13. Monthly Performance Report - Southern Health and Social Care ...

CONTENTPage1.0 Context 52.0 Reporting 53.0 Summary Report 63.1 Efficiency 63.2 Access & Targets 113.3 Clinical & Social Care Quality 163.4 Workforce 264.0 Additional Reporting 274.1 Access Targets 29Daycase Rates (Appendix II)4.2 Clinical & Social Care Quality 33Healthcare Associated Infection 33 C Diff Analysis 36 MRSA Analysis 37 MSSA Analysis 38 Hand Hygiene & Infection control training 39 Compliance with Antibiotics 41 HCAI Related Deaths 42 Environmental Cleanliness Report (Appendix IV)Quality Improvement Targets (Patient Care Indicators) 44Children & Young People Reporting 47 Unallocated Child Care Cases 47Clinical and Quality 48 Re-admission Rates with Peer comparison Mortality Rates with Peer comparisonAppendix I – Daycase Rates by procedureAppendix II – Environmental Cleanliness ReportMonthly Performance Report 16 February 10 4

CONTEXTThis report forms part of the Trusts performance management framework and setsout a summary of Trust performance for January against:• Priority for Action (PfA) 2009/10 Standards and Targets and• Key Performance Indicators (KPIs) of corporate performance2. REPORTINGThe PfA standards and targets and KPIs of corporate performance are presentedin this performance report within the key domains defined within the performancemanagement framework.• Efficiency of Care Delivery• Access & Targets• Clinical and Social Care Quality• Workforce – detailed reporting via HR & OD Directorate Report• Finance – will be reported through the Monthly Finance ReportThe level of performance will be assessed against each target/KPI as follows:Assessed Level of PerformanceTarget achieved/achievable or on track for achievement- No current riskTarget partially achieved/achievable- Minimal Risk, management actions required to minimise riskTarget not achieved/achievable- Risk, management actions requiredPerformance not yet assessedVariation in performance from the previous month’s position is indicated by thearrows: Improvement towards the target indicated by:Worsening performance from the target indicated by:No significant change in performance indicated by:Monthly Performance Report 16 February 10 5

3 SUMMARY REPORT3.1 DOMAIN: EFFICIENCYTarget/Indicator Baseline Target Actual CommentsPFA Diagnostic Sept 08 Apr 09 Jan 10Reporting(Imaging &Non-From April 2009Imaging)-all urgent testsreported within 2days-75% of routinewithin 2 weeks-100% of routinewithin 4 weeks(Target rolled overfrom 2008/09)PFA 4.4 TimelyHospitalDischargeFrom April 2009,-90% complexdischarges within48 hours-no. complexdischarge will takelonger than sevendays-all other patientsshould bedischarged withinsix hoursTarget rolled overfrom 2008/0926%77.9%89.3%Mar 0898.6%096.3%100%75%100%Mar 1090%0100%87%(Imaging)48%(Nonimaging)82%(Imaging)89%(Nonimaging)88%(Imaging)93%(Nonimaging)Jan 1097%(111/115)NI Ave: 86%096.2%(2305/2395)NI Ave:96%Whilst progress hasbeen made thereremains some riskwith the ability toachieve the targetfur urgent reportingprior toimplementation ofNIPACS (estimatedimplementationcommencementwithin SHSCT -March 10).The Trust continuesto sustain the targetfor complexdischarges andperform wellagainst the regionalaverage.‘Simple’dischargescomparable withthe regionalaverage.Monthly Performance Report 16 February 10 6

days)Target rolled overfrom 2008/09(This monitoringexcludes currentinpatients)- all patientsdischarged toreceive continuingcare plan toreceive visit within7 daysKPI ALOSEpisodic AverageLength of Stay forElective and NonElectiveAdmissions toHospitalKPI: OP DNA% patients who‘Did not attend’ anOP appointmentand did not advisethe hospital inadvance.PMSID haveindicated apotential target forthis area may beset, initialconsiderationsare 5% for newpatients and 8%for reviewpatients.PFA -Day CaseRate By March2011, all Trustsare required toachieve an overallday surgery rateof not less than75% for the‘basket’ of 24proceduresBaseline tobeestablishedProcessAverage2008/095.5Nonelective1.16ElectiveProcessAverage2008/097.5%5.6%7.5%BaselineSHSCT2007/0855.6%2008/09(Basket of24)59.5%To beagreedBenchmark8.6%(EnglishNationalAverage)TargetMarch 1175%Monitoringnot in placeJan 105.14Nonelective0.86ElectiveJan 1011%Total(Trust AvgApr-Dec 9.7%)7.4%Newpatients12.5%ReviewpatientsApr-Dec09Cumulative63.5%(coding level80.5%therefore %subject tochange)appropriatecommunityresettlementplaces.The averageLoS forelectiveepisodes inJan is betterthan theprocessaverage of08/09.Detailedreporting byprocedureincluded inAppendix I.Monthly Performance Report 16 February 10 8

KPI : %DischargesCoded-cumulativecoding positionMarch2008/09- 98.4%Target100%April – 6Jan 1081.9%KPI Freedom ofInformation (FOI)% requestsresponded towithin 20 daysSHSCTBaseline200887.5%(Regionalrange 50% -95%)Target100%Dec 0978%(7/9requests –respondedto within 20day limit)To allow forthe 20 daytime lag thisposition isbeing report amonth inarrears.KPI Staff Accessto IntranetNumber of staffas a percentageof the total Truststaffingcomplement, whohave access tothe Trust IntranetSHSCTBaselineMarch200955.72%InternalTarget55%Jan 1069.9%This targethas beenachieved.KPI IT HelpdeskresponseCalls received byIT Service Deskresolved on firstcontact. This willbe measuredagainst thebaseline at March2009SHSCTBaselineMarch20096.61%Target33%Jan 1022.1% Temporarycapacity gapin trained staffavailable isimpacting onachievementof this target.Monthly Performance Report 16 February 10 9

3.2 DOMAIN: ACCESS & TARGETSTarget/Indicator Baseline Target Actual CommentsPFA 3.1: Waiting Mar 09 Mar 10 Jan 10The 9 monthTime ArthritisDrug TherapiesBy March 2010, nofor 9monthpositiontarget hasbeenachieved.patients should waitlonger than 9 n/a 0 0The trust ismonths to now workingcommencetowards thespecialist drug Mar 08 Mar 11 Jan 10achievementtherapies for for 21of the 21 weektreatment of severe weektarget byarthritis,positionMarch 2011.By March 2011 –21 weeksTarget increasedfrom 2008/0918 0 9(patientswaiting over21 weeks)PFA 3.2 IP/DC, OP& DiagnosticAccess TargetsBy March 2010, nopatient will waitlonger than-9 weeks for a firstOP appointment,-9 weeks for adiagnostic test, and-13 weeks forIP/DC treatmentStandard rolledover from 2008/09The 9/9/13 week08/09 target mustbe sustained monthon month in2009/10.Mar 08(No. ofpatientswaiting)OP:1624Diag:188IP/DC:1614Mar 10OP:0Diag:0IP/DC:031 Jan 10OP193breachesDiag:13breachesIP/DC:225breaches193 OPsbreached -1 Gen Med1 LD, 1 CommPaeds, 23 OralSurgery, 55PainManagement,99 T&O, 13Urology.13 Diagnosticsbreached -12Urodynamics,1 Sleep Study.225 Inpatient /Daycasesbreached –125 Urology,13 Gen SurScopes, 1Gynae, 59T&O.See additionalreporting.Monthly Performance Report 16 February 10 11

PFA AHP AccessBy March 2010-no patients shouldwaiter longer than 9weeks from referralto commencementof AHP treatment.-the 13 week targetachieved in March09 should besustainedTarget increasedfrom 2008/09PFA Fractures-By March 2010,95% of patients willwait no longer than48 hours forinpatient fracturetreatment.- no patient shouldwait longer than 7days for treatmentTarget rolled overfrom 2008/09PFA CancerBy March 2009,- 98% of cancerpatients willcommencetreatment within 31days and-95% of patientsurgently referredwith suspectedcancer will begintreatment within 62days- all urgent GPreferrals for breastcancer are seen in14 days andTarget rolled overfrom 2008/09Mar 093220Mar 0975.6%0Mar 0899%96%100%Mar 1000Mar 0995%0Mar 0998%95%100%31 Jan 10140Jan 1066.7%(32/48)NI Ave 65%0Jan 10Position As atDec 09100%(59/59)100%(24/24)100%All areas areworking toachieve a 9week positionby the end ofFebruary andwaiting listreductionplans are inplace.14 OT patientsbreached theinterim Trusttarget inJanuary.Trustperformancedecreased thismonth due tohigh levels oftrauma andbed pressuresin early Jan.This wascomparablewith theregionalposition.CumulativePerformanceApr – Jan was65%Due to the 31and 62 daytime lag thesetargets arereportedretrospectively.Monthly Performance Report 16 February 10 12

PFA A&E AccessFrom April 2009,95% of patientstreated &discharged oradmitted within 4hrsStandard rolledover from 2008/09Mar 08SHSCT95.2%CAH92.9%DHH97.1%Mar 09SHSCT95%CAH95%DHH95%Jan 10SHSCT91%CAH86%DHH95%NIRegionalAverage(Dec 09):81%Reducedperformanceon the CAHsite waslargely due tobed pressuresin January.The Trust isactivelylooking atoptions toimprove thissituation.PFA 4.2 Care ofOlder PeopleFrom April 2009,-no older personwith continuing careneeds will waitmore than eightweeks for acompletedassessment,-with the maincomponents of caremet within a further12 weeksStandard rolledover from 2008/09Mar 0899.2%100%Mar 09100%100%Jan 10100%100%The Trustcontinues tosustain thistarget.PSA 5.3 Careleavers By March2010, ensure that atleast 70% of careleavers aged 19 arein education,training oremploymentRevised targetMar 0936Careleavers33(92%)In ETEMar 10-46Jan 1038Care leavers20(53% -20/38)In ETEMonthly Performance Report 16 February 10 13

PSA 5.4: CareleaversBy March 2010increase to 175 thenumber of careleavers aged 18-20living with theirformer foster carersor supported familyRevised targetPSA 6.3 MentalHealthAssessment andTreatmentBy March 2010-ensure no patientwaits longer than 9weeks from referralto assessment andcommencement oftreatment formental health,excludingpsychologicaltherapies,Target increasedfrom 2008/09-pyschologicaltherapies to sustain13 week maximumwaitTarget rolled overfrom 2008/09PSA 7.3SpecialisedWheelchairsBy March 2010- ensure an 18week maximumwaiting time for90% of allwheelchairsNew targetPFA – AutismBy March 2010-ensure that allchildren wait nolonger than 13weeks forMar 0927(End ofMonthposition)Mar 0926Mar 089431 Jul 0990%31 Jul 090Mar 1033Mar 1000Mar 1090%Mar 100Jan 1031(31 in Dec) 29 Jan 107(No. on PTLover 9weeks)0Jan 1093%(9/128waiting over18 weeks)31 Jan 100All areasworking toachieve 9week targetand waiting listreductionplans in place.This target hasbeenachieved.This target hasbeenachieved.Monthly Performance Report 16 February 10 14

assessment, and- a further 13 weeksfor commencementof specialisttreatmentNew target0 00PFA – AcquiredBrain InjuryBy March 2010,-ensure a 13 weekmaximum waitingtime from referral toassessment andcommencement ofspecialisedtreatment Newtarget31 Jul 090TargetMar 10031 Jan 100This target hasbeenachieved.PFA 7 – HousingAdaptations(Major HousingAdaptations)By March 2010- all lifts/ceilingtrack hoists to beinstalled within 22week of OTassessment/ optionappraisal(Minor HousingAdaptations)By March 2010- all minor urgentworks to becompleted within 10days - New target31 Oct0992.3%TargetMar 10100%31 Jan 1064%(5/14 >22weeks)n/aNo informationis available onthecomparabilityof this newtarget withregionalperformance.The Trustrequires to putin placearrangementsfor monitoringperformanceagainst theminor housingadaptationstarget.Monthly Performance Report 16 February 10 15

