University Hospital of North Staffordshire, Stoke on Trent

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients? 381

• Of these how many have an ensuite toilet? 332

• Of these how many have an ensuite toilet and shower or bath? 332

• Does this hospital site operate an accident and emergency unit?

• How many specialist palliative care beds do you have available at this site? 0

• Are staff scheduled to be on site for a rostered session or full shift every saturday to carry out: Imaging - Magnetic Resonance Imaging: Run 3 scanners 08:00-20:00 on Saturdays. Also have an on call system for hours outside this for specific emergency cases.

• Are staff scheduled to be on site for a rostered session or full shift every saturday to carry out: Imaging - Computed Tomography: 24/7 cover for CT based in Emergency Department, however additionally run 1 scanner on Saturday between 08:30-16:00

• Are staff scheduled to be on site for a rostered session or full shift every saturday to carry out: Imaging - Non-obstetric ultrasound: Non obstertic ultrasound has set sonographer led sessions Saturday morning and Sunday morning as well as full on call service provided by the Radiology Registrar backed up by a Consultant on call should complex procedures be required.

• Are staff scheduled to be on site for a rostered session or full shift every saturday to carry out: Imaging - DEXA Scan: NA Test not provided by UHNS

• Are staff scheduled to be on site for a rostered session or full shift every sunday to carry out: Imaging - Magnetic Resonance Imaging: Service is 08:00-20:00 and provide 24/7 on call emergency cases.

• Are staff scheduled to be on site for a rostered session or full shift every sunday to carry out: Imaging - Computed Tomography: 24/7 cover for CT based in Emergency Department, however additionally run 1 scanner on Saturday between 08:30-16:00

• Are staff scheduled to be on site for a rostered session or full shift every sunday to carry out: Imaging - Non-obstetric ultrasound: Non obstertic ultrasound has set sonographer led sessions Saturday morning and Sunday morning as well as full on call service provided by the Radiology Registrar backed up by a Consultant on call should complex procedures be required.

• Are staff scheduled to be on site for a rostered session or full shift every sunday to carry out: Imaging - DEXA Scan: NA Test not provided by UHNS

Trust Questions

• Do you have a process/policy for identifying patients for early supported discharge (ESD)?

• Does the trust treat private patients?

Patient Safety

Trust Questions

• Do you have a system for recording operations that resulted in a foreign body being left post surgery:

• What is the reporting system for a foreign body being left post surgery? Adverse Incident reporting System (Datix) Adverse Incident reporting system (Datix)

• Do you have a system for recording operations that were cancelled due to missing notes?

• What is the reporting system for operations that were cancelled due to missing notes? Adverse Incident Reporting System (Datix) Adverse Incident Reporting System (Datix)

• Do you have a system for recording operations that resulted in wrong site surgery taking place?

• What is the reporting system for operations that resulted in wrong site surgery taking place? Adverse Incident Reporting System (Datix) Adverse Incident Reporting System (Datix)

• During the period 01 April 2011 - 31 March 2012, how many operations resulted in a foreign body being left post surgery: 0

• During the period 01 April 2011 - 31 March 2012, how many operations were cancelled due to missing notes? 25 This includes missing X rays as well as notes

• During the period 01 April 2011 - 31 March 2012, how many operations resulted in wrong site surgery taking place? 0

• How many incident investigations using a full Root Cause Analysis were carried out in 2011/12? 244

• What percent of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed? 100%

• What percent of acute inpatients have a track and trigger warning system in place for the duration of the admission? 61-90%

• What percent of patients are risk assessed for venous thromboembolism on admission? 91-99%

• Is the Trust compliant with all relevant NPSA safety alerts issues in 2011/12? (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3).:

• Do the trust have a policy for providing educational programmes on using and interpreting clinical indicators? (training):

• Does the trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support):

• Is safety and quality data available on a central platform and actively disseminated to users?

