KPCT_-_11-43_NHS_Kirklees_CQC_

© Care Quality Commission 2011

Quality and Risk Profile (QRP) To support monitoring of compliance with essential standards of quality and safety

Kirklees PCT

5N2

March 2011


Introduction

As part of CQC’s monitoring of providers’ compliance with the essential standards of quality and safety, we need up-to-date, relevant information about each registered provider. The Quality and Risk Profile (QRP) is a tool that gathers all we know about a provider in one place.

How CQC uses the QRP

The QRP enables us to assess where risks lie and prompt any front line regulatory activity, such as an inspection. QRPs support our teams to make robust judgments about the quality of services, and will develop over time as we gather more information about a provider.

How providers and commissioners can use the QRP

QRPs are also an important tool for providers and commissioners – both to support continuous monitoring of compliance, by ensuring that everyone is working from the same information, and to improve the provision and commissioning of care.

Providers should find the QRP useful in supporting their internal monitoring of quality, by identifying areas of lower than average performance and, where necessary, taking action to address them. Commissioners (including, in time, the GP commissioning consortia) should also find the QRP invaluable in holding to account the providers that they commission services from, and in improving their commissioning for quality.


About this document

This document presents the latest version of the QRP for this organisation. We create a new version each month as we update the data sources that underpin the profiles. NHS trusts can access their own profiles from September 2010 and lead PCT commissioners will have had access to relevant trust profiles from October 2010.

The information in the QRP is organised by the 16 essential outcomes of quality and safety. It includes the following components:

• Context information – which includes background information about a provider or location.

• Information about outcomes – this includes risk estimates for the essential standards of quality and safety and the data items that underpin the estimates. They are organised at section level (which group together a number of essential standards) and at individual outcome level (for each of the 16 key essential standards).

• Contextual risk estimates – these are risk estimates that reflect the types of health services provided, the make-up of the provider’s local population and the organisational context of the provider.


Guidance

We recommend that you refer to the following guidance documents when reviewing the QRP:

• Quality and Risk Profiles: How to use the QRP – information about how to interpret the information within a QRP.

• Quality and Risk Profiles: Data sources – a detailed listing of all of the quantitative data sources within the QRP, and information about the qualitative sources included.

• Quality and Risk Profiles: Statistical guidance – information about the statistical model and analytic methods we use to calculate risk estimates in respect of the essential standards of quality and safety. It is a technical guide and assumes some statistical knowledge.

Further help and support

If you have any queries or want to provide feedback about the contents of this QRP, please contact our Customer Services team by phone or email:

Telephone: 03000 616161

Email: [email protected]


Tips on finding your way round this documentIf you are looking at this document on screen in Acrobat Reader you can…

Jump to information on each outcome using the bookmarks panel

Jump to information on each outcome by clicking on the links in the contents page

Jump between sections and outcomes by clicking on any dial

The button to open bookmarks is normally on the left of the page, or you’ll find it in the “View” menu

L H


ContentsLocation and Regulated Activities

Context Information

Information Relevant to many Outcomes

Section Summary Of Underlying Outcomes

Section 1: Involvement and information

Outcome 1 (R17) Respecting and involving people who use services

Outcome 2 (R18) Consent to care and treatment

Section 2: Personalised care, treatment and support

Outcome 4 (R9) Care and welfare of people who use services

Outcome 5 (R14) Meeting Nutritional Needs

Outcome 6 (R24) Cooperating with other providers

Section 3: Safeguarding and safety

Outcome 7 (R11) Safeguarding people who use services from abuse

Outcome 8 (R12) Cleanliness and infection control

Outcome 9 (R13) Management of medicines

Outcome 10 (R15) Safety and suitability of premises

Outcome 11 (R16) Safety, availability and suitability of equipment

Section 4: Suitability of staffing

Outcome 12 (R21) Requirements relating to workers

Outcome 13 (R22) Staffing

Outcome 14 (R23) Supporting Staff

Section 5: Quality and management

Outcome 16 (R10) Assessing and monitoring the quality of service provision

Outcome 17 (R19) Complaints

Outcome 21 (R20) Records

Overall Contextual risk estimate Inherent Risk Situational Risk Population Risk Uncertainty Risk

Quality and Risk Profile (QRP) to support monitoring compliance of the NHS

2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 2 of 127

ProviderProvider Code Provider Name Registered5N2 Kirklees PCT 01/04/2010

Location and Regulated ActivitiesLocations Location ID Regulated ActivityBarton Rehabilitation Centre Dental Clinic, St Luke's Hospital, Huddersfield, HD4 5RQ

5N2X5 Treatment of disease, disorder or injury

Batley Heatlh Centre Dental Clinic, 130 Upper Commercial Street, Batley, WF17 5ED

5N223 Treatment of disease, disorder or injury

Beckside Court, Bradford Road, Batley, WF17 5PW

5N233 Family planning Nursing care Treatment of disease, disorder or injury

Broughton House Surgery, 20 New Way, Batley, WF17 5QT


Cleckheaton Health Centre Dental Clinic, Greenside, Cleckheaton, BD19 5AP


Fartown Health Centre Dental Clinic, Spaines Road, Huddersfield, HD2 3QA


Holme Valley Memorial Hospital Dental Clinic, Huddersfield Road, Holmfirth, HD9 3TS


Holme Valley Memorial Hospital, Huddersfield Road, Holmfirth, HD9 3TS

5N219 Surgical procedures Treatment of disease, disorder or injury

Laura Mitchell Health Centre Dental Clinic, Great Albion Street, Halifax, HX1 5ND




Location and Regulated ActivitiesLocations Location ID Regulated ActivityMoorfields Primary Care Centre, 11 Park Road, Huddersfield, HD4 5RX


Princess Royal Community Health Centre Dental Clinic, Greenhead Road, Huddersfield, HD1 4EW


The Whitehouse Centre, 23 New North Parade, Huddersfield, HD1 5JU

5N2XX Treatment of disease, disorder or injury

Todmorden Health Centre Dental Clinic, Lower George Street, Todmorden, OL14 5QG


Walk-in Centre, Dewsbury District Hospital, Dewsbury, WF13 4HS




Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5

Context InformationItem Reference

Data Source Item Description Data Value Impact Outcome

CDAO01 Care Quality Commission: Register of accountable officers at February 2011

Controlled Drugs Accountable Officer

This organisation's ControlledDrugs Accountable Officer is listed as Mr. Neill Mcdonald

-

NPSARMS01 National Patient Safety Agency: Risk Management Systems

NPSA Risk Management System as of 29th October 2010

The current local risk management system supplierfor NPSA Incident Reporting is Datix

-




Information Relevant to many OutcomesItem Reference Data Source Item Description Data Value Impact

Outcome NHSLA01 NHS Litigation Authority (NHS LA): Risk

Management Standards at 4th February 2011

Level achieved by trust Level 1 (Documenting Policy) achieved as at 20-Aug-08

Amber

STAFFSURCTX01

Care Quality Commission: Survey of NHSStaff 2009/2010

Key finding 1: Staff feeling satisfied with the quality of work and patient care they are able to deliver

This trust was better than average when compared to other trusts for this key finding.

Green

STAFFSURCTX02


Key Finding 34: Staff job satisfaction


Green

STAFFSURCTX03


Key Finding 36: Staff recommendation of the trust as a place to work or receive treatment


Green

STAFFSURCTX04


Key Finding 40: Percentage of staff experiencing discrimination at work in last 12 months

This trust were in the highest (best) 20% when compared to other trusts for this key finding

Green



A key to the dials in the QRP

Reducing risk of non-compliance Increasing risk of non-compliance

Some data is available,but it is not sufficient tocalculate a risk estimate.