3.3 DOMAIN: CLINICAL AND SOCIAL CARE QUALITYTarget/Indicator Baseline Target Actual CommentsPFA - HCAIIn the year to, byMarch 2010,2007/08MRSAMar 10MRSAJan 10MRSA/Additionalreporting onHealthcareensure a14 9 2Associated-35% reduction in Episodes Episodes Episode Infection is(Ave

PFA 4 – DirectPaymentsBy March 2010,-number of directpayment casesincreases to 1,250Target increasedMar 09361Mar 10241(SHSCTtarget)Jan 10476This target isachieved.PFA Family GroupConferencesDuring 2009/10-ensure that at least500 cyp whoseassessed need ison levels 1,2 or 3 ofthe Hardiker modelhave participated ina FGC.Target rolled overfrom 2008/092008/0958Mar 1096(Ave 8 permonth)Jan 103(105 Apr -Dec)This target hasbeen achievedwith 108childrenhavingparticipated todate (Apr-Jan).Monthly Performance Report 16 February 10 17

PSA 5.2FamilysupportinterventionsOct 08 –March 09153Mar 10Jan 10This targetextrapolated tofull year is ontrack.By March 2010-provide familysupportinterventions to2000 childrenin vulnerablefamilies eachyearNew Target306Extrapolatedfor full year384(Ave 32 permonth)338(cumulativeposition)(Ave 34 permonth)(DecCumulative313)PFA 5.3 -Foster CarersBy March 2010,- increasefoster carers by300 (NI target)from the March2006 totalMar 06217Mar 10275Jan 10286This target hasbeen met. Thenumber ofFoster Carersfluctuatesmonth onmonth, showingdecreases overthe last threemonths.PSA 5.1 -Children inCareBy March 1090% of childrenadmitted toresidential careprior toadmissionshould-have hadformalassessment &placementmatchedthroughChildren’sResourcesPanelBaselineQ1 0967%TargetMar 1090%Jan 10100%(2/2 child)(Q1 averagepositionApr-June67%)(Q2 averagepositionJuly-Sept57%)(Q3 averagepositionOct-Dec88%)This target issubject tovariation due tothe smallnumber ofchildreninvolved,therefore aQuarterlyaverageposition will bereferenced.CumulativeperformanceApril-Jan =73% (19/26)Monthly Performance Report 16 February 10 18

-Every childtaken into careshould have aplan forpermanenceand timescaleagreed withinsix monthsPSA 6.2 MHealthResettlementBy March 2010,resettle 60patients fromhospital toappropriatecommunityplaces fromMarch 2006position.Baselinenotavailable2006/0702007/0862008/0914CumulativePositionMar 1012(cumulatively- achieved in2008/09)MonitoringnotavailableApr –Jan 106(includesresettlementscommenced)20CumulativePositionPMSIDreporting isnow in-year(09/10) and notcumulativeperformance.Trust achievedtarget in2008/09.Target Rolledover from2008/09PSA 7.1LearningDisabilityResettlementBy March 2010-resettle 90learningdisabilitypatients fromhospital toappropriateplaces incommunityfrom March2006 position.Target rolledover from2008/09Surgical Siteinfections(SSI)Bundlecompliancerate-orthopaedics(all electivehips & knees)Mar 0702008/0918CumulativePositionOct 0815%Mar 1017Mar 0995%Apr- Jan104(includesresettlementscommenced)22CumulativePositionJan 1092.31%PMSIDreporting isnow focused onin-yearresettlementand notcumulatively.The NI SafetyForum isseeking tostandardisehow all Trustsmeasure theBundleElements. ThisMonthly Performance Report 16 February 10 19

SSI rate (Hipsonly)BundleCompliancerate-CaesareanSection (auditof 20 cases permonthSSI Rate(C-section)Central LineInfections-Infection Rateper 1000 linedaysQ2 20080%CAH5%DHH5.26%Q2 2008CAH9.2%DHH19.2%Oct 08CAH3%DHH3%-95%95%25%reductionon Q42008 SSIRate (as ofFeb 09) –Target14.21%(NI Average14.5%)1.17%1.17%Q3 20090%(NI Ave:1.0%)95%85.71%Q3 2009CAH7.2%DHH1.4%(NI Ave:11.2%)Jan 1000may have animpact onoverall BundleCompliance inthe monthsahead until anynew practicesare embeddedsuccessfully.SSI Infectionrates, availableas a quarterlyposition, arenow included inreporting.This targetmeasures thenumber ofcentral linecatheter-relatedbloodstreaminfections-Compliancewith bundleCAH30%DHH0%95%95%70%80%Measurementreflects allCentral Lines atCAH & DHHand compliancewith the carebundleelements.VentilatorAcquiredPneumonia(VAP)- Ventilatordays betweeninfectionsOct 08517Mar 10300Jan 10366(Cum daysbetweeninfections584)This targetaims to achieve95%compliancewith all bundleelements inICU in CAH.The Trust metthe regionaltarget of 300Monthly Performance Report 16 February 10 20

- Compliancewith bundle100% 95% 100%Vent Daysbetweeninfections (584days free ofinfections).Crash CallRate-Rate per 1000deaths/dischargesMonitoringrolled over from2008/09Oct 08CAH3.7DHH0.9Mar 101.89 per1000deaths/dischargesJan 10CAH1.17 per1000DHH0.45 per1000(NI Range 0– 7.5)This QIP targetis focused onreducing crashcalls in A&E,ICU andcoronary care.Crash callsdecreasedsignificantly onboth sites inJan.MEWSModified EarlyWarningScoringSystemMental HealthIndicators-%compliancewith multidisciplinaryreviewSept 09CAH94.44%DHH100%TrustAve85.79%Oct 08CAH79%SLH67%Mar 1095%Mar 09100%Jan 10CAH90%(190/210)DHH93%(112/120)TrustAve91.5%Non-AcuteSites93%(112/120)Jan 10CAH100%SLH100%The modifiedearly warningscoring systemis a tool tosupport clinicalstaff assesspatientprogress viarecording ofkeyobservationaldata.This waspiloted in twowards and hasbeen rolled outTrust wide inSeptember2009. TheTrust will striveto meet the95% target.These targetsfocus oninpatientreview,assessmentand complianceMonthly Performance Report 16 February 10 21

-%compliancewith riskassessment-%compliancewithpatient/carerinvolvement inTPCAH63%SLH17%CAH88%SLH100%100%100%CAH80%SLH80%CAH100%SLH100%withpatient/carerinvolvement intreatmentplanningAll are sampledby randomaudit of 30activecasenotes eachmonthKPI -CrudeMortality RateDeaths as apercentage oftotal hospitaldeaths anddischargesPeerAverage2007/081.98%2008/091.92%Apr –Aug 091.72%TargetSHSCT2007/081.22%2008/091.18%Apr –Dec 091.5%The mortalityrate providedshows the Trustaverageagainst a peergroup of DistrictGeneralHospitals. Thishas beenextract from the‘CHKS’comparativebenchmarkingtool.See additionalreporting.KPI – ReadmissionrateDischargesfrom the Trustthat are readmittedto theTrust againwithin 28 daysas apercentage oftotal dischargesPeerAverage2007/086.5%2008/096.7%Apr –Aug 095.8%TargetSHSCT2007/085.3%2008/095.4%Apr –Dec 092.73%The readmissionrateprovided showsthe Trustaverageagainst a peergroup of DistrictGeneralHospitals. Thishas beenextracted fromthe ’CHKS’benchmarkingtool.See additionalreporting.Monthly Performance Report 16 February 10 22

KPIEnvironmentalCleanlinessCleanlinessMattersStrategyindicates that85% or aboveis anacceptablelevel ofcleanliness.KPI – LookedAfter childrenNumber whoreceived novisitKPI – ChildProtectionRegistrarNumber ofchildren onCPR over 2yearsKPI –UnallocatedChild CareCasesKPI – Health &Care Number% of potentialH+C matchesthat areachieved eachmonth for acutesystemtransactionsKPMGbaselineDHH90%STH88%CAH84%Mar 086QE Mar097.4%(31/420)Apr 0837Apr 09119Dec 08Baseline96%Target85%Target0Targetto beestablishedTarget0InternalTarget100%Jan 10DHH89%STH93%CAH93%Jan 103Jan 108%(35/432)Jan 1077(91 inDec)Jan 1080%This target hasbeen achieved.The Trustaveraged 93%on thisweighted scorefor all riskcategories.Additionalreportedincluded.Target to bedefined.See additionalreporting insection 4.0Trust averageyear to date is81%Regionalcomparatorsare not yetavailable.Monthly Performance Report 16 February 10 23

Priority 5(Target 7)PFA –Assessmentof Children atRiskFrom April 09-all Childprotectionreferrals shouldbe allocatedwithin 24 hoursof receiptMar 10100%Dec 10100%(28/28)Definitions arecurrently beingrefined for thisnewlyestablishedtargetthereforeJanuaryupdate will notbe availableBy March 2010,-90% of familysupportreferrals shouldbe allocated toa social workerwithin 20 daysfor initialassessment90% (initialassessment)91 %(160/175)-postassessment90% of casesrequiring familysupportpathwayassessmentallocated withinfurther 20working dayswith:initialassessmentcompletedwithin 10 days&:pathwayassessmentcompletedwithin 20 days90% (postassessment)10 days(initial)20 days(pathway)TBCTBCTBCMonthly Performance Report 16 February 10 24

New targets for which monitoring arrangements have yet to be established –Respite Targets: HSCB have recently completed an audit of respite care. Trustresponses will inform the new monitoring arrangements for the actual PFA targets.PFA Respite – dementiaBy March 2010-provide an additional 1200 dementia respite places compared to March 2008further 100 by March 2011 total New target monitoringPSA 7.2 – Respite Physical and sensory disabilityBy March 2010-improve access to Physical/sensory disability by providing an additional 100respite packages per year compared to March 2008 and a further 100 by March2011PSA 7.4 – Respite Learning DisabilityBy March 2010-improve access to learning disability by providing an additional 100 respitepackages a year compared to March 2008 and a further 100 by March 2011Monthly Performance Report 16 February 10 25

3.4 DOMAIN: WORKFORCETarget/Indicator Baseline Target Actual Comments2008/09 Mar 10 Dec 09This targethas been met.PFA 9.1 Each Trustshould reduce its levelof absenteeism to 5.5%in the year to March2010, reducing to 5.2%in the year to March20114.94%5.50%5.06% Monthly Performance Report 16 February 10 26

4.0 Analysis, Additional Information and Exception Reporting by Domain4.1 Access & Targets• IP/DC/OP• Fracture• RenalAppendix I- Daycase rates by Procedure4.2 Clinical and Social Care Quality• Healthcare Associated Infectiono C Diff Analysiso MRSA Analysiso MSSA Analysiso Hand Hygieneo Compliance with Antibioticso HCAI Related Deaths• Quality Improvement Targets (Patient Care Indicators)• Children & Young People Reportingo Unallocated Child Care CasesMonthly Performance Report 16 February 10 27

• Re-admission Rates with Peer comparison• Mortality Rates with Peer comparisonAppendix II (Environmental Cleanliness Report)Monthly Performance Report 16 February 10 28

