/KPCT_-_11-43_NHS_Kirklees_CQC_ by NHS Kirklees

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

Kirklees PCT 5N2 March 2011

ÂŠ 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.

About this document This document presents the latest version of the QRP for this organisation. We create a new version each month as we update the data sources that underpin the profiles. NHS trusts can access their own profiles from September 2010 and lead PCT commissioners will have had access to relevant trust profiles from October 2010. The information in the QRP is organised by the 16 essential outcomes of quality and safety. It includes the following components: • Context information – which includes background information about a provider or location. • Information about outcomes – this includes risk estimates for the essential standards of quality and safety and the data items that underpin the estimates. They are organised at section level (which group together a number of essential standards) and at individual outcome level (for each of the 16 key essential standards). • Contextual risk estimates – these are risk estimates that reflect the types of health services provided, the make-up of the provider’s local population and the organisational context of the provider.

Guidance We recommend that you refer to the following guidance documents when reviewing the QRP: • Quality and Risk Profiles: How to use the QRP – information about how to interpret the information within a QRP. • Quality and Risk Profiles: Data sources – a detailed listing of all of the quantitative data sources within the QRP, and information about the qualitative sources included. • Quality and Risk Profiles: Statistical guidance – information about the statistical model and analytic methods we use to calculate risk estimates in respect of the essential standards of quality and safety. It is a technical guide and assumes some statistical knowledge.

Further help and support If you have any queries or want to provide feedback about the contents of this QRP, please contact our Customer Services team by phone or email: Telephone: 03000 616161 Email: enquiries@cqc.org.uk

Tips on finding your way round this document If you are looking at this document on screen in Acrobat Reader you can… Jump to information on each outcome using the bookmarks panel The button to open bookmarks is normally on the left of the page, or you’ll find it in the “View” menu

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 L

Contents Location 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

Section 2: Personalised care, treatment and support

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

Section 3: Safeguarding and safety

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

Outcome 2 (R18) Consent to care and treatment Outcome 5 (R14) Meeting Nutritional Needs Outcome 6 (R24) Cooperating with other providers

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 ÂŠ Care Quality Commission 2011

Population Risk

Uncertainty Risk

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

Provider Provider Code 5N2

Provider Name Kirklees PCT

Registered 01/04/2010

Location and Regulated Activities Locations Barton Rehabilitation Centre Dental Clinic, St Luke's Hospital, Huddersfield, HD4 5RQ

Location ID 5N2X5

Regulated Activity 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 Activities Locations Moorfields Primary Care Centre, 11 Park Road, Huddersfield, HD4 5RX

Location ID 5N201

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Context Information Item Reference CDAO01

Data Source

Item Description

Data Value

Care Quality Commission: Register of accountable officers at February 2011

Controlled Drugs Accountable Officer

NPSARMS01

National Patient Safety Agency: Risk Management Systems

NPSA Risk Management System as of 29th October 2010

This organisation's Controlled Drugs Accountable Officer is listed as Mr. Neill Mcdonald The current local risk management system supplier for NPSA Incident Reporting is Datix

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Impact Outcome -

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Information Relevant to many Outcomes Item Reference

Data Source

Item Description

Data Value

Level achieved by trust

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

STAFFSURCTX01

NHS Litigation Authority (NHS LA): Risk Management Standards at 4th February 2011 Care Quality Commission: Survey of NHS Staff 2009/2010

STAFFSURCTX02

Care Quality Commission: Survey of NHS Staff 2009/2010

Key finding 1: Staff feeling satisfied with the quality of work and patient care they are able to deliver Key Finding 34: Staff job satisfaction

STAFFSURCTX03

Care Quality Commission: Survey of NHS Staff 2009/2010

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

STAFFSURCTX04

Care Quality Commission: Survey of NHS Staff 2009/2010

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

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

NHSLA01

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Impact Outcome Amber

Green

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A key to the dials in the QRP

Reducing risk of non-compliance

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

2 March 2011 14:04:54 PM

Increasing risk of non-compliance

There is no data available to inform this outcome or group 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)

Outcome 10 (R15)

Outcome 11 (R16)

Respecting and involving people who use services

Consent to care and treatment

Care and welfare of people who use services

Meeting Nutritional Needs

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

Outcome 12 (R21) Requirements relating to workers

2 March 2011 14:04:54 PM

Outcome 13 (R22) Staffing

Section 5: Quality and Management

Outcome 14 (R23)

Outcome 16 (R10)

Outcome 17 (R19)

Outcome 21 (R20)

Supporting Staff

Assessing and monitoring the quality of service provision

Complaints

Records

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Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Outcome 1 (R17)

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Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 1 (R17) Respecting and involving people who use services Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Good

31/03/2010

Similar to expected

Level 2

01/04/2009

31/03/2010

Similar to expected

Level 2

01/04/2009

31/03/2010

Similar to expected

Level 2

Item ID

Description

Data Source

Time Period Start

Time Period End

7518

PEAT scores for access and external areas - information - Data for HOLME VALLEY MEMORIAL HOSPITAL

04/01/2010

26/03/2010

8042

The Trust ensures that patients are informed about the proposed uses of their personal information and the importance of providing accurate information to NHS staff. The Trust has effective procedures for ensuring that detailed questions, raised by patients about how their information may be used, can be answered. The Trust has appropriate procedures for recognising and responding to patient requests for access to their health records. -

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) Department of Health, Information Governance Toolkit

01/04/2009

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

8043

8044

2 March 2011 14:04:54 PM

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 1 (R17) Respecting and involving people who use services Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Not Achieved

Item ID

Description

Data Source

Time Period Start

Time Period End

12192

NHS LA assessed outcome for Risk Management Standard Criterion 4.2 -

01/04/2008

08/11/2010

12199

NHS LA assessed outcome for Risk Management Standard Criterion 4.8 -

01/04/2008

12216

NHS LA assessed outcome for Risk Management Standard Criterion 5.10 -

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

01/04/2008

2 March 2011 14:04:54 PM

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Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 1 (R17) Respecting and involving people who use services Compariso n with Expected Tending towards better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Good

31/03/2010

Tending towards better than expected

Level 3

26/03/2010

Much better than expected

Excellent

Item ID

Description

Data Source

Time Period Start

Time Period End

7532

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

04/01/2010

26/03/2010

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. -

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) Department of Health, Information Governance Toolkit

01/04/2009

7531

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

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 2 (R18) Consent to care and treatment

Outcome 2 (R18)

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 2 (R18) Consent to care and treatment Item ID

Description

Data Source

Time Period Start

Time Period End

12193

NHS LA assessed outcome for Risk Management Standard Criterion 4.3 -

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

01/04/2008

08/11/2010

2 March 2011 14:04:54 PM

Compariso n with Expected Similar to expected

ÂŠ Care Quality Commission 2011

Value

Level 1 Achieved

Numer ator Value

Denomina tor Value

Expected Value

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Outcome 4 (R9)

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 4 (R9) Care and welfare of people who use services Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