There is no data availableto inform this outcome orgroup of outcomes.



Section Summary Of Underlying Outcomes

Section 1:Involvement and

Information

Section 2:Personalised Care,

Treatment and Support

Section 3:Safeguarding and Safety

Outcome 1(R17)

Outcome 2(R18)

Outcome 4(R9)

Outcome 5(R14)

Outcome 6(R24)

Outcome 7(R11)

Outcome 8(R12)

Outcome 9(R13)

Outcome10 (R15)

Outcome11 (R16)

Respecting and involving people who use services

Consent to care and treatment

Care and welfare of people who use

services

Meeting NutritionalNeeds

Cooperating with other providers

Safeguarding people who use services from

abuse

Cleanliness and infection control Mgmt of medicines

Safety and suitability of

premises

Safety, availability and suitability of

equipment

Section 4:Suitability of staffing

Section 5:Quality and Management

Outcome 12(R21)

Outcome 13(R22)

Outcome 14(R23)

Outcome 16(R10)

Outcome 17(R19)

Outcome 21(R20)

Requirements relating to workers Staffing Supporting Staff

Assessing and monitoring the

quality of service provision

Complaints Records




Outcome 1 (R17)Respecting and involving people who use services

Outcome 1 (R17)





Item ID

Description Data Source Time Period Start

Time Period End

Comparison with Expected

Value Numerator Value

Denominator Value

ExpectedValue

7518 PEAT scores for access andexternal areas - information - Data for HOLME VALLEY MEMORIAL HOSPITAL

National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010 26/03/2010 Similar to expected

Good NA NA NA

8042 The Trust ensures that patients are informed about the proposed uses of their personal information and theimportance of providing accurate information to NHSstaff. -

Department of Health, Information Governance Toolkit


Level 2 NA NA NA

8043 The Trust has effective procedures for ensuring thatdetailed questions, raised bypatients about how their information may be used, can be answered. -



Level 2 NA NA NA

8044 The Trust has appropriate procedures for recognising and responding to patient requests for access to their health records. -



Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

12192 NHS LA assessed outcome for Risk Management Standard Criterion 4.2 -

NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts


Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA




Level 1 Not Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

7532 PEAT score for Privacy and Dignity - modesty, dignity and respect - Data for HOLME VALLEY MEMORIAL HOSPITAL


04/01/2010 26/03/2010 Tending towards better than expected

Good NA NA NA

8041 The Trust ensures that patients are asked before their personal information is used outside of their care and that patients decisions to restrict disclosure of this information are respected. -



Level 3 NA NA NA

7531 PEAT score for Privacy and Dignity - confidentiality - Data for HOLME VALLEY MEMORIAL HOSPITAL


04/01/2010 26/03/2010 Much betterthan expected

Excellent NA NA NA




Outcome 2 (R18)Consent to care and treatment

Outcome 2 (R18)




Outcome 2 (R18)Consent to care and treatment

Item ID


TimePeriod End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA




Outcome 4 (R9)Care and welfare of people who use services

Outcome 4 (R9)





Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA

12211 NHS LA assessed outcome for Risk Management Standard Criterion 5.8 - Bestpractice - NICE, NCEs & national guidance -



Level 1 Achieved

NA NA NA

12213 NHS LA assessed outcome for Risk Management Standard Criterion 5.9 -Best practice - NSFs & High Level Enquiries -



Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue





NA NA NA

1268 Proportion of patients that spent less than four hours inA&E (all A&E/MIU/Wic (type1,2,3)) -

Department of Health, A &E Attendances and Performance (QMAE)


1 4693.00

4693.00 0.95




Outcome 5 (R14)Meeting nutritional needs

Outcome 5 (R14)





Item ID


Time Period End



Denominator Value

ExpectedValue

11248 PEAT score for Food and food services - availability ofequipment for measuring patients. - Data for HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA

11292 PEAT score for Food and food services - Existence of a trust nutritional screening group. - Data for HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA

11485 PEAT score for Food and food services - proportion of wards that operate a protected mealtime policy - Data for HOLME VALLEY MEMORIAL HOSPITAL



81%-100% NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11486 PEAT score for Food and food services - proportion of wards that are using a nutritional screening policy - Data for HOLME VALLEY MEMORIAL HOSPITAL



81%-100% NA NA NA

7523 PEAT score for food - menu,choice, availability, quality, quantity (portions), temperature, presentation, service and beverages - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA




Outcome 6 (R24)Cooperating with other providers

Outcome 6 (R24)




Outcome 6 (R24)Cooperating with other providers

Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA




Outcome 7 (R11) Safeguarding people who use services from abuse

Outcome 7 (R11)




Underlying Information for: Outcome 7 (R11)Safeguarding people who use services from abuse

Item ID


Time Period End



Denominator Value

ExpectedValue

12181 NHS LA assessed outcome for Risk Management Standard Criterion 3.2 - Safeguarding children -



Level 1 Achieved

NA NA NA





NA NA NA




Outcome 8 (R12) Cleanliness and infection control

Outcome 8 (R12)




Underlying Information for: Outcome 8 (R12)Cleanliness and infection control

Item ID


Time Period End



Denominator Value

ExpectedValue

11271 Key finding 20: Availability of hand washing materials -

Care Quality Commission, Survey of NHS Staff

28/08/2009 07/12/2009 Much worse than expected

Lowest (worst) 20%

NA NA NA

9678 PEAT score for infection control - proportion of applicable wards with adequate hand decontamination provision - Data for HOLME VALLEY MEMORIAL HOSPITAL



1 2.00 2.00 0.97

9682 PEAT score for infection Control - proportion of applicable wards with hand wash basins - Data for HOLME VALLEY MEMORIAL HOSPITAL



1 2.00 2.00 0.97





Item ID


Time Period End



Denominator Value

ExpectedValue

10037 Percentage score for site against National Specifications for Cleanliness of NHS - Data for HOLME VALLEY MEMORIAL HOSPITAL



0.92 92.00 100.00 0.93

11502 PEAT score for Trust Policy Information - Does the Trusthave clear, written cleaning arrangements and schedules? - Data for HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA

11503 PEAT score for Trust Policy Information - Are cleaning schedules publicly available on each ward and department? - Data for HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11504 PEAT score for Trust Policy Information - Does the hospital publicly display contact details of whom to contact in the event that facilities (including fixtures and fittings) are dirty? - Datafor HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA

11505 PEAT score for Trust Policy Information - Do the Trusts cleaning arrangements ensure that cleaning services (however and by whoever provided) are available 24 hours a day? - Data for HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA

11508 PEAT score for infection control - Does the Trusts hand hygiene policy promote hand hygiene at the point of care? - Data for HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11509 PEAT score for infection control - Does the Trusts hand hygiene policy explain when alcohol handrub is sufficient for hand hygiene and when soap and water hand washing must be performed? - Data for HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA

11510 PEAT score for infection control - Does the Trust have a structured hand hygiene audit program? - Data for HOLME VALLEY MEMORIAL HOSPITAL



Yes NA NA NA




Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA

12291 Findings at the latest Hygiene Code inspection or follow-up (2010/2011 programme) -

Care Quality Commission, Hygiene Code Inspection Outcomes


At last inspection 0 improvements were outstanding

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

7497 PEAT score for specific cleanliness (waste receptacles). - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

7498 PEAT score for toilet and bathroom cleanliness (excluding patient equipment and waste receptacles) - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