Trust Board Activity and Patient Safety

Trust Questions

• How many board members are there in the trust? 13

• Over the course of the last year, what percentage of board meeting time has been devoted specifically to discussing patient safety issues? 61-90%

• Over the past year, have board members received formal training in relation to patient safety?

• What training and development programmes have been attended? Board Development Seminar Programme has included aspects of how Trust can improve patient safety. Board Development Seminar Programme has included aspects of how Trust can improve patient safety.

• Have the board set explicit measurable goals for improving performance in relation to patient safety?

• Measurable goals: To have zero hospital associated infections To reduce patients falls by 30% To reduce the Trust HSMR To have zero avoidable hospital acquired pressure ulcers To have zero hospital associated infectionsTo reduce patients falls by 30%

• Have strategic goals and objectives related to patient safety been distributed to staff groups within the last 12 months?

• Ambulance staff groups have received these goals and objectives:

• Allied Health Professionals staff groups have received these goals and objectives:

• Doctors staff groups have received these goals and objectives:

• Health Informatics staff groups have received these goals and objectives:

• Management staff groups have received these goals and objectives:

• Nursing staff groups have received these goals and objectives:

• Healthcare Science staff groups have received these goals and objectives:

• Wider Healthcare team staff groups have received these goals and objectives:

• Other staff groups that have received these goals and objectives: N/A

• Does the board have formal procedures for reporting inappropriate behaviours in relation to patient safety on a regular basis?

• What are these procedures? Trust has established Professional Standards Committee. Also Trust has well established adverse incient reporting and whistleblowing procedures.

• Are there procedures for proactively responding to the reporting of staff concerns (e.g. 'whistle blowing') about patient safety?

• What are these procedures? Trust has Whistleblowing Policy and Procedures established Trust has Whistleblowing Policy and Procedures established

• Executive walk-arounds are reported at all board meetings:

• Patient stories are reported at all board meetings:

• Board members engaged clinicians to better understand patient safety issues are reported at all board meetings:

• Infection rates are reported at all board meetings:

• Mortality rates are reported at all board meetings:

• Readmission rates are reported at all board meetings:

• Incident rates and levels of harm are reported at all board meetings:

• Patient Safety Surveys are reported at all board meetings:

• Formal Complaints processes are reported at all board meetings:

• Medication errors are reported at all board meetings:

• CQC Quality and Risk Profiles (QRPs) are reported at all board meetings:

• Formal written reports about safety performance are reported at all board meetings:

• Other quantitative ('hard') data sources related to patient safety that are reported at all board meetings: N/A

• How many members of the board have clinical backgrounds? 2

• Does the board have a formal subcommittee that discusses patient safety issues? Quality Assurance Committee

• How many times a year does this subcommittee meet? 6

• Are patient safety measures included in the Chief Executive Officer's performance review?

• Details: Trust's Monthly performance report includes section on quality and safety including incident rate, falls, infection rates, VTE and Mortality.

• Does the board use any national reporting measures of patient safety?

• Details: Adverse incident rate per 100 admissions MRSA / C Dif rates

• Financial performance: importance within the organistaion (with '1' being the most important and '6' being the least important): 5

• Clininical effectiveness: importance within the organistaion (with '1' being the most important and '6' being the least important): 3

• Patient Safety: importance within the organistaion (with '1' being the most important and '6' being the least important): 1

• Patient Experience: importance within the organistaion (with '1' being the most important and '6' being the least important): 2

• Achieving waiting time targets: importance within the organistaion (with '1' being the most important and '6' being the least important): 6

• Staff satisfaction: importance within the organistaion (with '1' being the most important and '6' being the least important): 4

Stroke Medicine

Hospital Questions

• Does this hospital have a specialist stroke unit?

• What type of unit does the hospital have? Hyperacute stroke unit (HASU)

• The number of beds in the Stroke unit: 32

• Is a trained thrombolysis stroke nurse available 24/7? Yes on site

• Is a consultant stroke physician/neurologist available 24/7? Yes on call

• Is an ST3 physician with training in thrombolysis available 24/7? Yes on site

• Does the hospital have consultant led ward rounds for stroke wards seven days a week?

