quality account 2010-2011 North Cumbria University Hospitals NHS Trust

North Cumbria University Hospitals
NHS Trust
quality account 2010-2011
contents
PART 1
Statement from the Chief Executive
3
Introduction 5
PART 2
6
Priorities for Improvement: Safety
Priorities for Improvement: Effectiveness
7
8
Priorities for Improvement: Experience 10
Cumberland Infirmary
Our services 12
Our Values 13
Commitment to research 14
CQUIN
15
Registration & data quality
16
Monitoring our priorities
17
PART 3
18
Review of performance: Safety 19
Review of performance: Effectiveness 23
Review of performance: Experience 27
West Cumberland Hospital
Statements from stakeholders
34
How to provide feedback on the Quality 36
Account
2
chief executive
1
I am delighted to introduce the Quality Account for North Cumbria University Hospitals NHS Trust for 2010/2011 which provides information about our achievements over the last year and identifies our priorities for
the coming year. I hope it will provide information for local people, patients and their
families, stakeholders and our staff to be assured that our Trust
provides high quality services and that patient care remains our number one
priority.
This document complies with the Trust’s statutory duties under the Health
Act 2009 and the guidance issued by the Department of Health for the
development of the Quality Account for 2010/11. During the year, the new Government produced Equity and Excellence: Liberating the NHS, which
sets out a clear goal for the NHS to achieve results that are amongst the best in the world.
The past year has been another challenging year for the Trust and particularly our staff; this has
included the Trust and local health economy being in financial turnaround, which has resulted in a
number of internal and external work streams being set up to ensure we provide quality services that
are also efficient and provide value or money. In addition to this in February 2011, the Trust Board
approved a proposal to formally merge with or be acquired by an existing NHS Foundation Trust,
which is currently being progressed with NHS North West to ensure we choose a partner that will
continue to develop acute healthcare services for the local population of North Cumbria.
I am proud that even though this has been a challenging year; we can point to many
achievements regarding the quality of care we provide whilst at the same time going through
significant organisational change. This has included the Trust being recognised for the third year
running within the top 40 performing Trusts in an independent survey by Casper Healthcare
System (CHKS), a provider of healthcare intelligence. These are great achievements and I would
like to thank all our staff who work so hard to deliver high quality services to our patients. Details of
other achievements, as well as some of our challenges can be found within this Quality Account.
In April 2010 we were awarded full registration with the Care Quality Commission and in March 2011
have also received one unannounced visit at the Cumberland Infirmary.
It is important for me to include in my opening statement to this Quality Account, the Serious
Untoward Incident we had during the year in our Breast Screening Service. I would like to apologise
again for the distress and anguish this caused to the women directly involved and their families as
well as the wider population and the effect this incident has had on the overall confidence in the care
we deliver to patients. 3
chief executive
The Trust has carried out an in depth review
of this incident to ensure the full root causes
are understood so that lessons can be learned
across the healthcare system in relation to breast
screening. In January 2011 the Trust Board
approved a formal review of clinical
governance to be undertaken across the Trust
to ensure we further strengthen and improve our
governance arrangements in the places we need
to.
Listening to our patients and the public
continues to remain a key priority and is
part
of
our
organisational
values. During the year we have implemented
RealTime patient questionnaires to ensure
that we can act on the direct feedback we
receive from patients during their hospital visit.
Our strategy for Quality Improvement was a key
focus in 2009/10 in driving forward our priorities,
and has been successfully incorporated into the
new Governance, Risk Management and Quality
Strategy within the Trust. The key vision contained in the new strategy is
to ensure the Trust has in place an overarching
framework for Governance, Risk and Quality
to provide a safer environment for patients and
staff.
The Directors are required under the Health
Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health
Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each
financial year.
In preparing the Quality Account, the Directors
have taken steps to satisfy themselves that:
• The Quality Account presents a balanced
picture of North Cumbria University Hospitals
NHS Trust’s performance during 2010/2011
• The performance information reported in the
Quality Account is reliable and accurate
• There are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Account,
and these controls are subject to review to
confirm that they are working effectively in
practice
• The data underpinning the measures of
performance reported in the Quality
Account is robust and reliable, conforms to
specified data quality standards and prescribed
definitions, is subject to appropriate
scrutiny and review; and the Quality
Account has been prepared in accordance with
Department of Health guidance.
The Directors confirm to the best of their
Ensuring
our
governance
arrangements knowledge and belief they have complied with
continue to develop will be a key priority for the the above requirements in preparing the Quality
Trust going forward, particularly as it takes on Account. By order of the Board:
a new organisational form through merger and Mike Little
acquisition. The priorities set out in our Quality Chairman
Account will be driven forward to ensure that Date
our patients continue to see and experience
improvements in the quality of care we provide. Dr Neil Goodwin
Interim Chief Executive
Date
4
introduction
In developing our Quality Account for 2010/2011
and identifying the priorities for next year we have
tried to gain as many different perspectives and
views as possible, recognising that we need to
continue to build on this for the future.
Throughout the year there are many ways in
which we get feedback on our services from
patients and their families, and the public. Staff
views on our services and future priorities were
obtained from internal meetings including our
Trust Management Committee and Clinical
Standards Sub Group. The Trust has established several mechanisms
and sources for determining its key priorities for
quality improvement. These include, but are not
restricted to:
• Outcomes of Complaints and Incident
Investigations
• Our review of Clinical Governance
• Ward spot checks and internal mock
assessments against the essential standards of safety and quality as set out by the
Care Quality Commission
• Trust risk register
• The Trust’s CQUINs quality performance
indicators, as contained within the Acute
Services contract
The Trust has also considered key priorities for
North Cumbria as a whole to ensure our priorities can make an impact on the key health issues we face for example, dementia and palliative care.
5
2 priorities for improvement
Following consultation with our staff and stakeholders the diagram below illustrates our
identified priorities for 2011/2012:
SAFETY
• All wards to implement the Productive Ward
• Implement a Trust-wide framework to support the
implementation of the national ‘never events’ policy
• Revise the Trust’s system for patient safety walkabouts
EFFECTIVENESS
• All wards to implement the Productive Ward
• Review and revise the clinical indicators on all wards
• Develop a Trust-wide framework for the reviewing of
mortality and morbidity in all specialities
• Develop and improve the Trust’s performance in national
and local clinical audits
EXPERIENCE
• All wards to implement the Productive Ward
• Implement the patient and public involvement toolkit
• Review our management of complaints to ensure timely
responses and lessons are learned
• Improve the experience of patients and carers in relation to
dementia
6
safety
Priority 1 : Implement Productive Ward to all ward areas
Rationale: To increase the amount of time spent on direct patient care at the bedside. By doing
this the quality of that care is improved which in turn leads to a quicker recovery and an earlier
discharge.