7500 PEAT score for toilet and bathroom cleanliness (wastereceptacles) - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

7510 PEAT score for environment- linen - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

7514 PEAT score for environment- waste handling - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

9670 PEAT score for specific cleanliness (all areas exceptpatient equipment and waste receptacles). - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

9671 PEAT score for specific cleanliness (patient equipment). - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

9672 PEAT score for toilet and bathroom cleanliness (Patient equipment) - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA




Outcome 9 (R13) Management of medicines

Outcome 9 (R13)




Underlying Information for: Outcome 9 (R13)Management of medicines

Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA





NA NA NA

12471 Does the NHS body have a fully accredited or nominated Local Security Management Specialist (LSMS) making adequate progress through the accreditation process? -

Counter Fraud and Security Management Service, Security Management Service compliance data


Fully accredited/nominated LSMS in the process

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

12472 Does the NHS body have a designated person to take a responsibility for security management matters as a Security Management Director (SMD) with voting board membership? -



SMD appointed with voting board membership

NA NA NA

12473 Does the NHS body have a designated person to promote security management measures as aNon - Executive Director (NED) with Specialist Responsibility for Security Issues? -



Non-Executive Director appointed

NA NA NA

12474 Has the Local Security Management Specialist (LSMS) has submitted an annual workplan of projected work for that financial year? -



Information submitted where applicable

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

12475 Does the Local Security Management Specialist (LSMS) sufficiently attend the CFSMS quarterly regional LSMS meetings? -



Meetings sufficiently attended when applicable

NA NA NA




Outcome 10 (R15) Safety and suitability of premises

Outcome 10 (R15)




Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID


Time Period End



Denominator Value

ExpectedValue

7508 PEAT score for environment- toilet environment. - Data for HOLME VALLEY MEMORIAL HOSPITAL



Good NA NA NA

7517 PEAT scores for access andexternal areas - car parking - Data for HOLME VALLEY MEMORIAL HOSPITAL



Acceptable NA NA NA

7529 PEAT score for privacy and dignity - toilets and bathrooms - Data for HOLME VALLEY MEMORIAL HOSPITAL



Good NA NA NA






Time Period End



Denominator Value

ExpectedValue

7530 PEAT score for privacy and dignity - privacy - Data for HOLME VALLEY MEMORIAL HOSPITAL



Good NA NA NA

7550 The organisation has a Board Approved Estates Development Strategy which is currently being implemented to improve the quality, efficiency and effectiveness of the estates and facilities services. -

Department of Health, Estates Return Information Collection (ERIC)


Y NA NA NA

8532 Outcome of trusts risk assessment of fire safety -

Department of Health, Annual Statement of Fire Safety


Developed programme towork to reduce risks

NA NA NA

8533 The trust had an enforcement action issued by the Fire and Rescue Service Authority. -



No enforcement, no ongoing enforcement

NA NA NA

8534 The trust achieved compliance with Departmentof Health Fire Safety Policy -



Compliant NA NA NA






Time Period End



Denominator Value

ExpectedValue

9492 Ratio of the number of fires recorded as required by FIRECODE to the gross internal floor area -



0 0.00 22474.00 0.00




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA






Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA





NA NA NA





NA NA NA






Time Period End



Denominator Value

ExpectedValue





NA NA NA





NA NA NA





NA NA NA






Time Period End



Denominator Value

ExpectedValue

7511 PEAT score for environment- dÃ©cor - Data for HOLME VALLEY MEMORIAL HOSPITAL



Good NA NA NA

7512 PEAT score for environment- lighting - Data for HOLME VALLEY MEMORIAL HOSPITAL



Good NA NA NA

7547 Proportion of disabled car parking spaces available to total number of car parking spaces available for use. -



0.073 45.00 613.00 0.05

9493 Ratio of the number of false fires alarms not normally reported under FIRECODE to the gross internal floor area -



0 8.00 22474.00 0.00






Time Period End



Denominator Value

ExpectedValue

7507 PEAT score for Environment- bathroom environment - Data for HOLME VALLEY MEMORIAL HOSPITAL


04/01/2010 26/03/2010 Much better than expected

Excellent NA NA NA

7509 PEAT score for environment- maintenance - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

7513 PEAT score for environment- tidiness - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

7519 PEAT score for access and external areas - signage (internal and external) - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA






Time Period End



Denominator Value

ExpectedValue

7520 PEAT score for access and external areas - facilities for people with disabilities - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

7528 PEAT score for privacy and dignity - sleeping accommodation - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

9052 PEAT score for environment- provision of outdoor patientrecreational areas - Data forHOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA

9673 PEAT score for environment- furnishings - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA






Time Period End



Denominator Value

ExpectedValue

9674 PEAT score for environment- floors - Data for HOLME VALLEY MEMORIAL HOSPITAL



Excellent NA NA NA




Outcome 11 (R16) Safety, availability and suitability of equipment

Outcome 11 (R16)




Underlying Information for: Outcome 11 (R16)Safety, availability and suitability of equipment

Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA





NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue





NA NA NA





NA NA NA





NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue





NA NA NA




Outcome 12 (R21) Requirements relating to workers

Outcome 12 (R21)




Underlying Information for: Outcome 12 (R21)Requirements relating to workers

Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA





NA NA NA

11290 Key finding 39: Staff believing trust provides equal opportunities for career progression or promotion -



Highest (best)20%

NA NA NA




Outcome 13 (R22) Staffing

Outcome 13 (R22)




Underlying Information for: Outcome 13 (R22)Staffing

Item ID


Time Period End



Denominator Value

ExpectedValue

7067 Three month vacancy rate for all scientific, therapeutic & technical staff -

Information Centre for Health & Social Care (IC), Vacancysurvey


0 0.00 100.00 0.01

7068 Three month vacancy rate for qualified Allied Health Professionals -



0 0.00 100.00 0.01

7070 Three month vacancy rate for occupational therapy staff -



0 0.00 100.00 0.01

7071 Three month vacancy rate for physiotherapy staff -



0 0.00 100.00 0.00





Item ID


Time Period End



Denominator Value

ExpectedValue

7079 Three month vacancy rate for speech & language therapy staff -



0 0.00 100.00 0.00

9792 Three month vacancy rate for district nurses -



0 0.00 100.00 0.01

9793 Three month vacancy rate for health visitors -



0 0.00 100.00 0.01

9794 Three month vacancy rate for qualified school nurses -



0 0.00 100.00 0.00

9796 Three month vacancy rate for unqualified nursing, midwifery & health visiting staff -



0 0.00 100.00 0.00





Item ID


Time Period End



Denominator Value

ExpectedValue

9800 Three month vacancy rate for registered pharmacists -



0 0.00 100.00 0.01

11348 Three month vacancy rate for qualified nursing, midwifery & health visiting staff -



0 0.00 100.00 0.01

7065 Three month vacancy rate for all non-medical staff -



0 0.00 100.00 0.00

11260 Key finding 9: Staff working extra hours -



Below (better than) average

NA NA NA





Outcome 14 (R23)





Item ID


Time Period End



Denominator Value

ExpectedValue

12479 The proportion of published Violence Against Staff (VAS) figures reported to Physical Assaults Reporting System (PARS) for most recent year ending 31st March? -


