© 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
© Care Quality Commission 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.
© Care Quality Commission 2011
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.
© Care Quality Commission 2011
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]
© Care Quality Commission 2011
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
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© Care Quality Commission 2011
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
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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
5N2X7 Treatment of disease, disorder or injury
Cleckheaton Health Centre Dental Clinic, Greenside, Cleckheaton, BD19 5AP
5N221 Treatment of disease, disorder or injury
Fartown Health Centre Dental Clinic, Spaines Road, Huddersfield, HD2 3QA
5N207 Treatment of disease, disorder or injury
Holme Valley Memorial Hospital Dental Clinic, Huddersfield Road, Holmfirth, HD9 3TS
5N2X1 Treatment of disease, disorder or injury
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
5N2X6 Treatment of disease, disorder or injury
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Location and Regulated ActivitiesLocations Location ID Regulated ActivityMoorfields Primary Care Centre, 11 Park Road, Huddersfield, HD4 5RX
5N201 Treatment of disease, disorder or injury
Princess Royal Community Health Centre Dental Clinic, Greenhead Road, Huddersfield, HD1 4EW
5N203 Treatment of disease, disorder or injury
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
5N2X2 Treatment of disease, disorder or injury
Walk-in Centre, Dewsbury District Hospital, Dewsbury, WF13 4HS
5N220 Treatment of disease, disorder or injury
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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
-
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
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
Care Quality Commission: Survey of NHSStaff 2009/2010
Key Finding 34: Staff job satisfaction
This trust was better than average when compared to other trusts for this key finding.
Green
STAFFSURCTX03
Care Quality Commission: Survey of NHSStaff 2009/2010
Key Finding 36: Staff recommendation of the trust as a place to work or receive treatment
This trust was better than average when compared to other trusts for this key finding.
Green
STAFFSURCTX04
Care Quality Commission: Survey of NHSStaff 2009/2010
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
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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.
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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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 1 (R17)Respecting and involving people who use services
Outcome 1 (R17)
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 1 (R17)Respecting and involving people who use services
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
01/04/2009 31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009 31/03/2010 Similar to expected
Level 2 NA NA NA
8044 The Trust has appropriate procedures for recognising and responding to patient requests for access to their health records. -
Department of Health, Information Governance Toolkit
01/04/2009 31/03/2010 Similar to expected
Level 2 NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 1 (R17)Respecting and involving people who use services
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12199 NHS LA assessed outcome for Risk Management Standard Criterion 4.8 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12216 NHS LA assessed outcome for Risk Management Standard Criterion 5.10 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 1 (R17)Respecting and involving people who use services
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7532 PEAT score for Privacy and Dignity - modesty, dignity and respect - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
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. -
Department of Health, Information Governance Toolkit
01/04/2009 31/03/2010 Tending towards better than expected
Level 3 NA NA NA
7531 PEAT score for Privacy and Dignity - confidentiality - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 2 (R18)Consent to care and treatment
Outcome 2 (R18)
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 2 (R18)Consent to care and treatment
Item ID
Description Data Source Time Period Start
TimePeriod End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12193 NHS LA assessed outcome for Risk Management Standard Criterion 4.3 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 4 (R9)Care and welfare of people who use services
Outcome 4 (R9)
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 4 (R9)Care and welfare of people who use services
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12184 NHS LA assessed outcome for Risk Management Standard Criterion 3.4 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12191 NHS LA assessed outcome for Risk Management Standard Criterion 4.1 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12198 NHS LA assessed outcome for Risk Management Standard Criterion 4.7 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 4 (R9)Care and welfare of people who use services
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12199 NHS LA assessed outcome for Risk Management Standard Criterion 4.8 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12211 NHS LA assessed outcome for Risk Management Standard Criterion 5.8 - Bestpractice - NICE, NCEs & national guidance -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 31/03/2009 Similar to expected
Level 1 Achieved
NA NA NA
12213 NHS LA assessed outcome for Risk Management Standard Criterion 5.9 -Best practice - NSFs & High Level Enquiries -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 31/03/2009 Similar to expected
Level 1 Achieved
NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 4 (R9)Care and welfare of people who use services
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12216 NHS LA assessed outcome for Risk Management Standard Criterion 5.10 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Not Achieved
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)
01/10/2010 31/12/2010 Much betterthan expected
1 4693.00
4693.00 0.95
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 5 (R14)Meeting nutritional needs
Outcome 5 (R14)
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 5 (R14)Meeting nutritional needs
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
11248 PEAT score for Food and food services - availability ofequipment for measuring patients. - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
81%-100% NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 5 (R14)Meeting nutritional needs
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 6 (R24)Cooperating with other providers
Outcome 6 (R24)
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 6 (R24)Cooperating with other providers