Target: All wards will have commenced Productive Ward by 31 March 2012.
How will this be measured: This will be measured by establishing a baseline during quarter one
of 2011/2012 of all wards and agreeing a plan for each ward with specific milestones for achievement.
Priority 2 : Implement a Trust-wide framework to support the
implementation of the national ‘never events’ policy
Rationale: To ensure the Trust policies and practice support the guidance on the 25 events that
should never happen in a hospital.
Target: Development of a Trust wide framework to assess and monitor our adherence to our
policies to support the never events framework.
How will this be measured: Each Division will report on their compliance and evidence against the
Trust wide framework.
Priority 3 : Revise the Trust system for patient safety walkabouts
Rationale: To ensure that the Trust has in place a robust system for patient safety walkabouts
that adds value for our patients and staff.
Target: To expand the patient safety walkabout programme to provide clarity on who conducts
them and how they inform the patient safety issues across the organisation from Ward to Board.
How will this be measured:
• All wards and clinical departments will have a patient safety walkabout in 2011/2012
• Feedback to be included in Divisional Governance Quarterly Reports
• Annual report to be provided to Trust Board
• Issues escalated to Board on a monthly basis where necessary
7
effectiveness
Priority 4 : Implement Productive Ward to all ward areas
Rationale: To ensure the running of our wards is lean and minimises variability.
Target: All wards will have commenced Productive Ward by 31 March 2012.
How will this be measured: This will be measured by establishing a baseline during
Quarter 1 of 2011/2012 of all wards and agreeing a plan for each ward with specific milestones for
achievement.
Priority 5 : Review and revise ward clinical indicators
Rationale: To ensure we have a consistent measurement of the basic standards of care across our
ward areas which reflect the priorities set out by NHS North West.
Target: To implement revised ward clinical indicators that will be measured monthly by the end of
Quarter 2 2011/2012.
How will this be measured:
• The agreed clinical indicators will be approved by the Governance and Quality Committee in
July 2011.
• The monthly reports will be included in the Divisional Governance reports by the end of Quarter
3 2011/2012.
Priority 6 : Develop a framework for reviewing mortality and morbidity in
all specialities
Rationale: To have an agreed standard for the reviewing of mortality and morbidity across the Trust.
Target: To have a Trust-wide framework for undertaking mortality reviews in all clinical specialities.
How will this be measured: Each Divisional Speciality will report into the Divisional Management
Board quarterly with outcomes and lessons learnt in order to make improvements to patient safety.
8
effectiveness
Priority 7 : Develop and improve the Trust performance in national and
local clinical audits
Rationale: To ensure clinical audit is fully embedded within the organisation in order to support
continuous improvements in patient care and service delivery.
Target: To have in place a robust clinical audit programme that represents the Trust’s priorities as
well as ensures participation in all relevant national audits.
How will this be measured: • Monthly reports will be provided to the Divisional Management Boards
• The monthly reports will be included in the Divisional Governance reports quarterly
• The Trust Audit Calendar will be agreed by the Clinical Standards Sub Group by the end of
Quarter 1 2011/2012 and monitored at each meeting
• Exception reports on the Trust’s position and performance against national audits will be
reported to the Clinical Standards Group
9
experience
Priority 8 : To implement the Productive Ward to all ward areas
Rationale: To ensure the feedback from our patients on their experiences, contributes to improvements in individual ward areas as well as sharing good practice.
Target: All wards will have commenced Productive Ward by 31 March 2012.
How will this be measured:
• Monthly reports will be provided to the Divisional Management Boards
• The monthly reports will be included in the Divisional Governance quarterly reports
Priority 9 : To implement the patient and public involvement toolkit
Rationale: To support collaborative working with our patients and ensure there
is improvement in the patient experience, through involving our patients in the planning of service
development and changes that affect them.
Target: To implement the toolkit in target areas across the three clinical Divisions.
How will this be measured:
• Evidence on the use of the toolkit will to be reported in the Divisional quarterly reports.
• The Trust will include in its Quality Account for 2011/2012 an overview on the use of the toolkit
and the improvements which have been made as a result of implementing the toolkit.
10
experience
Priority 10 : Review our management of complaints to ensure timely
responses and lessons are learned
Rationale: To ensure our complaints process responds to all complaints in a timely manner and that
lessons are learnt where necessary.
Target: Review the Trust’s Complaints Policy by the end of Quarter 1 2011/2012.
How will this be measured:
• Monthly reports to be presented to the Divisional Management Board to monitor performance
• Exception reports will be included in the Divisional Governance quarterly reports
• Action plans resulting from complaints will be monitored by the Governance team
• Monthly reports to the Trust Board to outline monthly performance in managing complaints
together with any trends.
Priority 11 : Improve the experience of our patients and carers in relation
to dementia
Rationale: To ensure that patients suffering from dementia and their families experience care appropriate to their needs
Target: To have a competent and capable workforce to care for patients with dementia and their
families
How will this be measured: Implementation of the Department of Health training packages for staff.
11
our services
During 2010/2011, North Cumbria University Hospitals NHS Trust provided the services listed
within the Mandatory Goods & Services Schedule contained within its Terms of Authorisation as
a hospital Trust. The Trust has reviewed all the data available on the quality of care in all these
NHS services. This review has been undertaken in line with in-house patient and staff surveys.
Medicine
Surgery
Emergency Medicine
Directorate:
A&E
EAU
Acute Medicine
Head and Neck
Directorate:
Ear, Nose and Throat
Oral Surgery
Orthodontics
Ophthalmology
Audiology
Internal Medicine
Directorate:
Cancer Services
Palliative Care
Gastroenterology
Renal
Cardiology
Respiratory
Diabetes
Neurology
Dermatology
Rheumatology
Surgical Services
Directorate
General Surgery
Urology
Vascular Surgery
Endoscopy
Theatres
Anaesthetics
Family and Support
Services
Paediatrics
Neonatal Services
Maternity
Obstetric Services
Gynaecology
Pathology
Pharmacy
Radiology
Medical Physics
Allied Health
Professionals
Medical Records
Medical Photography
Critical Care,Theatres
and Anaesthetics
Medical Services
Directorate:
Directorate:
Trauma and
Outpatients
Orthopedics
Elderly Care
Critical Care
Stroke
Theatres Rehabilitation
Day Surgery
Disablement Services Sterile Services
Anaesthetics
Pain Management
The income generated by the NHS services reviewed in 2010/2011 represents 100% of the total
income generated from the provision of NHS services by North Cumbria University Hospitals NHS
Trust.
