit Research Network (TARN)
There has been an increase in our data quality and submission efficiency rates as a
result of new systems. The use of the Trauma Team has increased again since 2015
with 30 Trauma Team activations for the first quarter of 2016, compared to 19 in the
same time period in 2015. Whiston was again re-accredited as a trauma receiving
unit in 2015 and will undergo further re accreditation in 2016.
TARN data shows a reduction in the time from arrival to CT scan time for major
trauma patients who require an urgent CT, under NICE Head Injury Guidance. TARN
data shows that >50% of trauma teams are being led by a senior doctor and that in
the majority of cases a full trauma team responds to every trauma call alert. TARN
data shows that patients requiring blood products or tranexamic acid after trauma
are being managed appropriately and according to clinical guidance. Any cases
suggested by TARN for review are reviewed locally by a clinical team. Any trauma
deaths go through the Cheshire & Mersey Major Trauma Network clinical
governance mortality review process and lessons learnt are fed back locally.

Confidential Enquiries
Confidential Enquiry into Maternal Deaths - MBRRACE – UK, December 2014
The guideline for the Management of Maternal Collapse in Pregnancy and
Puerperium (including amniotic fluid embolism and uterine rupture) has been
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font updated with the recommendations from MBRRACE-UK. Presentations have been
updated to reflect recommendations for the Multidisciplinary Obstetric Drills, Skills,
and Simulation (MODSS) Emergency Study Day.

NCEPOD (National Confidential Enquiry into Patient Outcome and Death)/
Child Heath Programme
The Trust has participated in all eligible studies during 2015-16. Completed study
reports have been disseminated and reviewed with report recommendations
implemented or planned.
NCEPOD Sepsis study
Examples of implemented actions include a designated Consultant lead for Sepsis
and the implementation of a sepsis pathway and screening tool. Sepsis Nurses
providing a sepsis team approach are helping to ensure that appropriate treatment is
administered within one hour of presentation of severe sepsis. This is monitored via
CQuIN measures.

NCEPOD Subarachnoid Haemorrhage (SAH) study
A protocol for suspected SAH has been designed with planned implementation
during 2016. A local audit on confirmed SAH has been undertaken, the results of
which will be disseminated at the next Trust protected time audit session (May 16).

Reports to be published later in 2016:
 Acute Pancreatitis study
 Care of Patients with Mental Health Problems
Current NCEPOD/Child Health studies due for completion in 2017:
 Non-Invasive ventilation
 Young Persons Mental Health Study
 Chronic-Neurodisability (Cerebral Palsy)
The reports of 148 local clinical audits were reviewed by the provider in 2015-16 and
St Helens and Knowsley Teaching Hospitals NHS Trust has taken and intends to
take the following actions to improve the quality of healthcare provided

Annual Audit Care of the Dying Patient
The Individualised Care and Communication Record was rolled out Trust-wide. The
audit findings demonstrate a dramatic increase in compliance with end of life care
standards and documentation when this record was in use.

Audit of the Paediatrics Epilepsy Services
A new pro forma has been implemented, which includes confirmation of what
information has been given to families. An evidence-based web site:
is used to signpost parents to information about epilepsy and
all information given out in clinic is from this web site. Parents also receive
information in clinic on how to contact the epilepsy team.
Audit of the Neonatal Admission Proforma
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font A new neonatal admission pro forma is currently in use.

Quality & Safety of Percutaneous Endoscopic Gastrostomy (PEG) Tube
Insertion
Guidelines have been reviewed and are available on the intranet.

Diabetic Ketoacidosis Audit
An electronic form has been devised (which incorporates a plan of care) and will be
added to the discharge paperwork following training. Every patient admitted with a
primary diagnosis of diabetes will have this, which will be shared with everyone
involved in their care, including community staff.

Assessment & Management of Delirium in Medical Inpatients
The Frailty Discharge has been implemented on all the Older People wards; the
discharge summary template has been amended to prompt users to check if delirium
has resolved.

Audit on Reporting Cervical Cancer
The audit found good compliance with completing the relevant dataset. An electronic
system to report cervical loop specimens has been implemented.

Audit of Diagnosis and Management of Bacterial Meningitis & Meningococcal
Septicaemia in Adults
The Trust policy has been reviewed and implemented.

Trust Antibiotic Audit of Performance
Audit information is incorporated into Trust inductions. The online antibiotics policy
and the Mersey Micro app have been updated as per the review and a re-launch of
the antibiotic guideline has taken place.
Decompensated Chronic Liver Disease
Decompensated chronic liver disease care bundle has been launched. Training of
nurses to do ascitic tap and delivery of education/awareness of care bundle has
been completed.
Clexane in Lower Limb Plaster of Paris
ED pathway for lower limb plaster of paris has been implemented.
Re-Audit of DC Cardioversion for AF/ Flutter
The referral form has been updated and implemented in order to streamline the
referral process for Cardioversion.

Management of Ectopic Pregnancies
A discharge checklist has been created to ensure that the patient has appropriate
follow up in place. Continued counselling on the various management options is
offered.
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Induction of Labour 2014
The guideline has been updated. Alternative management for women who have
failed induction of labour following a 4th Prostin is being discussed.
Audit of Vulval Cancer: for existing Vulval Disorders
The Vulval Clinic is successfully managing vulval disorders in accordance with
guidelines.

Primary Total Hip Replacement-Transfusion Rates/Length of Stay
An orthopaedic pathway is underway. Tranexamic acid is now used routinely, as per
the guideline and at the discretion of the team performing the anaesthetic/surgery.

Audit reviewing the offer of HIV Testing: In an Integrated Sexual Health Service
Introduction of either oral swabs or dry blood spot testing to increase the uptake of
HIV has been implemented. Kits have been purchased and are currently used in
clinics for patients who are needle-phobic. Leaflets have been disseminated and
groups held for young people to better understand HIV and its transmission, in order
to raise awareness among young people to get HIV tested, as well as displaying
posters in clinic waiting rooms.
Audit of Compliance against the Clinical Audit Policy
Continuous monitoring of actions to be taken following audit is required, with
progress reported in the quarterly audit reports, which are provided to the Clinical
Effectiveness Council

Consent Audit Programme
Changes to the consent audit programme were undertaken during 2015-16 as a
result of new guidance and the Trust's revised Consent Policy, with 2 audits
undertaken by the individual specialties during the audit year. The initial audits have
been undertaken with a timelier re-audit to follow, to ensure that areas of poor
practice were highlighted and actioned quickly in order to maintain high standards
across the Trust. All results have been disseminated and discussed and some
individual specialities have delivered further training in this area.
Record Keeping Audit Programme
The Trust-wide record keeping programme continues to be undertaken annually.
Improvements have been demonstrated with a large number of record keeping
standards being consistently met in all specialties. The Trust record keeping policy
has been reviewed and amended and changes to the generic audit tool have been
made to streamline the content and to make the tool more user friendly, with
implementation planned from April 2016.
Identification & Management of Acute Kidney Injury (AKI)
Planned actions include continued encouragement in the use of AKI bundle, with
links to bundle tool available via the hospital intranet. Additional actions will be to
review the possibility of including AKI investigation & management fields on general
Acute Medical Unit (AMU) documentation. Further teaching is planned as earlier
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font identification and timely interventions for AKI significantly reduce the risk of
complications and morbidity/mortality.
HIV Testing in the Acute Medical Unit
Following the initial audit, posters showing HIV test indicator conditions were put up
around AMU. Raising awareness of indicators for HIV testing teaching sessions are
also planned for junior doctors.
Diagnosis & Stratification of patients with Myelodysplastic Syndromes (MDS)
Planned actions are for the inclusion of a ‘Diagnosis Summary Box' located at the
start of every clinic letter and to produce a specific MDS pro forma.
Audit of the Rheumatology Nurse Advice Line
All helplines have now been merged on to one number only and patients have been
informed of the changes.