Trust Questions

• Does the trust have a specialist stroke unit or units?

• Is the Trust part of a stroke care network?

• Details: Shropshire and Staffordshire Heart & Stroke Network

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the trust receive in the financial year (period 01 April 2011 - 31 March 2012)? 994

• Of these, what is the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission? 950

• Does the hospital have a team permanently onsite which is able to provide thrombolysis for stroke patients 24 hours per day and 7 days a week?

Trauma & Orthopaedics

Trust Questions

• Does the trust offer a trauma service?

• Does the trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday)?

• Does the trust offer an orthopaedics service?

• Does the trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)?

• Percentage of all patients attend the class prior to surgery (audited): 75

• Does the trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients?

• percentage of the trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery (estimate): 95

• Does the trust provide an equivalent physiotherapy service to both elective and trauma patients at the weekend? (i.e. is the service staffed on the weekend with the same skill mix, and numbers of staff):

• How is the staffing model different? Same skill mix, reduced staffing numbers, reduced hours. Prioritise discahrgaes and early mobility

• Does the Trust admit patients for total knee replacement (TKR) and total hip replacement (THR) prior to the day of surgery?

• Does the Trust routinely record patient records using a specific multi-disciplinary team THR/TKR pathway document?

• Is this data used to monitor compliance with the agreed pathway?

• Is criteria-based discharge used?

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress?

• Do 100% of hip and knee replacements follow an enhanced recovery pathway?

• How many hip and knee replacement patients follow an enhanced recovery pathway (% (estimate): 30

• Explanantion of why some patients do not follow the pathway: Current;ly only a small number of Consultants are using the pathway as a trial. Wil then be rolled out across the department.

• Are there daily goals for hip and knee patients to achieve?

• What day does the Trust aim to have patients ready for home? i.e. what are patients told in their information booklets and at the pre-op class: Day 3

• Apart from hip and knee replacement, what other procedures have enhanced recovery pathways? Fractured neck of femur

• For what percentage of hip fracture patients is the time to theatre within 36 hours of arrival to Emergency Department (or time of diagnosis (if an inpatient) to the start of anaesthesia)(%): 78

• What percentage of hip fracture patients are admitted under the joint care of a Consultant Geriatrician & a Consultant Orthopaedic Surgeon: 100

• What percentage of hip fracture patients are admitted using an assessment tool agreed by geriatric medicine, orthopaedic surgery and anaesthesia: 100

• What percentage of hip fracture patients are assessed by a geriatrician in perioperative period (defined as 72hrs from admission) (Geriatrician defined as Consultant; SAS or ST3+): 91

• What percentage of hip fracture patients receive a postoperative Geriatrician-directed Multi-professional rehabilitation team: 100

• What percentage of hip fracture patients receive postoperative Geriatrician-directed Fracture prevention assessments (falls and bone health): 96

• What percentage of hip fracture patients have a Pre and post op abbreviated mental test score (AMTS): 93

Paediatrics

Hospital Questions

• Does this hospital offer a paeditrics service?

Trust Questions

• Does the trust provide a paediatrics service?

• Is the trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit?

• Do the trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week?

• Paediatrician on site (SpR or higher) available 24 hours per day, 7 days per week:

• At least two registered children's nurses on duty 24hours per day in each children's ward available 24 hours per day, 7 days per week:

• Is there a designated facility on site for parents or guardians to stay overnight?

• What percentage of children who are admitted to a paediatric department with an acute medical problem are seen by a paediatrician on the middle grade or consultant rota within four hours of admission? 100% All Children who are admitted to the CAU and to the wards are seen by either the Consultant of the Week/ Registrar

• What percentage of children who are admitted to a paediatric department with an acute medical problem are seen by a consultant paediatrician (or equivalent staff, speciality and associate specialist grade doctor who is trained and assessed as competent in acute paediatric care), within the first 24 hours? 100% All Children who are admitted to the CAU and to the wards are seen by either the Consultant of the Week/ Registrar

• Do All SSPAUs (Short Stay Paediatric Assessment Units) have access to a paediatric consultant (or equivalent) opinion throughout all the hours they are open?