12
our values
Our values are to:
Embed quality and safety at the heart of everything we do
To achieve this we will:
• Treat our patients, the public and each other with honesty and openness
• Promote and protect each individual’s right to be treated with dignity and respect
• Measure and continuously improve the standards of safety and quality delivered to our
patients
• Provide a safe and clean environment that promotes patients’ comfort and well-being
• Support and develop our staff to deliver and achieve the best possible standards of care
• Measure and improve the experience of our patients and our staff
• Be polite, courteous and non-judgmental in our communication and engagement with each
other
• Be caring, compassionate and kind to others
Deliver excellence at every turn
To achieve this we will:
• Ensure we use our resources in the most efficient way
• Strive to get the basics right, first time, every time
• Practice efficient and effective team working by committing to achieving common goals in every
team and department
• Encourage involvement and ownership
• Use evidence, best practice and innovation to develop our services for the future
• Learn from our mistakes
• Celebrate and encourage excellence across our organisation and build pride in our reputation
• Be responsible and accountable for our own and collective actions
The NHS Constitution
All NHS bodies and private and third sector providers supplying NHS services are required by law
to take account of the NHS Constitution in their decisions and actions. North Cumbria University
Hospitals NHS Trust supports the NHS Constitution and undertakes to ensure that its requirements
are fulfilled.
The Constitution establishes the principles and values of the NHS in England and sets out rights to
which patients, public and staff are entitled, and pledges which the NHS is committed to achieve,
together with responsibilities which the public, patients and staff owe to one another to ensure that
the NHS operates fairly and effectively.
13
research & audit
During 2010/2011, 33 national clinical audits and 5 national confidential enquiries covered NHS
services that North Cumbria University Hospitals NHS Trust provides.
During this period, the Trust participated in 100% of national clinical audits and 100% of national
confidential enquiries in which it was eligible to participate.
The national clinical audits and national confidential enquiries that the Trust was eligible to
participate in are listed in the tables below:
Name of Audit
Adult Critical Care
Emergency Use of
Oxygen
Non Invasive Ventilation in adults
Pleural procedures
Potential Donor Audit
Adult community acquired pneumonia
0 neg blood use
Platelet Use
Lung Cancer
Head & Neck Cancer
Bowel Cancer
Myocardial Ischaemia
Heart Failure
Acute Stroke (SINAP)
Stroke Care
Paediatric Asthma
Childhood epilepsy
Paediatric Diabetes
Hip Knee and Ankle Replacement
Elective Surgery
(PROMS)
14
Type of Care
Acute Care
Acute Care
Audit Participation
Yes
Yes
% of Cases Submitted
100%
100%
Acute Care
Yes
Ongoing
Acute Care
Acute Care
Acute Care
Yes
Yes
Yes
100%
100%
100%
Blood Transfusion
Blood Transfusion
Cancer
Cancer
Cancer
Cardiovascular Disease
Cardiovascular Disease
Cardiovascular Disease
Cardiovascular Disease
Children
Children
Children
Elective Procedures
Yes
Yes
Yes
Yes
Yes
Yes
100%
100%
100%
100%
100%
100%
Yes
100%
Yes
100%
Yes
100%
Yes
Yes
Yes
Yes
100%
Ongoing
100%
100%
Elective Procedures
Yes
100%
research & audit
Name of Audit
Peripheral vascular
surgery
Carotid interventions
Ulcerative Colitis &
Crohn’s Disease
COPD
Adult asthma
Bronchiectisis
Chronic Pain
Parkinson’s Disease
Dementia
Type of Care
Audit Participation
% of Cases Submitted
Elective Procedures
Yes
100%
Elective procedures
Long-term Conditions
Yes
Yes
100%
Ongoing
Long-term Conditions
Long-term Conditions
Long-Term Conditions
Long-term Conditions
Long-term Conditions
Psychological Conditions
Renal Disease
Yes
Yes
Yes
Yes
Yes
Yes
100%
100%
100%
100%
100%
100%
Renal Replacement
Yes
100%
Therapy
Patient Transfer (NaRenal Disease
Yes
100%
tional Kidney Care
Audit)
Falls and Non-Hip Trauma
Yes
100%
Fractures
Hip Fracture
Trauma
Yes
100%
Severe Trauma
Trauma
Yes
100%
(TARN)
National Confidential Enquiries into Patient Outcome and Death (NCEPOD)
Cardiac Arrest
NCEPOD
Yes
Ongoing
Peri-Operative Care
NCEPOD
Yes
Ongoing
Nutrition
NCEPOD
Yes
22%
Elderly Surgery
NCEPOD
Yes
Ongoing
In addition to the audits and enquiries listed above, the Trust also took part in a number of other
national audits and datasets following its own guideline on participation in these projects:
• Oesophago-gastric cancer
• Mastectomy and breast reconstruction surgery
The number of patients receiving NHS services provided by North Cumbria University Hospitals
NHS Trust that were recruited during 2010/2011 to participate in research approved by a research
ethics committee was 1,010.
15
CQUIN
Part of North Cumbria University Hospitals NHS Trust’s income last year was conditional on
making quality improvements and reaching innovation goals that were agreed
between the Trust and NHS Cumbria (Cumbria’s teaching primary care trust). This is done
through a Commissioning for Quality and Innovation Payment Framework (CQUIN). These
initiatives play a very important part in the Trust’s drive for continuous quality
improvements and are therefore deliberately challenging with the overall aim to improve quality.
The % financial value of each of the targets within CQUIN is included in the table below along
with our progress against these targets, which represents 1.5% (£2.5 million) of our total contract
income.