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12196 NHS LA assessed outcome for Risk Management Standard Criterion 4.5 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 7 (R11) Safeguarding people who use services from abuse
Outcome 7 (R11)
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 7 (R11)Safeguarding people who use services from abuse
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12181 NHS LA assessed outcome for Risk Management Standard Criterion 3.2 - Safeguarding children -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 31/03/2009 Similar to expected
Level 1 Achieved
NA NA NA
12183 NHS LA assessed outcome for Risk Management Standard Criterion 3.3 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 8 (R12) Cleanliness and infection control
Outcome 8 (R12)
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 8 (R12)Cleanliness and infection control
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
1 2.00 2.00 0.97
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 8 (R12)Cleanliness and infection control
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
10037 Percentage score for site against National Specifications for Cleanliness of NHS - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
Yes NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 8 (R12)Cleanliness and infection control
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
Yes NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 8 (R12)Cleanliness and infection control
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
Yes NA NA NA
12177 NHS LA assessed outcome for Risk Management Standard Criterion 2.8 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 8 (R12)Cleanliness and infection control
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12186 NHS LA assessed outcome for Risk Management Standard Criterion 3.6 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12200 NHS LA assessed outcome for Risk Management Standard Criterion 4.9 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
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
01/09/2010 01/09/2010 Similar to expected
At last inspection 0 improvements were outstanding
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 31 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 8 (R12)Cleanliness and infection control
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7497 PEAT score for specific cleanliness (waste receptacles). - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
7498 PEAT score for toilet and bathroom cleanliness (excluding patient equipment and waste receptacles) - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
7500 PEAT score for toilet and bathroom cleanliness (wastereceptacles) - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 32 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 8 (R12)Cleanliness and infection control
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7510 PEAT score for environment- linen - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
7514 PEAT score for environment- waste handling - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
9670 PEAT score for specific cleanliness (all areas exceptpatient equipment and waste receptacles). - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 33 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 8 (R12)Cleanliness and infection control
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
9671 PEAT score for specific cleanliness (patient equipment). - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
9672 PEAT score for toilet and bathroom cleanliness (Patient equipment) - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much betterthan expected
Excellent NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 34 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 9 (R13) Management of medicines
Outcome 9 (R13)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 35 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 9 (R13)Management of medicines
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12187 NHS LA assessed outcome for Risk Management Standard Criterion 3.7 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12197 NHS LA assessed outcome for Risk Management Standard Criterion 4.6 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Not Achieved
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
30/09/2010 30/09/2010 Similar to expected
Fully accredited/nominated LSMS in the process
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 36 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 9 (R13)Management of medicines
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/09/2010 30/09/2010 Similar to expected
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/09/2010 30/09/2010 Similar to expected
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
31/07/2010 31/07/2010 Similar to expected
Information submitted where applicable
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 37 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 9 (R13)Management of medicines
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12475 Does the Local Security Management Specialist (LSMS) sufficiently attend the CFSMS quarterly regional LSMS meetings? -
Counter Fraud and Security Management Service, Security Management Service compliance data
01/01/2010 31/12/2010 Similar to expected
Meetings sufficiently attended when applicable
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 38 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 10 (R15) Safety and suitability of premises
Outcome 10 (R15)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 39 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7508 PEAT score for environment- toilet environment. - 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
7517 PEAT scores for access andexternal areas - car parking - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Similar to expected
Acceptable NA NA NA
7529 PEAT score for privacy and dignity - toilets and bathrooms - 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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 40 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7530 PEAT score for privacy and dignity - privacy - 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
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)
01/04/2009 31/03/2010 Similar to expected
Y NA NA NA
8532 Outcome of trusts risk assessment of fire safety -
Department of Health, Annual Statement of Fire Safety
01/01/2009 31/12/2009 Similar to expected
Developed programme towork to reduce risks
NA NA NA
8533 The trust had an enforcement action issued by the Fire and Rescue Service Authority. -
Department of Health, Annual Statement of Fire Safety
01/01/2009 31/12/2009 Similar to expected
No enforcement, no ongoing enforcement
NA NA NA
8534 The trust achieved compliance with Departmentof Health Fire Safety Policy -
Department of Health, Annual Statement of Fire Safety
01/01/2009 31/12/2009 Similar to expected