Item ID

Description

Data Source

Time Period Start

Time Period End

12184

NHS LA assessed outcome for Risk Management Standard Criterion 3.4 -

01/04/2008

08/11/2010

12191

NHS LA assessed outcome for Risk Management Standard Criterion 4.1 -

01/04/2008

12198

NHS LA assessed outcome for Risk Management Standard Criterion 4.7 -

01/04/2008

2 March 2011 14:04:54 PM

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 4 (R9) Care and welfare of people who use services Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

31/03/2009

Similar to expected

Level 1 Achieved

31/03/2009

Similar to expected

Level 1 Achieved

Item ID

Description

Data Source

Time Period Start

Time Period End

12199

NHS LA assessed outcome for Risk Management Standard Criterion 4.8 -

01/04/2008

08/11/2010

12211

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

01/04/2008

12213

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

01/04/2008

2 March 2011 14:04:54 PM

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

Time Period Start

Time Period End

12216

NHS LA assessed outcome for Risk Management Standard Criterion 5.10 -

01/04/2008

08/11/2010

1268

Proportion of patients that spent less than four hours in A&E (all A&E/MIU/Wic (type 1,2,3)) -

NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts Department of Health, A & E Attendances and Performance (QMAE)

01/10/2010

31/12/2010

2 March 2011 14:04:54 PM

Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Not Achieved

Much better than expected

4693.0 0

4693.00

0.95

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 5 (R14) Meeting nutritional needs

Outcome 5 (R14)

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 5 (R14) Meeting nutritional needs Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Yes

26/03/2010

Similar to expected

Yes

26/03/2010

Similar to expected

81%-100%

Item ID

Description

Data Source

Time Period Start

Time Period End

11248

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

04/01/2010

26/03/2010

11292

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

04/01/2010

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 Safety Agency (NPSA), Patient Environment Action Team (PEAT) National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

2 March 2011 14:04:54 PM

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 5 (R14) Meeting nutritional needs Item ID

Description

Data Source

Time Period Start

Time Period End

11486

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

04/01/2010

26/03/2010

7523

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

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

26/03/2010

2 March 2011 14:04:54 PM

Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

81%-100%

Much better than expected

Excellent

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 6 (R24) Cooperating with other providers

Outcome 6 (R24)

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 6 (R24) Cooperating with other providers Item ID

Description

Data Source

Time Period Start

Time Period End

12196

NHS LA assessed outcome for Risk Management Standard Criterion 4.5 -

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

01/04/2008

08/11/2010

2 March 2011 14:04:54 PM

Compariso n with Expected Similar to expected

ÂŠ Care Quality Commission 2011

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Outcome 7 (R11)

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 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

12181

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

01/04/2008

31/03/2009

12183

NHS LA assessed outcome for Risk Management Standard Criterion 3.3 -

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

01/04/2008

08/11/2010

2 March 2011 14:04:54 PM

Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

Similar to expected

Level 1 Not Achieved

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 8 (R12) Cleanliness and infection control

Outcome 8 (R12)

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 8 (R12) Cleanliness and infection control Compariso n with Expected Much worse than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Lowest (worst) 20%

26/03/2010

Similar to expected

2.00

0.97

26/03/2010

Similar to expected

2.00

0.97

Item ID

Description

Data Source

Time Period Start

Time Period End

11271

Key finding 20: Availability of hand washing materials -

Care Quality Commission, Survey of NHS Staff

28/08/2009

07/12/2009

9678

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

04/01/2010

9682

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

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

2 March 2011 14:04:54 PM

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 8 (R12) Cleanliness and infection control Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

0.92

92.00

100.00

0.93

26/03/2010

Similar to expected

Yes

26/03/2010

Similar to expected

Yes

Item ID

Description

Data Source

Time Period Start

Time Period End

10037

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

04/01/2010

26/03/2010

11502

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

04/01/2010

11503

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

04/01/2010

2 March 2011 14:04:54 PM

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 8 (R12) Cleanliness and infection control Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Yes

26/03/2010

Similar to expected

Yes

26/03/2010

Similar to expected

Yes

Item ID

Description

Data Source

Time Period Start

Time Period End

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? - Data for HOLME VALLEY MEMORIAL HOSPITAL 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 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 Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

26/03/2010

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

11505

11508

2 March 2011 14:04:54 PM

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 8 (R12) Cleanliness and infection control Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Yes

26/03/2010

Similar to expected

Yes

08/11/2010

Similar to expected

Level 1 Achieved

Item ID

Description

Data Source

Time Period Start

Time Period End

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

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

26/03/2010

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts

04/01/2010

01/04/2008

11510

12177

NHS LA assessed outcome for Risk Management Standard Criterion 2.8 -

2 March 2011 14:04:54 PM

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 8 (R12) Cleanliness and infection control Compariso n with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

01/09/2010

Similar to expected

At last inspection 0 improvement s were outstanding

Item ID

Description

Data Source

Time Period Start

Time Period End

12186

NHS LA assessed outcome for Risk Management Standard Criterion 3.6 -

01/04/2008

08/11/2010

12200

NHS LA assessed outcome for Risk Management Standard Criterion 4.9 -

01/04/2008

12291

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

NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts Care Quality Commission, Hygiene Code Inspection Outcomes

01/09/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 30 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 8 (R12) Cleanliness and infection control Compariso n with Expected Much better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Excellent

26/03/2010

Much better than expected

Excellent

26/03/2010

Much better than expected

Excellent

Item ID

Description

Data Source

Time Period Start

Time Period End

7497

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

04/01/2010

26/03/2010

7498

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

04/01/2010

7500

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

04/01/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 31 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 8 (R12) Cleanliness and infection control Compariso n with Expected Much better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Excellent

26/03/2010

Much better than expected

Excellent

26/03/2010

Much better than expected

Excellent

Item ID

Description

Data Source

Time Period Start

Time Period End

7510

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

04/01/2010

26/03/2010

7514

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

04/01/2010

9670

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

04/01/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 32 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

Time Period Start

Time Period End

9671

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

04/01/2010

26/03/2010

9672

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

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

26/03/2010

2 March 2011 14:04:54 PM

Compariso n with Expected Much better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Excellent

Much better than expected

Excellent

ÂŠ Care Quality Commission 2011

Page 33 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 9 (R13) Management of medicines

Outcome 9 (R13)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 34 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 9 (R13) Management of medicines Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Not Achieved

30/09/2010

Similar to expected

Fully accredited/no minated LSMS in the process

Item ID

Description

Data Source

Time Period Start

Time Period End

12187

NHS LA assessed outcome for Risk Management Standard Criterion 3.7 -

01/04/2008

08/11/2010

12197

NHS LA assessed outcome for Risk Management Standard Criterion 4.6 -

01/04/2008

12471

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

NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts Counter Fraud and Security Management Service, Security Management Service compliance data

30/09/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 35 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 9 (R13) Management of medicines Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

SMD appointed with voting board membership

30/09/2010

Similar to expected

NonExecutive Director appointed

31/07/2010

Similar to expected

Information submitted where applicable

Item ID

Description

Data Source

Time Period Start

Time Period End

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? -

30/09/2010

12473

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

30/09/2010

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

31/07/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 36 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

Time Period Start

Time Period End

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

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

ÂŠ Care Quality Commission 2011

Value

Numer ator Value

Denomina tor Value

Expected Value

Meetings sufficiently attended when applicable

Page 37 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 10 (R15) Safety and suitability of premises