4.1 Access & TargetsElective access targets: The Trust continues to work with the local Commissioner and Health and Social Care Board to securethe level of investment required for the development of recurrent solutions to ensure the maintenance of access targets issustainable.• Recurrent investment has been secured for ENT, neurology, Allied Health Professions and Pain Management services.• Management efforts continue to focus on securing the recurrent investments required for gynaecology, endoscopy,ophthalmology and Trauma & orthopaedics services.• Discussions regarding the future local urology service model have been initiated in parallel with consultation on the regionalurology review.• The Trust is also working with the BHSCT and SEHSCT to secure the additional local service capacity required for SHSCT inrespect of visiting regional services, specifically oral surgery and neurophysiology.Delay in securing investment has however introduced risk to achievement of access targets as non-recurrent solutions have had tobe sustained longer than anticipated leading to cost and operational pressures. Key areas of risk for the achievement of accesstargets in year have been discussed with, and recognised by, the Performance Management & Service Improvement Division inrespect of urology, endoscopy, trauma & orthopaedics and MRI services. Whilst the Trust continues to work towards sustaining itsaccess times for these areas it is anticipated that these services will not be delivered within the current access standards but willnot exceed a 17 week access time position.Robust operational and monitoring arrangements have been established to ensure maximisation of capacity to minimise the volumeand impact of any access standard breaches.Monthly Performance Report 16 February 10 29

Monthly Performance Report 16 February 10 30

Fractures: Until recurrent investment is secured for a 6 consultant model that enables weekend fracture lists to be delivered 52weeks of the year, this target remains at risk. A business case has been submitted and is under discussion with the commissionerand HSCB. In the interim analysis is underway to review demand for routine, urgent and sub specialist work.SHSCT - Fracture Access (% 48 Hour Target)120.0%100.0%% within 48 Hours80.0%60.0%40.0%20.0%SHSCT0.0%M a M aM a M aFeb- A pr - Jun- Jul - A ug-Sep-Oct- Nov- Dec- Jan- Feb- Apr - Jun- Jul - Aug-Sep-Oct - Nov- Dec- Janr- y-r - y-08 08 08 08 08 08 08 08 08 09 09 09 09 09 09 09 09 09 09 1008 0809 09SHSCT 55.3 65.7 61. 5 83.9 66.0 59.3 76. 0 100. 73.9 92.3 89.3 86. 0 83. 7 75.6 91.3 74. 5 85. 1 94.9 79.5 70.0 70.0 75. 7 76.1 66.795% T ARGET (M ARCH 09 AND M A RCH 10) 95.0 95.0 95. 0 95.0 95.0 95.0 95. 0 95. 0 95.0 95.0 95.0 95. 0 95. 0 95.0 95.0 95. 0 95. 0 95.0 95.0 95.0 95.0 95. 0 95.0 95.075% HOLDING T A RGE T 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75% 75%NI RE GI ONA L P OSIT ION 53% 74% 82% 80% 74% 72% 82% 78% 77% 85% 77% 73% 76% 86% 79% 76% 75% 83% 82% 79% 73% 80% 75% 65%95% TARGET(MARCH 09 ANDMARCH 10)75% HOLDINGTARGETNI REGIONALPOSITIONMonthly Performance Report 16 February 10 31

Renal – dialysis via fistula: This target is unlikely to be achieved in year due to the withdrawal of the visiting service fromBHSCT. Local surgeons have been trained to undertaken this procedure. The ability to achieve the target is reliant on the uptakeof the current patient cohort.65.0%SOUTHERN HEALTH AND SOCIAL CARE TRUST% Patients Receiving Dialysis via Fistula%Target % March 2009Target % March 201060.0%55.0%50.0%45.0%40.0%35.0%38.1%38.1% 38.8%38.9% 40.9%39.8%37.0%35.1% 35.7%36.5% 34.9%39.8%36.8%38.5%35.8%35.7%34.3%33.3%34.0%32.7% 33.7% 36.2%38.1%30.0%Mar-08Apr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10Feb-10Mar-10Monthly Performance Report 16 February 10 32

MSSAMRSA CDSC Data September 20090.400.350.300.250.200.150.100.050.00Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3MRSA patient episodes per 1,000 episodic occupied bed days25201510MRSA Cumulative TotalApr 2009 – 8 th Feb 20102 DaysTargetBelfast Trust Quarterly RatesNorthern Trust Quarterly RatesSouth Eastern Trust Quarterly RatesSouthern Trust Quarterly RatesWestern Trust Quarterly Rates2008 Trust annual MRSA rate52008 2009 2008 2009 2008 2009 2008 2009 2008 2009Belfast Northern SouthEastern Southern Western0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar3Monthly Performance Report 16 February 10 34

0.400.350.300.250.200.150.100.05MSSA CDSC Data September 20090.00Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3Quarter 1Quarter 2Quarter 3Quarter 4Quarter 1Quarter 2Quarter 3MSSA patient episodes per 1,000 episodic occupied bed days403530252015105MSSA Cumulative TotalApr 2009 – 8 th Feb 20102 DaysTargetBelfast Trust Quarterly RatesNorthern Trust Quarterly RatesSouth Eastern Trust Quarterly RatesSouthern Trust Quarterly RatesWestern Trust Quarterly Rates2008 Trust annual MSSA rate0Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar2008 2009 2008 2009 2008 2009 2008 2009 2008 20094Belfast Northern SouthEastern Southern WesternMonthly Performance Report 16 February 10 35`

C Diff Analysis40C difficileJan 2008 – 8 Feb 2010New cases of C diff2009 v 2010352030CAH181625DHH142015LurganOthersSouthern Trust12108200920101065Linear(SouthernTrust)4022008 JanFebMarAprMayJunJulAugSeptOctNovDec2009 JanFebMarAprMayJunJulAugSepOctNovDec2010 JanFeb0Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec13Last Case of C diffAs of 9 th February 2010New cases of C diffJan 2008 – 8 Feb 2010HospitalCAHLast Date06/02/2010Days44035DHH21/01/20102030LGHSTHMUL22/10/200906/11/200930/06/200911196225252015>48 hrs

MRSA AnalysisNew cases of MRSA2009 v 2010653743210MRSA by HospitalJan 2008 – 8 Feb 2010CraigavonDaisy HillLurganMullinure6520092010Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec4432102008 JanFebMarAprMayJunJulAugSepOctNovDec2009 JanFebMarAprMayJunJulAugSepOctNovDec2010 JanFeb6543210New cases of MRSAJan 2008 – 8 Feb 2010>48 hrs

New cases of MSSA2009 v 2010MSSA Analysis7386543210MSSA by HospitalJan 2008 – 8 Feb 2010CraigavonDaisy HillLurganSouth TyroneMullinure157620092010543Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec42102008 JanFebMarAprMayJunJulAugSepOctNovDec2009 JanFebMarAprMayJunJulAugSepOctNovDec2010 JanFeb876543210New cases of MSSAJan 2008 – 8 Feb 2010>48 hrs

Hand Hygiene Compliance AuditsHand hygiene has been well established as one of the key components to reduce healthcare associated infections. InDecember 2008, the SHSCT successfully launched the hand hygiene campaign Safe Hands Save Lives which has resulted in asubstantial increase in hand hygiene compliance across the Trust.COMPLIANCE BY TRUST LOCATIONAverage Staff Compliance across Trust100%100%95%95%90%90%85%85%Compliance %80%75%70%Nov-09Dec-09Jan-10Compliance80%75%70%Nov-09Dec-09Jan-1065%65%60%60%55%55%50%Craigavon Hospital Daisy Hill Hospital Non-Acute Hospitals St Luke's/LongstoneLocation/Site50%Nurse/Midwife Auxiliary Medical Doctor HCP DomesticsStaff Group39

Infection Control Training (April – Dec 2009)CareAssistantNursingAuxSocialWorkerOccupationalTherapistCourse TitleAdmin AHPAncillaryMedicalNursingTechnicalDomesticPhysioHCAGrandTotalClostridium Difficile Awareness 1 0 0 0 0 32 1 0 0 0 0 0 0 34Pandemic Flu AwarenessTraining 242 291 158 841 69 2019 342 235 134 1 6 8 1 4347Infection Control Training 18 65 3 479 7 291 74 27 19 9 0 0 0 992Hand Hygiene Training 0 0 0 0 0 5 6 0 0 0 0 0 0 11Peripheral Line Care 0 0 0 0 28 524 0 0 39 0 0 0 0 591Sharps Awareness Training 0 5 0 0 3 92 13 0 0 0 0 0 0 113C-Section Surveillance Training 0 0 0 0 0 6 0 0 0 0 0 0 0 6C-Section & WoundManagement Training 0 0 0 0 0 22 0 0 0 0 0 0 0 22Central Line Training 0 0 0 0 0 152 0 0 0 0 0 0 0 152Grand Total 261 361 161 1320 108 3153 436 262 192 10 6 8 1 6279Infection Control Training (April-Decem ber 09)25002000No. Trained150010005000ClostridiumDifficileAwarenessPandem ic FluAwarenessTrainingInfectionControlTrainingHand HygieneTrainingPeripheral LineCareSharpsAwarenessTrainingC-SectionSurveillanceTrainingC-Section &W oundManagem entTrainingCentral LineTrainingType of TrainingAdm in AHP Ancillary Care Assistant MedicalNursing Nursing Aux Social W orker Technical Dom esticPhysio Occupational Therapist HCA40

Compliance with AntibioticsHospitalNo. Antibiotics auditedFeb 09 Mar 09 Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sep 09 Oct 09 Nov 09 Dec 09 Jan 10CAH 191 246 147 134 134 157 138 87 106 62 62 87DHH 98 86 106 154 140 135 104 113 120 143 60 122STH 25 25 11 9 9 12 7 3 0 0 0 -Mullinure 12 14 14 12 4 8 4 7 4 17 4 4Lurgan 38 34 25 26 28 20 16 22 35 37 34 22Compliance with Antibiotic GuidelinesCompliance with antibiotic guidelines in the Southern TrustPercentage Compliance120%100%80%60%40%91%87%88%83%79%88%95%100%79%94%93%95%91%86%96%94%96%89%83%92%91%93%89%100%93%94%97%92%88%90%95%98%100%75%100%93%96%100%100%95%98%95%100%97%100%98%100%100%100%94%100%100%98%95%100%100%Percentage Compliance100%80%60%40%92%99% 98%95% 96% 95% 97%97%97%94%95%91%20%20%0%0%Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10Feb 09(n=392)Mar 09(n=405)Apr 09(n=299)May 09(n=335)Jun 09(n=314)Jul 09(n=331)Aug 09(n=280)Sep 09(n=232)Oct 09(n=268)Nov 09(n=263)Dec 09(n=199)Jan 10(n=235)CAH DHH STH Mullinure Lurgan41

Health Care Acquired Infection – Related DeathsMonitoring of HCAI deaths SHSCT, is now based on the date the death is registered and is fully aligned with the CentralServices Agency / NI Stats & Research Agency reporting.As part of the review of arrangements for monitoring death related data, processes have been established with AssociateMedical Directors to take forward issues arising from the morbidity & mortality meetings, including providing assurances thatcases where HCAI was recorded on the death certificate are discussed.Clostridium Difficile – Annual trend by hospital site and breakdown by Quarter for 2009No deaths were recorded for Jan 2010Number of SHSCT deaths with MRSA mentioned and recorded as the underlying causeof death certificate, 2002 – 2008 (validated)Number of SHSCT deaths with Clostridium Difficile mentioned and recorded as theunderlying cause on death certificate:Jan – Dec 2009 P& 1st – 31st Jan 2010 P (unvalidated)January – December 2009 P (unvalidated)12104Primary1a Primary1b Primary1c SecondaryClassification of C.DIFF on death certificate836241200Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010200220032004200520062007200820092010Craigavon Area Daisy Hill Hospital Lurgan Hospital Mullinure Hospital South Tyrone St Luke's Hospital All Other PlacesHospitalHospitalP – Provisional data pending publication of the Registrar General’s Annual Report for 2009 & 2010.NB Excludes deaths in all other places between 2002 – 2008, as this information is aggregated regionally in the Registrar General’s Annual Report.CAH(n=7) DHH(n=4) Lurgan(n=0) Mullinure(n=0) STH(n=1) SLH(n=0) All othern=12P – Provisional data pending publication of the Registrar General’s Annual Report for 2009Source: NI Stats & Research Agency and Central Services Agency combined weekly submission of HCAI death related dataplaces(n=0)This graph shows a significant drop in the number of deaths with Clostridium Difficile mentioned on the death certificate in 2009 (n=12), incomparison to 19 hospital CDI deaths in 2008, as demonstrated in the following graph.42