MRSA suppression therapy audit
Planned actions include the implementation of a daily ward audit on MRSA
prescriptions. ‘Decolonisation therapy' education sessions are planned for 2016.
Sepsis in Pneumonia
Sepsis specialist nurses have now been recruited and are in post. The use of B U F
A L O scoring system in patients with pneumonia is encouraged.
Adequacy of Clinical Information on X-Ray Requests from the ED
A new pro forma is to be developed.
Annual Audit of Compliance with Good Clinical Practice Regulations and the
Research Governance Framework
Auditing of essential standing operating procedures has been added to the annual
audit plan for 2016-17.
Early Morning Medical Emergency Team Calls to High Volume Areas
Audit findings have been disseminated to senior nursing and medical forums.
Implementation of electronic track and trigger has been completed. Escalation
issues are highlighted for high volume areas and local systems have been put in
place to address this.
Supracondylar Fractures of the Humerus in Children
An upper nerve assessment sheet is in final revision before distribution.
Recommendation of 2.0 mm k wire is in use and due to be re-audited in 2016 to
assess compliance.
Outcomes of DIEP Breast Reconstruction in Patients More Than 60 Years Old
Trainees to be instructed to update the DIEP database regularly following each case.
Re-audit Patient Identification/Alert Wrist Bands
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font A daily wrist band check is undertaken on each patient in every applicable clinical area in the Trust as part of a daily continuously monitored audit. The quality of the current identification bands has also been reviewed. 2.3.3. Participation in clinical research
Clinical research is a vital part of the work of the NHS, helping improve treatments for patients now and in the future. Indeed, there is a strong link between research and improved patient outcomes. The Trust's Research Development and Innovation (RDI) Strategy resonates with the Board objectives, vision, values and goals and ensures that we have robust systems to facilitate high quality research. We are committed to ensuring that our patients are given the opportunity to participate in safe research. During 2015-2016 STHK was involved in 151 studies of which 132 were supported by the National Institute for Health Research (NIHR). We have supported 19 Non-NIHR studies. The number of patients receiving NHS services provided or sub-contracted by St Helens and Knowsley Teaching Hospitals NHS Trust in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was 535. The total recruitment (N767) was made up of:  535 patients recruited to NIHR adopted studies, all of which were approved by a research ethics committee.  232 participants recruited to non-NIHR adopted studies i.e. local and student. Of these, 57 were patients and 175 were staff members.
The Trust has successfully recruited 535 participants against the proposed NIHR
Clinical Research Network (CRN) target of 500, similar to previous years. During
2015-16, the Trust continued to improve the quality, speed and co-ordination of
clinical research by unifying systems, improving collaboration with industry and
streamlining administrative processes. We have consistently achieved 100 %
against the NIHR target of issuing RDI approval within 15 days.
The Trust has impressive research activity across a wide range of clinical
specialities. Since 1st April 2015 we have approved 31 NIHR studies in the following
areas:
Speciality
Number of Studies
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Gastroenterology Woman & Child Health 2.3.3.1. Performance in initiation and delivery of research
(PID data)
We report quarterly to the Department of Health on the following performance measures (for clinical trials only):  Non-commercial studies: meeting a 70-day benchmark to recruit the first patient following RDI permission.  Commercial studies: recruiting to time and target for closed studies. St Helens and Knowsley Teaching Hospitals NHS Trust met the 70-day benchmark in seven of the eleven trials submitted in the data collection period for quarter 2 in 2015-16 (looking at the preceding 12 months from 01/10/2014 to 30/09/2015). The reason why four studies did not reach the benchmark was due to the lack of eligible patients. Only one of the four commercial studies did not recruit to time and target and again the reason was valid. 2.3.3.2. Commercially sponsored studies
We continue to increase our participation in commercially sponsored studies, with 8 commercial studies active within the Trust (4 last year) in diabetes, dermatology, gastroenterology, cancer and, rheumatology and more are planned for other areas including Cardiology and Emergency Department. The following are examples of how St Helens and Knowsley Teaching Hospitals NHS Trust has continuously strived to improve the quality of services provided through research:  Cancer research at the Trust has made excellent progress in 2015-16. Cancer research plays an essential role, not only in developing new approaches to managing disease, but also in improving the effectiveness of existing treatments. At present there are 17 open studies actively recruiting across all Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font tumour groups. This year 139 patients diagnosed with cancer have participated in a cancer research study.  The stroke unit is taking part in an international nursing study looking at positioning after stroke, the HeadPoST study. This study aims to compare the different practices used in different countries in order to better identify which components of care may benefit individual patients.  In September 2015, diabetes patients in St Helens were invited to be among the first in the world to trial a drug aimed to relieve pains associated with the condition. The clinical trial is taking place at St Helens Hospital and aims to investigate the potential of an innovative drug for chronic pain conditions such as diabetic neuropathy, a complication of the condition. 2.3.3.3. Key achievements
 The Trust was the first site in the UK to reach the GRACE study recruitment target. This is a study treating patients with idiopathic overactive bladder with urine incontinence.  In the month of December 2015, St Helens Hospital was the highest recruiter to the British Society for Rheumatology Rheumatoid Arthritis Register study set up to monitor the safety of treatments for ankylosing spondylitis.  In January 2016, the Trust was the top recruiter to the provision of psychological support to people in intensive care study, which aims to improve patients' well-being after a stay in the intensive care unit.  Also in January 2016, our Research Team helped recruit the 1000th patient to the PRISM trial. This is a multi–centre study that investigates whether progesterone, a natural pregnancy hormone, could help to reduce the risk of miscarriage for women with bleeding in early pregnancy. These achievements have only been made possible by the continued support from the committed Consultants, who take the role of Chief and Principal Investigators, the research teams, support services and most importantly the patients who give up their time to take part in clinical trials. We are a partner organisation in the North West Coast (NWC) CRN. This partnership working helps the Trust to support national commitments to research. On the 29th February 2016 we hosted a roadshow run by the NWC CRN. This was a practical work based event focussing on sharing best practice and engagement with research colleagues. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font

XX publications (research and academic) have resulted from our involvement in both NIHR and Non-NIHR research, which shows our commitment to transparency and desire to improve patient outcomes and experience across the NHS. 2.3.3.4. Research aims for 2016-17
Our aims for 2016-17 are to continue to:  Work in partnership with the CRN to meet the NIHR high level objectives  Generate research funding by increasing the number of commercially sponsored studies in our portfolio  Ensure high quality delivery of studies, to time and on target  Maintain research governance and assurance for staff undertaking research  Develop a culture that adopts new evidence based interventions and learns from innovative good practice 2.3.4. Goals agreed with commissioners
A proportion of St Helens and Knowsley Teaching Hospitals NHS Trust's income in 2015-16 was conditional on achieving quality improvement and innovation goals agreed between St Helens and Knowsley Teaching Hospitals NHS Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2015-16 and for the following 12 month period are available electronically at [provide a web-link] 2.3.5. Statements from the Care Quality Commission (CQC)
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font The CQC is the independent regulator for health and adult social care services in England. The CQC monitors the quality of services the NHS provides and takes action where these fall short of the fundamental standards required. The CQC uses a wide range of regularly updated sources of external information, as well as its own observations during planned and unplanned inspections to assess the quality of care a Trust provides. If it has cause for concern, it may undertake special reviews/investigations and impose certain conditions. The Trust's Chief Inspector of Hospitals CQC planned inspection of St Helens and Knowsley Teaching Hospitals NHS Trust took place in the week commencing 17th August 2015. A large team of inspectors visited both Whiston and St Helens hospitals during that week to talk to patients, carers and staff about the quality and safety of the care we provide. They reviewed care records and observed care being delivered. The Trust was able to demonstrate to the inspection team the high standard of work that is undertaken on a daily basis to ensure patients receive excellent care. St Helens and Knowsley Teaching Hospitals NHS Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Care Quality Commission has not taken enforcement action against St Helens and Knowsley Teaching Hospitals NHS Trust during 2015-16. St Helens and Knowsley Teaching Hospitals NHS Trust has not participated in any special reviews or investigations by the CQC during the reporting period. St Helens and Knowsley Teaching Hospitals NHS Trust is subject to periodic reviews by the Care Quality Commission and the last review was in August/September 2015. The CQC's assessment of the St Helens and Knowsley Teaching Hospitals NHS Trust following that review was good. St Helens Hospital was rated as outstanding and the Trust was rated overall as outstanding for the care it provides to patients, with the Outpatients and Diagnostic service also rated as outstanding on both sites. The Trust's maternity services were rated as requires improvement for responsive, safe and well-led, with the emergency department also rated as requires improvement for the responsive domain. Action plans are in place to deliver the required improvements, with key actions noted in the section below. 2.3.5.1. CQC ratings table for St Helens and Knowsley
Teaching Hospitals NHS Trust January 2016
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font St Helens and Knowsley Teaching Hospitals NHS Trust intends to take the following action to address the points made in the CQC's assessment:  Continue to work with our health economy partners to improve access to urgent and emergency care  Continue to strengthen the processes to further reduce risks within maternity  Maintain robust systems for the storage of medications  Continue to ensure the appropriate skill mix of staff and that the privacy and dignity of patients in coronary care unit is maintained at all times St Helens and Knowsley Teaching Hospitals NHS Trust has made the following progress by 31st March 2016 in taking such action:  Comprehensive action plan agreed with health economy partners to drive improvements in access to urgent and emergency care, including increasing the capacity within intermediate care in the community and reviewing and developing community services  Reviewed and improved the systems for managing and responding to serious incidents within maternity services, ensuring effective processes for implementing lessons learnt  Regularly auditing the safe storage of medications  Firmly embedded processes for reviewing staffing levels across the Trust on a daily basis to ensure safe staffing in all areas, with monthly reporting to the Board  Installed permanent screen in coronary care unit to ensure the privacy and dignity of patients is maintained at all times 2.3.6. Information governance and toolkit attainment levels
Information Governance is the term used to describe the standards and processes for ensuring that organisations comply with the laws and regulations regarding handling and dealing with personal information. Within our organisation we have clear policies and processes to ensure that information, including patient information, is handled in a confidential and secure manner. The designated individual within the Trust who is responsible for ensuring confidentiality of personal information is the Caldicott Guardian. This position is currently held by the Assistant Medical Director, who is Caldicott trained, registered and accredited. The Trust also has a Senior Information Risk Owner (SIRO), who is responsible for reviewing and reporting on information, as well as providing assurance on the management of information risk to the Board. This role is held by the Director of Informatics, who is SIRO trained, registered and accredited. The Trust continues to benchmark itself against the Information Governance Toolkit (IGT). The toolkit is an online system which allows NHS organisations and partners to assess themselves against Department of Health information governance policies and standards. It also allows members of the public to view our commitment to information governance standards. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font St Helens and Knowsley Teaching Hospitals NHS Trust Information Governance Assessment Report overall score for 2015-16 was 80% and was graded ‘green'. This indicates that the Trust is compliant in all sections of the IGT and indicates that there are effective data systems, standards and processes across the Trust to protect information. 2.3.7. Clinical coding error rate
St Helens and Knowsley Teaching Hospitals NHS Trust was subject to the Payment and Tariff Assurance Framework Audit for gastro-intestinal (GI) and urology services during the reporting period and the error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were: 2014 data reported in April 2015
External PbR Audit 2.3.8. Data quality