Outcome 10 (R15)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 38 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 10 (R15) Safety and suitability of premises Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Good

26/03/2010

Similar to expected

Acceptable

26/03/2010

Similar to expected

Good

Item ID

Description

Data Source

Time Period Start

Time Period End

7508

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

04/01/2010

26/03/2010

7517

PEAT scores for access and external areas - car parking - Data for HOLME VALLEY MEMORIAL HOSPITAL

04/01/2010

7529

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

04/01/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 39 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 10 (R15) Safety and suitability of premises Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Good

31/03/2010

Similar to expected

01/01/2009

31/12/2009

Similar to expected

Developed programme to work to reduce risks

01/01/2009

31/12/2009

Similar to expected

No enforcement, no ongoing enforcement

01/01/2009

31/12/2009

Similar to expected

Compliant

Item ID

Description

Data Source

Time Period Start

Time Period End

7530

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

04/01/2010

26/03/2010

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. Outcome of trusts risk assessment of fire safety -

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) Department of Health, Estates Return Information Collection (ERIC)

01/04/2009

Department of Health, Annual Statement of Fire Safety Department of Health, Annual Statement of Fire Safety Department of Health, Annual Statement of Fire Safety

8532

8533

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

8534

The trust achieved compliance with Department of Health Fire Safety Policy -

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 40 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 10 (R15) Safety and suitability of premises Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

0.00

22474.00

0.00

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

Item ID

Description

Data Source

Time Period Start

Time Period End

9492

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

01/04/2009

31/03/2010

12180

NHS LA assessed outcome for Risk Management Standard Criterion 3.1 -

01/04/2008

12184

NHS LA assessed outcome for Risk Management Standard Criterion 3.4 -

Department of Health, Estates Return Information Collection (ERIC) NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts

01/04/2008

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 41 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 10 (R15) Safety and suitability of premises Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

30/09/2010

Similar to expected

Fully accredited/no minated LSMS in the process

30/09/2010

Similar to expected

SMD appointed with voting board membership

Item ID

Description

Data Source

Time Period Start

Time Period End

12185

NHS LA assessed outcome for Risk Management Standard Criterion 3.5 -

01/04/2008

08/11/2010

12471

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

30/09/2010

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? -

NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts Counter Fraud and Security Management Service, Security Management Service compliance data Counter Fraud and Security Management Service, Security Management Service compliance data

30/09/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 42 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 10 (R15) Safety and suitability of premises Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

NonExecutive Director appointed

31/07/2010

Similar to expected

Information submitted where applicable

31/12/2010

Similar to expected

Meetings sufficiently attended when applicable

Item ID

Description

Data Source

Time Period Start

Time Period End

12473

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

30/09/2010

12474

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

31/07/2010

12475

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

01/01/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 43 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 10 (R15) Safety and suitability of premises Comparison with Expected Tending towards better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Good

26/03/2010

Tending towards better than expected

Good

01/04/2009

31/03/2010

Tending towards better than expected

0.073

45.00

613.00

0.05

01/04/2009

31/03/2010

Tending towards better than expected

8.00

22474.00

0.00

Item ID

Description

Data Source

Time Period Start

Time Period End

7511

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

04/01/2010

26/03/2010

7512

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

04/01/2010

7547

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

9493

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

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT) Department of Health, Estates Return Information Collection (ERIC) Department of Health, Estates Return Information Collection (ERIC)

2 March 2011 14:04:54 PM

Page 44 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 10 (R15) Safety and suitability of premises Comparison with Expected Much better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Excellent

26/03/2010

Much better than expected

Excellent

04/01/2010

26/03/2010

Much better than expected

Excellent

04/01/2010

26/03/2010

Much better than expected

Excellent

Item ID

Description

Data Source

Time Period Start

Time Period End

7507

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

04/01/2010

26/03/2010

7509

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

04/01/2010

7513

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

7519

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

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 45 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 10 (R15) Safety and suitability of premises Comparison with Expected Much better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Excellent

26/03/2010

Much better than expected

Excellent

04/01/2010

26/03/2010

Much better than expected

Excellent

04/01/2010

26/03/2010

Much better than expected

Excellent

Item ID

Description

Data Source

Time Period Start

Time Period End

7520

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

04/01/2010

26/03/2010

7528

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

04/01/2010

9052

PEAT score for environment - provision of outdoor patient recreational areas - Data for HOLME VALLEY MEMORIAL HOSPITAL

9673

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

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 46 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

Time Period Start

Time Period End

9674

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

National Patient Safety Agency (NPSA), Patient Environment Action Team (PEAT)

04/01/2010

26/03/2010

2 March 2011 14:04:54 PM

Comparison with Expected Much better than expected

ÂŠ Care Quality Commission 2011

Value

Numer ator Value

Denomina tor Value

Expected Value

Excellent

Page 47 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Outcome 11 (R16)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 48 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 11 (R16) Safety, availability and suitability of equipment Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

30/09/2010

Similar to expected

Fully accredited/no minated LSMS in the process

Item ID

Description

Data Source

Time Period Start

Time Period End

12176

NHS LA assessed outcome for Risk Management Standard Criterion 2.7 -

01/04/2008

08/11/2010

12187

NHS LA assessed outcome for Risk Management Standard Criterion 3.7 -

01/04/2008

12471

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

30/09/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 49 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 11 (R16) Safety, availability and suitability of equipment Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

SMD appointed with voting board membership

30/09/2010

Similar to expected

NonExecutive Director appointed

31/07/2010

Similar to expected

Information submitted where applicable

Item ID

Description

Data Source

Time Period Start

Time Period End

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? -

30/09/2010

12473

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

30/09/2010

12474

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

31/07/2010

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 50 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 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

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

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

ÂŠ Care Quality Commission 2011

Value

Numer ator Value

Denomina tor Value

Expected Value

Meetings sufficiently attended when applicable

Page 51 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 12 (R21) Requirements relating to workers

Outcome 12 (R21)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 52 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

12169

NHS LA assessed outcome for Risk Management Standard Criterion 1.9 -

12170

NHS LA assessed outcome for Risk Management Standard Criterion 1.10 -

11290

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

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Not Achieved

07/12/2009

Much better than expected

Highest (best) 20%

Time Period Start 01/04/2008

Time Period End

01/04/2008

28/08/2009

08/11/2010

ÂŠ Care Quality Commission 2011

Page 53 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 13 (R22) Staffing

Outcome 13 (R22)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 54 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 13 (R22) Staffing Item ID

Description

Data Source

7067

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

7068

Three month vacancy rate for qualified Allied Health Professionals -

7070

Three month vacancy rate for occupational therapy staff -

7071

Three month vacancy rate for physiotherapy staff -

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

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

0.00

100.00

0.01

31/03/2010

Similar to expected

0.00

100.00

0.01

31/03/2010

Similar to expected

0.00

100.00

0.01

31/03/2010

Similar to expected

0.00

100.00

0.00

Time Period Start 31/03/2010

Time Period End

31/03/2010

ÂŠ Care Quality Commission 2011

Page 55 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 13 (R22) Staffing Item ID