MRSA – Annual trend by hospital site and breakdown by Quarter for 2009No deaths were recorded for Jan 2010Number of SHSCT deaths with MRSA mentioned and recorded as the underlying causeof death certificate, 2002 – 2008 (validated)Number of SHSCT deaths with MRSA mentioned and recorded as the underlying cause ondeath certificate, Regional overview:Jan – Dec 2009 P& 1st – 31st Jan 2010 P (unvalidated)January – December 2009 P (unvalidated)121086432These 11 cases will be included inthe discussions on 30-day HCAIMortality, which is scheduled for 15 thJan 2010Primary1a Primary1b Primary1c SecondaryClassification of MRSA on death certificate41202002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920102002200320042005200620072008200920100Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4CAH(n=4) DHH(n=2) Lurgan(n=0) Mullinure(n=1) STH(n=0) SLH(n=0) All otherplaces(n=4)n=11Craigavon Area Daisy Hill Hospital Lurgan Hospital Mullinure Hospital South Tyrone St Luke's Hospital All Other PlacesHospitalHospitalP – Provisional data pending publication of the Registrar General’s Annual Report for 2009 & 2010.NB Excludes deaths in all other places between 2002 – 2008, as this information is aggregated regionally in the Registrar General’s Annual Report.This dataset is provisional pending publication of the Registrar General’s Annual Report for 200911 MRSA related deaths in SHSCT in 2008 & 2009.In this update, there has been no additional cases where MRSA was recorded as a cause of death on the death certificate.43

QUALITY IMPROVEMENT TARGETS (Patient Care Indicators)100%90%Table 1 - SHSCT SSI OrthopaedicTarget95%4%Infection Rates% Bundle Compliance80%70%60%50%40%30%20%% SSI Rate3%2%1%10%0%Feb-09Mar-09Apr-09May-09Jun-09Jul- Aug-09 09MonthSep-09Oct-09Nov-09Dec-09Jan-100%Q1 -2008Q2 -2008Q3 -2008Q4 -2008Q1 -2009Q2 -2009Q3 -2009Q4 -2009Quarter/YearCAH-Hip NI Average-Hip CAH-Knee NI Average-KneeNon-compliant element - 1/13 patients failed to meet the requirements of the Bundle. Although the diabetic patient's BM was checked Day 1 & 2post op, the results of Day 2 were not recorded in the patient's Medical RecordsT ab le 2 - SHSC T SSI C /Se ctio nIn f e c t io n Ra t e s10 0%9 0%Ta rg et95 %2 5 %% Bundle Compliance8 0%7 0%6 0%5 0%4 0%3 0%2 0%% SSI Rate2 0 %1 5 %1 0 %5 %1 0%0%Feb-09CA HMar-0 9A p r-09DHHMay -09Ju n-0 9Ju l-09A ug -0 9M o n thSe p-0 9Oc t-09Nov -0 9Dec -09Jan -100 %Q 1 -2 0 0 8Q 2 -2 0 0 8Q 3 -2 0 0 8Q 4 -2 0 0 8CA H DHH NI A v e r a g eQ 1 -2 0 0 9Q 2 -2 0 0 9Q u a r t e r /Y e a rQ 3 -2 0 0 9Q 4 -2 0 0 9CAH - Highest Overall Bundle Compliance since auditing commenced. 1/20 patients failed to meet the requirements of the Bundle. One diabeticpatient's Capillary Blood Glucose Level was not recorded Day 2 post op. DHH - 2nd highest Overall Bundle Compliance since auditing commenced.2/12 patients had self-shaved pre-section and there was no evidence in their Medical Records that they had received advice not to.44

% Bundle Compliance100%90%80%70%60%50%40%30%20%Table 3 - SHSCT VAPTarget95%Days Between VAPs400300200100Days Be tw e e n VAP's10%0%Feb-09Mar-09Apr-09May-09Jun-09Jul- Aug-09 09MonthSep-09Oct-09Nov-09Dec-09Jan-100Feb-09Mar-09A pr-09May-09Jun-09Jul- A ug-09 09M onthSep-09Oct-09Nov-09Dec-09Jan-10Second time in 09/10 that the Trust has exceeded its target of 300 Vent Days between VAP'sTable 4 - SHSCT Central LineInfection Rates% Bundle Compliance100%90%80%70%60%50%40%30%20%Target95%% Infection Rate6%5%4%3%2%1%Target1.1710%0%Feb-09CAHMar- Apr-09 09DHHMay-09Jun-09Jul- Aug-09 09MonthSep-09Oct-09Nov-09Dec-09Jan-100%Feb-09CAHMar-09Apr-09DHHMay-09Jun-09Jul-09Aug-09MonthSep-09Oct-09Nov-09Dec-09Jan-10CAH -Joint highest Overall Bundle Compliance since auditing commenced. Non-Compliant Elements - Subclavian Site not used/contraindicated in2/10 patients, Daily Review not completed in 3/10 patients. DHH - 2nd highest Overall Bundle Compliance since auditing commenced. Preferredmethod of Skin Prep not undertaken 1/5 pts. It is now 5 months since the last Central Line Infection.45

Per Thousand Discharges4.504.003.503.002.502.001.501.000.500.00Feb-09Mar-09Apr-09Table 5 - SHSCT Crash Call RatesMay-09Jun-09Jul- Aug-09 09MonthSep-09Oct-09Nov-09Dec-09Jan-10Crash Call CAH Crash Call DHH Trust AverageGoal1.89per1000D&D's100%90%80%% Compliance70%60%50%40%30%20%10%0%Feb-09Mar-09Apr-09May-09Table 6 MEWS AuditJun-09Jul- Aug-09 09MonthPilot CAH Pilot DHH Trustw ideSep-09Oct-09Nov-09Dec-09Jan-10Target95%Crash Calls decreased significantly on both sites in January 2010. The Trust's Crash Call Rate from Apr 09 - Jan 10 now stands at 1.83, which is underthe Trust's goal of 1.89 per thousand deaths/discharges in 09/10% Bundle Compliance100%90%80%70%60%50%40%30%20%10%0%Feb-09Mar-09Table 7- SHSCT Mental Health IndicatorsApr-09May-09Weekly Team Review SLHRisk Assessment SLHTreatment Plan SLHJun-09Jul- Aug- Sep- Oct- Nov-09 09 09 09 09MonthWeekly Team Review CAHRisk Assessment CAHTreatment Plan CAHDec-09Jan-10Target95%% Bundle Compliance100%90%80%70%60%50%40%30%20%10%0%Jun-09Jul-09MAU, CAHAug-09Table 8 - VTE - Compliance Rates VTESep-09Oct-09Nov-09Dec-09MonthJan-10Feb-10Mar-10Apr-10May-10Target95%M. H. - Risk Ax - 24/25 applicable pts had it signed by a Nurse & Doctor on adm. 31/32 were filled correctly & 30/32 had same signed as appropriateduring the inpatient episode. In 1 case the pt was not involved in the M'disc Care Plan. VTE - Compliance is increasing gradually in MAU, CAH. PilotSurg Ward at CAH has begun auditing this mth. Meetings have been arranged in DHH with a view to introducing the Risk Ax Form on a Pilot Wards.46

CHILDREN AND YOUNG PEOPLE REPORTINGUnallocated Child Care CasesSH S C TN o . of U n alloc ated C h ild re ns C as es a t m o n th e nd (Ap ril 08 - Ja n ua ry 2 01 0) - b y L oc alityNo. of Unallocated cases3 002 502 001 501 005006 03 36 3 48212 6399 1 403 45 42 2 93 63 2 49 12 192 3 1 71 3713 818101 271431 4 1 3 1 562 71 0656 105137 7 8 3444848 5534 4 1 4 5 46 4 9 5 76 5 5159484 126 26 22 26 19618 12Apr- M ay- Ju n- Jul- Aug- Sep- O ct- N o v- D ec- Ja n- F eb - M a r- Apr- M a y- Jun - Jul- Aug- Sep- O ct- N o v- D e c- Ja n-0 8 0 8 0 8 0 8 08 08 0 8 08 08 0 9 09 0 9 0 9 09 09 09 0 9 09 09 0 9 0 9 1 0N &MC &BA &D30 - 31 - 3 0- 31 - 31 - 3 0- 3 1- 30 - 3 1- 3 1- 2 8- 3 1- 3 0- 3 1- 3 0- 31 - 3 1- 3 0- 31 - 30 - 3 1- 31 -A pr- M ay- Ju n- Ju l- A ug - Sep- O ct- N o v- D e c- Ja n- Fe b- M ar- Apr- M a y- Jun - Jul- Aug- Sep- O ct- N ov- D ec- Jan -08 0 8 0 8 08 0 8 0 8 0 8 0 8 0 8 0 9 09 09 0 9 09 09 09 09 09 09 09 09 10N &M 0 3 0 0 2 3 1 7 3 4 2 6 3 3 6 0 48 21 2 2 9 12 19 13 8 10 10 18 14C &B 3 1 4 1 3 6 1 5 2 7 3 6 5 4 9 1 6 3 40 39 3 2 49 56 51 44 48 48 48 55 51A& D 34 4 1 4 5 46 4 9 4 1 5 7 7 7 8 3 1 37 1 06 1 27 6 5 59 26 26 22 26 19 6 18 12Action taken to mitigate risks and strengthen our system:a) There are no unallocated child protection cases.b) Heads of Service and Team Managers monitor and review unallocated cases and prioritise these forallocation.c) The majority of unallocated cases sit within the Family Support teams. These should begin to reduceover the next 3 months with the recruitment of additional social workers into the Family Support Service.d) The implementation of the fourth Gateway Team has kept unallocated cases at the front door of theService to a minimum. It will also allow the Gateway Service to complete short term pieces of work (4 - 8weeks) which will ease pressure on the Family Support Service.47

`CLINICAL AND QUALITY INDICATORSThe mortality and re-admission trending positions above have been extracted from CHKS benchmarking tool. This shows highlevel performance against crude mortality (which is not risk adjusted) and re-admissions within 28 days. Processes are beingestablished via the Medical Directors office to analyse these indicators at specialty/consultant level and identify any significantvariance for further analysis. (Reporting is subject to change associated with updated clinical coding positions.)Red Line - represent the SHSCT performance over the last two years (April 07 – Dec 09).Solid Black Line - represents the Trusts own average performance in the previous 12 months and the standard variations on thepositive and negative sides of this average (Sigma +/-1 and +/- 2)Blue line – represents the peer performance over the last two years (April 07 – Dec 09)48