Compliant NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 41 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
9492 Ratio of the number of fires recorded as required by FIRECODE to the gross internal floor area -
Department of Health, Estates Return Information Collection (ERIC)
01/04/2009 31/03/2010 Similar to expected
0 0.00 22474.00 0.00
12180 NHS LA assessed outcome for Risk Management Standard Criterion 3.1 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12184 NHS LA assessed outcome for Risk Management Standard Criterion 3.4 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 42 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12185 NHS LA assessed outcome for Risk Management Standard Criterion 3.5 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
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
30/09/2010 30/09/2010 Similar to expected
Fully accredited/nominated LSMS in the process
NA NA NA
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/09/2010 30/09/2010 Similar to expected
SMD appointed with voting board membership
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 43 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/09/2010 30/09/2010 Similar to expected
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
31/07/2010 31/07/2010 Similar to expected
Information submitted where applicable
NA NA NA
12475 Does the Local Security Management Specialist (LSMS) sufficiently attend the CFSMS quarterly regional LSMS meetings? -
Counter Fraud and Security Management Service, Security Management Service compliance data
01/01/2010 31/12/2010 Similar to expected
Meetings sufficiently attended when applicable
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 44 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7511 PEAT score for environment- décor - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Tending towards better than expected
Good NA NA NA
7512 PEAT score for environment- lighting - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Tending towards better than expected
Good NA NA NA
7547 Proportion of disabled car parking spaces available to total number of car parking spaces available for use. -
Department of Health, Estates Return Information Collection (ERIC)
01/04/2009 31/03/2010 Tending towards better than expected
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 -
Department of Health, Estates Return Information Collection (ERIC)
01/04/2009 31/03/2010 Tending towards better than expected
0 8.00 22474.00 0.00
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 45 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7507 PEAT score for Environment- bathroom environment - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
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
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much better than expected
Excellent NA NA NA
7513 PEAT score for environment- tidiness - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much better than expected
Excellent NA NA NA
7519 PEAT score for access and external areas - signage (internal and external) - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much better than expected
Excellent NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 46 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7520 PEAT score for access and external areas - facilities for people with disabilities - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much better than expected
Excellent NA NA NA
7528 PEAT score for privacy and dignity - sleeping accommodation - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much better than expected
Excellent NA NA NA
9052 PEAT score for environment- provision of outdoor patientrecreational areas - Data forHOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much better than expected
Excellent NA NA NA
9673 PEAT score for environment- furnishings - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much better than expected
Excellent NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 47 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 10 (R15) Safety and suitability of premisesItem ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
9674 PEAT score for environment- floors - Data for HOLME VALLEY MEMORIAL HOSPITAL
National Patient SafetyAgency (NPSA), Patient Environment Action Team (PEAT)
04/01/2010 26/03/2010 Much better than expected
Excellent NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 48 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 11 (R16) Safety, availability and suitability of equipment
Outcome 11 (R16)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 49 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 11 (R16)Safety, availability and suitability of equipment
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12176 NHS LA assessed outcome for Risk Management Standard Criterion 2.7 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12187 NHS LA assessed outcome for Risk Management Standard Criterion 3.7 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
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
30/09/2010 30/09/2010 Similar to expected
Fully accredited/nominated LSMS in the process
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 50 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 11 (R16)Safety, availability and suitability of equipment
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/09/2010 30/09/2010 Similar to expected
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/09/2010 30/09/2010 Similar to expected
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
31/07/2010 31/07/2010 Similar to expected
Information submitted where applicable
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 51 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 11 (R16)Safety, availability and suitability of equipment
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12475 Does the Local Security Management Specialist (LSMS) sufficiently attend the CFSMS quarterly regional LSMS meetings? -
Counter Fraud and Security Management Service, Security Management Service compliance data
01/01/2010 31/12/2010 Similar to expected
Meetings sufficiently attended when applicable
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 52 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 12 (R21) Requirements relating to workers
Outcome 12 (R21)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 53 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 12 (R21)Requirements relating to workers
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12169 NHS LA assessed outcome for Risk Management Standard Criterion 1.9 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12170 NHS LA assessed outcome for Risk Management Standard Criterion 1.10 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
11290 Key finding 39: Staff believing trust provides equal opportunities for career progression or promotion -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Much better than expected
Highest (best)20%