Number
Priority
CQUIN contract %
value
NATIONAL / REGIONAL CQUIN
1
Venous Thrombosis
0.15%
2
Patient Experience
0.15%
3
Trauma Audit (TARN)
0.01%
LOCAL CQUIN
4
Pressure sores/ulcers
0.19%
5
End of Life Care
0.19%
6
Slips, trips and falls
0.19%
7
Nurse-led discharge
0.19%
8
Nutrition
0.19%
ADVANCING QUALITY PROGRAMME
9
Heart Failure
0.01%
10
Acute MI
0.01%
11
Hip & Knee
0.01%
12
Community-acquired
0.01%
pneumonia
13
Stroke
0.01%
Key:
High risk
Moderate risk
On target
Complete
AMI = Acute myocardial infarction = heart attack
16
Status
Complete
Complete
Does not complete until June 2011
Complete
Complete
Complete
Complete
Complete
Complete
Complete
Complete
Complete
Complete
2011/2012
The CQUIN contract for 2011/2012 is being
finalised and will be published on our website in due course:
www.ncuh.nhs.uk
registration
Registration
safety, which the regulator will monitor. The new
Each year we are externally validated on our standards cover important issues for patients
performance by the Care Quality Commission such as treating people with respect, involving
(CQC). The CQC is the independent regulator of them in decisions about their care, keeping
health and social care in England. It regulates care clinical areas clean, and ensuring services are
provided by the NHS, local authorities, private safe.
companies and voluntary organisations. Its aim is
to make sure better care is provided for everyone North Cumbria University Hospitals NHS Trust
in hospitals, care homes and people’s own homes. has participated in one special review by the Care
Quality Commission as a result of a complaint
North Cumbria University Hospitals NHS received during 2010/11.
Trust is required to register with the Care
Quality Commission and its current status The Care Quality Commission received
is full registration without conditions. The concerning information with regards to staff
Care Quality Commission has not taken any moving and handling techniques, infection control
enforcement action against North Cumbria and maintenance of equipment that appeared
University Hospitals NHS Trust during 2010/11. to indicate potential breeches of the Health and
Social Care Act and its associated regulations.
From 1 April 2010, 378 NHS trusts in England The Trust provided relevant documentary
have to be registered with CQC by law to provide evidence as requested and the Care Quality
care. To be registered, trusts must show they Commission reached a judgement of continued
compliance with the regulations and standards.
meet new essential standards of quality and
17
data quality
Data quality
North Cumbria University Hospitals NHS Trust submitted records during 2010/2011 to the
Secondary Users service for inclusion in the Hospital Episode Statistics, which are included in the
latest published data. The percentage of records in the published data which included the patient’s
valid NHS number was:
-
-
-
96.9% for admitted patient care
97.0% for outpatient care
94.3% for accident and emergency care
The percentage of records in the published data which included the General Medical Practice Code
were:
-
-
-
99.7% for admitted patient care
99.6% for outpatient care
96.8% for accident and emergency care
The Trust has developed a Data Quality Strategy to put in place systems and processes that ensure
that quality of the data that it collects and uses is fit for purpose.
An overall strategic vision for data quality at NCUH will incorporate:
• A Data Quality Policy
• A Data Quality Group which will be composed of various member of other groups such as,
Health Records, Records Management, Information Governance and Clinical Governance. A
Dashboard will monitor DQ metrics, in line with NHS Information Centre, AQUA, CQC and Local
DQ metrics
• An audit programme to give the Board of Directors assurance that the performance information
they receive is based on sound data quality
Furthermore the Data Quality Strategy is tailored so that the management of data quality issues is
undertaken at directorate level.
Significant or systematic deficits will be dealt with and an appropriate course of action taken to
remedy them, ensuring staff making errors attend for re-training and, if required, individuals not
complying with the correct use of the system or making repeated errors after re-training may be
managed under the HR Capability Policy.
18
monitoring our priorities
The Trust is committed to monitoring the quality of care provided including the priorities set out in
our Quality Account. During 2010/2011, the Trust developed six core pillars of governance which
will be the principle framework to monitor the quality and safety priorities across our Trust.
The specific reports which will also be scrutinised throughout the year to monitor improvements in
quality will be:
• Monthly Trust Board Performance Report and Quality Dashboard
• Quarterly Divisional Governance Reports
• Mid-year report on the status of the Quality Account priorities to the Trust Board and our Stakeholders
A Director and Non Executive Director have been identified for each of the core domains of safety,
experience and effectiveness who will also assist with ensuring robust monitoring is in place.
19
3review of quality performance
The purpose of this section of our Quality Account is to provide information concerning the quality of
the services provided by the Trust throughout 2010/2011.
Background
North Cumbria University Hospitals NHS Trust provides acute secondary care from its two
hospitals - the Cumberland Infirmary in Carlisle and West Cumberland Hospital in Whitehaven. There are also outpatient services provided across the community hospitals in north Cumbria
together with a Birthing Centre at Penrith.
Our 2010/2011 quality measures:
Safety
Effectiveness
Experience
•Reduce hospital acquired
infections further
•Improve hygiene standards
•Reduce occurrence of
serious untoward incidents
•Reduce medication errors
•Reduce incidences of
slips, trips and falls
•Increase the number of
safety walkabouts
•Achieve all CQC standards
•Increase learning from
reported incidents and
complaints
•Improve performance in
national audits
•Reduce mortality to below
the national average
•Reduce readmissions to
below national average
•Build on our clinical
outcome measures
•Develop and implement
the patient and public
involvement toolkit
•Increase our team of
hospital volunteers
•Extend the real time data
collection exercise
•Use the information
from patients to make
improvements in services
•Maintain single-sex
accommodation
The following information details the Trust’s level of performance in delivering each of these key
objectives through assessing a number of appropriate quality measures.
20
what we said we would do:
safety
Infection prevention
MRSA
In accordance with the Department of Health’s
targets for reducing the incidence of MRSA
bacteraemia, the Trust has to achieve year
on year reductions. The Trust has made
significant progress in reducing MRSA
bacteraemia with having only 2 cases in
2010/2011 against an expectation that we
would have no more than 6 cases. The Trust
has also done considerable work with NHS
Cumbria (teaching primary care trust) to
define and clearly identify those cases of MRSA
Financial Year
2008-2009
2009-2010
2010-2011
Number of MRSA
bacteraemia cases
7
7
2
that are apportioned to the Trust; these are
patients who develop MRSA bacteraemia
more than 48 hours after admission and this
is how our figures are now recorded. Further
preventative measures for MRSA have
also been introduced through screening of
elective (planned) and non-elective patients
(emergency).