Appendix I – Daycase Rates by ProcedureCALCULATION OF % DAYCASE RATES FOR ALL BASKET OF PROCEDURESFigures Exclude IS Activity Run Date 10/02/10FY2009/10 (April - December)PROCEDURE SITE DAY CASES ELEC ADMIS% DAY CASERATEAnal FissureCAH 17 0 100.0%DHH 4 2 66.7%STH 6 0 100.0%Anal Fissure exc IS 27 2 93.1%ArthroscopyCAH 86 49 63.7%DHH 0 0 #DIV/0!STH 0 0 #DIV/0!Arthroscopy exc IS 86 49 63.7%PROCEDURE SITE DAY CASES ELEC ADMISBunion Operations% DAY CASERATECAH 0 2 0.0%DHH 0 0 #DIV/0!STH 0 0 #DIV/0!Bunion Operations exc IS 0 2 0.0%PROCEDURE SITE DAY CASES ELEC ADMISCarpal Tunnel Decompression% DAY CASERATECAH 78 4 95.1%DHH 38 9 80.9%STH 62 0 100.0%Carpal Tunnel exc IS 178 13 93.2%PROCEDURE SITE DAY CASES ELEC ADMISCircumcision% DAY CASERATECAH 33 29 53.2%DHH 19 2 90.5%STH 17 0 100.0%Circumcision exc IS 69 31 69.0%PROCEDURE SITE DAY CASES ELEC ADMISCorrection of squint% DAY CASERATECAH 0 0 #DIV/0!DHH 0 0 #DIV/0!STH 0 0 #DIV/0!Correction of squint exc IS 0 0 #DIV/0!Approved by Board of Directors 25 th February 2010

PROCEDURE SITE DAY CASES ELEC ADMISD&C/ Hysteroscopy% DAY CASERATECAH 230 89 72.1%DHH 176 19 90.3%STH 128 0 100.0%D&C/ Hysteroscopy exc IS 534 108 83.2%Excision of Breast Lump CAH 14 8 63.6%DHH 10 0 100.0%STH 8 0 100.0%Excision of Breast Lump exc IS 32 8 80.0%IND 1 0 100.0%PROCEDURE SITE DAY CASES ELEC ADMIS% DAY CASERATEExcision of DupuytrensCAH 5 3 62.5%ContractureDHH 0 0 #DIV/0!STH 0 0 #DIV/0!Excision of Dupuytrens Contracture exc IS 5 3 62.5%PROCEDURE SITE DAY CASES ELEC ADMISExcision of Ganglion% DAY CASERATECAH 10 2 83.3%DHH 0 0 #DIV/0!STH 22 0 100.0%Excision of Ganglion exc IS 32 2 94.1%PROCEDURE SITE DAY CASES ELEC ADMISExtraction of Cataract (with/without implant)% DAY CASERATECAH 0 0 #DIV/0!DHH 0 0 #DIV/0!STH 353 0 100.0%Extraction of Cataract exc IS 353 0 100.0%PROCEDURE SITE DAY CASES ELEC ADMISHaemorrhoidectomy% DAY CASERATECAH 8 9 47.1%DHH 0 3 0.0%STH 2 0 100.0%Haemorrhoidectomy exc IS 10 12 45.5%*** Note - Manual Adjustment made in November - 2 Patients CAHB27033 & CAHE194816 seen in STHbut transferred to CAH and had an overnight stay. These patients have been excluded from STH as andIP and included in CAH IP figures.PROCEDURE SITE DAY CASES ELEC ADMISHydrocele% DAY CASERATECAH 6 1 85.7%DHH 0 9 0.0%STH 3 0 100.0%

Hydrocele exc IS 9 10 47.4%PROCEDURE SITE DAY CASES ELEC ADMISInguinal Hernia% DAY CASERATECAH 43 68 38.7%DHH 10 72 12.2%STH 36 0 100.0%Inguinal Hernia exc IS 89 140 38.9%PROCEDURE SITE DAY CASES ELEC ADMISLaparoscopic Cholecystectomy% DAY CASERATECAH 17 116 12.8%DHH 0 95 0.0%STH 0 0 #DIV/0!Laparoscopic Chol exc IS 17 211 7.5%PROCEDURE SITE DAY CASES ELEC ADMISLaparoscopy% DAY CASERATECAH 176 76 69.8%DHH 59 26 69.4%STH 34 0 100.0%Laparoscopy inc IS 269 102 72.5%PROCEDURE SITE DAY CASES ELEC ADMISMyringotomy/ Grommets% DAY CASERATECAH 122 27 81.9%DHH 62 0 100.0%STH 38 0 100.0%Myringotomy/ Grommets inc IS 222 27 89.2%PROCEDURE SITE DAY CASES ELEC ADMISOperation on Bat Ears% DAY CASERATECAH 2 11 15.4%DHH 0 0 #DIV/0!STH 0 0 #DIV/0!Operation of Bat Ears exc IS 2 11 15.4%PROCEDURE SITE DAY CASES ELEC ADMISOrchidopexy% DAY CASERATECAH 5 3 62.5%DHH 6 1 85.7%STH 1 0 100.0%Orchidopexy exc IS 12 4 75.0%PROCEDURE SITE DAY CASES ELEC ADMIS% DAY CASERATE

Reduction of Nasal FractureCAH 70 23 75.3%DHH 16 0 100.0%STH 10 0 100.0%Reduc of Nasal Fracture exc IS 96 23 80.7%PROCEDURE SITE DAY CASES ELEC ADMISRemoval of Metalware% DAY CASERATECAH 2 19 9.5%DHH 0 0 #DIV/0!STH 0 0 #DIV/0!Removal of Metalware exc IS 2 19 9.5%PROCEDURE SITE DAY CASES ELEC ADMISSub Mucous Resection% DAY CASERATECAH 8 81 9.0%DHH 38 1 97.4%STH 22 0 100.0%Sub Mucous exc IS 68 82 45.3%*** Note - Manual Adjustment made in August - 1 Patient CAHE30697 seen in STH but transferred toCAH and had an overnight stay. This patient has been excluded from STH as and IP and included in CAHIP figures.PROCEDURE SITE DAY CASES ELEC ADMISTermination of Pregnancy% DAY CASERATECAH 0 0 #DIV/0!DHH 0 0 #DIV/0!STH 0 0 #DIV/0!Termination of Pregnancy exc IS 0 0 #DIV/0!PROCEDURE SITE DAY CASES ELEC ADMISTonsillectomy% DAY CASERATECAH 2 349 0.6%DHH 88 2 97.8%STH 0 0 #DIV/0!Tonsillectomy exc IS 90 351 20.4%IND 11 83 11.7%PROCEDURE SITE DAY CASES ELEC ADMIS% DAY CASERATETURPCAH 2 44 4.3%DHH 16 6 72.7%STH 1 0 100.0%TURP exc IS 19 50 27.5%PROCEDURE SITE DAY CASES ELEC ADMISVaricose Veins% DAY CASERATECAH 23 27 46.0%DHH 0 3 0.0%

STH 3 0 100.0%Varicose Veins exc IS 26 30 46.4%TRUST TOTAL SITE DAY CASES ELEC ADMISTRUST TOTAL% DAY CASERATECAH 959 1040 48.0%DHH 542 250 68.4%STH 746 0 100.0%TRUST TOTAL Exc IS 2247 1290 63.5%

Appendix II – Environmental Cleanliness ReportEnvironmental Cleanliness ReportPrepared by:Functional Support Services10/2/2010Approved by Board of Directors 25 th February 2010

ContentsSection1 Introduction2 Departmental Audit Results -Summary of Overall Weighted Scores for each Hospital3 Departmental Audit Results -Breakdown of Scores for each Hospital4 ICNA Audit Results5 Action Plan6 Exception Report

1. IntroductionThe Environmental Cleanliness Committee provides assurance that standards ofcleanliness within Trust facilities are met in a number of ways including themeasurement of environmental cleanliness standards.The Trust uses the Cleanliness Matters Toolkit (49 elements) issued by theDHSSPS as part of the Environmental Cleanliness Strategy, in order to undertakeinternal Departmental Audits. The results from Departmental Audits in hospitalsacross the Trust are included in section 3 of this report.From May 2009 the Infection Control Nurses Association (ICNA) audit toolinstead of the Cleanliness Matters Toolkit has been used to conduct ManagerialAudits. Managerial Audit results measured against the ICNA audit tool areincluded in section 4 of this report.A Senior Management team decision was taken in January 2010 to issue theICNA audit tool to ward/department managers in order that they can undertakethe audit and populate action plans for their own area so ward/departmentmanagers are aware of the issues likely to arise out of RQIA inspections and takeappropriate action pro-actively.The Cleanliness Matters Toolkit measures the standard of cleanliness and 85%or above indicates an acceptable level of cleanliness. Items to be cleaned arebroken down into 49 generic elements with specific environmental cleaningstandard requirements (eg floors, walls, furniture, bed frames, medical devicesetc). The overall scores are weighted taking into account all risk categories ievery high, high, moderate and low risk category areas.The RQIA uses the ICNA audit tool for their inspections. This audit tool is dividedup into 10 sections, under the following headings:-- Environment- Ward/departmental kitchens- Handling and disposal of linen- Waste management- Departmental waste handling and disposal- Safe handling and disposal of sharps- Management of patient equipment (general)- Management of patient equipment (specialist areas)- Hand hygiene- Clinical practicesThe ICNA level of compliance categories are as follows:-Compliant85% or abovePartial compliance 76 to 84%Minimal compliance 75% or below

The overall score is an average of the audit scores and the rating can only becompliant if all the scores are 85% or above. Weighting is not applied to ICNAaudit scores.The Environmental Cleanliness audits carried out by Trust staff measure thestandard of cleanliness within a sample of rooms on a ward and these havetended to concentrate on ward/clinical areas whilst the Environment Section ofthe ICNA tool also includes utility rooms and domestic stores.The following are some of the main differences between the two audit tools:-The ICNA tool assesses the cleanliness and maintenance of equipmentsuch as lockers, chairs and tables whereas the Cleanliness Matters Toolkitmeasures cleanliness.The Cleanliness Matters Toolkit concentrates more so on the fabric of thebuilding and includes entrances/exits, doors, light fittings, radiators andexternal grounds whereas these are not included in the ICNA tool.Patient equipment including commodes, drip stands etc, drug trolleys andpatient wash bowls are included in the Cleanliness Matters Toolkitwhereas in the ICNA tool they are included under Management of PatientEquipment Section rather than the Environment Section.The ICNA tool picks up on decontamination from a segregation point ofview however the Cleanliness Matters Toolkit is only concerned with thecleanliness of the sinks and not the purpose of the sinks.The ICNA tool requests evidence of an effective pre-planned programmefor curtain changes. This is not measured under the Cleanliness MattersToolkit.The INCA tool assesses cleaning equipment (colour coding, storage ofmops and buckets). These areas are not covered under theEnvironmental Cleanliness audits however Support Services hasimplemented practice audits which pick up on these issues.The Environmental Cleanliness audits cover the cleanliness of the kitchenwhereas the ICNA tool section on kitchens is divided into Ward andDepartmental and is similar to a kitchen inspection as it considers theoperations within the kitchen, eg temperature recordings.The DHSSPSNI hosted a workshop in 2009 to consider the various audit toolsused in HSC settings and a Steering Group has been established to review theCleanliness Matters Toolkit with a view to harmonising with other tools such asthe ICNA tool. Workstreams have been set up to take forward work ondeveloping a common approach to audit, standard definitions and cleaning plans,and training for staff involved in the audit process.