Description

Data Source

7079

Three month vacancy rate for speech & language therapy staff -

9792

Three month vacancy rate for district nurses -

9793

Three month vacancy rate for health visitors -

9794

Three month vacancy rate for qualified school nurses -

9796

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

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

0.00

100.00

0.00

31/03/2010

Similar to expected

0.00

100.00

0.01

31/03/2010

Similar to expected

0.00

100.00

0.01

31/03/2010

Similar to expected

0.00

100.00

0.00

31/03/2010

Similar to expected

0.00

100.00

0.00

Time Period Start 31/03/2010

Time Period End

31/03/2010

ÂŠ Care Quality Commission 2011

Page 56 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying Information for: Outcome 13 (R22) Staffing Item ID

Description

Data Source

9800

Three month vacancy rate for registered pharmacists -

11348

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

7065

Three month vacancy rate for all non-medical staff -

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

11260

Key finding 9: Staff working extra hours -

2 March 2011 14:04:54 PM

Care Quality Commission, Survey of NHS Staff

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

0.00

100.00

0.01

31/03/2010

Similar to expected

0.00

100.00

0.01

31/03/2010

Tending towards better than expected

0.00

100.00

0.00

28/08/2009

07/12/2009

Tending towards better than expected

Below (better than) average

Time Period Start 31/03/2010

Time Period End

31/03/2010

ÂŠ Care Quality Commission 2011

Page 57 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff

Outcome 14 (R23)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 58 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

12479

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

7554

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

8038

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

8039

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

Counter Fraud and Security Management Service, Security Management Service compliance data Department of Health, Estates Return Information Collection (ERIC) Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

2 March 2011 14:04:54 PM

Comparison with Expected Worse than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Less than 75% assaults reported where applicable

31/03/2010

Tending towards worse than expected

0.00

100.00

0.44

01/04/2009

31/03/2010

Similar to expected

Level 3

01/04/2009

31/03/2010

Similar to expected

Level 3

Time Period Start 01/04/2009

Time Period End

01/04/2009

31/03/2010

ÂŠ Care Quality Commission 2011

Page 59 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

10131

The Trust has ensured that its RA managers, agents and sponsors have sufficient knowledge and skills (inc. latest software, operational process guidance etc) to discharge its RA responsibilities Proportion of available working time lost to sickness absence -

Department of Health, Information Governance Toolkit

11247

11262

Key finding 11: Staff feeling there are good opportunities to develop their potential at work -

Information Centre for Health & Social Care (IC), NHS Staff Sickness Absence Care Quality Commission, Survey of NHS Staff

11276

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

Care Quality Commission, Survey of NHS Staff

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 3

30/09/2010

Similar to expected

0.046

4.63

100.00

0.04

28/08/2009

07/12/2009

Similar to expected

Average

28/08/2009

07/12/2009

Similar to expected

Average

Time Period Start 01/04/2009

Time Period End

01/09/2010

31/03/2010

ÂŠ Care Quality Commission 2011

Page 60 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

11289

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

Care Quality Commission, Survey of NHS Staff

12171

NHS LA assessed outcome for Risk Management Standard Criterion 2.1 -

12172

NHS LA assessed outcome for Risk Management Standard Criterion 2.2 -

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

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Average

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

Time Period Start 28/08/2009

Time Period End

01/04/2008

07/12/2009

ÂŠ Care Quality Commission 2011

Page 61 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

12173

NHS LA assessed outcome for Risk Management Standard Criterion 2.3 -

12174

NHS LA assessed outcome for Risk Management Standard Criterion 2.5 -

12175

NHS LA assessed outcome for Risk Management Standard Criterion 2.6 -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Not Achieved

Time Period Start 01/04/2008

Time Period End

01/04/2008

08/11/2010

ÂŠ Care Quality Commission 2011

Page 62 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

12176

NHS LA assessed outcome for Risk Management Standard Criterion 2.7 -

12177

NHS LA assessed outcome for Risk Management Standard Criterion 2.8 -

12178

NHS LA assessed outcome for Risk Management Standard Criterion 2.9 -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

Time Period Start 01/04/2008

Time Period End

01/04/2008

08/11/2010

ÂŠ Care Quality Commission 2011

Page 63 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

12179

NHS LA assessed outcome for Risk Management Standard Criterion 2.10 -

12188

NHS LA assessed outcome for Risk Management Standard Criterion 3.8 -

12189

NHS LA assessed outcome for Risk Management Standard Criterion 3.9 -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

Time Period Start 01/04/2008

Time Period End

01/04/2008

08/11/2010

ÂŠ Care Quality Commission 2011

Page 64 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

12190

NHS LA assessed outcome for Risk Management Standard Criterion 3.10 -

12471

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

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? -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

30/09/2010

Similar to expected

Fully accredited/no minated LSMS in the process

30/09/2010

Similar to expected

SMD appointed with voting board membership

Time Period Start 01/04/2008

Time Period End

30/09/2010

08/11/2010

ÂŠ Care Quality Commission 2011

Page 65 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

12473

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

12474

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

12475

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

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

NonExecutive Director appointed

31/07/2010

Similar to expected

Information submitted where applicable

31/12/2010

Similar to expected

Meetings sufficiently attended when applicable

Time Period Start 30/09/2010

Time Period End

31/07/2010

01/01/2010

30/09/2010

ÂŠ Care Quality Commission 2011

Page 66 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

12478

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

11256

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

Counter Fraud and Security Management Service, Security Management Service compliance data Care Quality Commission, Survey of NHS Staff

11257

Key finding 6: Work pressure felt by staff -

2 March 2011 14:04:54 PM

Care Quality Commission, Survey of NHS Staff

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Information submitted where applicable

07/12/2009

Tending towards better than expected

Above (better than) average

07/12/2009

Tending towards better than expected

Below (better than) average

Time Period Start 30/11/2010

Time Period End

28/08/2009

30/11/2010

ÂŠ Care Quality Commission 2011

Page 67 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

11263

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

Care Quality Commission, Survey of NHS Staff

11264

Key finding 13: Staff appraised in last 12 months -

11265

11266

Comparison with Expected Tending towards better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Above (better than) average

07/12/2009

Tending towards better than expected

Above (better than) average

28/08/2009

07/12/2009

Tending towards better than expected

Above (better than) average

28/08/2009

07/12/2009

Tending towards better than expected

Above (better than) average

Time Period Start 28/08/2009

Time Period End

Care Quality Commission, Survey of NHS Staff

28/08/2009

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

Care Quality Commission, Survey of NHS Staff

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

Care Quality Commission, Survey of NHS Staff

2 March 2011 14:04:54 PM

07/12/2009

ÂŠ Care Quality Commission 2011

Page 68 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

11267

Key finding 16: Support from immediate managers -

Care Quality Commission, Survey of NHS Staff

11268

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

11270

11278

Comparison with Expected Tending towards better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Above (better than) average

07/12/2009

Tending towards better than expected

Above (better than) average

28/08/2009

07/12/2009

Tending towards better than expected

Below (better than) average

28/08/2009

07/12/2009

Tending towards better than expected

Below (better than) average

Time Period Start 28/08/2009

Time Period End

Care Quality Commission, Survey of NHS Staff

28/08/2009

Key finding 19: Staff suffering work-related stress in last 12 months -

Care Quality Commission, Survey of NHS Staff

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

Care Quality Commission, Survey of NHS Staff

2 March 2011 14:04:54 PM

07/12/2009

ÂŠ Care Quality Commission 2011

Page 69 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

11279

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

Care Quality Commission, Survey of NHS Staff

11282

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

11283

11254

Comparison with Expected Tending towards better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Above (better than) average