The table below demonstrates that we have
reduced MRSA by more than two thirds:
NCUH rate (per
National average rate (per
10,000 bed days) 10,000 bed days)
0.35
0.43
0.35
0.27
0.10 (provisional)
Not yet published
C-Difficile
During 2009/10 whilst we achieved our reduction and remained below the nationally set
trajectory for Trust apportioned C-diff cases, the reduction remained static. As a result, for 2010/2011
a lower internal target was set than the one set nationally. This ensured we remained focussed on the
reduction of incidences of C-diff within our hospitals.
Financial Year
2008-2009
2009-2010
2010-2011
Number of C-diff
cases
128
130
57
NCUH rate (per
10,000 bed days)
6.6
6.7
2.9 (provisional)
National average rate
(per 10,000 bed days)
5.5
3.6
2.6*
Hand hygiene
Local hand hygiene audits are completed monthly across all clinical areas. This has proved to be
beneficial and has been achieved by greater emphasis being placed on the importance of hand
hygiene. The hand hygiene audits are ward/department based assessments with clear criteria for
achievement. The results from the audits are also publicised on each ward area. If an area is found
to be under performing there is a clear programme for training and re-audit to focus on improvement.
21
what we said we would do:
safety
Reducing the occurrence of Serious Untoward Incidents (SUI)
A Serious Untoward Incident refers to a
circumstance or situation in which one or more
patients (past or current) or staff are involved in
an event that is likely to produce significant legal,
media or other interest that may result in loss of
the Trust’s reputation or assets. It is reportable
externally to NHS Cumbria.
and our performance in dealing with them within
recommended 45 working days.
The Trust has also developed partnership
working with NHS Cumbria which has the
responsibility for the performance management of SUIs. This has also included appointing
external leads to chair SUI panels particularly
The Trust has reviewed its reporting and where the incident has issues across pathways
monitoring arrangements for the manage- of care between providers.
ment of SUIs. This has included improved
reporting and the sharing of outcomes For the year 2010/2011, the Trust had 12 SUIs.
from these incidents across all the clinical
Divisions.
The improvements made to Division reporting
against the core pillar of governance during the
A new reporting framework has been developed year will continue to be developed in 2011/2012
to ensure the Board has clarity on all open SUIs particularly in relation to learning lessons.
Reducing medication errors
During 2010/2011, the Trust implemented an online reporting system for all incidents. A key driver
for this was to improve real-time reporting on incidents and errors. Reductions in medication
errors have been achieved in most specialities with the exception of the Medical Division. A key
priority for medicines management during 2011/2012 is improving the Trust position in relation to
mandatory training. The graph below shows the Trust’s figures for medication errors for 2009/2010
and 2010/2011:
22
what we said we would do:
safety
Slips, trips and falls
The multidisciplinary Falls Operational Group chaired by the Director of Nursing, Quality and
Governance remains in place and has continued to drive the reduction in slips, trips and falls within
our hospitals. The graph below illustrates the continued reduction of inpatient falls from 2009 to
2011:
Slips, Trips and Falls
2009, 2010 and 2011
200
150
100
50
0
Jan Feb Mar Apr May Jun
2011 109
93
105
Jul
Aug Sep Oct Nov Dec
84
2010 113 102 110 110 120 116 101
70
74
81
2009 151 156 138 144 139 130
105
95
102 100 127
88
66
75
Slips, Trips and Falls Link Persons have been an immense support to the front line clinical staff in
achieving this reduction. The Trust Board, whilst pleased with the continued reduction, is continuing
to monitor this with a key focus for this year being placed upon harm caused as the result of a fall. The Slips, Trips and Falls Link Persons will continue to support the ward staff and the Trust is aware
of the wards where there is a higher incidence of inpatient falls and support will be targeted in these
areas. Reducing slips, trips and falls will remain a key priority area for quality and safety and is
included in our CQUIN measures for 2011/2012.
23
what we said we would do:
safety
Patient safety walkabouts
Patient safety walkabouts have continued
throughout the year and are carried out jointly
with an Executive Director and a Non Executive
Director. Action plans are completed after the
walkabouts and key observations noted in order
to feedback to the clinical teams.
Whilst improvements were seen in 2010/2011,
the Trust wants to further expand the programme
to ensure all wards and departments are visited
and that we have a clear framework for how this
information links back into our patient safety
priorities.
CQC quality visits
In April 2010, the Trust was fully registered with the Care Quality Commission (CQC) without
conditions. In November 2010 the CQC published the essential standards of safety and quality,
which have been fully introduced into the Trust’s Governance strategy.
During the year, the CQC were commissioned by the Department of Health to inspect 100
hospitals with the specific focus on the care of older people, in relation to the following outcomes:
• Outcome 1 (Regulation 17) – Respecting and involving people who use services
• Outcome 5 (Regulation 14) – Meeting nutritional needs
The Cumberland Infirmary was inspected as part of this work and whilst the formal report has yet to be
published, the Trust received very positive feedback on the standards of care observed in relation
to these important outcomes.
The Trust has developed its evidence and monitoring arrangements against the CQC standards
during the year which has included internal mock-assessments being undertaken against the
essential standards of safety and quality.
Increase learning from reported incidents and complaints
At the heart of the Trust’s governance framework is the importance of continuous improvement and
learning lessons when things go wrong. During the year, the Trust has developed the role of the
Governance Facilitators to ensure that complaints and incidents are scrutinised on a weekly basis.
All Divisions also report on the lessons learned from complaints and incidents as part of their
divisional quarterly reporting to the Governance and Quality Committee.
24
what we said we would do:
effectiveness
Improve performance in national audits
mortality rate is 88 for 2010/2011 against a
National and local clinical audit reports are national rate of 100.
reviewed within individual clinical specialities
and any necessary improvements are made Reduce readmissions to below national
within services. A key priority area for the Trust average
in the coming year will be to strengthen the The Trust’s readmission rate within 28 days for
monitoring of the improvements resulting from 2010/2011 is 5.5% against our peer group of
clinical audits to ensure these are embedded 6.7%. The Trust has a number of work streams
across the Trust. During the year, the Trust has in place to ensure this is monitored against best
set up a new Clinical Standards Group which practice.
will formally review the outcomes from national and local clinical audits in order to provide Build on our clinical outcome measures
robust assurance to the Governance and Quality During the year the Trust implemented specific
Committee. In addition to this, the Clinical clinical indicators across all wards. The outcomes
Governance Review which commenced in have been published and reviewed within
January 2011, has also reviewed the support individual wards as well as collectively within the
structures
and
resources
for
clinical senior nursing team. This has enabled variances
audit and effectiveness which will result in performance to be identified and improved
in changes being made during 2011/2012 across the organisation. For 2011/2012,
to further strengthen this across the the clinical indicators will be streamlined in
organisation.
accordance with NHS North West with the aim
of establishing ten ward indicators that can be
measured between providers.