The Trust continues to be committed to ensure accurate and up-to-date information
is available to communicate effectively with GPs and others involved in delivering
care to patients. Good quality information underpins effective delivery of patient care
and supports better decision-making, which is essential for delivering improvements.
The data quality framework is fully embedded within the organisation. Robust
governance arrangements are in place to ensure the effective management of this
process. Audit outcomes are monitored by the Information Steering Group and the
Management of Information and Technology Council to ensure that the Trust
continues to maintain performance in line with national standards. The data quality
framework is reviewed on an annual basis to ensure new requirements are reflected
in the audit plan. The standard national data quality items that are routinely
monitored are as follows:-
 Blank/invalid NHS Number
 Unknown or dummy practice codes  Blank or invalid registered GP practice  Patient postcode St Helens and Knowsley Teaching Hospitals NHS Trust will be taking the following actions to improve data quality:  Continuing to run regular reports by the Data Quality Team to monitor data quality throughout the Trust  Liaising with line managers and end users to address issues Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font  Identifying training needs  Providing data quality awareness sessions about the importance of good quality 2.3.9. NHS number and general medical practice code validity
St Helens and Knowsley Teaching Hospitals NHS Trust submitted records during 2015-16 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which:  Included the patient's valid NHS number was: o 99.3% - Admitted patient care o 99.4% - Outpatient care o 99.1% - Accident and Emergency care  Included the patient's valid General Medical Practice Code was: o 100% - Admitted patient care o 100% - Outpatient care o 99.9% - Accident and Emergency care (Source: SUS Data Quality Dashboard latest published report: April 2015 – November 2015) In all cases, the Trust performs better than the national average, with percentages greater than the national percentage, demonstrating the importance the Trust places on data quality. Benchmarking information
The Department of Health specifies that the Quality Account includes information on a core set of outcome indicators, which the NHS should be aiming to improve against. All trusts are required to report against these indicators using a standard format. The following data is made available to NHS trusts by the Health and Social Care Information Centre (HSCIC). The Trust has more up-to-date information for some measures, however, only data with specified national benchmarks from the central data sources can be reported. Therefore, some information included in this report must out of necessity be from the previous year or earlier and the timeframes are included in the report. It is not always possible to provide the national average and best and worst performers for some indicators due to the way the data is provided. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Benchmarking Information
Please note the information below is based on the latest nationally reported data with specified benchmarks from the central data
sources. Data highlighted in purple text provides local data on the Trust's most recent performance.
StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
Latest reporting period
The St Helens and Knowsley Teaching Hospitals NHS Trust Value of the summary hospital-level considers that this 1. mortality indicator ("SHMI") for the data is as described Trust for the reporting period for the following Banding of the summary hospital- 2. level mortality indicator ("SHMI") for the Trust for the reporting period Percentage of patient deaths with palliative care* coded at either diagnosis or specialty level for the 3. Trust for the reporting period  The mortality data is provided *This is a contextual indicator used to help interpret the above indicator, as Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
the SHMI methodology does not make any adjustments for patients recorded as receiving palliative care, because The St Helens and there is wide variation in how these are Knowsley Teaching coded between Trusts. Hospitals NHS Trust has taken the following actions to improve the indicator and percentage in (a) and (b), and so the quality of its services, by:  Monthly monitoring of available measures of mortality mortality and morbidity reviews in all directorates for inpatient deaths, with detailed, multi-disciplinary review of selected cases to ensure patients have received Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
appropriate care and lessons learnt are disseminated to further improve the care provided. The St Helens and Patient reported outcome measures Knowsley Teaching 4. (PROMs) scores for groin hernia (provisional) (provisional) (provisional) (provisional) Hospitals NHS Trust considers that the outcome scores are PROMs scores for varicose vein as described for the following reasons: Due to reasons of confidentiality, the Information Centre has suppressed (provisional) (provisional) (provisional) (provisional) figures for those areas highlighted with an '*' (an asterisk). This is because is a validated tool the underlying data has small numbers and administered (between 1 and 5) for the Trust by PROMs scores for hip replacement (provisional) (provisional) (provisional) (provisional) The St Helens and Knowsley Teaching PROMs scores for knee replacement Trust has taken the (provisional) (provisional) (provisional) (provisional) following actions to Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
outcome scores, and so the quality of its services, by:  Delivering a number of actions to improve patient experiences following hip replacement surgery, including increasing the numbers of patients attending joint school prior to surgery to increase awareness of what to expect  Monitoring the PROMs data at the Clinical Effectiveness Council Percentage of patients aged 0 to 15 The St Helens and 8. readmitted to a hospital which forms Knowsley Teaching part of the Trust within 28 days of Hospitals NHS Trust Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
being discharged from a hospital which considers that these forms part of the Trust. percentages are as described for the following reasons:  The data is consistent with Dr Foster's standardised ratios for re-admissions monitored monthly by the Percentage of patients aged 16+ readmitted to a hospital which forms part of the Trust within 28 days of The St Helens and being discharged from a hospital which forms part of the Trust. Teaching Hospitals NHS Trust has taken the following actions to improve these percentages, and so the quality of its services, by: improve discharge information as a patient Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
experience priority (see section 2.2)  Reviewing and improving discharge planning The St Helens and Knowsley Teaching Hospitals NHS Trust considers that this data is as described for the following reasons: Trust's responsiveness to the personal vision and drive needs of its patients during the reporting period (CQC national inpatient survey score). care ensures that patients are at the centre of all the Trust does  The Trust was rated outstanding overall for caring by the Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
CQC following their inspection in 2015  The survey is conducted by an independent and approved survey provider (Quality Health), with scores taken from the CQC website The St Helens and Knowsley Teaching Hospitals NHS Trust has taken the following actions to improve this data, and so the quality of its services, by:  Promoting a culture of patient-centred care  Responding to patient feedback through patient forums, national and local Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
surveys, friends and family test results, complaints and Patient Advice and Liaison Service (PALS)  Working closely with Healthwatch colleagues to address priorities identified by patients, including improving discharge planning The St Helens and Knowsley Teaching Hospitals NHS Trust considers that this Percentage of staff employed by, or percentage is as under contract to, the Trust during the described for the 11. reporting period who would following reasons; recommend the Trust as a provider of  The Trust provides care to their family or friends. a positive working environment for staff with a proactive Health, Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
Work and Well-being Service provided by an independent provider, Quality Health. The St Helens and Knowsley Teaching Hospitals NHS Trust has taken the following actions to improve this percentage, and so the quality of its services, by: positive culture with clear visible leadership, clarity of vision and actively promoting behavioural standards for all staff  Engagement of staff at all levels Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
in the development of the vision and values of the Trust  Honest and open culture, with staff supported to raise concerns via Speak Out Safely champions The St Helens and Knowsley Teaching Hospitals NHS Trust considers that this data is as described for the following reasons: % experiencing harassment, bullying  The survey is or abuse from staff in last 12 months conducted by an independent provider  The Trust actively promotes an open and supportive culture The St Helens and Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
Knowsley Teaching Hospitals NHS Trust has taken the following actions to improve this percentage, and so the quality of its services, by: Speak up Safely guardians and champions to support staff in raising concerns  Letters sent to all staff regarding Raising Concerns and Speak up Safely  Utilise the Valuing Our People Steering Group to identify the location of spikes in incidents and take appropriate action Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
St Helens HealthWatch regarding raising concerns  Two large staff engagement events for staff, spanning all roles and professionals, to bring different perspectives to the following workshops ‘Realising the Trust values' and ‘Speak out Safely.' The St Helens and Knowsley Teaching Hospitals NHS Trust considers that this % believing the organisation provides 13. equal opportunities for career described for the progression / promotion following reasons:  The survey is conducted by an independent provider Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
 The Trust actively promotes equality within the workplace and reports this annually to the Board The St Helens and Knowsley Teaching Hospitals NHS Trust has taken the following actions to improve this percentage, and so the quality of its services, by:  Developed an action plan with the Equality, Diversity & Inclusion Steering Group which includes obtaining the Navajo charter mark, completing EDS2 objectives including a representative workforce at all Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
 Published the baseline workforce race equality scheme report for 2015 together with an action plan that includes the indicator ‘Relative likelihood of black and minority ethnic staff accessing non- mandatory training and continuing professional development as compared to white staff.' The St Helens and Knowsley Teaching Hospitals NHS Trust Percentage of patients who would considers that this 14. recommend the Trust as a provider of percentage is as care to their family or friends. described for the following reasons:  The Trust's Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
vision and drive to provide 5-star patient care ensures that patients are at the centre of all the Trust does  The Trust was rated outstanding overall for caring by the CQC following their inspection in 2015  The survey is conducted by an independent provider The St Helens and Knowsley Teaching Hospitals NHS Trust has taken the following actions to improve this percentage, and so the quality of its Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
provide the highest quality of care, through the 5-star patient care vision and the Trust values lessons learnt and implementing actions to ensure improvements to care to ensure that patients have a positive experience The St Helens and Teaching Hospitals Percentage of patients who were considers that this admitted to hospital and who were risk percentage is as assessed for venous described for the thromboembolism (VTE) following reasons: Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
target of 95% of patients having a VTE risk assessment within 24 hours of admission to ensure that they receive the most appropriate treatment analysis (RCA) undertaken on VTEs recorded on Datix to ensure best practice is followed risk assessments are submitted to NHS England each month The St Helens and Knowsley Teaching Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
Hospitals NHS Trust is taking the following actions to improve this percentage, and so the quality of its services, by:  Maintaining focus on, and closely monitoring, the rate of risk assessments undertaken each month audits on the administration of appropriate medications to prevent blood clots RCA investigations on all patients who develop a hospital acquired venous Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
thrombosis to ensure that best practice has been followed learning from these reviews  Providing on- going training for clinical staff. The St Helens and Knowsley Teaching Hospitals NHS Trust considers that this rate is as described for the following reasons: Rate per 100,000 bed days of cases of Clostridium difficile (C. difficile) infection reported within the Trust a priority for the amongst patients aged 2 or over  All new cases of C. difficile infection are identified by the laboratory and reported to the Infection Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
Prevention and Control Team, who co-ordinate mandatory reporting to Health Protection England  The Trust is maintaining compliance with the national guidance on testing stool specimens in patients with diarrhoea  All cases are thoroughly investigated using RCA, which is reported back to a multidisciplinary panel chaired by an Executive Director to ensure Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
appropriate care was provided and lessons learnt are disseminated across the Trust. The St Helens and Knowsley Teaching Hospitals NHS Trust has taken the following actions to improve this rate, and so the quality of its services, by:  Ensuring that all staff are compliant with mandatory training for infection prevention and control promoting the use of hand washing and hand gels to those visiting Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font StHK data for
National
Performer
Performer
Indicator
Trust Statement
previous reporting
proactive and responsive infection prevention service to increase levels of compliance comprehensive guidance is in place on antibiotic prescribing Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Rate of patient safety incidents reported within the Trust per 1000 bed *High reporters should be shown as Based on acute (non-specialist) trusts described for the with complete data. Oct 14 – Mar 15 The data on HSCIC website for this indicator is 7 months old; our local data for this indicator for performance up to (number of incidents 31/03/16 is 4427 incidents for the period of April 15 - September 15. This equates to 38.10 incidents per 1,000 bed days. We believe the local data is a more meaningful measure of performance because incident management and investigation is a fluid process and subject to change. In addition data not yet published by the NRLS indicates our  The data has performance to be 4458 for the period of October 15 – March 16, this equates to 34.52 incidents per 1,000 bed days. Rate of patient safety incidents reported within the Trust resulting in Oct 14 – Mar 15 severe harm or death per 1000 bed (number of incidents *High reporters should be shown as Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font The data on HSCIC website for this indicator is 7 months old; our local data for this indicator for performance up to 31/03/16 is 20 incidents for the period of April 15 - September 15. This equates to 0.17 incidents per 1,000 bed days. We The St Helens and believe the local data is a more meaningful measure of performance Knowsley Teaching because incident management and Hospitals NHS Trust investigation is a fluid process and subject to change. In addition data not yet following actions to published by the NRLS indicates our improve this number performance to be 16 for the period of and rate, and so the October 15 – March 16, this equates to 0.12 incidents per 1,000 bed days.  Committing to Oct 14 – Mar 15 investigations of Percentage of patient safety incidents that resulted in severe harm or death (29 severe harm or death/4213 total) Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font  Providing staff  Monitoring key indicators at the  Continuing to reporting culture Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Performance against national targets and regulatory
The Trust aims to meet all national targets and priorities and our performance against the key indicators for 2015-16 is shown in the table below: Performance
Indicator
Performance
Performance
Cancelled operations (% of patients treated following cancellation) Referral to treatment targets (% within 18 percentile targets) - Admitted Referral to treatment targets (% within 18 percentile targets) - Non-admitted Referral to treatment targets (% within 18 percentile targets) – Incomplete pathways Cancer: 31-day wait from diagnosis to first treatment Cancer: 31-day wait for second or subsequent treatment: - anti-cancer drug Cancer: 62-day wait for first treatment: - from urgent GP - from consultant 100.0% Apr-15 to Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Performance
Indicator
Performance
Performance
screening referral Cancer: 2 week wait from referral to date - urgent GP suspected cancer referrals - symptomatic breast Emergency Department waiting times within 4 hours - Type 1 only Percentage of patients admitted with stroke spending at least 90% of their stay on a stroke unit To date 30 hospital acquired cases though subject to appeal 39 positive samples 9 cases successfully appealed, April-15 to Clostridium Difficile 2 cases awaiting March-16 Liverpool CCG review 4 cases awaiting DN: Update when final figure known following appeals Methicillin-resistant staphylococcus aureus Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 3. Section 3 – Quality of care provided