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 54 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 13 (R22) Staffing
Outcome 13 (R22)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 55 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 13 (R22)Staffing
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7067 Three month vacancy rate for all scientific, therapeutic & technical staff -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.01
7068 Three month vacancy rate for qualified Allied Health Professionals -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.01
7070 Three month vacancy rate for occupational therapy staff -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.01
7071 Three month vacancy rate for physiotherapy staff -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.00
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 56 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 13 (R22)Staffing
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
7079 Three month vacancy rate for speech & language therapy staff -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.00
9792 Three month vacancy rate for district nurses -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.01
9793 Three month vacancy rate for health visitors -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.01
9794 Three month vacancy rate for qualified school nurses -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.00
9796 Three month vacancy rate for unqualified nursing, midwifery & health visiting staff -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.00
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 57 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying Information for: Outcome 13 (R22)Staffing
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
9800 Three month vacancy rate for registered pharmacists -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.01
11348 Three month vacancy rate for qualified nursing, midwifery & health visiting staff -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Similar to expected
0 0.00 100.00 0.01
7065 Three month vacancy rate for all non-medical staff -
Information Centre for Health & Social Care (IC), Vacancysurvey
31/03/2010 31/03/2010 Tending towards better than expected
0 0.00 100.00 0.00
11260 Key finding 9: Staff working extra hours -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Below (better than) average
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 58 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Outcome 14 (R23)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 59 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
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. -
Department of Health, Estates Return Information Collection (ERIC)
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. -
Department of Health, Information Governance Toolkit
01/04/2009 31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009 31/03/2010 Similar to expected
Level 3 NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 60 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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 -
Department of Health, Information Governance Toolkit
01/04/2009 31/03/2010 Similar to expected
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
01/09/2010 30/09/2010 Similar to expected
0.046 4.63 100.00 0.04
11262 Key finding 11: Staff feeling there are good opportunitiesto develop their potential at work -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Similar to expected
Average NA NA NA
11276 Key finding 25: Staff experiencing physical violence from staff in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Similar to expected
Average NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 61 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
11289 Key finding 38: Staff having equality and diversity training in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Similar to expected
Average NA NA NA
12171 NHS LA assessed outcome for Risk Management Standard Criterion 2.1 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12172 NHS LA assessed outcome for Risk Management Standard Criterion 2.2 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 62 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12173 NHS LA assessed outcome for Risk Management Standard Criterion 2.3 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12174 NHS LA assessed outcome for Risk Management Standard Criterion 2.5 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12175 NHS LA assessed outcome for Risk Management Standard Criterion 2.6 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 63 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12176 NHS LA assessed outcome for Risk Management Standard Criterion 2.7 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12177 NHS LA assessed outcome for Risk Management Standard Criterion 2.8 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12178 NHS LA assessed outcome for Risk Management Standard Criterion 2.9 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 64 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12179 NHS LA assessed outcome for Risk Management Standard Criterion 2.10 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12188 NHS LA assessed outcome for Risk Management Standard Criterion 3.8 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12189 NHS LA assessed outcome for Risk Management Standard Criterion 3.9 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 65 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12190 NHS LA assessed outcome for Risk Management Standard Criterion 3.10 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008 08/11/2010 Similar to expected
Level 1 Achieved
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
30/09/2010 30/09/2010 Similar to expected
Fully accredited/nominated LSMS in the process
NA NA NA
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/09/2010 30/09/2010 Similar to expected
SMD appointed with voting board membership
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 66 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/09/2010 30/09/2010 Similar to expected
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? -
Counter Fraud and Security Management Service, Security Management Service compliance data
31/07/2010 31/07/2010 Similar to expected
Information submitted where applicable
NA NA NA
12475 Does the Local Security Management Specialist (LSMS) sufficiently attend the CFSMS quarterly regional LSMS meetings? -
Counter Fraud and Security Management Service, Security Management Service compliance data
01/01/2010 31/12/2010 Similar to expected
Meetings sufficiently attended when applicable
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 67 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12478 Have Violence Against Staff (VAS) statistics been reported to NHS SMS for most recent year ending 31st March? -
Counter Fraud and Security Management Service, Security Management Service compliance data
30/11/2010 30/11/2010 Similar to expected