2. Departmental Audit Results - Summary of Overall Weighted Scores using the Cleanliness Matters ToolkitHospitalApr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10Feb-10Mar-10St Luke's 85 93 88 86 88 84 90 94 90 85 91 93 90 93 90 91 94 91 90 95 90 86South Tyrone 85 89 89 86 86 90 87 90 90 89 89 92 89 93 90 90 90 90 89 91 92 93Longstone 85 89 91 89 87 92 91 88 94 93 92 93 91 89 90 90 88 94 90 84 93 92Mullinure 93 90 90 91 94 95 91 94 93 95 94 96 95 95 96 91 84 85 88 96 95 96CAH 90 92 92 93 91 91 95 94 94 93 93 92 93 94 93 93 93 92 93 92 94 93Lurgan 83 85 92 86 91 94 93 93 93 94 93 96 93 93 95 94 98 97 97 97 98DHH 94 93 94 94 95 94 92 94 95 93 95 93 92 87 88 90 93 91 93 93 93 89Bluestone 86 84 89 95 91 95 93 95 95 92 90 95 92 91 92 92 94Average 88 90 91 90 90 90 91 92 93 92 93 93 93 92 92 91 91 92 91 93 93 93The scores reflect the overall weighted score for each hospital taking into account all risk categories ie very high, high, moderateand low risk category areas.Approved by Board of Directors 25 th February 2010

3. Departmental Audit Results - Breakdown of Scores for each HospitalCraigavon Hospital1009590Score85807570Apr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10MonthVery High Risk Areas High Risk Areas Moderate Risk Areas Low Risk Areas Cleanliness StandardLurgan Hospital1009590Score85807570Apr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10MonthHigh Risk Areas Moderate Risk Areas Low Risk Areas Cleanliness StandardApproved by Board of Directors 25 th February 2010

Bluestone1009590Score85807570Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10MonthHigh Risk Areas Moderate Risk Areas Low Risk Areas Cleanliness StandardDaisy Hill Hospital1009590Score85807570Apr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10MonthVery High Risk Areas High Risk Areas Moderate Risk Areas Low Risk Areas Cleanliness StandardApproved by Board of Directors 25 th February 2010

St Luke's Hospital1009590Score85807570Apr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10MonthHigh Risk Areas Moderate Risk Areas Low Risk Areas Cleanliness StandardSouth Tyrone Hospital100959085Score8075706560Apr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10MonthVery High Risk Areas High Risk Areas Moderate Risk Areas Low Risk Areas Cleanliness Standard

Longstone1009590Score85807570Apr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10MonthHigh Risk Areas Moderate Risk Areas Low Risk Areas Cleanliness StandardMullinure1009590Score85807570Apr-08May-08Jun-08Jul-08Aug-08Sep-08Oct-08Nov-08Dec-08Jan-09Feb-09Mar-09Apr-09May-09Jun-09Jul-09Aug-09Sep-09Oct-09Nov-09Dec-09Jan-10MonthHigh Risk Areas Moderate Risk Areas Low Risk Areas Cleanliness StandardApproved by Board of Directors 25 th February 2010

4. ICNA Audit Results143 audits have been undertaken in hospitals across the Trust between May andDecember 2009 using the ICNA toolkit. There has been a marked increase in thenumber of audits conducted in recent months to try and bridge the gap between theEnvironmental Cleanliness audit scores and RQIA audit scores.The following table shows the results for each audit, ie the scores have not beenaveraged to give the overall percentage score.Hospital Ward/Dept Audit Audit Date Score AssessmentCraigavon 1 East Environment 16/06/2009 87% CompliantCraigavon 2 South Environment 08/12/2009 86% CompliantCraigavon 4 South Kitchen 21/08/2009 93% CompliantCraigavon 4 South Departmental Waste 21/08/2009 89% CompliantCraigavon A&E Departmental Waste 29/09/2009 86% CompliantCraigavon ICU Environment 17/06/2009 86% CompliantCraigavon Physiotherapy Patient Equipment (Specialist) 09/09/2009 87% CompliantDaisy Hill Coronary Care Patient Equipment (General) 28/10/2009 90% CompliantDaisy Hill Female Medical Departmental Waste 08/07/2009 85% CompliantDaisy Hill HighEnvironment 28/10/2009 85% CompliantDependencyDaisy Hill HighPatient Equipment (General) 28/10/2009 86% CompliantDependencyDaisy Hill Male Medical Patient Equipment (General) 08/07/2009 96% CompliantDaisy Hill Male Medical Departmental Waste 08/07/2009 85% CompliantLongstone Cherryvilla Personal Protective Equipment 03/08/2009 100% CompliantLongstone Cherryvilla Safe Handling and Disposal of 01/12/2009 94% CompliantSharpsLongstone Clover Personal Protective Equipment 30/07/2009 100% CompliantLongstone Donard Personal Protective Equipment 01/08/2009 100% CompliantLongstone IATU Personal Protective Equipment 30/07/2009 100% CompliantLongstone Mourne Personal Protective Equipment 01/08/2009 100% CompliantLongstone Sperrin Personal Protective Equipment 01/08/2009 100% CompliantLurgan Day Hosp Environment 30/09/2009 94% CompliantLurgan Ward 4 Environment 30/09/2009 89% CompliantMullinure Ward 1 Personal Protective Equipment 30/07/2009 94% CompliantSouth A Floor Personal Protective Equipment 30/07/2009 100% CompliantTyroneSouth Loane House 2 Personal Protective Equipment 30/07/2009 100% CompliantTyroneSt Lukes Addiction Unit Personal Protective Equipment 29/07/2009 95% CompliantSt Lukes Villa 1 Personal Protective Equipment 06/08/2009 89% CompliantSt Lukes Villa 2 Personal Protective Equipment 30/07/2009 100% CompliantSt Lukes Villa 3 Personal Protective Equipment 04/08/2009 90% Compliant

St Lukes Ward 2 Personal Protective Equipment 30/07/2009 100% CompliantSt Lukes Ward 3 Personal Protective Equipment 13/08/2009 94% CompliantSt Lukes Ward 5 Hand Hygiene 02/06/2009 86% CompliantSt Lukes Ward 5 Personal Protective Equipment 02/06/2009 100% CompliantSt Lukes Ward 5 Personal Protective Equipment 29/07/2009 94% CompliantSt Lukes Ward 5 Patient Equipment (General) 29/09/2009 88% CompliantCraigavon 1 East Kitchen 16/06/2009 71% Minimal ComplianceCraigavon 1 North Environment 16/06/2009 70% Minimal ComplianceCraigavon 1 North Kitchen 16/06/2009 43% Minimal ComplianceCraigavon 1 North Environment 09/09/2009 60% Minimal ComplianceCraigavon 1 North Kitchen 09/09/2009 67% Minimal ComplianceCraigavon 1 North Patient Equipment (General) 09/09/2009 74% Minimal ComplianceCraigavon 1 North Departmental Waste 09/09/2009 74% Minimal ComplianceCraigavon 1 South Environment 16/06/2009 74% Minimal ComplianceCraigavon 1 South Kitchen 16/06/2009 59% Minimal ComplianceCraigavon 2 North Environment 08/12/2009 57% Minimal ComplianceCraigavon 2 North Environment 08/12/2009 75% Minimal ComplianceCraigavon 2 North Handling and Disposal of Linen 08/12/2009 56% Minimal ComplianceCraigavon 2 North Departmental Waste 08/12/2009 74% Minimal ComplianceCraigavon 2 South Environment 08/12/2009 69% Minimal ComplianceCraigavon 2 South Handling and Disposal of Linen 08/12/2009 67% Minimal ComplianceCraigavon 4 South Environment 21/08/2009 67% Minimal ComplianceCraigavon 4 South Patient Equipment (General) 21/08/2009 71% Minimal ComplianceCraigavon A&E Environment 29/09/2009 73% Minimal ComplianceCraigavon A&E Environment 29/09/2009 61% Minimal ComplianceCraigavon A&E Handling and Disposal of Linen 29/09/2009 67% Minimal ComplianceCraigavon ICU Kitchen 17/06/2009 70% Minimal ComplianceCraigavon MAU Environment 16/06/2009 73% Minimal ComplianceCraigavon OT Environment 29/09/2009 43% Minimal ComplianceCraigavon Physiotherapy Environment 09/09/2009 43% Minimal ComplianceCraigavon Physiotherapy Environment 09/09/2009 29% Minimal ComplianceCraigavon X-ray Environment 24/06/2009 63% Minimal ComplianceCraigavon X-ray Environment 24/06/2009 60% Minimal ComplianceDaisy Hill Coronary Care Environment 28/10/2009 70% Minimal ComplianceDaisy Hill Coronary Care Departmental Waste 28/10/2009 74% Minimal ComplianceDaisy Hill Coronary Care Kitchen 28/10/2009 72% Minimal ComplianceDaisy Hill Day Procedure Environment 08/07/2009 71% Minimal ComplianceDaisy Hill Day Procedure Kitchen 08/07/2009 71% Minimal ComplianceDaisy Hill Day Procedure Patient Equipment (General) 08/07/2009 69% Minimal ComplianceDaisy Hill Day Procedure Departmental Waste 08/07/2009 50% Minimal ComplianceDaisy Hill Female Medical Kitchen 08/07/2009 65% Minimal ComplianceDaisy Hill Male Medical Kitchen 08/07/2009 65% Minimal ComplianceDaisy Hill Male Medical Handling and Disposal of Linen 08/07/2009 66% Minimal ComplianceDaisy Hill Male Surgical Environment 27/05/2009 65% Minimal ComplianceDaisy Hill Medical/Stroke Environment 27/05/2009 53% Minimal ComplianceDaisy Hill Paediatrics Environment 24/06/2009 73% Minimal ComplianceDaisy Hill Paediatrics Kitchen 24/06/2009 72% Minimal ComplianceDaisy Hill Paediatrics Environment 24/06/2009 73% Minimal ComplianceDaisy Hill Paediatrics Kitchen 24/06/2009 72% Minimal Compliance

Daisy Hill Rehab Environment 24/06/2009 69% Minimal ComplianceDaisy Hill Rehab Kitchen 24/06/2009 72% Minimal ComplianceDaisy Hill Rehab Patient Equipment (General) 24/06/2009 60% Minimal ComplianceLongstone Cherryvilla Environment 01/12/2009 32% Minimal ComplianceLongstone Cherryvilla Handling and Disposal of Linen 01/12/2009 50% Minimal ComplianceLongstone Cherryvilla Patient Equipment (General) 01/12/2009 65% Minimal ComplianceLongstone Cherryvilla Kitchen 01/12/2009 70% Minimal ComplianceLongstone Donard Environment 22/09/2009 52% Minimal ComplianceLongstone Donard Handling and Disposal of Linen 22/09/2009 57% Minimal ComplianceLongstone Donard Patient Equipment (General) 22/09/2009 60% Minimal ComplianceLongstone Donard Kitchen 22/09/2009 65% Minimal ComplianceLongstone Mourne Environment 22/09/2009 66% Minimal ComplianceLongstone Mourne Kitchen 22/09/2009 63% Minimal ComplianceLongstone Mourne Handling and Disposal of Linen 22/09/2009 50% Minimal ComplianceLongstone Mourne Patient Equipment (General) 22/09/2009 48% Minimal ComplianceSouth A Floor Environment 04/06/2009 46% Minimal ComplianceTyroneSouth Loane House 2 Environment 09/06/2009 52% Minimal ComplianceTyroneSouth Loane House 2 Kitchen 09/06/2009 58% Minimal ComplianceTyroneSouth Out Patients Environment 04/06/2009 71% Minimal ComplianceTyroneSt Lukes Villa 2 Kitchen 06/10/2009 61% Minimal ComplianceSt Lukes Villa 2 Handling and Disposal of Linen 06/10/2009 31% Minimal ComplianceSt Lukes Villa 2 Safe Handling and Disposal of 06/10/2009 75% Minimal ComplianceSharpsSt Lukes Villa 2 Patient Equipment (General) 06/10/2009 47% Minimal ComplianceSt Lukes Villa 2 Environment 06/10/2009 41% Minimal ComplianceSt Lukes Ward 2 Departmental Waste 30/06/2009 72% Minimal ComplianceSt Lukes Ward 2 Safe Handling and Disposal of 30/06/2009 67% Minimal ComplianceSharpsSt Lukes Ward 2 Patient Equipment (General) 30/06/2009 67% Minimal ComplianceSt Lukes Ward 2 Environment 30/06/2009 45% Minimal ComplianceSt Lukes Ward 2 Handling and Disposal of Linen 30/06/2009 73% Minimal ComplianceSt Lukes Ward 3 Handling and Disposal of Linen 02/07/2009 63% Minimal ComplianceSt Lukes Ward 3 Safe Handling and Disposal of 02/07/2009 74% Minimal ComplianceSharpsSt Lukes Ward 3 Patient Equipment (General) 02/07/2009 33% Minimal ComplianceSt Lukes Ward 5 Environment 29/09/2009 69% Minimal ComplianceSt Lukes Ward 5 Kitchen 29/09/2009 63% Minimal ComplianceSt Lukes Ward 5 Handling and Disposal of Linen 29/09/2009 62% Minimal ComplianceCraigavon 1 North Environment 09/09/2009 76% Partial ComplianceCraigavon 2 North Kitchen 08/12/2009 81% Partial ComplianceCraigavon 2 South Kitchen 08/12/2009 78% Partial ComplianceCraigavon 2 South Patient Equipment (General) 08/12/2009 77% Partial ComplianceCraigavon 4 South Environment 21/08/2009 76% Partial ComplianceCraigavon A&E Kitchen 29/09/2009 81% Partial ComplianceCraigavon A&E Patient Equipment (General) 29/09/2009 79% Partial ComplianceCraigavon MAU Environment 16/06/2009 79% Partial Compliance