• Is at least one medical handover in every 24 hour period led by a paediatric consultant (or equivalent)?

• Are specialist paediatricians available for immediate telephone advice for acute problems for all specialties, and for all paediatricians?

• Do all children's social care, police and health teams have access to a paediatrician with child protection experience and skills (of at least Level 3 safeguarding competencies) available to provide immediate advice and subsequent assessment, if necessary , for children under 18 years of age where there are child protection concerns. (The requirement is for advice, clinical assessment and the timely provision of an appropriate medical opinion, supported with a written report)?

Palliative Care

Trust Questions

• Does the trust provide a palliative care service?

• How is specialist palliative care is delivered at this hospital? A multi-disciplinary specialist palliative care team

• Does the hospital's specialist palliative team include: A consultant in palliative medicine,A palliative care nurse

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week? Hospital team is available 9-5 7 days per week. Out of Hours palliative care provided by Douglas MacMillan Hospice 24/7 advice line

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital?

• Does the trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme? Patients are regularly surveyed on the delivery of palliative care within the Trust

Care of the Elderly

Trust Questions

• Does the trust have a named senior clinician who takes the lead for quality improvement in dementia in the trust?

• Name and job title: Dr Marilyn Browne - Consultant Geriatrician Dr Ibrahim Morgan - Consultant Geriatrician

• Does the trust have an explicit care pathway for the management and care of people with dementia in hospital? The Trust does however have a training programme for staff to undertsand and be aware of dementia and needs of patients

• Is there a process for identifying patients who are at risk of dehydration an malnutrition? Trust uses Butterfly and 'Thjis is Me' documents to assist with identification of patient needs. Within Elderly Care there is also heightened awareness with use of red trays, red jug lids and protected meal times.

• During the period 01 April 2011 - 31 March 2012, the total number of patients recorded as malnourished or dehydrated according to the trust's incident reporting system: 0 Zero incidents reporting malnourished or dehydrated patients whilst in hospital

• Does the trust currently audit the number of "slips, trips and falls" using a risk management system?

• Is this information submitted to the NPSA's National Reporting and Learning System (NRLS) via the local risk management systems or e-forms?

• The total number of incidents during the period 01 April 2011 - 31 March 2012 for the category: No harm: 1279

• The total number of incidents during the period 01 April 2011 - 31 March 2012 for the category: Low harm - harm requiring first-aid level treatment, or extra observation only (e.g. bruises, grazes): 410

• The total number of incidents during the period 01 April 2011 - 31 March 2012 for the category: Moderate harm - harm requiring hospital treatment or a prolonged length of stay but from which a full recovery is expected (e.g. fractured clavicle, laceration requiring suturing): 79

• The total number of incidents during the period 01 April 2011 - 31 March 2012 for the category: Severe harm - harm causing permanent disability (e.g. brain injury, hip fractures where the patient is unlikely to regain their former level of independence): 3

• The total number of incidents during the period 01 April 2011 - 31 March 2012 for the category: Death - where death is directly attributable to the fall: 0

Staffing

Hospital Questions

• Foundation Doctors, Year 1 & 2 Scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00am: 4

• Foundation Doctors, Year 1 & 2 On call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00am: 0

• Foundation Doctors, Year 1 & 2 on call from home on Sunday June 17th at 11:00am: 0

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00am: 21

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00am: 0

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post on call from home on Sunday June 17th at 11:00am: 0

• ST3 or higher (specialist training) scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00am: 29

• ST3 or higher (specialist training) on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00am: 0

• ST3 or higher (specialist training) on call from home on Sunday June 17th at 11:00am: 0

• Staff grade post equivalent to ST3 or higher scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00am: 29 included in ST3 figure above as we do not differentiate between the two

• Staff grade post equivalent to ST3 or higher on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00am: 0