This section of the Quality Account reviews the Trust's performance for quality and
quality improvement indicators not covered in the report so far. It includes an update
on progress in delivering the Trust's own strategies and in meeting the targets
identified in last year's Quality Account.
3.1. Summary of how we did in achieving our strategies
3.1.1. Clinical and Quality Strategy 2014-18
The Trust's vision to provide 5-star patient care encapsulates the Trust's approach to quality in striving to achieve the best possible care for patients. The Clinical & Quality Strategy 2014-18 presents the clinical and quality priorities that will support the achievement of the vision, set within the context of the strategic priorities for the wider NHS and our local health and social care community. It reiterates the Trust's commitment to provide the best quality of care. The latest review of progress in delivering the Strategy was undertaken in January 2016 and reported to the Board. It indicated that the Trust was achieving many of the key performance indicators set out in the Strategy and was making good progress in the majority of areas, with action plans in place to address under-performing areas. Progress in delivering a number of the priorities is provided throughout the Quality Account, including sections 2.3.10 and 2.3.11. The Trust is currently re-writing the strategy in light of the changing external context and following agreement of this year's Trust objectives. 3.1.2. Nursing and Midwifery Strategy 2014-18

The five year strategy outlines an ambitious plan for developing and sustaining a
flexible, well-educated, confident, competent, caring and compassionate nursing and
midwifery workforce to enable the Trust to deliver its corporate objectives. It is
structured around the Chief Nursing Officer's six enduring values and behaviours
that underpin compassion in practice, the six Cs. These are care, compassion,
communication, competence, courage and commitment.
The following outlines the key achievements in 2015-16:
Care
 Rated as outstanding by the CQC inspection in the caring domain
 Continued progress in the reduction of avoidable harm in line with the Trust's sign up to safety pledge, including achievement of the target for MRSA bacteraemia and Clostridium difficile  Introduction of standard operating procedure for reviewing daily staffing levels in clinical areas, with average ward staffing levels demonstrating fill rates for registered and unregistered staff higher than the target of 90% against expected staff Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font  Updated the Safeguarding Adults and Children Training Needs Analysis and training competencies in line with updated national guidance  Implemented Malnutrition Universal Screening Tool (MUST) risk assessment across the trust
Compassion
 Provision of good dementia care through improving the environment, engaging
and training volunteers to be dining assistants and compliance with national standards. The Trust is supporting John's Campaign, which calls for families and carer's of people with dementia to have the same rights as the parents of sick children and to be allowed to remain with them in hospital for as many hours as they are needed and as they are able to give.  Enhanced end of life care provided for patients by appointing a Consultant in Palliative Medicine, provision of comprehensive education programme, provision of ward information boards for end of life carer and rolling out the individualised care and communication record for the care of the patient in the last hours/days
Courage
 Embedded the use of the HALT tool across the Trust. The tool is a hierarchy
flattening tool that supports colleagues to challenge each other to ensure safe practice.  Implementation of a quality accreditation tool for all general wards, with wards receiving a bronze, silver or gold award based on the results of a comprehensive assessment of the quality of care and leadership provided. Action plans are produced for each element that requires improvement. Ward 4D, our burns ward was the first ward to receive the gold award.  Ward performance indicators displayed on each ward, providing an overview of the quality of the care provided.
Commitment
 Implementation of Care Certificate for health care assistants
 Health care assistant development programme and competency framework in  Practice Education Facilitators continue to meet the quality standards for practice placements for students  Local and international recruitment drive leading to the appointment of a significant number of nursing staff
Competence
 Reviewed and extended the preceptorship programme for newly qualified nurses
to offer a 12 month preceptorship programme that incorporate the band 5 competency framework  Developed a new programme that offers 3rd year student nurses the opportunity to gain competence in clinical skills during their training that they can use once qualified and employed by the Trust to improve the quality of patient care  On-going support for qualified nurses and midwives to complete post-registration education modules at degree and masters level as part of the continuous Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font professional development (CPD)-apply process to develop the competencies of staff and improve the quality of patient care.  Implementation of a nursing and midwifery staff revalidation programme to ensure all relevant staff were supported to complete the revalidation requirements introduced by the Nursing and Midwifery Council for registered nurses and midwives  Leadership development programme commenced for the ward managers, lead nurses and matrons, with four cohorts due to complete in May 2016 and further cohorts commencing in April  Care certificate programme in place for health care assistants Communication
 Improvements made to the timeliness of complaints' responses
 Implemented a revised process for general nursing documentation, following consultation with staff  Developed a combined risk assessment e-form that incorporates delirium, falls, tissue viability, moving and handling and malnutrition ‘MUST' assessments that will form part of the patient track package and lead to improved care for patients 3.1.3. Communications and Engagement Strategy 2013-16
The strategy sets out the overall framework for how the Trust intends to communicate and engage with all of its stakeholders and audiences in a number of ways. It reiterates the Trust's commitment to improving engagement and the importance of clear, honest, timely and relevant communications, delivered in a way everyone understands. Good communication is essential for the effective functioning of the organisation and to maintain a good reputation for delivering good quality care. Key achievements in improving communications during 2015-16 include:  Active promotion of the Trust's vision for 5-star patient care  Launch of the Trust's new website, which was tested prior to its launch by a specially chosen patient group with varied experience of web use from first time users to experienced users. The website is increasingly used by patients and the public to find information about the Trust, including the range of services provided and how well the Trust is performing.  Continued use of social media, with a rise in the number of people accessing information through the Trust's Facebook, Twitter and YouTube accounts.  New, standardised ward entrance and department noticeboard information, with all patient facing communication materials on display reviewed and updated  Work on the new intranet site for staff The current Communications and Engagement Strategy comes to an end in 2016 and the Trust is working on an updated Strategy, scheduled for approval in April. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 3.2. Equality, Diversity and Inclusion Strategy
The Trust's Equality, Diversity and Inclusion Strategy outlines the Trust's commitment to promoting equality in all its functions and to valuing the diversity of staff and service users. The principles of equality, diversity and human rights are intrinsic to the Trust's core business. We are committed to delivering high quality services that are accessible, responsive and appropriate to meet the needs of all our patients. In this respect, patient pathways have been designed to reduce variations in care and improve outcomes, whilst recognising the needs of individual patients. In addition, we aim to be an employer of choice and ensure that all our staff have equality of access to jobs, to promotion and to training opportunities. The Trust is committed to creating an environment where everyone is treated with dignity, fairness and respect and to developing a culture of support and inclusion for all our employees and for those patients who access our services. The Trust has continued to utilise the Equality Delivery System (EDS) to measure its equality progress. The EDS is a toolkit, designed to support NHS organisations to deliver better outcomes for patients and a better working environment for staff. The Trust has published the EDS2 Summary Report which details its progress against all eighteen of the equality outcomes. The Trust met the agreed targets for 2015-16 in respect of the refreshed Equality Delivery System (EDS2) by reaching a level of ‘achieving' across five outcomes independently assessed by its Healthwatch partners. This provided a solid foundation for the period. The agreed targets are shown in the table below: When people use NHS services their safety is prioritised and they are free from mistakes, mistreatment and abuse People, carers and communities can readily access hospital, community health or primary care services and should not be denied access on unreasonable grounds People report positive experiences of the NHS Fair NHS recruitment and selection processes lead to a more representative workforce at all levels Flexible working options are available to all staff consistent with the needs of the service and the way people lead their lives. The Trust's Equality and Diversity Steering Group continues to meet quarterly, ensuring that the Trust complies with externally set standards and establishes, monitors and reviews content and methods of providing assurance to the Patient Experience Council and the Workforce Council in relation to all areas of equality and diversity. The Steering Group is composed of a range of staff from all disciplines: clinical, non-clinical, staff-side, Healthwatch representatives and independent service users. Work is in progress to develop the Group's function in providing an effective challenge to the Trust where necessary and appropriate. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font The Workforce Council, for example, has supported an initiative emanating from the
Steering Group to work towards achieving the locally-based Navajo Charter Mark in
respect of good practice in working with its lesbian, gay, bisexual and transgender
(LGBT) population, both staff and patients. A task and finish group has been set up
and is developing a work programme around this particular protected characteristic,
which, whilst focused on the achievement of the standard, is developing robust and
sustainable processes supporting inclusivity and accessibility for all patients.
The following initiatives are examples of the Trust's determination to achieve
this:
 The Trust's successful bid for funding from Health Education North West to
establish, implement and publicise an integrated pathway that enables access for a highly significant and often excluded group to acute services (such as imaging, endoscopy, orthodontics etc.) led to the production of a toolkit with guidance and learning materials which were successfully showcased in November 2015 at a regional event.  Work to distribute this across the primary and social care networks is in place and is expected to lead to the wider usage of accessible pathways for all patients with protected characteristics  Establishment of a Steering Group and Task and Finish Group, inclusive of local Healthwatch and voluntary sector representatives to implement the Accessible Information Standard, to ensure that the information and communication needs of disabled patients, service users and carers are met  Representation and contribution to the local learning disability agenda through both St Helens and Knowsley ‘Healthcare for All' sub-group  St Helens locality achieved a joint second place in the country for its submission to the Learning Disability Self-Assessment Process to which the Trust made significant submissions, thus achieving good assurance in those areas associated with the accessibility of people with a learning disability to acute care services  The Trust has made significant contributions to the local St Helens and Knowsley Crisis Care Concordat Action Plan which is available on the concordat website  As part of its work internally, the Trust has produced its first Annual Report for Patients with Mental Health Needs (2014-15) published in November 2015 detailing the services available and setting actions for the following year  As part of its contribution to achieving ‘parity of esteem' the Trust has a Mental Health Training Sub-Group which is tasked with developing knowledge and awareness of training materials and resources to support Trust staff to meet the needs of patients with mental health needs in accessible and workplace friendly formats, such as handover and ward meetings rather than large classroom based events  The Trust's use of interpreters in the periods 2013-14 and 2014-15 has increased by 83% for foreign language interpretation and 55% for British Sign Language interpretation reflecting a much greater awareness of need and the importance of obtaining interpreters to meet patient need and obtain improved health outcomes Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font  Merseyside Police have a monthly drop-in session within the main reception on the Whiston site to support initiatives on hate crime which have been very successful and have been extended as a result  The Trust hosts a fully commissioned Carers' Support Service which operates within the Integrated Discharge Team supporting carers across all localities. The Trust is represented on and is a contributor to the St Helens Young Carers Board and is working with individual young carers to understand their needs and to improve responses to the needs of young carers once identified within the Trust  Well-established Dignity Champions Network in place, which meets bi-monthly with efforts being made in the coming year to expand this to include care home providers in the community building on our common purpose to support this vulnerable population  The Trust has been allocated the resources and physical space to establish a ‘Changing Places Facility' to ensure that any adult with changing needs who is a visitor to the Trust can manage their care in a dignified and appropriate manner. Equal opportunities for those with disabilities are essential. The Trust is an equal opportunity employer and has control measures in place to ensure that all of the organisation's obligations under equality, diversity and human rights legislation are complied with. All of the above initiatives are reliant on developing and maintaining good working relationships across all sectors of the social and healthcare economy. This is a major part of the Trust's work in this area and is supported through the various multidisciplinary steering groups in place. 3.3. Human Resources and Workforce Strategy 2014-19