07/12/2009

Tending towards better than expected

Above (better than) average

28/08/2009

07/12/2009

Tending towards better than expected

Above (better than) average

28/08/2009

07/12/2009

Much better than expected

Highest (best) 20%

Time Period Start 28/08/2009

Time Period End

Care Quality Commission, Survey of NHS Staff

28/08/2009

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

Care Quality Commission, Survey of NHS Staff

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

Care Quality Commission, Survey of NHS Staff

2 March 2011 14:04:54 PM

07/12/2009

ÂŠ Care Quality Commission 2011

Page 70 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Comparison with Expected Much better than expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Highest (best) 20%

07/12/2009

Much better than expected

Highest (best) 20%

28/08/2009

07/12/2009

Much better than expected

Highest (best) 20%

Care Quality Commission, Survey of NHS Staff

28/08/2009

07/12/2009

Much better than expected

Lowest (best) 20%

Care Quality Commission, Survey of NHS Staff

28/08/2009

07/12/2009

Much better than expected

Lowest (best) 20%

Item ID

Description

Data Source

Time Period Start 28/08/2009

Time Period End

11258

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

Care Quality Commission, Survey of NHS Staff

11259

Key finding 8: Quality of work-life balance -

Care Quality Commission, Survey of NHS Staff

28/08/2009

11261

Key finding 10: Staff using flexible working options -

Care Quality Commission, Survey of NHS Staff

11275

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

11277

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

2 March 2011 14:04:54 PM

07/12/2009

ÂŠ Care Quality Commission 2011

Page 71 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 14 (R23) Supporting Staff Item ID

Description

Data Source

11281

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

Care Quality Commission, Survey of NHS Staff

2 March 2011 14:04:54 PM

Time Period Start 28/08/2009

Time Period End 07/12/2009

Comparison with Expected Much better than expected

ÂŠ Care Quality Commission 2011

Value

Numer ator Value

Denomina tor Value

Expected Value

Lowest (best) 20%

Page 72 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Outcome 16 (R10)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 73 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

8254

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

10515

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

11274

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

National Patient Safety Agency (NPSA), National Reporting Learning System (NRLS) National Patient Safety Agency (NPSA), National Reporting Learning System (NRLS) Care Quality Commission, Survey of NHS Staff

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

4 months of reporting

31/03/2010

Similar to expected

0.019

18.88

1000.00

0.03

07/12/2009

Similar to expected

Average

Time Period Start 01/10/20 09

Time Period End

01/10/20 09

28/08/20 09

31/03/2010

ÂŠ Care Quality Commission 2011

Page 74 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

12161

NHS LA assessed outcome for Risk Management Standard Criterion 1.1 -

12162

NHS LA assessed outcome for Risk Management Standard Criterion 1.2 -

12163

NHS LA assessed outcome for Risk Management Standard Criterion 1.3 -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Not Achieved

Time Period Start 01/04/20 08

Time Period End

01/04/20 08

08/11/2010

ÂŠ Care Quality Commission 2011

Page 75 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

12164

NHS LA assessed outcome for Risk Management Standard Criterion 1.5 -

12165

NHS LA assessed outcome for Risk Management Standard Criterion 1.6 -

12166

NHS LA assessed outcome for Risk Management Standard Criterion 1.7 -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

Time Period Start 01/04/20 08

Time Period End

01/04/20 08

08/11/2010

ÂŠ Care Quality Commission 2011

Page 76 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

12203

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

12208

NHS LA assessed outcome for Risk Management Standard Criterion 5.5 -

12209

NHS LA assessed outcome for Risk Management Standard Criterion 5.6 -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Not Achieved

08/11/2010

Similar to expected

Level 1 Achieved

Time Period Start 01/04/20 08

Time Period End

01/04/20 08

08/11/2010

ÂŠ Care Quality Commission 2011

Page 77 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

12210

NHS LA assessed outcome for Risk Management Standard Criterion 5.7 -

12211

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

12213

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

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

Level 1 Not Achieved

31/03/2009

Similar to expected

Level 1 Achieved

31/03/2009

Similar to expected

Level 1 Achieved

Time Period Start 01/04/20 08

Time Period End

01/04/20 08

08/11/2010

ÂŠ Care Quality Commission 2011

Page 78 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

12336

Compliance with Department of Health central returns of data deadlines -

12376

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

12357

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

11273

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

Department of Health, Central Returns Timeliness of Returns National Patient Safety Agency (NPSA), Central Alerting System National Patient Safety Agency (NPSA), Central Alerting System Care Quality Commission, Survey of NHS Staff

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numer ator Value

Denomina tor Value

Expected Value

0.063

3.00

48.00

0.02

14/02/2011

Similar to expected

0.87

120.00

138.00

0.90

01/08/20 09

14/02/2011

Tending towards better than expected

150.00

0.98

28/08/20 09

07/12/2009

Much better than expected

Highest (best) 20%

Time Period Start 01/04/20 09

Time Period End

01/02/20 10

31/03/2010

ÂŠ Care Quality Commission 2011

Page 79 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

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

Description

Data Source

11284

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

Care Quality Commission, Survey of NHS Staff

2 March 2011 14:04:54 PM

Time Period Start 28/08/20 09

Time Period End 07/12/2009

Comparison with Expected Much better than expected

ÂŠ Care Quality Commission 2011

Value

Numer ator Value

Denomina tor Value

Expected Value

Highest (best) 20%

Page 80 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 17 (R19) Complaints

Outcome 17 (R19)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 81 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 17 (R19) Complaints Item ID

Description

Data Source

12204

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

12205

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

12207

NHS LA assessed outcome for Risk Management Standard Criterion 5.4 -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomina tor Value

Expected Value

Level 1 Achieved

31/03/2010

Similar to expected

Level 1 Achieved

08/11/2010

Similar to expected

Level 1 Achieved

Time Period Start 01/04/20 08

Time Period End

01/04/20 08

31/03/2010

ÂŠ Care Quality Commission 2011

Page 82 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 17 (R19) Complaints Item ID

Description

Data Source

12208

NHS LA assessed outcome for Risk Management Standard Criterion 5.5 -

12209

NHS LA assessed outcome for Risk Management Standard Criterion 5.6 -

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

2 March 2011 14:04:54 PM

Time Period Start 01/04/20 08

Time Period End

01/04/20 08

08/11/2010

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomina tor Value

Expected Value

Level 1 Not Achieved

Similar to expected

Level 1 Achieved

ÂŠ Care Quality Commission 2011

Page 83 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records

Outcome 21 (R20)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 84 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

8045

The trust has established appropriate confidentiality audit procedures in line with the requirements of the National Programme for IT. The Trust has adequate governance in place to support the current and evolving Information Governance agenda. How would you assess your Trustâ€™s ability to access expertise across the Confidentiality & Data Protection Assurance agenda? How would you assess your Trustâ€™s ability to access expertise across the Information Security agenda? How would you assess your Trustâ€™s ability to access expertise across the Information Quality and Records Management Agenda? -

