Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital

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40 2. 2012/13 Quality Schemes Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13 6b. Antibiotic Prescribing (Indications) Proportion of antimicrobial prescriptions with an indication specified on the drug chart. 2012/13 Target – 65% 2012/13 Achieved – 82% 6c. Antibiotic Prescribing (Compliance with Guidelines) Compliance with Guidelines or Documentation of Reason for Use of Alternative Antibiotic Agent. 2012/13 Target – 75% 2012/13 Achieved – 91% 7. Scoping and Implementation of High Impact Innovations In 2011 the Department of Health identified six high impact innovations that would yield productivity gains for the NHS as a whole. The Trust has been required to scope the implementation of these. 2012/13 Target – Production of a plan for 2013-14 2012/13 Achieved – Report submitted to NHS Devon 8. Emergency Department Patient Flows This indicator has tested a series of changes which have improved the way in which patients are managed in the Emergency Department. Improvements in processes have reduced delays for individual patients. 2012/13 Target – Achieve agreed action plan 2012/13 Achieved – Tests of change achieved and 95% access target achieved 9. Early Supported Discharge for Stroke This indicator has introduced innovative practice which reduces the amount of time spent in hospital for patients who have suffered a stroke. 2012/13 Target – Reduction in super spell length of stay 2012/13 – Data not yet available, but achievement is anticipated 10. Nutrition and Hydration This is a two-part indicator. One part has ensured that patients who are assessed as requiring additional nutritional support are receiving the appropriate diet. The second part of this indicator has ensured that patients awaiting surgery are made ‘nil by mouth’ appropriately but not starved for an unnecessarily long time. 10a. Nutrition and Hydration (Implementation of ‘Nil by Mouth’) Percentage of patients for whom there is Compliance with Recommended Timeframes for ‘nil by mouth’ (for patients who require elective orthopaedic surgery, both day case and inpatient, and for paediatric and adult orthopaedic surgery). 2012/13 Target – Achieve agreed trajectory 2012/13 Achieved – 100% 10b. Nutrition and Hydration (MUST Assessment) Percentage of patients for whom treatment plans triggered by assessments are fully and correctly implemented. 2012/13 Target – 90% 2012/13 Achieved – 100% 11. Nosocomial Pneumonia This indicator sees the introduction of a series of care interventions that have reduced the risk of patients acquiring pneumonia in hospital. 11a. Nosocomial Pneumonia (Head up Tilt Positioning) Percentage of beds with ‘heads up positioning’ in identified ‘high-risk’ groups. 2012/13 Target – Achieve agreed trajectory (85%) 2012/13 Achieved – 100% in identified high risk groups 11b. Nosocomial Pneumonia (Compliance with Naso-Gastric Tube Placement) Percentage compliance with Placement Bundle (Part 1) to Reduce Incidence of Nosocomial Pneumonia. 2012/13 Target – Achieve agreed trajectory (90%) 2012/13 Achieved – 94% 11c. Nosocomial Pneumonia (compliance with Naso-Gastric Tube Management Bundle Percentage compliance with Naso- Gastric Tube Management Bundle (Part 2) to Reduce Incidence of Nosocomial Pneumonia. 2012/13 Target – Achieve agreed trajectory (90%) 2012/13 Achieved – 99 %
2. 2012/13 Quality Schemes Royal Devon and Exeter NHS Foundation Trust Quality Report 2012/13 41 Statements from the Care Quality Commission (CQC) The Royal Devon and Exeter NHS Foundation Trust is required to register with the Care Quality Commission (CQC) and its current registration status is registered in full without conditions. The CQC has not taken enforcement action against the Royal Devon and Exeter NHS Foundation Trust during 2012/13. The Royal Devon and Exeter NHS Foundation Trust has participated in special reviews or investigations by the CQC relating to the following areas during 2012/13: • 16th July 2012 – This unannounced review was part of the CQC’s routine schedule of planned reviews. The inspection focused on Mardon House, the Trust’s Neuro-rehabilitation Centre. The CQC found that the Royal Devon and Exeter NHS Foundation Trust was meeting all the essential standards of quality and safety inspected • 6th, 7th and 9th November 2012 – This unannounced review was part of the CQC’s routine schedule of planned reviews. Eight standards were inspected and the CQC found that the Royal Devon and Exeter NHS Foundation Trust meet five of the standards fully and action was required for three of the standards. The Royal Devon & Exeter NHS Foundation Trust intends to take the following action to address the conclusion or requirements reported by the Care Quality Commission: the development of an action plan approved by the Board of Directors which will enhance documentation processes within theatres and also on the wards (a summary of the inspection can be found on the CQC website: www.cqc.org.uk/ directory/rh801). The Royal Devon & Exeter NHS Foundation Trust has made the following progress by 31st March 2013 in taking such action: all actions contained within the action plan have been completed by the target date of 31st March 2013 and approved by the Governance Committee on 8th April 2013. The completed action plan has been forwarded to the CQC, who are planning to undertake a repeat inspection to ensure the actions meet the standards. Update on CQC inspections detailed in the 2011/12 Quality Account • 9th and 10th November 2011 – The action plan to improve documentation of personalised delivery of care was completed and signed off by the Governance Committee 1st June 2012 • 21st and 23rd March 2012 – The outcome of the responsive review of compliance of all providers of Termination of Pregnancy Services, following national concerns, found the Trust was meeting the regulation in relation to the maintenance of HSA1 form.
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