The Trust recognises that its staff are central to the provision of excellent services to our patients, their loved ones, commissioners and our local communities. Our five year HR and Workforce Strategy sets out our plans to develop a management culture and style that empowers, builds teams and recognises and nurtures talent through learning and development. We will be open and honest with staff, provide support throughout organisational change and invest in health and well-being. We will promote standards of behaviour that encourage a culture of caring, kindness and mutual respect. The delivery of the strategy will enable our staff to continue to provide 5-star patient care throughout the Trust. There are a number of supporting strategies to help achieve this: • Health, Work & Well-Being Strategy 2016-21 Recruitment & Retention Strategy 2015-20 Equality, Diversity & Inclusion Strategy 2016-17 Learning & Development Strategy 2016-21 The Trust is committed to providing employment opportunities for local people. In September 2015 we worked in collaboration with the Skills Academy for Health, St Helens College and Job Centre Plus to offer structured work placements to long term unemployed people from the local community in an effort to provide them with the skills to gain employment. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font This work supported eight individuals back into the workplace in both administration and health care assistant roles. Seven of these went on to secure on-going employment, four in permanent posts at the Trust, another at a local Trust and a care home with the rest joining our bank. This was a great success and one that we are looking to repeat this year with up to 24 long term unemployed people. 3.3.1. Staff survey key questions
The Trust takes the national staff survey extremely seriously and uses the findings to both reinforce good practice and to identify areas for improvement. The Trust's response rate for the 2015 survey was 55%, which is 3% higher than last year and is amongst the highest response rates for acute trusts nationally. The Trust has once again performed extremely well and scored in the top 20% of all acute trusts nationally for 22 of the 32 indicators, including:  Staff recommending the organisation as a place to work and receive treatment  Staff satisfaction with the quality of work and patient care they are able to deliver  Staff looking forward to going to work and enthusiasm for their jobs In addition, staff stated that care of patients is the organisation's top priority, with the percentage of staff confirming this in the top 20% of acute trusts nationally and improving from 79% last year to 83% this year. These measures can be used as further indicators that the care provided to patients is of a high quality. The chart below shows how the Trust compares with other acute trusts on an overall indicator of staff engagement. Possible scores range from 1 to 5, with 1 indicating poorly engaged staff (with their work, their team and their trust) and 5 indicating a highly engaged workforce. The Trust's score of 3.92 was in the highest (best) 20% when compared with trusts of a similar type nationally and has improved since last year. National 2015 average for Acute The table below highlights the scores for some of the areas where Trust was among the highest nationally: Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Care of patients is the organisation's top priority Organisation acts on patient concerns Staff would recommend organisation as a place to work If a relative needed treatment they would be happy with standard of care Staff satisfaction with the quality of work and patient care they are able to deliver Whilst the overwhelming majority of responses to the 2015 survey were positive, the following list highlights the areas where staff experience was not as positive as we would want:  Whilst the overall result for the Trust is better than the national average for staff stating they had experienced discrimination at work in the last 12 months, a number of respondents from black and ethnic minority groups reported that they had experienced some form of discrimination. The Trust does not tolerate discrimination in any form and additional work is being undertaken to understand what led to this outcome and where it occurred to identify the actions that need be taken to prevent a reoccurrence  The percentage of staff reporting good communication between senior management and staff has seen a marginal improvement since the 2014 survey and does place the Trust in the best 20% of acute trust nationally. However the results indicate that the majority of respondents feel that communication is not as effective as they would wish.  Whilst the number of respondents experiencing physical violence from patients, relatives, the public and staff is very low this still continues to be a concern as it is greater than the national average for similar trusts  68% of staff stated they were able to contribute towards improvements at work which is slightly below the national average In order to address these concerns the Trust is reviewing the detail of the responses to get a better understanding of which service areas are affected. This detailed analysis will enable the Trust to deliver appropriate corrective actions during 2016-17. 3.3.2. Health, work and well-being
The Boorman review (2009) stated that NHS organisations which prioritise staff health and well-being achieve enhanced performance and improve patient care. In recognition of the benefits of a healthy workforce, the Trust has a proactive Health, Work and Well-Being (HWWB) Service in place. The Trust scored in the top 20% of acute hospitals nationally in the latest staff survey for interest in and actions on Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font health and well-being, demonstrating our commitment to staff welfare. The Service has worked alongside Human Resources and managers during the year to try to reduce sickness absence, including helping staff to remain healthy and supporting staff to return to work following absence. Stress continues to be the main cause of absence and over the last twelve months there have been workshops developed by the Service to signpost staff to relevant support so that they can be proactive in managing their stress issues. These have included ‘You and Your Well-Being' and the ‘Letting Off Steam Initiative' where staff could drop in and see a Counsellor without an appointment. The HWWB Service has worked in partnership with the Health and Safety Team, performing a trend analysis to see where the highest number of incidents have occurred and then arranged roadshows to advise staff, for example, on the reduction of slips, trips and falls. The Service has also put on roadshows for general health promotion which encompass National Institute for Health and Care Excellence (NICE) Guidance. The Flu Campaign for 2015-16 was launched at the HWWB annual open day in September. The Trust's vaccination uptake for frontline staff was 78.6%, an overachievement of the target of 75%. The HWWB Service successfully completed its annual self-assessment for Safe Effective Quality Occupational Health Services and was once again successful in reaching all of the required standards. New systems have been put in place to work towards a paper-lite work area to deliver a more effective and efficient service. The new starter health assessment is now paperless and further developments will include the roll out of IT systems so that all management referrals and responses will be electronic and, therefore, more timely. 3.3.3. Education and training
The Clinical Education team have successfully implemented a number of new initiatives during the year including:  Introduction of the Care Certificate, which defines a set of minimum standards that all social care and health support workers maintain in their daily working life. It defines the new minimum standards that should be covered for all new care support workers and forms part of redesigned induction training for our Healthcare Assistants.  Increased the use of simulation and technology enhanced learning to support clinical competence and patient safety. In-situ simulation, already implemented across a number of areas, has been expanded with the introduction of paediatric simulation in the emergency department. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font The Trust's non-clinical development priorities are delivered by the Leadership &
Organisational Development (L&OD) team, who provide a diverse range of
programmes that support knowledge, skills and competency development,
behavioural awareness and change for individuals and teams, across all staff
groups. This supports our staff to deliver 5-star patient care. Over the past 12
months examples of the work the L&OD team have introduced and delivered are:
 Apprenticeships: over 100 staff are progressing through an apprenticeship in a
range of level 2/3 qualifications, including Health - Maternity & Paediatric Support, Health - Clinical Healthcare Support, Team Leading, Team Management and Business Administration.  Coaching Skills: a range of workshops developed and rolled out to provide
coaching skills for managers/leaders, from Supervisors, team leaders and managers up to Board members. The objectives of these workshops are to develop communication skills and support the use of coaching style conversations with team members and colleagues, with the wider aim of embedding a coaching culture within the Trust.  Little Big Conversations: L&OD have developed and implemented these staff
engagement and consultation events; the first being two half-day events held during 2015 that covered the subjects of ‘Speak out Safely' and ‘Realising the Trust Values'. A cross-section of around 40 Trust staff attended each event.  Ward Manager and Matrons Leadership Development: initiated in 2015 this is
a nine month programme that was developed in-house by L&OD; for Trust band 7 & 8 nursing leaders (80+ staff) across four cohorts. The programme is designed to support nursing staff in their roles as leaders of teams/departments; to reflect and build on their strengths, their role and abilities, to learn new skills and to learn more about themselves and how they can pro-actively take this learning back to the work-place to have even greater influence on care. They gain skills that will drive and sustain change, building a culture of patient-focused care at a departmental or functional level. They also gain greater business acumen and develop enhanced people management skills. The programme supports the Nursing and Midwifery Council's revalidation requirements including reflection and professional development discussions. 3.4. Patient safety
St Helens and Knowsley Teaching Hospitals NHS Trust was recognised for exceptional surgical safety and was selected as a finalist in the National Patient Safety Awards, in the category of Education and Training in Patient Safety. The successful project demonstrated the impact of a team-wide approach in Human Factors training. All members of the Trust's theatre teams were trained in Human Factors and the use of newly designed safe systems. The new systems were designed to enhance the overall safety of surgical procedures, whilst supporting the working needs of the clinical teams providing high quality patient care. Human Factors is the study of the interface between humans, equipment, the environment and each other. The project was measured over a three year period and demonstrated outstanding reductions in episodes of patient harm. Low harm was Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font reduced by 58%, moderate harm by 70% and zero episodes of severe harm were recorded following the implementation of the project. This continuous work stream is just one of multiple projects currently enhancing the safety of each and every patient who enters the Trust and is a significant part of ensuring that the organisation provides 5-star patient care. 3.4.1. Patient safety improvement plan: sign up to safety
campaign