Information submitted where applicable
NA NA NA
11256 Key finding 5: Quality of job design (clear content, feedback and staff involvement) -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11257 Key finding 6: Work pressure felt by staff -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Below (better than) average
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 68 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
11263 Key finding 12: Staff receiving job-relevant training, learning or development in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11264 Key finding 13: Staff appraised in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11265 Key finding 14: Staff having well structured appraisals in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11266 Key finding 15: Staff appraised with personal development plans in last 12months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 69 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
11267 Key finding 16: Support fromimmediate managers -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11268 Key finding 17: Staff having health and safety training in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11270 Key finding 19: Staff suffering work-related stressin last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Below (better than) average
NA NA NA
11278 Key finding 27: Staff experiencing harassment, bullying or abuse from staff in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Below (better than) average
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 70 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
11279 Key finding 28: Perceptions of effective action from employer towards violence and harassment -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11282 Key finding 31: Staff reporting good communication between senior management and staff -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11283 Key finding 32: Staff agreeing that they understand their role and where it fits in -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Tending towards better than expected
Above (betterthan) average
NA NA NA
11254 Key finding 3: Staff feeling valued by their work colleagues -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Much better than expected
Highest (best)20%
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 71 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
11258 Key finding 7: Staff working in a well structured team environment -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Much better than expected
Highest (best)20%
NA NA NA
11259 Key finding 8: Quality of work-life balance -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Much better than expected
Highest (best)20%
NA NA NA
11261 Key finding 10: Staff using flexible working options -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Much better than expected
Highest (best)20%
NA NA NA
11275 Key finding 24: Staff experiencing physical violence from patients/relatives in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Much better than expected
Lowest (best)20%
NA NA NA
11277 Key finding 26: Staff experiencing harassment, bullying or abuse from patients/relatives in last 12 months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Much better than expected
Lowest (best)20%
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 72 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 14 (R23) Supporting Staff
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
11281 Key finding 30: Staff feeling pressure to attend work when feeling unwell in last 3months -
Care Quality Commission, Survey of NHS Staff
28/08/2009 07/12/2009 Much better than expected
Lowest (best)20%
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 73 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 16 (R10) Assessing and monitoring the quality of service provision
Outcome 16 (R10)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 74 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 16 (R10) Assessing and monitoring the quality of service provision
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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
31/03/2010 Similar to expected
0.019 18.88 1000.00 0.03
11274 Key finding 23: Fairness andeffectiveness of procedures for reporting errors, near misses or incidents -
Care Quality Commission, Survey of NHS Staff
28/08/2009
07/12/2009 Similar to expected
Average NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 75 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 16 (R10) Assessing and monitoring the quality of service provision
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12161 NHS LA assessed outcome for Risk Management Standard Criterion 1.1 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12162 NHS LA assessed outcome for Risk Management Standard Criterion 1.2 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12163 NHS LA assessed outcome for Risk Management Standard Criterion 1.3 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 76 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 16 (R10) Assessing and monitoring the quality of service provision
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12164 NHS LA assessed outcome for Risk Management Standard Criterion 1.5 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12165 NHS LA assessed outcome for Risk Management Standard Criterion 1.6 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12166 NHS LA assessed outcome for Risk Management Standard Criterion 1.7 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 77 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 16 (R10) Assessing and monitoring the quality of service provision
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12203 NHS LA assessed outcome for Risk Management Standard Criterion 5.2 - Incident reporting -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
12208 NHS LA assessed outcome for Risk Management Standard Criterion 5.5 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
12209 NHS LA assessed outcome for Risk Management Standard Criterion 5.6 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 78 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 16 (R10) Assessing and monitoring the quality of service provision
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12210 NHS LA assessed outcome for Risk Management Standard Criterion 5.7 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
12211 NHS LA assessed outcome for Risk Management Standard Criterion 5.8 - Bestpractice - NICE, NCEs & national guidance -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
31/03/2009 Similar to expected
Level 1 Achieved
NA NA NA
12213 NHS LA assessed outcome for Risk Management Standard Criterion 5.9 -Best practice - NSFs & High Level Enquiries -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
31/03/2009 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 79 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 16 (R10) Assessing and monitoring the quality of service provision