Department of Health, Information Governance Toolkit

8027

8028

8029

8030

2 March 2011 14:04:54 PM

Comparison with Expected Worse than expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 1

31/03/2010

Similar to expected

Level 3

01/04/20 09

31/03/2010

Similar to expected

Level 3

01/04/20 09

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

31/03/2010

Page 85 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

8031

The Trust has in place a comprehensive Information Governance Policy and associated Strategy and Improvement Plans all signed off by the Board. The Trust has up to date and tested business continuity plans for all critical infrastructure components and core information systems. The Trust has in place a comprehensive Information Lifecycle Management (ILM) Policy and associated Strategy and Improvement Plans all signed off by the Board The Trust ensures that staff and those working on behalf of the Trust comply with the terms and conditions set out on the RA01 form. -

Department of Health, Information Governance Toolkit

8032

8033

8035

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 3

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 3

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit

31/03/2010

ÂŠ Care Quality Commission 2011

Page 86 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

8036

The Trust ensures that it has formal contractual arrangements that include compliance with information governance requirements, with all contractors and support organisations. The Trust ensures that all individuals carrying out work on behalf of the Trust have employment contracts which require compliance with information governance standards. The Trust has a Confidentiality Code of Conduct that provides staff with clear guidance on the disclosure of patient personal information. The trust has agreed protocols governing the sharing of patientidentifiable information with other organisations where this is required. -

Department of Health, Information Governance Toolkit

8037

8040

8046

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 2

31/03/2010

Similar to expected

Level 3

01/04/20 09

31/03/2010

Similar to expected

Level 3

01/04/20 09

31/03/2010

Similar to expected

Level 3

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

31/03/2010

ÂŠ Care Quality Commission 2011

Page 87 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

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). The Trust ensures that all new processes, software and hardware comply with confidentiality and data protection requirements. The Trust has a formal information security risk assessment and management programme that is implemented and regularly reviewed. The Trust have documented and accessible information security event reporting, investigation and resolution procedures in place that are explained to staff. -

Department of Health, Information Governance Toolkit

8049

8050

8051

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 3

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit

31/03/2010

ÂŠ Care Quality Commission 2011

Page 88 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

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). The Trust ensures that the Operating and Application and information systems under its control support appropriate access control functionality. Defined, documented and agreed access rights for all users of Trust information systems and services available. The Trust has established a register of all its major information assets and assigned responsibility or â€˜ownershipâ€™ for each. The Trust ensures that digital information shared with other organisations is secured in transit. -

Department of Health, Information Governance Toolkit

8054

8055

8056

8057

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 2

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

31/03/2010

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

8058

The Trust has adequate procedures in place to ensure the availability of information processing facilities, communications services and data. The Trust has procedures in place to prevent information processing being interrupted or disrupted through equipment failure, environmental hazard or human error. The Trust ensures that its Information systems are capable of the rapid detection, isolation and removal of malicious code and unauthorised mobile code. 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

8059

8060

8061

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 2

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 3

01/04/20 09

31/03/2010

Similar to expected

Level 2

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit

31/03/2010

ÂŠ Care Quality Commission 2011

Page 90 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 2

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

Department of Health, Information Governance Toolkit

01/04/20 09

31/03/2010

Similar to expected

Level 2

Department of Health, Information Governance Toolkit

01/04/20 09

31/03/2010

Similar to expected

Level 2

Item ID

Description

Data Source

8062

The Trust has appropriate procedures in place to ensure that communication networks under the Trustâ€™s control operate in a secure manner. The Trust has appropriate procedures for ensuring that mobile computing and teleworking are conducted in a secure manner. The Trust has a strategy to ensure the correct NHS number is recorded for each active patient and that it is used routinely in clinical communications. The Trust has trust-wide, multi-professional audit of clinical record keeping standards, including accuracy, for all professional groups in all specialties. The Trust has robust procedures and processes for all data collection activities across the Trust. -

Department of Health, Information Governance Toolkit

8063

8065

8067

8069

2 March 2011 14:04:54 PM

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

01/04/20 09

31/03/2010

Page 91 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

8072

The Trust has procedures in place to ensure that when new services are provided or where changes within the system are made, that these do not adversely impact on information quality. The Trust ensures that NHS standard definitions, values and validation programmes are incorporated within key systems and that local documentation is updated as standards develop. The Trust use external data quality reports for monitoring and improving quality. -

Department of Health, Information Governance Toolkit

8073

8074

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. -

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 2

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

31/03/2010

ÂŠ Care Quality Commission 2011

Page 92 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

8081

The Trust has (or access) a formal, targeted training programme for all staff involved in the collection and management of patientrelated data covering the operation of key systems. The Trust has sufficient governance processes in place to ensure adherence to the principles enshrined in the Code of Conduct for Payment by Results. The Trust has documented and implemented procedures for the creation and filing of electronic corporate records to enable efficient retrieval and effective records management. The Trust have documented and implemented procedures for the creation, filing and tracking/tracing of paper corporate records to enable efficient retrieval and effective records management. -

Department of Health, Information Governance Toolkit

8083

8084

8085

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 2

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit

31/03/2010

ÂŠ Care Quality Commission 2011

Page 93 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

8086

The Trust has publicly available documented and implemented procedures to ensure compliance with the Freedom Of Information Act 2000. The Trust has carried out an audit of its corporate records and information as part of the records lifecycle management strategy. The Trust have a Board level Senior Information Risk Owner (SIRO) who takes ownership of the Trustâ€™s information risk policy 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

8087

10132

10133

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 2

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

01/04/20 09

31/03/2010

Similar to expected

Level 2

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit Department of Health, Information Governance Toolkit

01/04/20 09

Department of Health, Information Governance Toolkit

31/03/2010

Page 94 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

10134

The PCT has established working arrangements with its main commissioning partners to develop processes to assure itself of the validity of the trustsâ€™ data. 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. NHS LA assessed outcome for Risk Management Standard Criterion 1.8 Clinical records management -

Department of Health, Information Governance Toolkit

10135

12167

2 March 2011 14:04:54 PM

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 2

31/03/2010

Similar to expected

Level 2

31/03/2010

Similar to expected

Level 1 Achieved

Time Period Start 01/04/20 09

Time Period End

Department of Health, Information Governance Toolkit

01/04/20 09

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

01/04/20 08

31/03/2010

Page 95 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Outcome 21 (R20) Records Item ID

Description

Data Source

12194

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

8047

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

NHS Litigation Authority (NHS LA), Risk Management Standards for Primary Care Trusts Department of Health, Information Governance Toolkit

2 March 2011 14:04:54 PM

Time Period Start 01/04/20 08

Time Period End

01/04/20 09

31/03/2010

Comparison with Expected Similar to expected

Value

Numera tor Value

Denomin ator Value

Expected Value

Level 1 Not Achieved

Tending towards better than expected

Level 3

ÂŠ Care Quality Commission 2011

Page 96 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Risk Profile : Inherent, Situational, Population and Uncertainty risk

Overall Contextual risk estimate

Inherent Risk

The 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

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Page 97 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Inherent Risk

Item IRADM00 1

Description An organisation's ratio of elective to nonelective admissions. This indicator separates out specialist from nonspecialist acute hospitals.

