Item 8 - Sheffield Health and Social Care

Safeguarding childrenFood and nutritionLocal audit activityLocal clinical audits are conducted by staff and teamsevaluating aspects of the care they themselves haveselected as being important to their teams. Our maincommissioner, Sheffield CCG, also asks the Trust tocomplete a number of local clinical audits each year, toreview local quality and safety priorities. On a quarterlybasis the Board review the progress of other local audits.2.9 Data qualityGood quality information underpins the effectivedelivery of care and is essential if improvements inquality care are to be made. Adherence to gooddata quality principles (complete, accurate, relevant,accessible, timely) allows us to support teams and theBoard of Directors in understanding how we are doingand identifying areas that require support and attention.External Auditors have tested the accuracy ofthe data and our systems used to monitor thefollowing indicators:• 7 day follow up – everyone dischargedfrom hospital should receive support in thecommunity within 7 days of being dischargedResults – The audit identified that the majority ofstaff have ‘some’ understanding of the kinds ofchild abuse (particularly type of abuse). Most staffknow who to contact if a child has been abused(this includes line manager, safeguard lead)The actions we have taken are:We will continue with our training programmeto maintain and improve awareness.Results – The audit has revealed that nutritionalassessments are being done on admission for96% of patients on the older adult wards. Weneed to extend this practice to our other wards.The actions we have taken are:We will extend the practice of undertakingnutritional assessments to our adult wards.• ‘Gate keeping’ – everyone admitted tohospital should be assessed and consideredfor home treatmentAs with previous years, the audit has confirmedthe validity and accuracy of the data used within theTrust to monitor, assess and report our performance.The Trust submitted records during 2012/13 to theSecondary uses service (SUS) for inclusion in theHospital episodes Statistics which are included in thelatest published data. The percentage of records inthe published data which included the patient’s validNHS number was 99.9% for admitted care. Thepercentage of records in the published data whichincluded the patients valid General PractitionerRegistration Code was 95.7% for admitted care.No other information was submitted.The latest published data from the SUS regardingdata quality under the mental health minimum dataset is for April 2012- December 2013. The Trust’sperformance on data quality compares well tonational averages and is summarised as follows:Percentage of valid records Data quality 2012/13 National averageNHS Number 99.9% 99.4%Date of birth 100% 99.7%Gender 100% 99.4%Postcode 99.6% 99.0%Commissioner code 100% 99.3%GP Code 99.5% 98.3%Primary diagnosis 100% 98.5%HoNOS outcome 100% 88.9%The data and comparative data is from the published MHMDS Reports for the Q1 – Q3 periods inclusiveClinical coding error ratesSheffield Health and Social Care NHS FoundationTrust was not subject to the Payment by Resultsclinical coding audit during 2012/13 by theAudit Commission.2.10 Information governanceWe aim to deliver the best practice standardsin Information Governance by ensuring thatinformation is dealt with legally, securely andeffectively in order to deliver the best possiblecare to our service users.Concerns were highlighted in a number of areasduring 2011/12. The Trust undertook developmentand improvement actions in response to thefollowing issues:• Information governance management -Improving the provision of training aboutinformation governance• Clinical information assurance - Completionof staff training and audit for clinical coding• Corporate information assurance - Completinga review and audit of corporate records.During the year we completed our assessmentsthrough the NHS Connecting for Health InformationGovernance Toolkit. The Trust undertook andsubmitted a baseline assessment in October2012 anda final assessment and submission in March 2013.Following the improvement actions we hadundertaken, Sheffield Health and Social CareNHS Foundation Trust’s Information GovernanceAssessment Report overall score for 2012/13was 69% for the 45 standards and was gradedsatisfactory/green.AchievedCriteria 2011/12 2012/13 Current gradeInformation Governance Management 66% 73% SatisfactoryConfidentiality and Data Protection Assurance 74% 74% SatisfactoryInformation Security Assurance 64% 66% SatisfactoryClinical Information Assurance 73% 73% SatisfactorySecondary Use Assurance 41% 66% SatisfactoryCorporate Information Assurance 22% 66% SatisfactoryOverall 60% 69% Satisfactory111112