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12336 Compliance with Department of Health central returns of data deadlines -
Department of Health, Central Returns - Timeliness ofReturns
01/04/2009
31/03/2010 Similar to expected
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
14/02/2011 Similar to expected
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 -
Care Quality Commission, Survey of NHS Staff
28/08/2009
07/12/2009 Much better than expected
Highest (best)20%
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 80 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 16 (R10) Assessing and monitoring the quality of service provision
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
11284 Key finding 33: Staff able to contribute towards improvements at work -
Care Quality Commission, Survey of NHS Staff
28/08/2009
07/12/2009 Much better than expected
Highest (best)20%
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 81 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 17 (R19) Complaints
Outcome 17 (R19)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 82 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 17 (R19) Complaints
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12204 NHS LA assessed outcome for Risk Management Standard Criterion 5.2 - Raising concerns -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
31/03/2010 Similar to expected
Level 1 Achieved
NA NA NA
12205 NHS LA assessed outcome for Risk Management Standard Criterion 5.3 - Complaints -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
31/03/2010 Similar to expected
Level 1 Achieved
NA NA NA
12207 NHS LA assessed outcome for Risk Management Standard Criterion 5.4 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 83 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 17 (R19) Complaints
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
12208 NHS LA assessed outcome for Risk Management Standard Criterion 5.5 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
12209 NHS LA assessed outcome for Risk Management Standard Criterion 5.6 -
NHS Litigation Authority (NHS LA), Risk Management Standards forPrimary Care Trusts
01/04/2008
08/11/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 84 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Outcome 21 (R20)
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 85 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
8045 The trust has established appropriate confidentiality audit procedures in line withthe requirements of the National Programme for IT. -
Department of Health, Information Governance Toolkit
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 3 NA NA NA
8028 How would you assess yourTrust’s ability to access expertise across the Confidentiality & Data Protection Assurance agenda? -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 3 NA NA NA
8029 How would you assess yourTrust’s ability to access expertise across the Information Security agenda? -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
8030 How would you assess yourTrust’s ability to access expertise across the Information Quality and Records Management Agenda? -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 86 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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 -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 3 NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 87 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 3 NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 88 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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). -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 3 NA NA NA
8049 The Trust ensures that all new processes, software and hardware comply with confidentiality and data protection requirements. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
8050 The Trust has a formal information security risk assessment and management programme that is implemented and regularly reviewed. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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). -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
8055 Defined, documented and agreed access rights for all users of Trust information systems and services available. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
8056 The Trust has established aregister of all its major information assets and assigned responsibility or ‘ownership’ for each. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
8057 The Trust ensures that digital information shared with other organisations is secured in transit. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
8058 The Trust has adequate procedures in place to ensure the availability of information processing facilities, communications services and data. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
8062 The Trust has appropriate procedures in place to ensure that communication networks under the Trust’s control operate in a secure manner. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
8063 The Trust has appropriate procedures for ensuring thatmobile computing and teleworking are conducted in a secure manner. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
8069 The Trust has robust procedures and processes for all data collection activities across the Trust. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
8074 The Trust use external data quality reports for monitoring and improving quality. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
Denominator Value
ExpectedValue
8086 The Trust has publicly available documented and implemented procedures to ensure compliance with the Freedom Of Information Act2000. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
10132 The Trust have a Board level Senior Information Risk Owner (SIRO) who takes ownership of the Trust’s information risk policy -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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 -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
Level 2 NA NA NA
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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 trusts’ data. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Similar to expected
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
31/03/2010 Similar to expected
Level 1 Achieved
NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Outcome 21 (R20)Records
Item ID
Description Data Source Time Period Start
Time Period End
Comparison with Expected
Value Numerator Value
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
31/03/2010 Similar to expected
Level 1 Not Achieved
NA NA NA
8047 The trust has put in place safe-haven procedures for all routine flows of patient personal information to the organisation. -
Department of Health, Information Governance Toolkit
01/04/2009
31/03/2010 Tending towards better than expected
Level 3 NA NA NA
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
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.
