Annual report 2010/11 - East Cheshire NHS Trust

Registration under the Health and Social CareAct 2008 (Regulated Activity) Regulations 2009and the Care Quality Commission (Registration)Regulations 2009In April 2010 all NHS health care providers were requiredby law to register with the Care Quality Commission anddeclare compliance against 28 regulations. 16 regulationsrelated to quality and safety of care received by patients.Any area of non-compliance had to be declared and anaction plan put in place which would be reviewed by theCare Quality Commission. Registration could be issued with‘no condition’ or ‘with conditions’.East Cheshire NHS Trust successfully registered with theCare Quality Commission declaring full compliance with allof the regulations. The trust registration was granted withno condition attached to it and retained this positionthroughout 2010/11. As part of the regulations the trust isrequired to notify the Care Quality Commission of anychanges to service. During 2010/11 the trust has made threenotifications to the Care Quality Commission in relation to:• The integration of East Cheshire NHS Trust and CheshireEast Community Health in April 2011.• Change in the provision of Nuclear Medicine Service fromEast Cheshire NHS Trust to Stockport Foundation Trust viaService Level Agreement from 17 May 2010.• Tatton Ward located at Knutsford Community and DistrictHospital, was temporarily closed from September 2010.The closure was a proactive move on behalf of the trust,due to difficulties in recruiting sufficient clinical staff cover.Incident reporting statisticsComparative reporting rate, per 100 admissions,for 30 acute organisations from 1 April 2010 to30 September 201012.0010.008.006.004.002.000.00Reported incidents per 100 admissionsIt is a Care Quality Commission (CQC) requirement that allpatient safety incidents are reported to the National PatientSafety Agency (NPSA).The data published by the National Patient Safety Agency isbased on six months worth of data submitted by the trustfrom April to September 2010.East Cheshire NHS Trust is classified by the NPSA as a smallacute. There are 30 trusts in this cluster group (East CheshireNHS Trust being amongst that 30). If the small acute trustsare placed in order, to be in the top 25% of reporters in thecluster group the trust must be placed at position 23 orhigher on the graph.East Cheshire NHS Trust is, based on the latest data released,at position 21 on the graph (6.41 incidents/100 admissions).The trust is therefore 0.2 incidents/100 admissions awayfrom being in the top 25% of reporters in their clustergroup. This data shows that the trust has to marginallyincrease its reporting to become one of the top 25% ofreporters.The following chart identifies where East Cheshire NHS Trustwas (position wise) on the graphs for the reports used forthis analysis and also indicates where (percentage wise) thetrust was based on that position.Period for reports Position on graph % Area of(in cluster group) reportingApril – September 16 Mid 50%2008October 2008 – 3 Lower 25%March 2009April – September 7 Lower 25%2009 (higher end)October 2009 – 12 Mid 50%March 2010April – September 21 Mid 50%2010 (higher end)KEY: East Cheshire NHS Trust reporting rate = 6.41incidents reported per 100 admissions.3031