Reducing mortality
The mortaility rate for our Trust is a figure that
confirms how many deaths we have had in Waiting Times
comparison to the national average and with The Trust has reduced waiting times and has
our peer group. It also takes account of the achieved and maintained the national target
complexity of the patients we care for. The for 18 week referral to treatment for patients in
Trust has in place a dedicated system that our all specialities. We are recognised as one of
Divisions use to benchmark their performance the top performing Trusts in the North West in
and review clinical complications and misad- continuing to maintain this target.
ventures.This system will continue to be further
embedded during 2011/2012. The Trust’s
Measure
Source
2009/2010
2010/2011
Trend
Risk adjusted mortality rate
CHKS
84
88
Stable
Total readmissions within 28 days
CHKS
5.2% peer 6.2%
5.5%
peer 6.7%
Better than
our peers
25
what we said we would do:
effectiveness
Advancing quality
Advancing Quality is an ambitious programme that focuses on improving the quality of care for
patients and saving lives. It ensures patients have an overall better experience in hospital, leading
to a better health related quality of life.
Advancing Quality draws upon proven best practice developed nationally and globally. There are
four clinical pathways that have been in existence since the conception of the programme and
we are now into the third year of reporting. There is a fifth pathway for stroke care that has been
introduced during 2010/11 and the available data for this is from Quarters 3 and 4 for the reporting
period.
The clinical pathways are:
• Acute myocardial infarction
• Heart failure
• Hip and knee replacement
• Community acquired pneumonia
• Stroke ( pilot commenced 2010 )
It is anticipated that during 2011/12 the programme will be expanded further. The following graphs
illustrate the high quality care provided within the Trust for the established clinical pathways and
also indicate our targets and achievements for the period April 2010 to March 2011. The following
graph illustrates the high quality care provided within the Trust for the clinical pathway for acute
myocardial infarction, or heart attack.
Table 1: Acute Myocardial Infarction 2010/11
Myocardial Infarction April 2010 - December 2010
100.0%
90.0%
80.0%
ADULT SMOKING CESSATION
ADVICE /COUNSELING
70.0%
BETA BLOCKER PRECRIBED AT
DISCHARGE
60.0%
FIBRINOLYTIC THERAPY RECEIVED
WITHIN 30 MIN OF HOSP ARRIVAL
50.0%
ASPIRIN AT ARRIVAL
40.0%
ASPIRIN PRECRIBED AT DISCHARGE
30.0%
ACEI OR ARB FOR LVSD
Apr-10
26
Jun-10
Aug-10
Oct-10
Dec-10
what we said we would do:
effectiveness
Table 1 illustrates how the Trust has implemented the clinical pathway for acute myocardial
infarction. We were required to attain an AQ target of 87.88% overal and achieved 92.19%. It also
illustrates that more than 80% of patients were prescribed a beta blocker at
discharge. The Trust has introduced a number of initiatives to support the success of this
pathway and the management of this pathway is improving.
Table 2: Heart Failure 2010/11
Heart Failure April 2010 - December 2010
100.0%
90.0%
DISCHARGE INSTRUCTIONS
80.0%
EVALUATION OF LVS
FUNCTION
70.0%
60.0%
ACEI OR ARB FOR LVSD
50.0%
ADULT SMOKING CESSATION
ADVICE/COUNSILLING
40.0%
30.0%
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Table 2 above demonstrates further success in our heart failure pathway. We were required to
meet an AQ target of 65.34% and achieved 94.4% This has mainly been due to the work done by
the clinical teams within the heart failure sub-group focussing on staff and patient education.
Every patient admitted with heart failure is offered a multi-agency education programme. Our
Heart Failure Specialist Nurses and Doctors provide this along with individualised care treatment
plans. Furthermore, the Trust has in place a programme of continuous education and succession
planning to ensure all staff who join the service receive training to maintain this level of expertise.
This provides assurance to patients that the service is of a high standard.
27
what we said we would do:
effectiveness
Table 3: Community-acquired pneumonia 2010/11
Pneumonia January 2010 - December 2010
100.0%
OXYGENATION ASSESS
90.0%
80.0%
BLOOD CULTURES PERFORMED IN
A+E PRIOR TO INIT ABX RECEIVED IN
IN HOS
70.0%
60.0%
ADULT SMOKING CESS
ADVICE/COUNS
50.0%
40.0%
30.0%
INIT ABX RECEIVED WITHIN 6 HRS
20.0%
10.0%
0.0%
Apr-10
Jun-10
Aug-10
Oct-10
Dec-10
INIT ABX SELECTION FOR CAP IN
IMMUNOCOMPRESSANT PTS
We were required to reach a target of 78.4% and achieved 90.4%. Following the
commitment the Trust has made in improving smoking cessation support, we have seen a 20%
increase in the number of patients giving up smoking during 2010/2011 in comparison to the
previous year. The Trust is working closely with its primary care colleagues on a smoking
cessation programme as part of our Advancing Quality projects.
Hip and knee replacements
Table 4 illustrates the pathway that has been developed for our hip and knee
replacement care which includes nurse led pre-assessment clinics. We were
required
to
meet
an
AQ
target
of
93.2%
and
achieved
94.3%.
Nurses are extending their skills to include non-medical prescribing. Patients
received a personalised care pathway to ensure they are as fit as possible before undergoing
surgery. The Trust has invested in these specialist nurses and supported them through training
programmes in order to reduce post operative complications.
The pathway has been combined with the Caledonian Technique which is an enhanced recovery programme and involves pre-operative education, multimodal analgesia and multi-disciplinary
education post operatively. This has reduced patients’ length of stay in hospital. The actual length of
stay for hip and knee replacements is between 3 and 14 days. The average length of stay 2010/2011
for elective hip and knee replacements was 6.8 days compared with 7.2 days for 2009/2010.