Hospital Episode Statistics (HES)
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Inherent Risk
Item Description Data Source RationaleTime Period Value
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.
Hospital Episode Statistics (HES)
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.
Hospital Episode Statistics (HES)
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Inherent Risk
Item Description Data Source RationaleTime Period Value
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
Hospital Episode Statistics (HES)
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.
Hospital Episode Statistics (HES)
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Inherent Risk
Item Description Data Source RationaleTime Period Value
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
should be considered in conjunction with IRMAT001-IRMAT004.
Hospital Episode Statistics (HES)
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
should be considered in conjunction with IRMAT001-IRMAT004.
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Inherent Risk
Item Description Data Source RationaleTime Period Value
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
Hospital Episode Statistics (HES)
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Inherent Risk
Item Description Data Source RationaleTime Period Value
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
There is a relationship between volume and clinical outcome with higher volumes being
associated with better clinical outcomes.
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
Hospital Episode Statistics (HES)
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
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
Hospital Episode Statistics (HES)
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Inherent Risk
Item Description Data Source RationaleTime Period Value
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
Hospital Episode Statistics (HES)
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
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.
Hospital Episode Statistics (HES)
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
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
Hospital Episode Statistics (HES)
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Inherent Risk
Item Description Data Source RationaleTime Period Value
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
Hospital Episode Statistics (HES)
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
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.
Hospital Episode Statistics (HES)
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Situational Risk
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
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Situational Risk
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.
Unlikely to be risky
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.
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.
Unlikely to be risky
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Situational Risk
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.
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.
Likely to be risky
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
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
Unlikely to be risky
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
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.
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
Unlikely to be risky
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.
Hospital Episode Statistics (HES)
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
Not Applicable
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 112 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRICM004 The proportion of patients
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.
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
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.
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
Somewhat likely to be risky
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 113 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRICM006 The proportion of patients
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.
Hospital Episode Statistics (HES)
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.
01/10/2009 - 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.
Hospital Episode Statistics (HES)
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.
01/10/2009 - 30/09/2010
Not Applicable
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 114 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRICM008 The proportion of patients
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.
Hospital Episode Statistics (HES)
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.
01/10/2009 - 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.
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
Somewhat likely to be risky
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 115 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
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).
Hospital Episode Statistics (HES)
Barriers to providing a good service to this group include; poor communication; GP’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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 116 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
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; GP’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
Somewhat likely to be risky
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 117 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
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.
Quality Outcomes Framework
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
Unlikely to be risky
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.
Quality Outcomes Framework
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
Somewhat likely to be risky
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 118 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRLTC003 The proportion of patients
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
Hospital Episode Statistics (HES)
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
Hospital Episode Statistics (HES)
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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 119 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRLTC005 The proportion of patients
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.
Hospital Episode Statistics (HES)
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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 120 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRLTC006 The proportion of patients
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.
Hospital Episode Statistics (HES)
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
Hospital Episode Statistics (HES)
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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 121 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRLTC008 The proportion of patients
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.
Hospital Episode Statistics (HES)
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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 122 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRLTC009 The proportion of patients
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.
Hospital Episode Statistics (HES)
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)
Unlikely to be risky
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
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).
Quality Outcomes Framework
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
Somewhat likely to be risky
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
Hospital Episode Statistics (HES)
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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
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Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
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
Hospital Episode Statistics (HES)
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
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 125 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
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
Unlikely to be risky
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
Somewhat likely to be risky
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 126 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Population Risk
Item Description Data Source Rationale Time Period ValuePRTEP001 The number of births to
teenage (15-17) mothers as a proportion of total births (AS).
Hospital Episode Statistics (HES)
Early pregnancy may have negative impact a mother’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 mother’s psychological immaturity and lack of parenting skills, are related to childhood accidents and illness.
01/10/2009 - 30/09/2010
Not Applicable
Quality and Risk Profile (QRP) to support monitoring compliance of the NHS
2 March 2011 14:04:54 PM © Care Quality Commission 2011 Page 127 of 127
Provider Code Provider Name Data Version5N2 Kirklees PCT 2.5
Underlying information: Uncertainty Risk
Item Description Data Source RationaleTime Period Value
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
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