Craigavon MAU Kitchen 16/06/2009 81% Partial ComplianceCraigavon OT Kitchen 29/09/2009 76% Partial ComplianceCraigavon OT Patient Equipment (Specialist) 29/09/2009 81% Partial ComplianceCraigavon X-ray Environment 24/06/2009 78% Partial ComplianceDaisy Hill Female Medical Environment 08/07/2009 77% Partial ComplianceDaisy Hill Female Medical Patient Equipment (General) 08/07/2009 81% Partial ComplianceDaisy Hill Female Medical Handling and Disposal of Linen 08/07/2009 77% Partial ComplianceDaisy Hill HighKitchen 28/10/2009 83% Partial ComplianceDependencyDaisy Hill HighDepartmental Waste 28/10/2009 84% Partial ComplianceDependencyDaisy Hill Male Medical Environment 08/07/2009 76% Partial ComplianceDaisy Hill Paediatrics Patient Equipment (General) 24/06/2009 79% Partial ComplianceDaisy Hill Paediatrics Departmental Waste 24/06/2009 80% Partial ComplianceDaisy Hill Paediatrics Patient Equipment (General) 24/06/2009 79% Partial ComplianceDaisy Hill Paediatrics Departmental Waste 24/06/2009 80% Partial ComplianceDaisy Hill Rehab Departmental Waste 24/06/2009 80% Partial ComplianceLongstone Cherryvilla Departmental Waste 01/12/2009 82% Partial ComplianceLurgan Stroke Unit Environment 30/09/2009 82% Partial ComplianceLurgan Ward 6 Environment 30/09/2009 81% Partial ComplianceSouth Loane House 2 Handling and Disposal of Linen 09/06/2009 78% Partial ComplianceTyroneSt Lukes Villa 2 Departmental Waste 06/10/2009 78% Partial ComplianceSt Lukes Ward 5 Patient Equipment (General) 02/06/2009 77% Partial ComplianceSt Lukes Ward 5 Safe Handling and Disposal ofSharps29/09/2009 82% Partial ComplianceLevel of ComplianceCompliant85% or abovePartial compliance 76 to 84%Minimal compliance 75% or belowAudit of Infection Control StandardsLevel of Compliance Score Range No. of Scores which fall intothis rangeCompliant 85% or above 35Partial compliance 81 to 84% 11Partial compliance 76 to 80% 19Minimum compliance 66 to 75% 29Minimum compliance 51 to 65% 24Minimum compliance 50% or less 15Total No. of Audits carried out 143

5. Action PlanThis Action Plan was developed from recommendations following Departmental Audits. The Action Plan is work inprogress and when actions are completed they will be removed.MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateNov-09 CAH Mod Cedars 79 78 82 Low and high dustingissues, walls requirerepainting.Sep-09 CAH VeryHighNov-09 CAH VeryHighJul-09 CAH VeryHighDelivery 84 84 80 84 Major construction workongoing in the area. Worksdue to be completed March2010, in the meantimeSupport Services workingclosely with Bus. &Planning and Nursing to tryand address problems asbest possible.Delivery 83 85 82 76 Ongoing building works inthis area.Delivery 84 85 76 82 Dusting issues due toongoing building works.Some estate work to bereported after building workcompleted.Cleaning issuesaddressed withDomestic. Paintingreferred to Estates toassess and cost.Aug-09 CAH Mod Elms 74 87 11 Painting & floor covering,required in all flats andcommunal areas. Newkitchens required in all flats.Furniture & beddingrequiredA business case isbeing prepared torequest fundingNov-09 CAH Mod Elms 84 86 79 Painting & floor covering, A business case isrequired in all flats and being prepared tocommunal areas. New request fundingkitchens required in all flats.Furniture & beddingrequiredRepaintingNo further actionat presentNo further actionat presentAwaiting detailsof further worksRefurbishmentwill be completedpending fundingRefurbishmentwill be completedpending fundingSupportServicesSupportServicesApproved by Board of Directors 25 th February 2010

MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateJun-09 CAH Mod Laundry 83 81 100 90 Cleaning issues - lowdusting. Estates issues -area in need ofrefurbishment. Sanitaryareas need refurbished,floors need replaced andpainting throughout thearea.Cleaning issuesaddressed.Jul-09 CAH Mod Laundry 72 76 59 Cleaning issues - floors and Cleaning issueslow dusting. Estates issues addressed with- area in need of Domestic.refurbishment. Sanitaryareas need refurbished,floors need replaced andpainting throughout thearea.Sep-09 CAH Mod Laundry 74 76 71 Cleaning issues - floors and Cleaning issueslow dusting. Estates issues addressed with- area in need of Domestic.refurbishment. Sanitaryareas need refurbished,floors need replaced andpainting throughout thearea.Oct-09 CAH Mod Laundry 84 80 100 Estates issues - area inneed of refurbishment.Sanitary areas needrefurbished, floors needreplaced and paintingthroughout the area.Jan-10 CAH Mod Laundry 67 65 84 67 Estates issues - area inneed of refurbishment.Sanitary areas needrefurbished, floors needreplaced and paintingthroughout the area.Nov-09 CAH Mod Lifts, levels 84 91 50 Estates issues - lifts andlevels in need ofrefurbishment. Floors needreplaced, sanitary areasneed refurbished andpainting required.Referred to Estates toassess and cost.

MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateAug-09 CAH Mod Maples 83 79 100 Painting & floor covering,required in all flats andcommunal areas. Newkitchens required in all flats.Furniture & beddingrequiredA business case isbeing prepared torequest fundingJun-09 CAH Mod Stores 60 57 50 71 There are insufficient hoursgoing into this area, poorstorage practices areevident and stores area isin need of refurbishment.Jul-09 CAH Mod Stores 80 79 82 There are insufficient hoursgoing into this area, poorstorage practices areevident and stores area isin need of refurbishment.Aug-09 CAH Mod Stores 82 82 84 There are insufficient hoursgoing into this area, poorstorage practices areevident and stores area isin need of refurbishment.Some additionalhours have been putinto stores and StoresManager is reviewingstorage issues.Some additionalhours have been putinto stores and StoresManager is reviewingstorage issues.Some additionalhours have been putinto stores and StoresManager is reviewingstorage issues.Refurbishmentwill be completedpending fundingSupportServicesJim CrozierJim CrozierJim CrozierSep-09 CAH Mod Stores 68 67 67 73 There are insufficient hoursgoing into this area, poorstorage practices areevident and stores area isin need of refurbishment.Some additionalhours have been putinto stores and StoresManager is reviewingstorage issues.Jim CrozierNov-09 CAH Mod Stores 79 75 94 There are insufficient hoursgoing into this area, poorstorage practices areevident and stores area isin need of refurbishment.Jan-10 CAH Mod Stores 74 67 94 There are insufficient hoursgoing into this area, poorstorage practices areevident and stores area isin need of refurbishment.Some additionalhours have been putinto stores and StoresManager is reviewingstorage issues.Some additionalhours have been putinto stores and StoresManager is reviewingstorage issues.Jim CrozierJim Crozier

MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateOct-09 CAH Low Transport 74 77 63 High and low dusting.Estates - floors needreplaced, painting required.Cleaning issuesaddressed withDomestic. Floors andpainting referred toEstates to assess andcost.£1500includingall prepaintrepairs.Jan-10 Daisy Hill High A & E 59 47 72 71 Cleaning in most roomsfalling below standards.Painting and minormaintenance repairs.Additional input hours(3 Sat & 3 E fromW/E 12/2/10). Thiswill improve cleaningstandards. Paintingand maintenancerepairs carried out.31/01/2010Sep-09 Daisy Hill High A&E 80 76 93 80 Low level dusting. Build upin corners. Hoover floor inSister’s Office and high andlow level dusting. Ventsdusty. Bathroom tilecracked, light needscleaned and new pull cord.Repainting of walls inFracture Waiting Area andchair needs recovered.insufficient domestic hoursinto this area.Jun-09 Daisy Hill Low AmbulanceControl78 77 70 85 All areas need repainted.Shower curtain needsreplaced. High leveldusting. Hallway and RestRoom cluttered.Domestic Assistantaddressed cleaningissues. Paintingissue referred toEstates to assess andcost. Chair removed16/9/09 forrecovering. Ventscleaned in Oct 09.Additional domestichours have gone intothis area on atemporary basis.High level cleaningcompleted. Showercurtain replaced.Painting issuesreferred to Estates toassess and cost.Cluttered issues to beaddressed byAmbulance Staff.Repaint Contractor £750Decantmay benecessaryRepaint Contractor £750

MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateSep-09 Daisy Hill Low AmbulanceControl84 80 90 90 High and low level dusting.Study Room carpet needsshampooed and wallsrepainted. Main Entrancesloping roof needs cleaned.Tops of lockers dusty.Walls in ladies WC requireto be washed.Domestic issuesaddressed. Deepclean completedOctober 09. Paintingissues referred toEstates to assess andcost.Repaint Contractor £750Jan-10 Daisy Hill Mod CardiologyOPD84 81 67 100 High and low level dusting. Cleaning addressed. 31/01/2010Jun-09 Daisy Hill High CoronaryCare81 86 75 75 Wall ledges need painted.Dust on high and lowsurfacesDomestic Asstaddressed cleaningissues. Paintingissues referred toEstates to assess andcost.Repaint Contractor £1000Decantmay berequiredOct-09 Daisy Hill High CoronaryCareJan-10 Daisy Hill High CoronaryCare80 86 70 75 Walls need repainted.Windows smeared. Duston window ledge. Build-upin corners.84 82 88 88 Light dust on lockers &skirting boards. Minorpainting repairs.Domestic issuesaddressed. Windowcleaners due thismonth. Paintingreferred to Estates toassess and cost.Cleaning addressed& staff informed.Painting completed.Repaint Contractor £1000Decantmay berequired31/01/2010

MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateAug-09 Daisy Hill High FemaleMedicalSep-09 Daisy Hill High FemaleMedicalSep-09 Daisy Hill High MaleMedicalOct-09 Daisy Hill High MaleMedicalJun-09 Daisy Hill High MaleMedical84 84 89 80 Vents dusty. Build up incorners. High and lowdust. Shower curtain dirty.Vinyl wall covering comingaway from walls in showerareas.Vents completed –Toilet areas 08/09/09Wards 10/10/09.Domestic addressedcleaning issues.Shower curtain hasbeen replaced. Wallcovering in all showerareas throughout theHospital referred toEstates to assess andcost.74 67 91 76 Low and high level dusting. Domestic AssistantBuild up under soapdispensers. Debris onfloors. Glass smeared.addressed cleaningissues. Paintingissues referred toDoors need repainted - WC Estates to assess and8056, Sluice Room andwalls in Ward 19, 21 and22. Beds dusty.Performance issuescost. Performanceissues addressedwith the member ofstaff.highlighted.83 78 91 88 Heavy dust on beds. Domestic AssistantUnder sinks dirty. Prep addressed cleaningRoom, build up in corners. issues. PaintingBuild up on taps. Outside of issue referred tobins dirty. Ward 2 - walls Estates to assess andneed repainted and damp cost. Nursing topatches on ceiling. address dust onbeds.79 72 86 88 High ledges dusty, floorsneed scrubbed. Build-upunder soap dispenser.Mirror dirty. Walls needrepainted.77 71 95 72 High and Low level dusting,bins dirty, under sinks dirty.Doors and walls needrepainted.Domestic issuesaddressed. Otherissues referred toEstates to assess andcost.Domestic Asstaddressed cleaningissues. Paintingissues referred toEstates to assess andcost.Repaint Contractor £2250Decantmay benecessaryRepaint Contractor £2250Decantmay benecessaryRepaint Contractor £750Repaint Contractor £2500Decantmay berequiredRepaint Contractor £2500Decantmay berequired

MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateAug-09 Daisy Hill High MaleMedicalJan-10 Daisy Hill High MaleMedicalJun-09 Daisy Hill High MaleSurgicalJan-10 Daisy Hill High MaleSurgical81 76 86 88 Vents dusty. Low and highsurfaces dusty. Walls needpainted in Ward 3.Performance issueshighlighted.84 83 94 79 Waste bins & under sinksneed cleaned. Minor paintrepairs.80 79 76 88 Painting issues. Parts offloor covering needrepaired. Daily cleaningissues, ie glass smeared,bin dirty, debris on floor,dust on cupboard. Wallledges need repainted.Domestic Assistantaddressed cleaningissues. Vent cleaningcompleted 09/09/09.Painting issuesreferred to Estates toassess and cost.Performance issuesaddressed with themember of staff.Cleaning addressed& staff informed.Painting completed31.1.10.Domestic Asstaddressed cleaningissues. Painting andfloor repairs referredto Estates to assessand cost.84 80 89 88 Soap dispensers requirecleaning. Limescale onCleaning actioned &staff informed.taps. Minor painting repairs. Painting will becompleted 26/2/10.Steam cleanerbeing purchasedto address buildup in corners.Repaint.Ward Managerliaising withEstates toarrange access tofix floor. Repaint.Contractor £2500Decantmay berequired£2500Decantmay berequired31/01/2010Sep-09 Daisy Hill High Medical/Stroke Unit82 80 79 88 Holes in wall need filledand repainted in Ward 5.High and low level dusting.Floor area needs scrubbed.Dust on medicalequipment.Jun-09 Longstone High Donard 82 77 100 70 Estates issues - damage towalls and doors.Oct-09 Longstone High Donard 83 83 100 78 Painting required in kitchen,day room, side room andstore. High and low leveldusting required.Domestic Assistantaddressed cleaningissues. Nursing toaddress medicalequipment. Otherissues referred toEstates to assess andcost.Issues referred toEstates to assess andcost.Painting referred toEstates to assess andcost. High and lowlevel dustingcompleted.Repaint Contractor £750

MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateNov-09 Longstone High Donard 83 80 100 84 High/Low level dusting.Painting required.Jul-09 Longstone High Sperrin 81 89 82 74 Replacement floor coveringrequired for corridor.Refurbishment of wardkitchen required. High &low level dusting required.Aug-09 Longstone High Sperrin 84 80 88 86 Replacement floor coveringrequired for corridor.Refurbishment of wardkitchen required. High &low level dusting required.Dec-09 Longstone High Sperrin 84 84 92 82 Replacement floor coveringrequired for corridor.Refurbishment of wardkitchen required. High &low level dusting required.Sep-09Nov-09Sep-09SouthTyroneSouthTyroneSouthTyroneLowLowLowC FloorAdminExternalGroundsF FloorLeft, Admin81 85 82 74 Removal of clutter. Paintingrequired. Replacementlight fittings required.Replacement ceiling tilesrequired.High/Low leveldusting completed.Painting referred toEstates to assess andcost.Replacement flooring& kitchenrefurbishmentreferred to Estates toassess and cost.High & low leveldusting completed.Replacement flooring& kitchenrefurbishmentreferred to Estates toassess and cost.High & low leveldusting completed.Replacement flooring& kitchenrefurbishmentreferred to Estates toassess and cost.High & low leveldusting completed.De-clutter discussedwith appropriate staff.Estates issuesreferred to Estates toassess and cost.Painting tocommence25/1/1072 76 60 69 Debris externally. Estates82 86 71 88 High/low level dustingrequired. Waiting area andtoilet walls require painting.Domestic issuesbeing addressed.Estates issuesreferred to Estates toassess and cost.£7,000£7,000£7,000£500Jul-09SouthTyroneModHospitalReception81 81 88 75 Painting issues at entrance,waiting area, toilet & dirtyutility-room. Ceiling tiles tobe replaced. Toilet floorPainting programmeand replacementceiling tiles referred toEstates to assess and£500

MonthHospitalRisk CategoryDepartmentAverage ScoreBelow 85 %Domestic %Nursing/Manager %Estates %Domestic/Estates IssuesIdentifiedAction Taken toAddress IssuesAction PlannedBy WhomTimescaleAny CostImplicationsCompletion DateOct-09Aug-09Sep-09SouthTyroneSouthTyroneSouthTyroneModLowModHospitalReceptionMedicalRecords,Corr IIOut-of-Hoursneeds wet scrub. Cleanequipment in domesticstore.75 71 71 87 Walls, doors, entrance,toilet and domestic storerequire painting. High andlow level dusting required.Hard floors require wetscrub.71 67 70 77 Walls require repaintingthroughout, light fittingsrequire removed forcleaning, medical records1,2 cluttered, low and highsurfaces damp dustingrequired.82 92 100 55 Painting requiredthroughout, radiatorsrequire cleaned. Highdusting required.Oct-09 St Luke’s Mod Mortuary 82 82 100 79 Painting required. High andlow level dusting required.Jan-10 St Luke's High Addict Unit 84 84 100 76 Painting required. Ceilingtiles need replaced. Lowdusting required.cost. Toilet wetscrubbed. Cleaningequipment dampwiped.Painting issuesreferred to Estates toassess and cost.High and low leveldusting completed.Floors wet scrubbed.Dusting issuesaddressed.Painting issuesreferred to Estates toassess and cost.Painting referred toEstates to assess andcost. High and lowlevel dustingcompleted.Painting referred toEstates to assess andcost.Jan-10 St Luke's Low Chapel 82 90 33 73 Painting required. Referred to Estates toassess and cost.Jan-10 St Luke's Mod Mortuary 77 74 75 86 Damp proofing and paintingrequired.Jun-09 St Luke's Mod OT 84 83 90 89 Refurbishment of OT notcompleteReferred to Estates toassess and cost.Refurbishmentdelayed due to leak inroof£500£1,500£1,400£5,000£2,000

6. Exception ReportThis exception report includes items which are outstanding from Action Plansdeveloped following either internal Environmental Cleanliness or RQIAUnannounced Inspections. These items relate mainly to the fabric of thebuildings.Audit Facility Dept Work RequiredEC Departmental CAH Elms RefurbishmentEC Departmental CAH Maples RefurbishmentEC Departmental CAH Laundry RefurbishmentEC Departmental CAH Stores Refurbishment. Storage issues tobe reviewed.EC Departmental CAH Transport PaintingEC Departmental DHH Walls to be recovered in all showerareas throughout hospital.EC Departmental DHH Ambulance Painting.ControlEC Departmental DHH Coronary Care PaintingEC Departmental DHH Female Medical PaintingEC Departmental DHH Male Medical Painting. Damp patches on ceiling.EC Departmental DHH Male Surgical Painting. Floor needs repaired.EC Departmental Longstone Donard Painting required and refurbishmentof ward kitchen.EC Departmental Longstone Mourne Kitchen and Bay 10 flooring to bereplaced.EC Departmental Longstone Sperrin Floor covering to be replaced.Refurbishment of ward kitchen.EC Departmental Longstone Cedarwood Refurbishment of domestic store.EC Departmental Longstone IATU Refurbishment of staff shower roomand patient shower room.EC Departmental South C Floor Admin Ceiling tiles to be replaced.TyroneEC Departmental SouthTyroneF Floor Admin Ceiling tiles to be replaced, paintingrequired.EC Departmental SouthTyroneReception Ceiling tiles to be replaced, paintingrequired.EC Departmental South Medical Painting required throughout.Tyrone Records Corr IIEC Departmental St Lukes Mortuary PaintingEC Departmental St Lukes Ward 2 Touch up paint work on doorframes, clean door vents,replacement flooring toilets, nightduty station.EC Departmental St Lukes Ward 3 Clean door vents, replacement floorcovering clinical room, quiet roomApproved by Board of Directors 25 th February 2010

and nurses station.EC Departmental St Lukes Villa 2 Painting of day rooms.EC Departmental St Lukes Villa 3 Replacement floor covering incorridor.EC Departmental St Lukes Addiction Unit Painting to stairway, landing andday room.EC Departmental St Lukes OT Repair to leaking roof.RQIA 10/8/09 South Loane House Locked cupboard required in store.TyroneRQIA 19/2/09 DHH A&E Provide patient bathroom or showerarea. Refurbishment of domesticstore, toilet beside domestic storeand dirty utility. Macerator orwasher disinfector required in thedepartment. Scrub sink in resus isrequired.RQIA 19/2/09 DHH Medical/Stroke Repair damage to floors in bays 3and 4. Ward kitchen to berefurbished.RQIA 19/2/09 DHH Male Surgical Replace floor in ward 3.RQIA 19/2/09 DHH Outpatients Repair walls and repaint. Sinks tobe repaired/replaced. There is aneed to provide a segregation areafor waste.RQIA 9/4/09 DHH Delivery Suite Refurbishment of changing rooms.RQIA 14/10/09 CAH A&E Rolling programme for repaintingneeds to be established.Wheelchairs to be checked fordamage to upholstery and repairedor replaced.RQIA 14/10/09 CAH Outpatients ENT needs refurbished andredecorated.RQIA 7/3/08 CAH 2 South Refurbishment of ward kitchen.RQIA 7/3/08 CAH Outpatients Refurbishment of dirty utility.General Comments

♦♦♦♦♦♦♦♦National Colour Coding has been implemented with the exception of someitems which are not available as stock items. Posters displaying colourcoding information are being developed and will be displayed in domesticstores.There are a lot of water taps throughout the wards and departments whichdo not comply with HTM64 as they are not sensor taps.System to be established to ensure that mattresses are checked on bedsand couches to ensure that they are not damaged or stained.Cleaning schedules for wards and departments to be updated and agreedarrangements to be put in place for their display in the wards anddepartments.Infection Control Training for staff to be provided on a rolling basis.Storage of bedpans at ward level to be agreed and suitable racks providedin all sluice/dirty utility rooms.Sharps and waste management training to be provided to staff.Toilet rolls and paper hand towels to be made available in dispensers.Trials of hand towels have taken place and the new contract is due tocommence 1/5/2010. It had been originally scheduled to start 1/12/2009 butthe date was extended.