01/04/2009 31/03/2010 Worse than expected

Less than 75% assaults reported where applicable

NA NA NA

7554 Proportion of all staff employed by the NHS Trust that required and received customer care training in thereporting year. -


01/04/2009 31/03/2010 Tending towards worse than expected

0 0.00 100.00 0.44

8038 The Trusts staff induction procedures effectively raise the awareness of information governance. -



Level 3 NA NA NA

8039 The Trust assesses staff training needs and ensures job/role specific information governance training is provided to all staff. -



Level 3 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

10131 The Trust has ensured that its RA managers, agents and sponsors have sufficientknowledge and skills (inc. latest software, operational process guidance etc) to discharge its RA responsibilities -



Level 3 NA NA NA

11247 Proportion of available working time lost to sicknessabsence -

Information Centre for Health & Social Care (IC), NHS Staff Sickness Absence


0.046 4.63 100.00 0.04

11262 Key finding 11: Staff feeling there are good opportunitiesto develop their potential at work -



Average NA NA NA

11276 Key finding 25: Staff experiencing physical violence from staff in last 12 months -



Average NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11289 Key finding 38: Staff having equality and diversity training in last 12 months -



Average NA NA NA




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA





NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA




Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue




Level 1 Achieved

NA NA NA





NA NA NA





NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue





NA NA NA





NA NA NA





NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

12478 Have Violence Against Staff (VAS) statistics been reported to NHS SMS for most recent year ending 31st March? -




NA NA NA

11256 Key finding 5: Quality of job design (clear content, feedback and staff involvement) -



Above (betterthan) average

NA NA NA

11257 Key finding 6: Work pressure felt by staff -




NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11263 Key finding 12: Staff receiving job-relevant training, learning or development in last 12 months -




NA NA NA

11264 Key finding 13: Staff appraised in last 12 months -




NA NA NA

11265 Key finding 14: Staff having well structured appraisals in last 12 months -




NA NA NA

11266 Key finding 15: Staff appraised with personal development plans in last 12months -




NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11267 Key finding 16: Support fromimmediate managers -




NA NA NA

11268 Key finding 17: Staff having health and safety training in last 12 months -




NA NA NA

11270 Key finding 19: Staff suffering work-related stressin last 12 months -




NA NA NA

11278 Key finding 27: Staff experiencing harassment, bullying or abuse from staff in last 12 months -




NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11279 Key finding 28: Perceptions of effective action from employer towards violence and harassment -




NA NA NA

11282 Key finding 31: Staff reporting good communication between senior management and staff -




NA NA NA

11283 Key finding 32: Staff agreeing that they understand their role and where it fits in -




NA NA NA

11254 Key finding 3: Staff feeling valued by their work colleagues -



Highest (best)20%

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11258 Key finding 7: Staff working in a well structured team environment -



Highest (best)20%

NA NA NA

11259 Key finding 8: Quality of work-life balance -



Highest (best)20%

NA NA NA

11261 Key finding 10: Staff using flexible working options -



Highest (best)20%

NA NA NA

11275 Key finding 24: Staff experiencing physical violence from patients/relatives in last 12 months -



Lowest (best)20%

NA NA NA

11277 Key finding 26: Staff experiencing harassment, bullying or abuse from patients/relatives in last 12 months -



Lowest (best)20%

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11281 Key finding 30: Staff feeling pressure to attend work when feeling unwell in last 3months -



Lowest (best)20%

NA NA NA





Outcome 16 (R10)





Item ID


Time Period End



Denominator Value

ExpectedValue

8254 Consistency of reporting to the National Reporting Learning System (NRLS) -

National Patient SafetyAgency (NPSA), National Reporting Learning System (NRLS)

01/10/2009

31/03/2010 Similar to expected

4 months of reporting

NA NA NA

10515 Rate of reporting per 1,000 bed days to the National Reporting Learning System (NRLS) for Primary Care Trusts with inpatient provision -

National Patient SafetyAgency (NPSA), National Reporting Learning System (NRLS)

01/10/2009


0.019 18.88 1000.00 0.03

11274 Key finding 23: Fairness andeffectiveness of procedures for reporting errors, near misses or incidents -


28/08/2009


Average NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue



01/04/2008


Level 1 Achieved

NA NA NA



01/04/2008


Level 1 Achieved

NA NA NA



01/04/2008



NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue



01/04/2008


Level 1 Achieved

NA NA NA



01/04/2008


Level 1 Achieved

NA NA NA



01/04/2008


Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

12203 NHS LA assessed outcome for Risk Management Standard Criterion 5.2 - Incident reporting -


01/04/2008


Level 1 Achieved

NA NA NA



01/04/2008



NA NA NA



01/04/2008


Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue



01/04/2008



NA NA NA

12211 NHS LA assessed outcome for Risk Management Standard Criterion 5.8 - Bestpractice - NICE, NCEs & national guidance -


01/04/2008


Level 1 Achieved

NA NA NA

12213 NHS LA assessed outcome for Risk Management Standard Criterion 5.9 -Best practice - NSFs & High Level Enquiries -


01/04/2008


Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

12336 Compliance with Department of Health central returns of data deadlines -

Department of Health, Central Returns - Timeliness ofReturns

01/04/2009


0.063 3.00 48.00 0.02

12376 Proportion of alerts acknowledged within deadline out of total number of alerts issued to the organisation -

National Patient SafetyAgency (NPSA), Central Alerting System

01/02/2010


0.87 120.00 138.00 0.90

12357 Proportion of alerts completed out of total number of alerts issued and due for completion within the time-period. -

National Patient SafetyAgency (NPSA), Central Alerting System

01/08/2009

14/02/2011 Tending towards better than expected

1 150.00 150.00 0.98

11273 Key finding 22: Staff reporting errors, near misses or incidents -


28/08/2009

07/12/2009 Much better than expected

Highest (best)20%

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

11284 Key finding 33: Staff able to contribute towards improvements at work -


28/08/2009

07/12/2009 Much better than expected

Highest (best)20%

NA NA NA





Outcome 17 (R19)





Item ID


Time Period End



Denominator Value

ExpectedValue

12204 NHS LA assessed outcome for Risk Management Standard Criterion 5.2 - Raising concerns -


01/04/2008


Level 1 Achieved

NA NA NA

12205 NHS LA assessed outcome for Risk Management Standard Criterion 5.3 - Complaints -


01/04/2008


Level 1 Achieved

NA NA NA



01/04/2008


Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue



01/04/2008



NA NA NA



01/04/2008


Level 1 Achieved

NA NA NA




Outcome 21 (R20)Records

Outcome 21 (R20)





Item ID


Time Period End



Denominator Value

ExpectedValue

8045 The trust has established appropriate confidentiality audit procedures in line withthe requirements of the National Programme for IT. -


01/04/2009

31/03/2010 Worse than expected

Level 1 NA NA NA

8027 The Trust has adequate governance in place to support the current and evolving Information Governance agenda. -


01/04/2009


Level 3 NA NA NA

8028 How would you assess yourTrustâ€™s ability to access expertise across the Confidentiality & Data Protection Assurance agenda? -


01/04/2009


Level 3 NA NA NA

8029 How would you assess yourTrustâ€™s ability to access expertise across the Information Security agenda? -


01/04/2009


Level 2 NA NA NA

8030 How would you assess yourTrustâ€™s ability to access expertise across the Information Quality and Records Management Agenda? -