28
what we said we would do:
effectiveness
Table 4: Hip and Knee Replacement 2010/11
ADVANCING QUALITY HIP AND KNEE FIGURES FOR YEAR 3 APRIL 2010 -DECEMBER
2010
100%
90%
80%
70%
PROPHYLACTIC ANTIBIOTIC RECEIVED WITHIN 1
HOUR PRIOR TO SURGICAL INCISION
60%
PROPHYLACTIC ANTIBIOTIC SELECTION FOR
SURGICAL PATIENT
50%
40%
PROPHYLACTIC ANTIBIOTIC DISCONTINUED WITHIN
24 HOURS AFTER SURGERY END TIME
30%
RECOMMENDED VENOUS THROMBOEMBOLISM
PROPHYLAXIS OREDERED
20%
10%
REVIEWED APPROPRIATE VTE PROPHYLAXIS
WITHIN 24HRS PRIOR TO SURG TO 24 HRS AFTER
SURG
0%
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Stroke care
The pathway for stroke care was introduced to the Advancing Quality programme during 2010/2011
and the reporting period and data has been collected for Quarter 3 & Quarter 4 for 2010/11. The
Trust can demonstrate good progress with the agreed targets. The AQ target required is 90% and
we achieved 81.7%. An action plan is in place to make continual improvement.
The Trust has dedicated beds for stroke patients which is excellent practice and has identified
dedicated support services, such as physiotherapy, occupational therapy and speech and language
therapy. These services have received increased investment to prioritise the care for our stroke
patients and to meet the requirements of the pathway.
Our Trust is the lead provider of a new Telestroke service that will link eight hospital sites in the Cumbria and Lancashire region which will be introduced during 2011/2012.
Using video telecommunications, the new service will allow the hospitals to deliver
thrombolysis therapy (a first line intervention on the onset of a stroke) whatever the time
of day or night. Thrombolysis is the clot-busting treatment for stroke and needs to be
delivered under the supervision of a clinician.
29
what we said we would do:
effectiveness
Develop and implement the patient experience toolkit
The Patient Experience Toolkit has been developed during the year and approved in the new
Communication and Engagement Strategy.
It is a dynamic over-arching framework to support collaborative working with our patients. It will ensure
the Trust will improve patient experience and involvement together with the perceptions of carers and
the public. Collaborative working will drive this toolkit forward, gaining assurance that patients are at
the forefront of service improvements that meet their needs whilst reflecting best practice in the Trust.
The toolkit has been developed to build on engagement at clinical service level within our Divisions,
led by the Head of Nursing for each Division, and building up a bank of knowledge and expertise
across the Trust.
Examination of patient feedback will be key to the success of this toolkit and will highlight areas
which need improvement to provide a better service for patients and supply the evidence for change.
Therefore, we have continued to include this as a priority for 2011/2012 as the feedback from our
patients is at the heart of assessing the quality of care we give.
Patient panels
There are four branches of the Patient Panel,
divided by their geographical location, and the
members are former patients of the hospitals.
There is a wide range of topics discussed at the
meetings and this enables members to become
active in developments in local healthcare. The
members are all very enthusiastic and passionate in supporting the Trust to improve patient
30
safety and patient experience by helping staff
to improve services. The meetings are well supported.
The Patient Panels have been instrumental during this last year in the completion of inpatient
satisfaction surveys. The Trust recognises the
valuable work these panels do.
what we said we would do:
effectiveness
National inpatient satisfaction survey
Each year, the Care Quality Commission carries out a survey with inpatients who have received
care from our hospitals. The Trust scores in the 2010 are below together with our action plan with
the priorities we have set for improvements.
Based on patients’
responses to the
2010 survey. All
scores are out of 10.
This trust scored:
Expected range for
this Trust:
For questions about the emergency/A & E department answered by emergency patients only
8.3
7 to 8.2
For questions about waiting lists and planned
admissions, answered by those referred to
hospital
For questions about waiting to get a bed on a
ward
For questions about the hospital and ward
6.6
6.1 to 7.2
8.5
7 to 8.9
8.2
7.6 to 8.4
For questions about doctors
8.5
8.1 to 8.9
For questions about nurses
8.7
7.8 to 8.7
For questions about care and treatment
7.6
7 to 7.9
For questions about operations and procedures,
answered by patients who had an operation or
procedure
For questions about leaving the hospital
8.3
7.9 to 8.7
6.6
6.2 to 7.3
An action plan is in place to address areas for improvement in the coming year and includes:
• Improve staff awareness of the inpatient services survey and engage them in our action plans
• Carry out a survey on meals and choice through our RealTime patient experience tracker and
gather feedback for any further development
• Monitor of RealTime Patient experience tracker, analyse the results and provide information on
all wards
• Review our discharge process and the information that we provide to patients on “what happens next”
• Monitor our facilities to maintain patient privacy and dignity through continuous audits
• Improve information for our patients about discharge medication
31
what we said we would do:
experience
Increase our team of hospital volunteers
During 2010/11 a task and finish group was created
and developed a robust system to identify, recruit,
and appoint volunteers to our Trust. There is now
in place a tailored induction programme, along
with a framework for support. The governance
review which commenced in January 2011 will also
further strengthen the support for volunteers with
a new coordinator role created for our volunteers. RealTime patient and staff surveys
The Trust has introduced a RealTime Patient
Experience Tracker where patients can use handheld monitors to enter their feedback concerning
their care and experience.
The scheme has been expanded to capture
staff satisfaction that ensures we have a fuller
picture that is instructive and will identify areas that
require closer scrutiny with regard to the delivery
of patient care.
The chart below illustrates the high level of
patient reported satisfaction for 2010. There is a
recorded level of more than 90% for the year:
32
what we said we would do:
experience
Use the information from patients to make improvements in services
This is linked to the RealTime
capturing of patient experience
and there is evidence of service
changes
within
wards
and
departments as a result. The Productive Ward development has been
further supported by the outcomes
from the RealTime exercise. The
Trust has also involved patients in
changes to the design of services,
for example the Outpatient Redesign
project.
It is also important to highlight
the significant engagement and
involvement of the West Cumbria
community and its support groups on the development of the new West Cumberland Hospital. A
formal stakeholders group has been working closely with the project team in developing the plans
for the new hospital build, which will continue to grow and develop as the project progresses.
