The Trust has today published the results of its first self-assessment on its performance regarding the Healthcare Commission’s core standards for April 2005 to March 2006. The good news is that we are compliant with all the 24 core standards in hospital care – a huge tribute to everybody’s hard work over the last year.

The standards are part of the Healthcare Commission’s new-style ‘health check’ which has replaced the old star-rating system. Along with all other trusts in the country, we will now take part in this annual exercise which includes a self-assessment section concentrating on the broader issues which aim to ‘measure what matters’ to patients, the public, clinicians and healthcare managers. The standards fall into seven categories: safety, clinical and cost effectiveness, governance, patient focus, accessible and responsive care, care environment and amenities and public health. For the first time the views on the quality of services have been included from our local community including patient and public representatives.

In October we published a ‘draft declaration’ about the Trust’s performance. This was to assess the way the new system would operate.

In this first draft assessment we stated that against the 24 core healthcare standards (each of which have several different sections) our performance was as follows:

38 responses where the Trust was compliant
one response where the Trust was non-compliant
five responses where the Trust had insufficient assurance

Since October work has focused on the areas where we were non-compliant or had insufficient assurance. Risk assessments were completed and action plans drafted to address the issues which included: training, health promotion, healthcare policy, use of medical equipment and skills updating where it was shown that we needed to do more work to evidence performance against the standard.

The one standard where there were concerns regarding compliance was infection control. Hospital acquired infection has been a particular issue during the last year and the subject of intense focus. Understanding that patients’ confidence is damaged by this issue, the hospital has recognised the improvements we needed to make and worked hard to carry them out. We have focused on: staff education; audits of IV practice, uniform, hand washing; high profile awareness campaigns for staff and the public – Together we can fight infection, Clean your hands and Take 5!; the establishment of an MRSA-free area for elective surgery with a ‘seek and treat’ policy for patients before admission; the use of antibiotic coated intravenous devices in certain clinical areas where high there is a high incidence of MRSA and the adoption of the national guidelines Saving Lives for good practice.

The Trust has made progress on this standard, but still recognises that the momentum for improvement must be sustained. The number of new MRSA-positive patients decreased in 2005 by 9%, the incidence of Clostridium difficile-associated diarrhoea fell by 28% and MRSA bloodstream infections reduced by 14%.

The declaration forms part of the overall Annual Health Check and the Healthcare Commission will in September give the hospital a performance rating which will indicate whether our services are excellent, good, fair or weak.

To read the declaration, follow this link.

For information about the Healthcare Commission, follow this link.

Last updated: 9 May 2006