01/04/2009


Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8031 The Trust has in place a comprehensive Information Governance Policy and associated Strategy and Improvement Plans all signed off by the Board. -


01/04/2009


Level 3 NA NA NA

8032 The Trust has up to date and tested business continuity plans for all critical infrastructure components and core information systems. -


01/04/2009


Level 2 NA NA NA

8033 The Trust has in place a comprehensive Information Lifecycle Management (ILM) Policy and associatedStrategy and Improvement Plans all signed off by the Board -


01/04/2009


Level 2 NA NA NA

8035 The Trust ensures that staff and those working on behalfof the Trust comply with the terms and conditions set outon the RA01 form. -


01/04/2009


Level 3 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8036 The Trust ensures that it has formal contractual arrangements that include compliance with informationgovernance requirements, with all contractors and support organisations. -


01/04/2009


Level 2 NA NA NA

8037 The Trust ensures that all individuals carrying out work on behalf of the Trust have employment contracts which require compliance with information governancestandards. -


01/04/2009


Level 3 NA NA NA

8040 The Trust has a Confidentiality Code of Conduct that provides staff with clear guidance on the disclosure of patient personal information. -


01/04/2009


Level 3 NA NA NA

8046 The trust has agreed protocols governing the sharing of patient-identifiable information with other organisations where this is required. -


01/04/2009


Level 3 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8048 The Trust complies with data protection requirements in respect of transfers of personal data about patients or staff to countries outside of the European Economic Area (EEA). -


01/04/2009


Level 3 NA NA NA

8049 The Trust ensures that all new processes, software and hardware comply with confidentiality and data protection requirements. -


01/04/2009


Level 2 NA NA NA

8050 The Trust has a formal information security risk assessment and management programme that is implemented and regularly reviewed. -


01/04/2009


Level 2 NA NA NA

8051 The Trust have documentedand accessible information security event reporting, investigation and resolution procedures in place that areexplained to staff. -


01/04/2009


Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8052 The Trust has established business processes that ensure all staff smartcards and access profiles issued are appropriate and satisfy their obligations as Registration Authorities (RAs). -


01/04/2009


Level 2 NA NA NA

8054 The Trust ensures that the Operating and Application and information systems under its control support appropriate access control functionality. -


01/04/2009


Level 2 NA NA NA

8055 Defined, documented and agreed access rights for all users of Trust information systems and services available. -


01/04/2009


Level 2 NA NA NA

8056 The Trust has established aregister of all its major information assets and assigned responsibility or â€˜ownershipâ€™ for each. -


01/04/2009


Level 2 NA NA NA

8057 The Trust ensures that digital information shared with other organisations is secured in transit. -


01/04/2009


Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8058 The Trust has adequate procedures in place to ensure the availability of information processing facilities, communications services and data. -


01/04/2009


Level 2 NA NA NA

8059 The Trust has procedures inplace to prevent informationprocessing being interrupted or disrupted through equipment failure, environmental hazard or human error. -


01/04/2009


Level 2 NA NA NA

8060 The Trust ensures that its Information systems are capable of the rapid detection, isolation and removal of malicious code and unauthorised mobile code. -


01/04/2009


Level 3 NA NA NA

8061 The Trust has in place appropriate procedures for ensuring that the development and introduction of any new local information systems and support are conducted in a secure and structured manner. -


01/04/2009


Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8062 The Trust has appropriate procedures in place to ensure that communication networks under the Trustâ€™s control operate in a secure manner. -


01/04/2009


Level 2 NA NA NA

8063 The Trust has appropriate procedures for ensuring thatmobile computing and teleworking are conducted in a secure manner. -


01/04/2009


Level 2 NA NA NA

8065 The Trust has a strategy to ensure the correct NHS number is recorded for eachactive patient and that it is used routinely in clinical communications. -


01/04/2009


Level 2 NA NA NA

8067 The Trust has trust-wide, multi-professional audit of clinical record keeping standards, including accuracy, for all professional groups in all specialties. -


01/04/2009


Level 2 NA NA NA

8069 The Trust has robust procedures and processes for all data collection activities across the Trust. -


01/04/2009


Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8072 The Trust has procedures inplace to ensure that when new services are provided or where changes within thesystem are made, that these do not adversely impact on information quality. -


01/04/2009


Level 2 NA NA NA

8073 The Trust ensures that NHSstandard definitions, values and validation programmes are incorporated within key systems and that local documentation is updated as standards develop. -


01/04/2009


Level 2 NA NA NA

8074 The Trust use external data quality reports for monitoring and improving quality. -


01/04/2009


Level 2 NA NA NA

8076 The Trust has documented procedures for using both local and national benchmarking to identify possible data quality issues and to analyse trends over time to ensure any issues are investigated. -


01/04/2009


Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8081 The Trust has (or access) a formal, targeted training programme for all staff involved in the collection and management of patient-related data covering the operation of key systems. -


01/04/2009


Level 2 NA NA NA

8083 The Trust has sufficient governance processes in place to ensure adherence to the principles enshrined in the Code of Conduct for Payment by Results. -


01/04/2009


Level 2 NA NA NA

8084 The Trust has documented and implemented procedures for the creation and filing of electronic corporate records to enable efficient retrieval and effective records management. -


01/04/2009


Level 2 NA NA NA

8085 The Trust have documentedand implemented procedures for the creation, filing and tracking/tracing of paper corporate records to enable efficient retrieval andeffective records management. -


01/04/2009


Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

8086 The Trust has publicly available documented and implemented procedures to ensure compliance with the Freedom Of Information Act2000. -


01/04/2009


Level 2 NA NA NA

8087 The Trust has carried out an audit of its corporate records and information as part of the records lifecycle management strategy. -


01/04/2009


Level 2 NA NA NA

10132 The Trust have a Board level Senior Information Risk Owner (SIRO) who takes ownership of the Trustâ€™s information risk policy -


01/04/2009


Level 2 NA NA NA

10133 The Trust ensures that Registration Authority equipment (hardware and software) and consumables meet current specifications, is adequately maintained and securely stored -


01/04/2009


Level 2 NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

10134 The PCT has established working arrangements with its main commissioning partners to develop processes to assure itself ofthe validity of the trustsâ€™ data. -


01/04/2009


Level 2 NA NA NA

10135 The PCT has engaged fully with Audit Commissions Payment by Results (PbR) data assurance framework, in accordance with the requirements of the Audit Commission and NHS Connecting for Health. -


01/04/2009


Level 2 NA NA NA

12167 NHS LA assessed outcome for Risk Management Standard Criterion 1.8 - Clinical records management -

NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary CareTrusts

01/04/2008


Level 1 Achieved

NA NA NA





Item ID


Time Period End



Denominator Value

ExpectedValue

12194 NHS LA assessed outcome for Risk Management Standard Criterion 4.4 - Clinical record-keeping standards -

NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary CareTrusts

01/04/2008



NA NA NA

8047 The trust has put in place safe-haven procedures for all routine flows of patient personal information to the organisation. -


01/04/2009

31/03/2010 Tending towards better than expected

Level 3 NA NA NA




Risk Profile : Inherent, Situational, Population and Uncertainty risk

Overall Contextual risk estimate

Inherent RiskThe risk attributable to an organisation by virtue of its care case mix

Situational Risk The risk attributable to the care provider by virtue of its organisational context

Population Risk

Features in the local population that have been shown to affect care outcomes or access to care

Uncertainty Risk Assessment of the completeness of population, situational and inherent risk




Underlying information: Inherent Risk

Item Description Data Source RationaleTime Period Value

IRADM001

An organisation's ratio of elective to nonelective admissions. This indicator

separates out specialist from non-specialist acute hospitals.