• Staff grade post equivalent to ST3 or higher on call from home on Sunday June 17th at 11:00am: 0

• Foundation Doctors, Year 1 & 2 responsible for current medical inpatients and new medical admissions scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00am: 4

• Foundation Doctors, Year 1 & 2 responsible for current medical inpatients and new medical admissions on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round, on Sunday June 17th at 11:00am: 0

• Foundation Doctors, Year 1 & 2 responsible for current medical inpatients and new medical admissions on call from home on Sunday June 17th at 11:00am: 0

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post responsible for current medical inpatients and new medical admissions scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00am: 21

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post responsible for current medical inpatients and new medical admissions on call, but physically on site either as a requirement of terms of on call or as routine practice: 0

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post responsible for current medical inpatients and new medical admissions on call from home on Sunday June 17th at 11:00am: 0

• ST3 or higher (specialist training) responsible for current medical inpatients and new medical admissions scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00am: 29

• ST3 or higher (specialist training) responsible for current medical inpatients and new medical admissions on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00am: 0

• ST3 or higher (specialist training) responsible for current medical inpatients and new medical admissions on call from home on Sunday June 17th at 11:00am: 5

• Staff grade post equivalent to ST3 or higher responsible for current medical inpatients and new medical admissions scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00am: 29 Included in figures above for ST3 as we do not differentiate bewteen the two

• Staff grade post equivalent to ST3 or higher responsible for current medical inpatients and new medical admissions on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 1: 0

• Staff grade post equivalent to ST3 or higher responsible for current medical inpatients and new medical admissions on call from home on Sunday June 17th at 11:00am: 5 Included in the figures above for ST3 as we do ot differentiate between the two

• Foundation Doctors, Year 1 & 2 scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00pm: 1

• Foundation Doctors, Year 1 & 2 on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00pm: 0

• Foundation Doctors, Year 1 & 2 on call from home on Sunday June 17th at 11:00pm: 0

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00pm: 17

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00pm: 0

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post on call from home on Sunday June 17th at 11:00pm: 0

• ST3 or higher (specialist training) scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00pm: 29

• ST3 or higher (specialist training) on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00pm: 0

• ST3 or higher (specialist training) on call from home on Sunday June 17th at 11:00pm: 5

• Staff grade post equivalent to ST3 or higher scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00pm: INcluded in the figures above for ST3 as we do not differntiate between the two

• Foundation Doctors, Year 1 & 2 responsible for current medical inpatients and new medical admissions scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00pm: 1

• Foundation Doctors, Year 1 & 2 responsible for current medical inpatients and new medical admissions on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00pm: 0

• Foundation Doctors, Year 1 & 2 responsible for current medical inpatients and new medical admissions on call from home on Sunday June 17th at 11:00pm: 0

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post responsible for current medical inpatients and new medical admissions scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00pm: 17

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post responsible for current medical inpatients and new medical admissions on call, but physically on site either as a requirement of terms of on call or as routine practice: 0

• ST1/ST2 or CT1/CT2 (core training/specialist training ) or equivalent non-deanery post responsible for current medical inpatients and new medical admissions on call from home on Sunday June 17th at 11:00pm: 0

• ST3 or higher (specialist training) responsible for current medical inpatients and new medical admissions Scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00pm: 29

• ST3 or higher (specialist training) responsible for current medical inpatients and new medical admissions on call, but physically on site either as a requirement of terms of on call or as routine practice, e.g. Ward round on Sunday June 17th at 11:00pm: 0

• ST3 or higher (specialist training) responsible for current medical inpatients and new medical admissions on call from home on Sunday June 17th at 11:00pm: 5

• Staff grade post equivalent to ST3 or higher responsible for current medical inpatients and new medical admissions Scheduled to be on site for rostered session or full shift on Sunday June 17th at 11:00pm: Included in the figures above for ST3 as we do not differentiate between the two

• Does the hospital have a formal "hospital at night" system?

• ST3 or higher (specialist training) in the "hospital at night" team: 6