The Trust's patient safety improvement plan includes our commitment to the 2015
Sign up to Safety plan which puts safety first by committing to reducing avoidable
harm by half and to publishing our goals and plans that have been developed locally.
Our commitment is to:
 Reduce avoidable harm by 50% over three years (2015-18) - avoidable harm is
harm that can be prevented  Maintain a 50% reduction in theatre-related episodes of avoidable harm. Data for 2015-16 shows a 52% reduction in episodes of patient harm, measured against the project benchmark date from 2012-13.  Reduce the incidence of Clostridium difficile and avoidable MRSA infections. There were no incidents of MRSA bacteraemia in 2015-16 and the incidence of Clostridium difficile was reduced from the previous year.  Reduce prescribing error rates through the implementation of an error response and re-education system.  Implement an Electronic Modified Early Warning Score (eMEWS) System to increase the efficiencies in the identification of the deteriorating patient, ensuring appropriate escalation and timely intervention. This was implemented in 2015-16 and its effectiveness will be implemented in 2016-17.  Reduce to zero the number of never events reported in the organisation. There have been no never events since May 2013.  The Trust will have zero tolerance on hospital acquired grade 4 pressure ulcers and will continue to seek to reduce harm from pressure ulcers at all grades by 50%. There has been a 15% overall reduction in all grades of pressure ulcers this year, with a 50% reduction of grade 3 and no grade 4s.  Continue to seek a reduction in harm from inpatient falls. There has been an overall 4% reduction in falls resulting in harm during 2015-16. However, following the implementation of the new falls prevention strategy and action plan in September there has been a significant improvement in the prevention of falls in the second half of the year. The actions have included fitting additional handrails on Older People's wards, use of non-slip anti-embolism stockings, refocus on staff training, increased surveillance and audit, investment in falls alarms and staff engagement via an open day.  Introduce patient safety briefings to increase staff awareness of risk. Pilot studies have commenced to test the use of the patient safety briefing tool. 3.4.2. Duty of candour
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font The duty of candour is a legal duty on hospital, community and mental health trusts to inform and apologise to patients if there have been mistakes in their care that have, or could have, led to significant harm (categorised as moderate harm or greater in severity). The Trust promotes a culture of openness, honesty and transparency and our statutory duty of candour is delivered under the Being Open - A Duty to be Candid Policy, which sets out our commitment to being open when communicating with patients, their relatives and carers about any failure in care or treatment. This includes an apology and a full explanation of what happened with all the available facts. The Trust operates an open learning culture, within which all staff feel confident to raise concerns when risks are identified and then contribute fully to the investigation process in the knowledge that learning from harm and the prevention of future harm are the organisation's key priorities. The Trust's incident reporting systems have been upgraded to record the information provided to the patient, family or carers to ensure that the Trust's ambition to be 100% compliant with this national statute is both measurable and delivered consistently in line with the Trust's policy. Every patient who suffers or is suspected of suffering an incident of harm categorised as moderate harm or above will receive an apology in person, followed by a letter of apology within 10 working days of the date that the incident was identified. The letter explains the investigation process and provides assurance that the organisation will learn lessons and implement change to ensure that the risk of any further episodes of avoidable patient harm is reduced. 3.4.3. Infection prevention and control
The Trust's infection prevention and control priorities are to:  Reduce the incidence of Clostridium difficile infections by working collaboratively across the whole health economy  Identify, monitor and prevent the spread of multi-resistant organisms throughout The Trust had a Trust Development Authority (TDA) peer review infection control visit in June 2015. The TDA team consisted of infection control specialists, quality leads, chief nurses and GP representatives from the local Clinical Commissioning Groups and community and acute hospitals in the North West. The team visited various clinical areas at the St Helens and Whiston hospital sites and interviewed staff, including consultants, junior doctors, matrons, nurses, housekeepers and domestics regarding infection control practice. The feedback from the visit noted that the team was impressed with the engagement and ownership of staff at all levels on infection control issues and were assured that infection control is embedded within the Trust. The team highlighted the high Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font standard of cleanliness in the hospitals, the bright and airy nature of the buildings and the ratio of individual side rooms to four-bedded bays within the hospital. The areas for improvement highlighted have been addressed, including improving aseptic non-touch technique (ANTT) facilities in the Emergency Department and usage of personal protective equipment (PPE) by domestic staff. Overall the experience was extremely valuable for both the Trust and members of the TDA team. 3.4.4. Safety Thermometer
The NHS Safety Thermometer is a national improvement tool for measuring, monitoring and analysing patient harms and ‘harm free' care during hospital stays. This measures four key harms: pressure ulcers, falls, catheter acquired urinary tract infection and venous thromboembolism (VTE) (blood clots). The Trust has continued to achieve over 98% new harm free care, that is harm that has occurred whilst an inpatient. Data for all inpatients is collected on one day every month. This identifies harms that patients are admitted with from home and harms which occurred whilst in hospital. The results from this audit are validated by specialist nursing staff. Once validated, the information is then submitted to the NHS Information Centre. The Trust has consistently achieved new harm free care above 98% and is one of the best performing trusts in the region. Overall, the Trust has made significant progress in embedding good practice in relation to the prevention of pressure ulcers, falls with harm and VTE. This was achieved by:  Ensuring education and training is available for all ward staff to enable them to complete and submit the NHS safety thermometer as required  Establishing tissue viability link nurses within the ward areas  Identifying trends and themes from the five most recent root cause analysis investigations of falls that resulted in harm  Evaluating the performance of the implementation of the action plans and their  Formation of a monthly panel to review the Trust's moderate harmful falls with input from ward staff  Formation of the strategic falls group to meet monthly to oversee the implementation of the revised falls strategy and performance manage the associated action plans  Ensuring, when possible, a one-to-one staffing ratio is implemented when indicated by the risk assessment for falls  All patients over the age of 65 having a lying and standing blood pressure performed as soon as practicable Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font  Replacing all anti-embolic stockings with non-slip versions  Continuing to provide education for all clinical staff on VTE, resulting in increased compliance with the prescribing and administration of anticoagulants to prevent these occurring 3.5. Clinical effectiveness
The Clinical Effectiveness Council meets monthly and monitors key outcome and effectiveness indicators, such as mortality, nationally bench-marked cardiac arrest data, critical care performance, hip fracture performance, readmissions, Advancing Quality, clinical audit and application of NICE guidance. Several areas reviewed by the Council are outlined in the sections below. 3.5.1. Mortality
The Trust benchmarks strongly in the North West for crude mortality and against the government's preferred measure, the Standardised Hospital Mortality Index (SHMI), where St Helens and Knowsley Teaching Hospitals NHS Trust is amongst the best in the North West as shown in the table below: The Clinical Effectiveness Council examines mortality not only for the Trust as a whole, but also for a wide range of patient groups. For example, mortality in over 75-year olds, as shown in the table below: Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font In 2015-16, the Trust invited external review of its mortality processes by Mersey Internal Audit Agency and gained ‘significant assurance' that the processes were robust. 3.5.2. Clinical microbiology