Maintain same-sex accommodation
The Trust worked hard to virtually eliminate mixed-sex accommodation for patients and achieved
this by 31 March 2010. This has been maintained during 2010/2011 with the commitment to
providing every patient with same-sex sleeping areas, bathroom and toilet facilities. In exceptional
circumstances (for instance where a patient needs critical care) providing fast effective care may
take priority over ensuring same-sex accommodation. On the rare occasions when this mixing does
occur we are committed to ensure it is for the least time possible and only when in the best interests
of patient care.
The Trust was once again in the best performing 20% of Trusts as reported in the inpatient survey
in response to:
•
Did you ever share a sleeping area with patients of the opposite sex?
And within the intermediate 60% of Trusts in response to:
•
Did you ever use the same bathroom or shower area as patients of the opposite sex?
33
what we said we would do:
experience
Cancer targets
Two-week wait (2ww)
All patients referred by their GP have their first appointment within a maximum of 14 calendar days.
The clock starts when the referral is received within the hospital. The following table indicates the
outcome of the 14 day rule for 2010/11 in comparison to national targets:
14-DAY RULE (2ww)
All 2ww patients seen between dates specified
(excluding Breast Symptomatic patients)
Breast Symptomatic patients seen between dates specified
Seen within
target
Total
seen
National
target
7,728
% of total
seen within
target
94.5%
7,303
1,128
1,326
85.1%
93%
93%
62-day standard
This target applies to those patients initially referred via the GP with suspected cancer (i.e. via the
Two-Week Wait route). The first definitive treatment must be delivered within 62 calendar days from
the date of initial GP referral. Once again the table below clearly demonstrates the Trust’s success in
surpassing the national target during 2010/11. Furthermore this is monitored weekly and is reported
monthly to the Trust Board and this will continue during 2011/12.
62-DAY PATHWAY
All 62-day patients treated between dates
specified
62-day patients referred from a National
Screening Programme, treated between dates
specified
62-day patients with a Consultant Upgrade
Date recorded, treated between dates specified
Treated
within target
Total
treated
National
target
721
% of total
treated
within target
88.9%
641
55
57.5*
95.7%
90%
1
1
100%
N/A
85%
* Where reference is made to .5 this means that we may share a patient’s care pathway with another hospital provider.
34
stakeholder engagement
The following section of our Quality Account includes the views of our Stakeholders about the Trust
and the quality of care it delivers to patients across north Cumbria. The following organisations
were invited to comment - NHS Cumbria; Cumbria’s Health and Well-being Scrutiny Committee and
Cumbria LINk.
Below is the joint response from Cumbria Health and Well-being Scrutiny Committee and Cumbria
Local Involvement Network (LINk):
What aspects of our Quality Account did you like best?
The Trust has maintained its standards from 2009/10 in producing a Quality Account that is well
presented, honest and easy to understand. The Account demonstrates that the Trust is performing
well in most areas. Using trend information, where available, and setting out remedial actions where
performance targets have not been met, is particularly helpful.
What aspects of our Quality Account did you like least?
Use of phrases like `reduce further’ without clear quantification. Some acronyms on performance
charts are unexplained (pages 24-26) – a key or brief glossary would help. More evidence of patient views/feed-back would have also helped.
Did you find the report was useful in explaining the following?
The quality of our services in 2010/2011 Yes
The values of the Trust Yes
Our priorities for this coming year Yes The improvements that have taken place Yes (but quantification not always clear)
What Advancing Quality means? Not sure
Was the report clear and easy to understand? Yes Was it interesting to read? Yes 35
glossary of terms
CHKS: Casper Healthcare System, a provider of healthcare intelligence or data collection.
CQC: Care Quality Commission, the independent regulator of all health and social care.
ACEI: Angiotensin Converting Enzyme Inhibitor
ARB: Angiotensin Receptor Blockers
LVSD: Left Ventricular Systolic Dysfunction
INIT ABX: Initial antibiotics
Divisional Management Boards: The management committees responsible for operationally
managing patient services.
Clinical Standards Sub-Group: A committee which reports directly to the Trust Board on all
medical and non-medical clinical standards. This is chaired by the Medical Director and involves senior
clinicians in the Trust.
Governance and Quality Committee: A committee which reports directly to the Trust Board and is
chaired by a Non-Executive Director. It has the responsibility of scrutinising and providing assurance to the Trust Board about the governance and quality issues in the Trust.
Mandatory Goods and Service Schedule: This is a document which sets out the volumes or amount of
services that will be provided under legally binding contracts with the commissioning body i.e a primary
care trust such as NHS Cumbria.
NCEPOD: National Confidential Enquiries into patient outcomes and death.
CQUIN: Commissioning for Quality and Innovation Payment Framework. These are a set of national and
locally agreed standards that must be met by a provider, such as a hospital trust. The available payment
for these quality improvements is conditional on full achievement.
Information Governance Toolkit: This is a set of requirements that we must meet and to ensure that we
have the evidence to prove that we have met them.
RealTime Patient Experience Tracker: This is where patients use hand-held monitors in order to provide
feedback concerning their care and experience.
MRSA: Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium responsible for several difficult-to-treat infections in humans. It may also be called multidrug-resistant Staphylococcus
aureus or oxacillin-resistant Staphylococcus aureus (ORSA).
C-diff: C. difficile is the most serious cause of antibiotic-associated diarrhoea (AAD) and can lead to
pseudomembranous colitis, a severe infection of the colon, often resulting from eradication of the normal
gut flora by antibiotics.
36
tell us what you think
We welcome feedback, comments and suggestions concerning our Quality Account. You can provide
this by completing and returning this questionnaire which helps us to inform next year’s report to
provide you with the best information about our Trust that we can.
What aspects of our Quality Account did you like best?
What aspects of our Quality Account did you like least?
Did you find the report was useful in explaining the following?
The quality of our services in 2010/2011
Yes
No
The values of the Trust
Yes
No
Our priorities for this coming year
Yes
No
The improvements that have taken place
Yes
No
What Advancing Quality means?
Yes
No
Was the report clear and easy to understand? Yes
No
Was it interesting to read?
Yes
No
Please return to the Communications Department, Management Suite, North Cumbria University
Hospitals NHS Trust, Newtown Road, Carlisle, Cumbria, CA2 7HY
Other formats
If you would like to receive this document in another format or language please call the Communications
Department on 01228 814344, email [email protected] or write to the Cumberland Infirmary
using the address above.
37
`