Hospital Episode Statistics (HES)

Elective procedures have been shown to be less risky than nonelective ones as elective

patients are more likely to be in better condition when admitted,

be treated by a more experienced physician and

have higher long term survival rates.

01/10/2009-

30/09/2010

Not Applicable

IRHRP001 The number of children's (0-17) admissions as a proportion of total

admissions. This indicator is a member of the "high risk patients" suite of indicators and should be considered in conjunction with

IRHRP001-IRHRP003.


Hospitals without dedicated paediatric facilities should only admit children as day cases or

one night surgical care. Children under three years of age must only be accepted in an inpatient or outpatient unit with full paediatric nursing and

medical staff

01/10/2009-

30/09/2010

Not Applicable






IRHRP002 The number of admissions for trauma to head, thorax and abdomen as a proportion of total admissions. This

indicator is a member of the "high risk patients" suite of indicators and should

be considered in conjunction with IRHRP001-IRHRP003.


Trauma injuries are one of the leading causes of death and

secondary morbidity in western societies. Additionally, these injuries are very difficult to

diagnose, and often require prompt treatment, and thus patients with head, thorax or

abdomen injuries are considered to be high risk.

01/10/2009-

30/09/2010

Not Applicable

IRHRP003 The number of admissions by transfer as a proportion of total admissions.

This indicator is a member of the "highrisk patients" suite of indicators and should be considered in conjunction

with IRHRP001-IRHRP003.


Acute interhospital transfer is associated with adverse clinical

outcomes in critically ill patients. These include: delay in admission to ICU; prolonged stay in ICU when compared to

non-transferred patients; increased mortality and morbidity and adverse

psychological effects during transfer.

01/10/2009-

30/09/2010

Not Applicable






IRMAT001 The number of caesarean births (OPCS = R17.1, R17.2, R17.8, R17.9, R18.1, R18.2, R18.8, R18.9, R25.1, R25.2) as a proportion of total births.

This indicator is a member of the "maternity" suite of indicators and

should be considered in conjunction with IR


Birth by Caesarean section has been shown to have negative

clinical outcomes on both mother and offspring. Repeat

elective caesarean birth is associated with an increase in the risk of complications such

as bleeding, the need for blood transfusion, infecection,

damage to the bladder and bowel, and clots in teh veins of

the legs. Babies born by caesarean may develop some difficulties with breathing and may need to spend time in a

special care nursery.

01/10/2009-

30/09/2010

Not Applicable

IRMAT002 The number of multiple births (ICD10 =Z37.2, Z37.3, Z37.4, Z37.5, Z37.6,

Z37.7) as a proportion of total births. This indicator is a member of the "maternity" suite of indicators and

should be considered in conjunction with IRMAT001-IRMAT004.


Multiple births are associated with decreased birthweight, andincreased perinatal & neo-natal

mortality. Children from multiple pregnancies have a

higher rate of permanent physical and mental disabilities

than do singletons.

01/10/2009-

30/09/2010

Not Applicable






IRMAT003 Number of high risk births (ICD10 = Z35) as a proportion of total births. This indicator is a member of the "maternity" suite of indicators and



The provision of effective care to patients whose pregnancies are categorised as high risk;

Women diagnosed with a high-risk pregnancy may need the expert advice and care of a

perinatologist. A woman with a high-risk pregnancy will need

closer monitoring than the average pregnant woman, and the fetus may be at higher risk of stillbirth, premature birth, or

planned or emergency caesarian birth.

01/10/2009-

30/09/2010

Not Applicable

IRMAT004 The number of birth to mothers aged 35+ as a proportion of all births. This

indicator is a member of the "maternity" suite of indicators and


Information Centre for Health& Social Care (IC), Hospital

Episode Statistics (HES)

Increased maternal age is associated with increased risk

of fetal death, birth abnormalities and

complications during gestation.

01/10/2009-

30/09/2010

Not Applicable






IRMHI001 The number of mental health staff whoreported in the NHS staff survey that they have been a victim of violence or

witnessed violence toward patients.

Care Quality Commission, NHS Staff Survey

Threats of violence and actual violence against staff and

patients are highly prevalent and increasing in the

psychiatric population. Patients who exhibit violent behaviour

are more difficult to treat effectively.

2009/10 Not Applicable

IROCC001

The number of occupied beds over thetotal number of available beds at a

care provider.

Department of Health, Hospital Activity Statistics

A target occupancy level of 85% has been suggested as the recommended balance

between unused bed capacity and efficient inpatient flow.

01/04/2009-

31/03/2010

Not Applicable

IRVOL001 Trusts with greater than 200 elective surgical cases per annum (OPCS procedure codes K43-46) are less risky than those with less than this

number. This indicator is a member of the "volume" suite of indicators and should be considered in conjunction

with


There is a relationship between volume and clinical outcome with higher volumes being

associated with better clinical outcomes.

01/10/2009-

30/09/2010

Not Applicable






IRVOL002 Trusts that perform this procedure withgreater than 200 beds are less risky

than those with less than this number. This indicator is a member of the

"volume" suite of indicators and shouldbe considered in conjunction with

IRVOL001-IRVOL008.

Hospital Episode Statistics (HES) and Department of Health, Hospital Activity

Statistics



01/04/2009-

31/03/2010

Not Applicable

IRVOL003 Trusts with greater than 400 elective surgical cases per annum (OPCS procedure codes K49-50, K75) are

less risky than those with less than thisnumber. This indicator is a member of

the "volume" suite of indicators and should be considered in conjunction




01/10/2009-

30/09/2010

Not Applicable

IRVOL004 Trusts with greater than 109 elective surgical cases per annum (OPCS procedure code J18) are less risky

than those with less than this number. This indicator is a member of the

"volume" suite of indicators and shouldbe considered in conjunction with

IRVO




01/10/2009-

30/09/2010

Not Applicable






IRVOL005 Trusts treating more than 73 elective diagnostic (i.e. without therapeutic surgery) cases per annum (ICD10

diagnosis codes K80-82) are less riskythan those with less than this number.

This indicator is a member of the "volume" suite of indicators and sho




01/10/2009-

30/09/2010

Not Applicable

IRVOL006 Trusts with 3.5 or more elective surgical cases per annum are less risky than those with less than this

number. This indicator is a member of the "volume" suite of indicators and should be considered in conjunction

with IRVOL001-IRVOL008.




01/10/2009-

30/09/2010

Not Applicable

IRVOL007 Trusts with more than 17 elective therapeutic surgical cases per annum (ICD10 diagnosis codes C18-20 with

therapeutic surgery) are less risky thanthose with less than this number. This indicator is a member of the "volume"

suite of indicators and should




01/10/2009-

30/09/2010

Not Applicable






IRVOL008 Trusts with more than 50 elective surgical cases per annum (ICD-10 = I71.3, I71.4 OPCS = L18.3, L18.4, L18.5, L18.6, L18.8, L18.9, L19.3,

L19.4, L19.5, L19.6, L19.8, L19.9) are less risky than those with less than thisnumber. This indicator is a member o




01/10/2009-

30/09/2010

Not Applicable




Underlying information: Situational Risk

Item Description Data Source Rationale Time Period ValueSRCCC001

The number of finished consultant episodes coded as "unsafe to audit" from the annual audit of the Payment byResults programme. One of the "clinical coding comparator" suite of indicators and should be considered in conjunctionwith the indicators SRCCC0

Audit Commission, Payment by Results (PbR) Data Assurance Framework

Audits are an effective way to monitor internal governance structures and thus trusts that perform poorly on such assessments reflect ineffective information management and are considered to be more risky.