In 2014, the Trust introduced a full 24 hour, seven day on-site clinical microbiology
service, the first in the region. This was enhanced in 2015-16, by increasing the
number of staff on site during the night. From June 2015, our service has also
provided clinical microbiology to Southport & Ormskirk Hospital NHS Trust and
community users from the St Helens and Knowsley Teaching Hospitals NHS Trust
site. This has led to a more effective and efficient service, with all urgent samples
being processed within an hour of arrival and approximately 125,000 (25% total
workload) clinical specimens processed during the night with the results now
available a day earlier for our patients. Further improvements mean that all positive
blood cultures (usually about 10 per day) are dealt with when they flag positive. This
has meant that the medical staff have far more information, up to five hours earlier,
with which to target appropriate therapy.
3.5.3. Stroke performance
The Trust's stroke performance was subject to an internal improvement plan monitored by Clinical Effectiveness Council (discussed in last year's Quality Account). The Trust has seen transformational change and is now the 3rd best performer in England in the Sentinel Stroke National Audit Programme. DN: Insert in call out box The Therapies Service has seen steady improvement recently against the Sentinel Stroke National Audit Programme (SSNAP) and the Trust overall SNNAP performance is now at A (levels A-E, A being the highest); SNNAP has been used to drive quality improvement and an example is the introduction of the breakfast club. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font This is a new initiative introduced by therapies on the stroke ward, where a room has been decorated to resemble a home dining room. The catering staff provide breakfast for a number of stroke patients in this designated area rather than at their bedsides. This group activity has a number of benefits for the patients, including delivering a number of activities of daily living, ensuring improved self-esteem through washing, dressing and combing of hair, improved mobility in transferring from the bedside to the dining room and improved posture through seating at a normal table. A key benefit is interaction with other patients, providing the opportunity to practice communication and cognition. 3.5.4. NICE guidance
The Trust's systems for reviewing and adopting NICE guidance (evidence-based best practice) were assessed internally and externally by the Care Quality Commission (CQC) and found to be high quality. 3.5.5. Intensive Care National Audit & Research Centre
(ICNARC)
The Trust benchmarked favourably against this national audit, not least in terms of a transformation programme to improve timely transfer from Critical Care Unit to the wards, which has seen the Trust move from substantial delayed discharges to strong performance. Mortality against one of the two predictive models for critical care has risen and the Trust is undertaking work to understand the difference between the two mortality models. 3.5.6. Advancing quality (AQ)
This was presented in detail in the Quality Account for 2014-15. 3.5.7. Copeland risk adjustment barometer (CRAB)
CRAB monitors surgeon performance and provides assurance that individual surgeons are performing well in the spectrum of their individual practice. Performance of surgeons both individually and collectively is strong. 3.5.8. Never events
Never Events are serious incidents that are preventable due to national guidance or safety recommendations that healthcare providers should put in place. The Trust remains free from never events and has a Safer Surgery Collaborative that constantly looks for new ways to improve surgical safety. One of its developments, the HALT tool, has been proven to prevent never events and is being adopted elsewhere nationally. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 3.5.9. Clinical audit
The Trust has an active clinical audit programme and is an active participant in required national audits where performance is strong. Our management of clinical audit was reviewed by Mersey Internal Audit Agency this year and found to provide significant assurance. Details of the work undertaken this year are contained in section 2.3.2 above. 3.5.1. Accreditation of Department of Anaesthesia
The Department of Anaesthesia at St Helens and Knowsley Teaching Hospitals NHS Trust is the first in the North West region and only the 8th department in the country to be awarded accreditation status by the Royal College of Anaesthetists. The accreditation process included an in-depth review of both Whiston and St Helens sites by the anaesthesia clinical services accreditation (ACSA) panel. The panel consisted of five people who benchmarked the service against an extensive list of standards by means of interview, paperwork examination and 2 separate site review walk-abouts. They looked at four domains; the care pathway, equipment facilities and staffing, patient experience and clinical governance. All of the standards are mapped to the five key lines of enquiry used by the CQC. 3.5.2. Promoting health
The Trust actively promotes the health and well-being of patients by undertaking a holistic assessment on admission that looks at physical, social, emotional and spiritual needs. Patients are referred or signposted to relevant services, for example, dieticians, smoking cessation and substance misuse. The initial review of patients includes a number of risk assessments that are used to highlight specific concerns that are acted upon, including nutrition and hydration and falls. The Trust has a Smoke Free Policy in place that ensures a healthy environment for staff, patients and visitors, with measures in place to support staff and patients to give up smoking. In addition, the Maternity Service was awarded the Baby Friendly Initiative, which actively promotes breast feeding. 3.6. Patient experience
Whiston and St Helens hospitals were named as the best hospitals in the UK for patient experience in 2015. The award from CHKS Top Hospitals recognised the consistently high standards of care provided to patients at St Helens and Knowsley Teaching Hospitals NHS Trust. The Trust was chosen following an analysis of external performance data in five areas:  CQC inpatient survey  CQC Emergency Department, outpatients and maternity surveys  National Friends and Family Test (FFT) scores Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font  Patient-Led Assessment of the Care Environment (PLACE) in which the Trust has also been named the best acute provider in the NHS  Patient Reported Outcome Measures (PROMS) This award underlines the hard work of all staff who continue to strive for excellence and reflects the Trust's vision to provide 5-star patient care. The Trust has been shortlisted again in this category for the forthcoming awards. The Trust actively engages with patients through a number of initiatives:  Introduction of Patient Participation Group looking at services across the Trust and ways to further improve care and the environment on a monthly basis.  Patient stories at the Trust Board and the Patient Experience Council to discuss both experiences that were positive and those we can learn from to make services better, no matter how small the change  Learning from patient stories and providing ‘lessons learnt' to staff across the  Support from the specialist cancer nurses for Gutsy Guys, a group of patients who have in some way either directly or via a loved one been affected by an upper gastro-intestinal (GI) cancer, such as stomach or oesophageal cancer. This year the patients ran an event to promote early symptoms of upper GI cancers for both the public and professionals. The Trust is committed to listening to our patients and engaging with them to improve the services we deliver. The Patient Advice and Liaison Service (PALS) is the Trust's eyes and ears and the team interacts on a daily basis with our patients, relatives and carers to provide help, advice and support. Two main areas for improvement were identified from feedback from patients; the availability of the team and higher visibility, particularly with the office environment. This has led to extending the opening hours, with greater access for our patients, and a refurbished office to provide greater presence in the main reception area, with a more comfortable environment for our patients to share their experiences. DN: Display in call out box A further area for improvement identified through patient comments was the booking and rearrangement of appointments. A new ‘queue buster' system has been commissioned by the Trust, that calls patients back should they choose not to wait in a queue at busy times. If they opt for the call back option, they can hang up and, without losing their space in the queue, an appointments clerk calls them back when it is their turn. The new service has been working well, with patients commenting on how useful the service is. DN: Display in call out box The Trauma and Orthopaedic Directorate also created an admission lounge in March 2015. It was developed as part of the Directorate's strategy to improve patients' experience pre-operatively. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Patients are informed at their pre-operative assessment that they will attend the lounge on the day of surgery. The admissions nurse explains to the group what will happen on the day and they are given an information leaflet about the reasons for their stay in the lounge. Patients attend on the day of their operation and are assessed by the medical teams. Patients are given an estimated time of surgery and they are free to come and go as they please, being called to theatre from the lounge area at the appropriate time. The unit has seen approximately 1700 patients in the last ten months. The number of patients who have had their surgery cancelled due to lack of available beds has reduced as a result of this initiative. Patients are pleased with the unit as they feel they are well informed and do not have to worry about not getting a bed. A dedicated nursing team is available to assist patients and keep them regularly informed about what is going on, thus improving the patient experience. 3.6.1. Friends and Family Test
The national Friends and Family Test (FFT) evaluates patient experience as soon after treatment as possible, highlighting when there are high levels of patient satisfaction and where improvements could be made. National Performance
Reporting
Indicator
Lowest Highest
Friends & Family Test - Response Rate Friends & Family Test - Rate Friends & Family Test - Response Rate Friends & Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Indicator
Reporting STHK
National Performance
Friends & Family Test - recommended Friends & Family Test - recommended Friends & Family Test - recommended Friends & Family Test - Response Rate Friends & Family Test - Response Rate Friends & Family Test - Response Rate Friends & Sector Providers Friends & Family Test - recommended Friends & Family Test - recommended Friends & Family Test - recommended Friends & Family Test - recommended 27/04/2016 Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font
At the beginning of January 2016 we changed service providers to roll out Friends
and Family Test to all areas and to increase the numbers being surveyed from 3500
to 35000 each month. The new provider has a fully automated reporting system
providing informative reports with comments collated into themes and with trends
incorporating demographic data.
This will enable areas to obtain and review all responses and to continue to monitor
and maintain a high quality and standard of service. This new system also enables
areas to produce action plans as a direct result of the feedback received that will
enable best practice to be shared to other areas throughout the trust.
DN: present in call out box
The list below provides examples of some of the comments received and the
responses provided to this feedback from the FFT during 2015-16:
 You said, "The staff did not give us proper information."
 We are working on our discharge checklist to provide accurate and updated information on discharge from hospital.
 You said, "Short staffed, need more nursing assistants."
 We are currently recruiting into our vacancies and review this regularly. Staffing is reviewed on a daily basis and any identified shortfalls are managed appropriately.
 You said "The staff are very helpful and are there when you need them,
they are all a lovely bunch."
 We replied, "We are here to help you and your family at this time. We endeavour to make ourselves available to you in a friendly and approachable manner."
 You said, "99/100; the only slight fault, it appeared not enough nurses on
duty Saturday PM. They were overrun with issues more important than
mine."
 Ward staff were reminded to consider the feelings of all patients as the smallest things often makes the biggest impact.
 You said, "The treatment given was first class, the staff, especially the
nurses and catering staff were friendly and efficient. The food was good. "
We said, "Thank you to the caterers who provide a good choice of food."

 You said, "I was immediately put at ease. The friendliness and
professionalism of all staff was amazing, despite being in a single ward the
3 weeks just flew by".
 We said, "Positive feedback disseminated to all disciplines at daily Multi- Disciplinary Team." 3.6.2. Complaints
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font The Trust takes patients' complaints extremely seriously and has put measures in place during the year to improve the timeliness of responses to those who made the effort to highlight concerns about their care. The average time to respond to new complaints improved from 35.5% in 2014-15 to 61.4% of new complaints responded to within the agreed timescale during 2015-16. In 2015-16, the Trust received a total of 276 written complaints. One written complaint was withdrawn, resulting in a total of 275 written complaints for the year, compared to 281 in 2014-15. The Trust has made a number of changes to services following complaints, including:  Introduced open visiting on a number of wards to improve communication with patients, carers and families  Increased the presence of pharmacy technicians on the wards to reduce the need for medication charts to be removed from the clinical areas, thus reducing the number of missed doses  Provided customer care and conflict resolution training for staff  Additional training on electronic system to ensure discharge letters are sent  Outpatient referral forms amended to ensure patients' additional needs are identified prior to attending the department so that these can be more readily met  Amendments made to information leaflets to raise awareness that patients may be seen by different medical staff  Posters displaying the uniforms different staff members wear installed on each  Reinforcement of the Trust's ACE behavioural standards
3.7. Summary of national patient surveys
3.7.1. National cancer patient experience survey (NCPES)
The Trust participated in the NCPES survey, however the results have not yet been published. The findings of the survey will be published in next year's Quality Account. NHS England, in response to the 2014 National Cancer Patient Experience Survey, set up a buddying scheme to enable those trusts rated in the top five to provide mentorship and support to those in the bottom five. St Helens and Knowsley Teaching Hospitals NHS Trust was 4th nationally and was buddied with Ashford and St Peter's Hospitals NHS Foundation Trust. This led to the sharing of best practice to raise performance. The programme ran from May to December 2015. The two trusts had multiple teleconferences, during that time, to discuss challenges in delivery of cancer care and a team from Ashford and St Peter's had the opportunity to visit St Helens and Knowsley Teaching Hospitals NHS Trust for a day to look at our cancer services, meet the team and visit diagnostic services. Ashford and St Peter's Hospitals NHS Foundation Trust have introduced some new working structures and improved their engagement with their executive team to move the cancer agenda forward, as a result of the scheme. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 3.7.2. National inpatient survey
The Trust participated in the annual National Inpatient Survey coordinated by the CQC. The results were published in June 2015 and were broadly consistent with the previous year's survey for our Trust. The feedback from patients continues to indicate that the care provided at Whiston and St Helens hospitals is amongst the best in the country. The Trust was included in the ‘best performing' trusts nationally across five indicators and was not included in the ‘worst performing' trusts for a single indicator. The standards of hygiene continue to be amongst the best in the country and the Trust achieved one of the highest national scores for ensuring that patients were given enough privacy when being examined or treated. The areas where we were rated in the best performing Trusts are:  Were you given enough privacy when being examined or treated?  In your opinion, how clean was the hospital room or ward that you were in?  How clean were the toilets and bathrooms that you used in the hospital?  Were you ever bothered by noise at night from other patients?  Were you ever bothered by noise at night from hospital staff? The full benchmarked results can be found on the Care Quality Commission's website a 3.7.3. National survey of women's experiences of maternity
services 2015
The results of the survey were published in December 2015 and show that the Trust received the highest score nationally for six of the questions, including being:  Given the help needed when contacting a midwife during pregnancy  Involved enough in decisions about antenatal care  Spoken to in an understandable way during labour and birth  Told who to contact if needing advice about emotional changes after birth The Trust did not score in the worse ratings for any of the questions asked and the answers given demonstrated that the care was above the national average in a number of questions, especially in relation to:  Information received  Being given enough time to ask questions  Involvement of partner or someone close during labour  Cleanliness of the facilities. We are taking a number of actions to further improve the service, including developing our normality strategy to increase the range of choices for women for both the lead professional and the place of birth. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 3.8. Summary of how we did against our 2015-16 Quality Account priorities