Data Source Hospital Episode Statistics (HES)

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)

2 March 2011 14:04:54 PM

Rationale 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. 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

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

01/10/2009 30/09/2010

Value Not Applicable

Not Applicable

Page 98 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Inherent Risk

Item IRHRP002

Description 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.

Data Source Hospital Episode Statistics (HES)

IRHRP003

The number of admissions by transfer 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)

2 March 2011 14:04:54 PM

Rationale 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. 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.

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

01/10/2009 30/09/2010

Value Not Applicable

Not Applicable

Page 99 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Inherent Risk

Item IRMAT001

Description 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

Data Source Hospital Episode Statistics (HES)

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)

2 March 2011 14:04:54 PM

Rationale 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. Multiple births are associated with decreased birthweight, and increased perinatal & neo-natal mortality. Children from multiple pregnancies have a higher rate of permanent physical and mental disabilities than do singletons.

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

01/10/2009 30/09/2010

Value Not Applicable

Not Applicable

Page 100 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Inherent Risk

Item IRMAT003

Description 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.

Data Source Hospital Episode Statistics (HES)

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)

2 March 2011 14:04:54 PM

Rationale The provision of effective care to patients whose pregnancies are categorised as high risk; Women diagnosed with a highrisk 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. Increased maternal age is associated with increased risk of fetal death, birth abnormalities and complications during gestation.

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

01/10/2009 30/09/2010

Value Not Applicable

Not Applicable

Page 101 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Inherent Risk

Item IRMHI001

Description The number of mental health staff who reported in the NHS staff survey that they have been a victim of violence or witnessed violence toward patients.

Data Source Care Quality Commission, NHS Staff Survey

IROCC00 1

The number of occupied beds over the total number of available beds at a care provider.

Department of Health, Hospital Activity Statistics

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)

2 March 2011 14:04:54 PM

Rationale 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. A target occupancy level of 85% has been suggested as the recommended balance between unused bed capacity and efficient inpatient flow. There is a relationship between volume and clinical outcome with higher volumes being associated with better clinical outcomes.

ÂŠ Care Quality Commission 2011

Time Period 2009/10

Value Not Applicable

01/04/2009 31/03/2010

Not Applicable

01/10/2009 30/09/2010

Not Applicable

Page 102 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Inherent Risk

Item IRVOL002

IRVOL003

IRVOL004

Description Trusts that perform this procedure with greater 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 should be considered in conjunction with IRVOL001-IRVOL008. Trusts with greater than 400 elective surgical cases per annum (OPCS procedure codes K49-50, K75) 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 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 should be considered in conjunction with IRVO

2 March 2011 14:04:54 PM

Time Period 01/04/2009 31/03/2010

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

Rationale There is a relationship between volume and clinical outcome with higher volumes being associated with better clinical outcomes.

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

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

ÂŠ Care Quality Commission 2011

Value Not Applicable

Page 103 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Inherent Risk

Item IRVOL005

IRVOL006

IRVOL007

Description Trusts treating more than 73 elective diagnostic (i.e. without therapeutic surgery) cases per annum (ICD10 diagnosis codes K80-82) are less risky than those with less than this number. This indicator is a member of the "volume" suite of indicators and sho 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. Trusts with more than 17 elective therapeutic surgical cases per annum (ICD10 diagnosis codes C18-20 with therapeutic surgery) are less risky than those with less than this number. This indicator is a member of the "volume" suite of indicators and should

2 March 2011 14:04:54 PM

Time Period 01/10/2009 30/09/2010

Data Source Hospital Episode Statistics (HES)

Rationale There is a relationship between volume and clinical outcome with higher volumes being associated with better clinical outcomes.

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

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

ÂŠ Care Quality Commission 2011

Value Not Applicable

Page 104 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Inherent Risk

Item IRVOL008

Description 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 this number. This indicator is a member o

2 March 2011 14:04:54 PM

Data Source Hospital Episode Statistics (HES)

Rationale There is a relationship between volume and clinical outcome with higher volumes being associated with better clinical outcomes.

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

Value Not Applicable

Page 105 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Situational Risk

Item SRCCC 001

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

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

SRCCC 002

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)

2 March 2011 14:04:54 PM

Rationale 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. 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

ÂŠ Care Quality Commission 2011

Time Period 01/04/2009 31/03/2010

Value Not Applicable

01/10/2009 30/09/2010

Not Applicable

Page 106 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Situational Risk

Item SRRMG 001

SRRMG 002

SRRMG 003

Description 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. 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 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

2 March 2011 14:04:54 PM

Data Source NHS Litigation Authority (NHS LA), Risk Management Standards

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

Time Period 28/09/2007 25/11/2010

Value Somewhat likely to be risky

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

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.

ÂŠ Care Quality Commission 2011

Not Applicable

Page 107 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Situational Risk

Item SRWRN 001

Description 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 conjunction with the indicators SRWRN001SRWRN004.

Data Source Care Quality Commission, Periodic Review

SRWRN 002

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. 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

SRWRN 003

2 March 2011 14:04:54 PM

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

Rationale Organisational culture and environment have been identified as weak signals of risk and the multiplication of several weak signals can build to provide a high degree of risk within an organisation. High vacancy rates may be indicative of various unfavourable staffing conditions such as poor working conditions or poor management. High vacancy rates may be indicative of various unfavourable staffing conditions such as poor working conditions or poor management.

ÂŠ Care Quality Commission 2011

Time Period 2009/10

Value Unlikely to be risky

Unlikely to be risky

Page 108 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Situational Risk

Item SRWRN 004

Description 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.

2 March 2011 14:04:54 PM

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

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

ÂŠ Care Quality Commission 2011

Time Period

Value Likely to be risky

Page 109 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRETH001

Description The number of different ethnicities represented in a community.

Data Source Office for National Statistics, 2001 Census

PRICM001

The proportion of patients admitted to hospital with cancer (AS, ICD-10 = C00D48). This indicator is a member of the "comorbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.

Quality Outcomes Framework

2 March 2011 14:04:54 PM

Rationale 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 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.

ÂŠ Care Quality Commission 2011

Time Period 2001 (released Deember 2009)

Value Somewhat likely to be risky

01/04/2008 31/03/2009

Unlikely to be risky

Page 110 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRICM002

Description 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.

Data Source Quality Outcomes Framework

PRICM003

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

Hospital Episode Statistics (HES)

2 March 2011 14:04:54 PM

Rationale 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. 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.

ÂŠ Care Quality Commission 2011

Time Period 01/04/2008 31/03/2009

Value Unlikely to be risky

01/04/2008 31/03/2009

Not Applicable

Page 111 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRICM004

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

Data Source Quality Outcomes Framework

PRICM005

The proportion of patients admitted to hospital with diabetes (AS, ICD-10 = E10E14). This indicator is a member of the "comorbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.

Quality Outcomes Framework

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Time Period 01/04/2008 31/03/2009

Value Likely to be risky

01/04/2008 31/03/2009

Somewhat likely to be risky

Page 112 of 127

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRICM006

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

Data Source Hospital Episode Statistics (HES)

PRICM007

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

Hospital Episode Statistics (HES)

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

Value Not Applicable

01/10/2009 30/09/2010

Not Applicable

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRICM008

Description 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.