01/04/2009 - 31/03/2010

Not Applicable

SRCCC002

The number of HES coding errors as a proportion of all HES episodes. One of the "clinical coding comparator" suite of indicators and should be considered in conjunction with the indicators SRCCC001.


Internal governance structures aim to successfully manage risks to performance, and through organisational learning drive improvements in quality. However, ineffective governance procedures result in performance influencing risks, and thus unintended cons

01/10/2009 - 30/09/2010

Not Applicable





Item Description Data Source Rationale Time Period ValueSRRMG001

Assesses healthcare organisations against risk management standards. This is one of the "risk management" suite of indicators and should be considered in conjunction with the indicators SRRMG001-SRRMG003.

NHS Litigation Authority (NHS LA), Risk Management Standards

Organisations with strong and proactive risk management tactics are considered to be less risky.

28/09/2007 - 25/11/2010

Somewhat likely tobe risky

SRRMG002

As organisations request what level they want to be assessed for, this indicator compares the level requested against the "risk management" score achieved. This is one of the "risk management" suite of indicators and should be considered in conjunction wi

NHS Litigation Authority (NHS LA), Risk Management Standards

Organisations with strong and proactive risk management tactics are considered to be less risky.

28/09/2007 - 25/11/2010

Unlikely to be risky

SRRMG003

Occurs after an organisation that has declared compliant against all registration requirements has a condition placed against them. This is one of the "risk management" suite of indicators and should be considered in conjunction with the indicators SRRMG0

Care Quality Commission

Organisations that declare compliant while not being so (either knowingly or unknowingly) represent a risk in that they either have poor governance frameworks or are intentionally trying to game the system.

Not Applicable





Item Description Data Source Rationale Time Period ValueSRWRN001

Uses selected questions from the NHS Staff Survey to calculate a job satisfaction key score. This is one of the"work environment" suite of indicators and should be considered in conjunctionwith the indicators SRWRN001- SRWRN004.

Care Quality Commission, Periodic Review

Organisational culture and environment have been identified as weak signals of risk and the multiplicationof several weak signals canbuild to provide a high degree of risk within an organisation.

2009/10 Unlikely to be risky

SRWRN002

Three month vacancies for nurses expressed as a percentage of three month vacancies plus nurses in post. This is one of the "work environment" suite of indicators and should be considered in conjunction with the indicators SRWRN001- SRWRN004.

Information Centre for Health & Social Care (IC), Vacancies survey

High vacancy rates may be indicative of various unfavourable staffing conditions such as poor working conditions or poor management.


SRWRN003

Three month vacancies for doctors expressed as a percentage of three month vacancies plus doctors in post. This is one of the "work environment" suite of indicators and should be considered in conjunction with the indicators SRWRN001- SRWRN004.








Item Description Data Source Rationale Time Period ValueSRWRN004

Three month vacancies for specialists expressed as a percentage of three month vacancies plus specialists in post. One of the "work environment" suite of indicators and should be considered in conjunction with the indicators SRWRN001- SRWRN004.



Likely to be risky




Underlying information: Population Risk

Item Description Data Source Rationale Time Period ValuePRETH001 The number of different

ethnicities represented in a community.

Office for National Statistics, 2001 Census

Ethnic minorities have been shown to have a higher prevalence of certain diseases (coronary diseases, diabetes and cardiovascular diseases), face greater access challenges and be more likely to experience communication deficits,longer waiting times and h

2001 (released Deember 2009)

Somewhat likely to be risky

PRICM001 The proportion of patients admitted to hospital with cancer (AS, ICD-10 = C00-D48). This indicator is a member of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.

Quality Outcomes Framework

There is a strong association between comorbidity and the volume and variety of health care services that are used. Persons with more than one chronic condition reported having used more services, in terms of volume and variety, than those with only one condition.

01/04/2008 - 31/03/2009






Item Description Data Source Rationale Time Period ValuePRICM002 The proportion of patients

admitted to hospital with chronic renal failure (AS, ICD-10 = N18). This indicator is a member of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.



01/04/2008 - 31/03/2009


PRICM003 The proportion of patients admitted to hospital with COPD (AS, ICD-10 = J43, J44). This indicator is a member of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.



01/04/2008 - 31/03/2009

Not Applicable






admitted to hospital with coronary heart disease (AS, ICD-10 = I25). This indicator is a member of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.



01/04/2008 - 31/03/2009

Likely to be risky

PRICM005 The proportion of patients admitted to hospital with diabetes (AS, ICD-10 = E10-E14). This indicator is a member of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.



01/04/2008 - 31/03/2009







admitted to hospital with heart failure (AS, ICD-10 = I50). This indicator is a member of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.



01/10/2009 - 30/09/2010

Not Applicable

PRICM007 The proportion of patients admitted to hospital with pneumonia (AS, ICD-10 = J12 - J18). This indicator is amember of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.



01/10/2009 - 30/09/2010

Not Applicable






admitted to hospital with fracture of the neck of femur (AS, ICD-10 = S72.0). This indicator is a member of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.



01/10/2009 - 30/09/2010

Not Applicable

PRICM009 The proportion of patients admitted to hospital with a stroke (AS, ICD-10 = 160-164). This indicator is a member of the "co-morbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.



01/04/2008 - 31/03/2009






Item Description Data Source Rationale Time Period ValuePRIMD001 A composite domain

deprivation score relating in the main to income and material deprivation.

Department for Communities and Local Government

Patients from more deprived areas are more likely to have more risk factors, complications and co-morbidities.

Likely to be risky

PRLDI001 The proportion of patients admitted to hospital who have autism or Down's syndrome (AS, ICD-10 = F84.0, F84.1, F84.5, Q90).


Barriers to providing a good service to this group include; poor communication; GPâ€™s requiring specialists knowledge of health needs and diagnostic procedures relating to people with learning disabilities; lack of adequate consultation time. Screening programmes are also challenging for individuals with learningdisabilities, especially for breast and cervical cancer.

01/10/2009 - 30/09/2010

Not Applicable





Item Description Data Source Rationale Time Period ValuePRLDI002 The proportion of the PCT

population who have a learning disability (PCT).

Quality and Outcomes Framework

Barriers to providing a good service to this group include; poor communication; GPâ€™s requiring specialists knowledge of health needs and diagnostic procedures relating to people with learning disabilities; lack of adequate consultation time. Screening programmes are also challenging for individuals with learningdisabilities, especially for breast and cervical cancer.

01/04/2008 - 31/03/2009






Item Description Data Source Rationale Time Period ValuePRLTC001 The proportion of patients

admitted to hospital with epilepsy (AS, ICD-10 = G41,G41). This indicator is a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRLTC001-PRLTC010.


Sudden unexpected death is substantially more common in people with epilepsy than in the general population. People withepilepsy are at a significantly higher risk from suicide and suffer seizure attributed fractures of the spine, forearms, femurs, lowerlegs and feet and toes at higher rate than the general population.

01/04/2008 - 31/03/2009


PRLTC002 The proportion of patients admitted to hospital with asthma (AS, ICD-10 = J45, J46). This indicator is a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRLTC001-PRLTC010.