Every year the Trust identifies its priorities for delivering high quality care to patients, which are set out in the Quality Account. The
section below provides a review of how well the Trust did in achieving the targets set last year.
2015-16 Progress in achieving quality goals
Quality Improvement Goal
Progress
delivered
Priority 1: Reduce avoidable  2015-16 figures demonstrate a 50% reduction in grade 3 & and no grade 4 harm by 50% in the next 3 pressure ulcers and a 16% reduction in grade 2 pressure ulcers. Grade 1 years (falls, pressure ulcers, pressure ulcers have remained the same. Overall there has been a 15% medication incidents) reduction in all pressure ulcers.  The year one target for reducing prescribing errors was to increase the reporting of prescribing errors by 50%. This target was achieved in January 2016. It is essential to fully understand the causes of prescribing errors and the plan for this year is to optimise all potential reduction strategies. This work will be further supported by the introduction of a Trust wide e-prescribing system in 2016. The data demonstrates a 30% reduction in harm related to prescribing errors in 15-16 compared to 14-15  The early recognition and response to deteriorating patients is progressing well, with the introduction of an electronic vital signs recording and escalation system. The system began roll out in December 2015 and it is anticipated it will be operating across all Trust areas by summer 2016.  The Trust had maintained its impressive record of zero never events since May 2013. Annually the NHS reports over 300 never events nationally which highlights this as a significant achievement by the Trust for over almost three years.  The Trust continues to pilot new and innovative ways of reducing harm from inpatient falls. The Trust's new falls prevention strategy and associated actions have seen a significant decrease in harm from falls since its implementation in October 2015. A 13% decrease in the overall harm from falls and a 48% Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Quality Improvement Goal
Progress
delivered
decrease in falls resulting in moderate harm or above has been demonstrated from October 2015 to March 2016, compared to the first half of the financial year.  The Trust is currently piloting safety briefings as part of ward handovers between staff. The final safety huddle tool will be rolled out Trust wide in Spring 2016, following a period of refinement. Priority 2: To further embed  Evidence of learning from complaints is provided via reports to the Board, the the process for learning from Quality Committee and the Patient Experience Council. incidents and complaints  Improvements have been made to the electronic system, Datix, in order to better capture the actions taken, lessons learned and outcomes of complaints investigations. The Central Complaints Team have developed a short course for staff to use the investigations section and the actions module, which will be rolled-out across all Care Groups from April 2016.  10% increase in incident reporting & key lessons cascaded through Patient Safety Newsletter, team meetings, safety huddles  There is a continued focus on increasing the quality of investigations to ensure that the key factors causing incidents are identified and then the relevant action plans delivered to mitigate the future risk of same types of harm. This includes involving patients and families in the investigation process to ensure that all available information pertaining to the episode of harm is captured and all causation factors full understood and mitigated against. Additional focus will be placed on the timeliness of completing investigation reports during 2016-17 to ensure that these are undertaken within the required deadlines. Priority 3: Ensure safer staffing Achieving  Monthly safer staffing reports are provided to the Board and Quality Committee, levels are achieved which note high levels of compliance.  More detailed reports are provided twice yearly and include the use of the Shelford tool to assess staffing requirements in response to changing patient dependency and acuity which are reported to the Board. Priority 1: Further reduce Progress in reducing mortality in people admitted at weekends has fallen short of Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Quality Improvement Goal
Progress
delivered
mortality of weekend plan and intensive focus will be given to this area in 2016-17. admissions. Priority 2: Reduce variations in Achieving The Trust has received assurance from internal work and externally from the CQC care to improve outcomes and internal audit that its systems and processes for incorporating evidence-based clinical care based on national guidance is effective Priority 3: Improve pathways Good progress has been made in improving integration between specialist of care for people with long community and primary care delivered for people with long-term conditions. The term conditions including frailty Trust, together with other speciality and community providers and all the local CCGs, has signed up to increased vertical and horizontal integration as part of the local delivery system and the sustainability transformation plan. Priority 1: To improve the 61.5% Stage 1 complaints received in 2015-16 and resolved within agreed timeliness of complaint timescales compared to 35.5% in 2014-15 Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font Quality Improvement Goal
Progress
delivered
Priority 2: Enhance the Discharge processes continue to be the focus of the Trust's rapid improvement discharge planning process work. Improvements have been made to the electronic discharge planning report, which is accessed by the multidisciplinary team to ensure timely effective discharges. It is also a tool to highlight the needs of the patient to reduce any delays in discharge planning and identify social care needs. Work is continuing with the Medical Directors to ensure that all patients have a documented workable estimated date of discharge. This along with an agreed Standard Operation Procedure is being embedded in all ward areas with all grades of staff. Weekly length of stay meetings with a representative from the Local Authority and the CCG discuss any patients with a stay of more than 14 days. Ward-based Discharge Coordinators expedite any delays and they ensure effective discharge planning in a timely manner with a plan of care in place that will prevent re-admission. The Integrated Discharge Team ensure that through holistic working the patients' needs are identified and met prior to discharge. There is an on-going project to encourage the ward staff to utilize the ward based pharmacy teams, which should improve the timing of discharge medication being processed through the dispensary. Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 4.1. Statement of directors' responsibilities in respect of the
Quality Account

The Board of Directors is required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2012) to prepare a Quality Account for each financial year. The Department of Health issues guidance on the form and content of the annual Quality Account, which has been included in this Quality Account. In preparing the Quality Account, Directors are required to take steps to satisfy themselves that:  The Quality Account presents a balanced picture of the Trust's performance over the period covered 2015-16  The performance information reported in the Quality Account is reliable and  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 The Board of 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 Richard Fraser Chairman Date: XX 2016 Ann Marr Chief Executive Date: XX 2016 Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 4.2. Written statements by other bodies
4.2.1. Local Healthwatch
4.2.2. Overview and Scrutiny Committee
4.2.3. Clinical Commissioning Groups (presentations due in May
4.2.4. Independent Auditor (onsite audit due mid-April of
Clostridium difficile and incidents) 4.2.5. Amendments made to the Quality Account following
receipt of the written statements from other bodies
Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font 4.3. Abbreviations
Acute Medical Unit Acute kidney injury Aseptic Non-Touch Technique Advancing Quality Advancing Quality Alliance British Thoracic Society College of Emergency Medicine Child and adolescent mental health services Clinical Commissioning Groups Chronic Obstructive Airways Disease Care Quality Commission Commissioning for Quality and Innovation Clinical Research Network Integrated Risk Management, Incident Reporting, Complaints Management System Emergency Department Electronic Document Management System Equality Delivery System Electronic Modified Early Warning Score Falls and Fragility Fractures Audit Programme Friends & Family Test General Practitioner Gastro-intestinal Healthcare Acquired Infections Hospital Episode Statistics Health and Social Care Information Centre Hospital standardised mortality ratio Health, Work and Well-being Implant Breast Reconstruction Audit International Classification of Diseases Intensive Care National Audit & Research Centre Information Commissioner's Office Information Governance Toolkit Lesbian, gay, bisexual, transgender Long-term condition MBRRACE- Mothers and Babies - Reducing Risk through Audits and Confidential UK Enquiries across the UK Myelodysplastic Syndromes Medical Emergency Team Myocardial Ischaemia National Audit Project Multidisciplinary Obstetric Drills, Skills, and Simulation Methicillin-resistant staphylococcus aureus National Audit Oesophago-Gastric Cancer National Bowel Cancer Audit Programme National Cardiac Arrest Audit National Confidential Enquiry into Patient Outcome and Death Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font National Diabetes Audit Adult National Diabetes Foot Care Audit National Emergency Laparotomy Audit National Institute for Health and Care Excellence National Institute for Health Research National Joint Registry National Lung Cancer Audit National Neonatal Audit Programme National Prostate Cancer Audit National Patient Safety Agency National Reporting Learning System Patient Advice and Liaison Service Payment by Results Percutaneous Endoscopic Gastrostomy Patient-Led Assessments of the Care Environment Paediatric National Diabetes Audit Personal protective equipment Patient Reported Outcome Measures Root Cause Analysis Research Development and Innovation Summary Hospital-level Mortality Indicator Senior Information Risk Owner Sentinel Stroke National Audit Programme Sustainability and Transformation Plan Subarachnoid Haemorrhage Secondary Uses Service Trauma Audit & Research Network Trust Development Authority Transient Ischaemic Attack Venous Thromboembolism Draft Version 12 Key: Required text in blue font, mandated text in green font, DN = drafting notes + updates required in red font

Source: http://www.healthwatchsthelens.co.uk/sites/default/files/st_helens_and_knowsley_trust_-_draft_quality_account_2015-16_-_v12.pdf