Data Source Hospital Episode Statistics (HES)

PRICM009

The proportion of patients admitted to hospital with a stroke (AS, ICD-10 = 160164). This indicator is a member of the "comorbidities" suite of indicators and should be considered in conjunction with the indicators PRICM001-PRICM009.

Quality Outcomes Framework

2 March 2011 14:04:54 PM

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

Value Not Applicable

01/04/2008 31/03/2009

Somewhat likely to be risky

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRIMD001

Description A composite domain deprivation score relating in the main to income and material deprivation.

Data Source Department for Communities and Local Government

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)

2 March 2011 14:04:54 PM

Rationale Time Period Patients from more deprived areas are more likely to have more risk factors, complications and comorbidities. Barriers to providing a 01/10/2009 good service to this 30/09/2010 group include; poor communication; GPâ€™s requiring specialists knowledge of health needs and diagnostic procedures relating to people with learning disabilities; lack of adequate consultation time. Screening programmes are also challenging for individuals with learning disabilities, especially for breast and cervical cancer.

Value Likely to be risky

Not Applicable

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRLDI002

Description The proportion of the PCT population who have a learning disability (PCT).

2 March 2011 14:04:54 PM

Data Source Quality and Outcomes Framework

Rationale Time Period Barriers to providing a 01/04/2008 good service to this 31/03/2009 group include; poor communication; GPâ€™s requiring specialists knowledge of health needs and diagnostic procedures relating to people with learning disabilities; lack of adequate consultation time. Screening programmes are also challenging for individuals with learning disabilities, especially for breast and cervical cancer.

Value Somewhat likely to be risky

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRLTC001

Description 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.

Data Source Quality Outcomes Framework

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

2 March 2011 14:04:54 PM

Rationale Sudden unexpected death is substantially more common in people with epilepsy than in the general population. People with epilepsy are at a significantly higher risk from suicide and suffer seizure attributed fractures of the spine, forearms, femurs, lower legs and feet and toes at higher rate than the general population. Asthma is a leading cause of hospital admission for children aged 3-12. Timely and effective outpatient care can substantially reduce hospitalisations for everyone with asthma. Children from disadvantaged socioeconomic groups are over represented in the hospitalised population.

ÂŠ Care Quality Commission 2011

Time Period 01/04/2008 31/03/2009

Value Unlikely to be risky

01/04/2008 31/03/2009

Somewhat likely to be risky

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRLTC003

PRLTC004

Description 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 The proportion of patients admitted to hospital with inflammatory intestinal disease (AS, ICD-10 = K50K52, K58). This indicator is a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRL

2 March 2011 14:04:54 PM

Data Source Hospital Episode Statistics (HES)

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

Time Period 01/10/2009 30/09/2010

Value Not Applicable

Hospital Episode Statistics (HES)

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

01/10/2009 30/09/2010

Not Applicable

ÂŠ Care Quality Commission 2011

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRLTC005

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

2 March 2011 14:04:54 PM

Data Source Hospital Episode Statistics (HES)

Rationale 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 50fold higher than those in women without SLE. Cerebrovascular, coronary, and peripheral vascular thromboembolic events are major causes of morbidity.

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

Value Not Applicable

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRLTC006

Description 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.

Data Source Hospital Episode Statistics (HES)

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)

2 March 2011 14:04:54 PM

Rationale Non-Hodgkin lymphoma is a possible complication of celiac disease and may lead to a large portion of lymphoma cases. Other complications of Celiac disease include adenocarcionma of the small intestine, and squamous cell carcinomas of the esophagus, mouth and pharynx. Haemoglobin disorders are life limiting for sufferers due to disease and secondary morbidities including rickets, scoliosis, spinal deformities, nerve compression, fractures and sever osteoporosis.

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

Value Not Applicable

01/10/2009 30/09/2010

Not Applicable

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRLTC008

Description 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.

2 March 2011 14:04:54 PM

Data Source Hospital Episode Statistics (HES)

Rationale Although survival from cystic fibrosis (CF) is increasing rapidly, suffers usually die in early adulthood. There is also involvement of the gastrointestinal tract in most patients, with 85% showing pancreatic insufficiency as a result of obstruction of the pancreatic ducts and subsequent scarring an ddestruction 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 treatment for patients with advanced cycstic fibrosis.

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

Value Not Applicable

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRLTC009

Description The proportion of patients admitted to hospital with multiple sclerosis (AS, ICD10 = G35). This indicator is a member of the "long term conditions " suite of indicators and should be considered in conjunction with the indicators PRLTC001-PRLTC010.

Data Source Hospital Episode Statistics (HES)

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

2 March 2011 14:04:54 PM

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

ÂŠ Care Quality Commission 2011

Time Period 01/10/2009 30/09/2010

Value Not Applicable

2001 (released Deember 2009)

Unlikely to be risky

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRMHI001

PRPHP001

Description 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). 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 health priorities" suite of indicators and should be considered in conjunction with the indicators PRPH

2 March 2011 14:04:54 PM

Data Source Quality Outcomes Framework

Hospital Episode Statistics (HES)

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

ÂŠ Care Quality Commission 2011

Time Period 01/04/2008 31/03/2009

Value Somewhat likely to be risky

01/10/2009 30/09/2010

Not Applicable

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRPHP002

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

Data Source Quality and Outcomes Framework

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)

2 March 2011 14:04:54 PM

Rationale 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 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.

ÂŠ Care Quality Commission 2011

Time Period 01/04/2008 31/03/2009

Value Likely to be risky

01/10/2009 30/09/2010

Not Applicable

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRPMC301

Description The number of active GPs in a primary care trust

Data Source NHS Connecting for Health, Office of National Statistics

PRPOP001

The proportion of people aged 65+ who have been admitted to hospital (AS) and the proportion of people aged 65+ in the general PCT population.(PCT) The proportion of people aged 0-17 who have been admitted to hospital (AS) and the proportion of people aged 0-17 in the general PCT population (PCT).

Office for National Statistics

PRPOP002

2 March 2011 14:04:54 PM

Office for National Statistics

Rationale Good primary care systems (ones with a sufficient number of GPs to serve a population) are associated with improved health outcomes. People aged 65 and over more likely to require hospital treatment and to display multiple morbidity. 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

ÂŠ Care Quality Commission 2011

Time Period

Value Likely to be risky

Mid-2009 population estimates

Unlikely to be risky

Mid-2009 population estimates

Somewhat likely to be risky

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Population Risk

Item PRTEP001

Description The number of births to teenage (15-17) mothers as a proportion of total births (AS).

2 March 2011 14:04:54 PM

Data Source Hospital Episode Statistics (HES)

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

Time Period 01/10/2009 30/09/2010

Value Not Applicable

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

Provider Code 5N2

Provider Name Kirklees PCT

Data Version 2.5

Underlying information: Uncertainty Risk

Item URCOM001

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

2 March 2011 14:04:54 PM

Data Source CQC

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

ÂŠ Care Quality Commission 2011

Time Period February 2011

Value

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