Asthma is a leading cause of hospital admission for children aged 3-12. Timely and effective outpatient carecan substantially reduce hospitalisations for everyone with asthma. Children from disadvantaged socio-economic groups are over represented in the hospitalised population.

01/04/2008 - 31/03/2009







admitted to hospital as a result of a severe allergic reaction (AS, ICD-10 = T78.0, T78.2). This indicator is a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicator


Increasing prevalence of severe anaphylactic reaction especially foodmediated anaphylaxis. Peanuts, tree nuts, fish,and shellfish the most often implicated agents.

01/10/2009 - 30/09/2010

Not Applicable

PRLTC004 The proportion of patients admitted to hospital with inflammatory intestinal disease (AS, ICD-10 = K50-K52, K58). This indicator is amember of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRL


Inflammatory intestinal disease present in 22%of the general population. It is often associated with secondary morbidities such as gastrointestinalcancer, osteoporosis and depression.

01/10/2009 - 30/09/2010

Not Applicable






admitted to hospital with Lupus erythematosus (AS, ICD-10 = L93). This indicatoris a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRLTC001-PRLTC010.


Women with systemic lupus erythematosus (SLE) have a higher frequency of coronary heart disease and exhibit rates of myocardial infarction (MI) that are up to 50-fold higher than those in women without SLE. Cerebrovascular, coronary, and peripheral vascular thromboembolic events are major causes of morbidity.

01/10/2009 - 30/09/2010

Not Applicable






admitted to hospital with Celiac disease (AS, ICD-10 = K90.0). This indicator is a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRLTC001-PRLTC010.


Non-Hodgkin lymphoma is a possiblecomplication of celiac disease and may lead to a large portion of lymphoma cases. Othercomplications of Celiac disease include adenocarcionma of the small intestine, and squamous cell carcinomas of the esophagus, mouth and pharynx.

01/10/2009 - 30/09/2010

Not Applicable

PRLTC007 The proportion of patients admitted to hospital with Thalassemia/sickle-cell anaemia (AS, ICD-10 = D56,D57). This indicator is a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRLTC00


Haemoglobin disorders are life limiting for sufferers due to disease and secondary morbidities including rickets, scoliosis, spinaldeformities, nerve compression, fractures and sever osteoporosis.

01/10/2009 - 30/09/2010

Not Applicable






admitted to hospital with cystic fibrosis (AS, ICD-10 = E84). This indicator is a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRLTC001-PRLTC010.


Although survival from cystic fibrosis (CF) is increasing rapidly, suffers usually die in early adulthood. There is also involvement of the gastrointestinal tractin most patients, with 85% showing pancreatic insufficiency as a result of obstruction of the pancreatic ducts and subsequent scarring anddestruction of excocrine function. Bacterial infection is also a major problem for CF patients. At present, double-lung or heart-lung transplantation is the only definitive treatmentfor patients with advanced cycstic fibrosis.

01/10/2009 - 30/09/2010

Not Applicable






admitted to hospital with multiple sclerosis (AS, ICD-10 = G35). This indicator is amember of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRLTC001-PRLTC010.


Multiple sclerosis (MS) is a complex trait in which susceptibility is determined by the interplay of genes and environmental factors. Risk factors for (MS) include smoking, Epstein-Barr virus infection manifesting asInfectious Mononucleosis in adolescents and young adults, recombinant hepatitis B vaccine. Family members of affected individuals have a greater risk of disease than the general population.

01/10/2009 - 30/09/2010

Not Applicable

PRLTC010 The proportion of PCT population with limiting long term illness (PCT). This indicator is a member of the "long term conditions" suite of indicators and should be considered in conjunction with the indicators PRLTC001-PRLTC010.

Office of National Statistics

Chronic limiting long term illness restricts activity and results in greater use of health services as patients age.

2001 (released Deember 2009)






Item Description Data Source Rationale Time Period ValuePRMHI001 The proportion of people in

the PCT population with a serious mental illness (PCT) and the proportion of people admitted to hospital who have a serious mental illness(AS, ICD-10 = F20, F22, F25, F31).


People with a serious mental illness are a difficult group to treat as they may find it difficult to communicatetheir problems or lack the capacity to consent to treatment.

01/04/2008 - 31/03/2009


PRPHP001 The proportion of patients admitted to hospital with alcohol related problems (AS, ICD-10 = Y90, Y91, Z71.4). This indicator is a member of the "public healthpriorities" suite of indicators and should be considered in conjunction with the indicators PRPH


Heavy alcohol use is associated with the onset of heart disease, stroke, cancers, liver cirrhosis, anterograde amnesias, temporary cognitive deficits, sleep problems, and peripheral neuropathy. Alcohol-use disorders are responsible for a large proportion of the health-care burden in almost all populations.

01/10/2009 - 30/09/2010

Not Applicable





Item Description Data Source Rationale Time Period ValuePRPHP002 The proportion of patients

admitted to hospital who are obese (AS, ICD-10 = E66). This indicator is a member ofthe "public health priorities" suite of indicators and s

Quality and Outcomes Framework

Obesity is associated with many chronic health conditions including increased mortality and increased risk for coronary heart disease, osteoarthritis, diabetes mellitus, hypertension, and certain types of cancer. Being obese is equivalent to ageing 20 yea

01/04/2008 - 31/03/2009

Likely to be risky

PRPHP003 The proportion of patients admitted to hospital with drug related conditions (AS, ICD-10 = T40, T41.0, T38.7, T43.6, Z71.5). This indicator is a member of the "public health priorities" suite of indicators and should be considered in conjunction with the


Chronic drug users are prone to several chronic health effects related to their drug us including higher use of emergency rooms. Additionally, they are costly to treat.

01/10/2009 - 30/09/2010

Not Applicable





Item Description Data Source Rationale Time Period ValuePRPMC301 The number of active GPs in

a primary care trustNHS Connecting for Health, Office of NationalStatistics

Good primary care systems (ones with a sufficient number of GPs to serve a population) are associated with improved health outcomes.

Likely to be risky

PRPOP001 The proportion of people aged 65+ who have been admitted to hospital (AS) andthe proportion of people aged 65+ in the general PCTpopulation.(PCT)

Office for National Statistics

People aged 65 and over more likely to require hospital treatment and to display multiple morbidity.

Mid-2009 population estimates


PRPOP002 The proportion of people aged 0-17 who have been admitted to hospital (AS) andthe proportion of people aged 0-17 in the general PCT population (PCT).

Office for National Statistics

Hospitals without dedicated paediatric facilities should only admit children as day cases or one night surgical care. Children under three years of age must only be accepted in an inpatientor outpatient unit with full paediatric nursing and medical staff

Mid-2009 population estimates






Item Description Data Source Rationale Time Period ValuePRTEP001 The number of births to

teenage (15-17) mothers as a proportion of total births (AS).


Early pregnancy may have negative impact a motherâ€™s health and the health and development of her baby. Babies born to teenage mothers have a higher rate of infant mortality and morbidity than babies born to older mothers. Poverty and the motherâ€™s psychological immaturity and lack of parenting skills, are related to childhood accidents and illness.

01/10/2009 - 30/09/2010

Not Applicable




Underlying information: Uncertainty Risk


URCOM001 The number of indicators an organisation has data for over the number of applicable indicators expressed as a percentage.

CQC This reflects the amount of data available for scoring inherent, population and situational risk

February 2011

KPCT_-_11-43_NHS_Kirklees_CQC_

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