Select Committee on Health Written Evidence

Memorandum by the Healthcare Commission (PS 52)


  1.  The safety of healthcare is of fundamental importance. Even organisations that provide world-class clinically effective care make mistakes: how they respond to those incidents to learn and prevent them happening again, and how they anticipate and prevent incidents, is a fundamental aspect of organisational culture and has a major impact on outcomes for patients. Safety should be at the heart of all that trust boards do.

  2.  This submission draws on the Healthcare Commission's experience and findings and in particular addresses terms of reference 2a, 2d and 3.


  3.  The Healthcare Commission has had a significant impact on the awareness of and focus on the safety of patients. We have a twofold approach.

  4.  Firstly we focus on organisational culture: whether organisations report incidents, analyse and systematically learn from them, to make improvements for the benefit of service users in general. We look from "ward to board", at whether staff feel supported to report incidents and feel action is taken; at what is reported to boards and how boards act on it. We also look at whether organisations implement learning from national analysis published by organisations like the NPSA.

  5.  Secondly, we test how organisations are managing the greatest risks to safety. Information on the most common types of safety incidents is shown in Appendix 1: we prioritise our programme based on this data and on further engagement. For some risks—ionising radiation, controlled drugs and infection control—we have been asked by Government to carry out work because of particular risks to safety.


Broad assessment of compliance

  6.  The onus is on Boards to assure themselves that their organisation is safe, and under the Annual Healthcheck, each NHS trust makes a self-assessment and public declaration on whether they are meeting the Government's core standards[296], 12 of which relate to safety (Appendix 2).

  7.  We systematically assess whether these standards are in place, by cross-checking trusts' declarations and looking at whether organisations meet requirements and guidance which underpin the standards[297].

  8.  93% of 220 NHS trusts participating in the independent evaluation of our work thought core standards assessment had a positive impact on the care of patients, and 67% agreed it had improved the safety of patients[298].

In-depth reviews and inspections

  9.  The Commission believes that the broad-brush assessment of compliance with standards is not sufficient to assess safety and quality, and therefore complements it with in-depth reviews of areas of concern. We often do this by following patient pathways rather than focusing on single organisations in order to reflect patient's experiences better: furthermore transfer between organisations is a key point of risk to safety. Where possible, we look at both outcomes and processes to ensure that the safety of patients is systematic and sustainable[299].

  10.  We have:

    —  Published 22 topic-based reviews and studies

    —  Carried out 20 national surveys of patients and staff

    —  Visited acute trusts to assess compliance with the hygiene code, monitored compliance with controlled drugs legislation and embarked on a programme of proactive inspection of providers of radiotherapy services, in order to ensure compliance with regulations.

  11.  Assessment of safety threads throughout this work has been targeted and influential. We have identified areas of concern, provided information for trusts and the public on good and poor practice and recommended remedial action[300]. 70% of trusts participating in the evaluation of our approach said that the four reviews they had been involved with had positive impacts for patients.

Interventions and investigations

  12.  We take action where cases of serious concern around the safety and care of patients are raised. The Commission has had over 300 cases referred to it and completed 15 investigations[301] as well as a wide range of other interventions, covering both NHS and independent healthcare[302].

  13.  Investigations have promoted improvement in the individual trust concerned and impacted across the provision of healthcare services. Thirty- five per cent of trusts report that the investigations in other trusts had a significant impact on improving standards in their own trust and a further 55% reported that they had had a small impact[303].

  14.  The capacity to probe trusts in this way and the power to recommend special measures add significant force to the Commission's regulatory model.

Comparative information

  15.  The public reporting of comparative information is an important driver for improvement and we publish benchmarking indicators relating to safety culture and key risks for organisations to use to assess their own performance. We have recently engaged widely with trusts to ensure this set is comprehensive, reflecting a range of risks, draws on good local practice and is practical to drive improvement in healthcare.

Partnership working

  16.  We have promoted joint working between national-level bodies through the "Safety Charter", and the Concordat and associated regional and national risk summits.


  17.  It is important that Boards assess their position in relation to safety and maintain a focus on it, in order to drive sustained improvement. Trust boards make an annual declaration of compliance with the core standards for better health[304], 12 of which are safety-related (see Appendix 2). They cover safety culture (eg whether organisations report and learn from incidents) and key risks (eg managing medicines and infection control). In their entirety they give a broad picture of trust performance on safety.

  18.  Performance on the safety standards is highly variable, with some having the lowest compliance rates of all standards (see Appendix 2). Furthermore in 2007/8, declared compliance on three safety standards got worse[305]. We suspect that this is because trusts are now more aware of what they need to do, for example, in relation to decontamination requirements published by the MHRA, which is positive. We also suspect, however, that trusts' declarations on some other standards may reflect a similar underestimation of what is required, and are testing this out in our cross-checking visits in relation to core standard C1a, C1b and C4b this year.


Reporting and learning the lessons from incidents

  19.  Nearly 800,000 incidents are reported from English trusts to the NPSA each year[306], and reporting levels are on an upward trend. 98% of trusts declared that they were meeting the core standard requiring them to report and learn from incidents. Reporting is however underdeveloped in some settings. Only 2,150 (0.2% of) reported incidents were from general practice last year, in spite of the fact that the greatest number of contacts with patients occur in that setting[307] and the greatest proportion of complaints relates to primary care[308]. Even among acute trusts, some report only low levels of incidents, or do not report regularly. This reflects our experience of incidents involving radiation[309]. And research shows that even reporting systems capture only a fraction of incidents[310]. So there is a need for considerable improvement.

  20.  Furthermore reporting is worthless unless incidents are analysed in order that improvements are implemented. Based on our assessments, is our belief that the link between incidents and systematic analysis to identify common factors and action required is often missing. Our annual healthcheck visits to trusts have found this in some cases, and it is borne out by our survey of NHS staff[311]. Furthermore our work on second-stage NHS complaints found that trusts have much to do to improve the way in which they use the lessons from complaints to improve services. We are currently looking at how organisations implement learning from incidents, taking inpatient falls as a tracer, and will publish findings in the New Year.

Learning from cases of service failure

  21.  There are clear common trends in the investigations we have undertaken:[312] poor leadership, ineffective management, inadequate teamwork with staff feeling unable to communicate problems and a lack of clarity about who was responsible for what across the trust. A common finding has been NHS trust boards concentrating on some of their activities, such as the delivery of targets or mergers, at the expense of others. Investigations often uncovered a breakdown in leadership and management, with a lack of clarity on responsibilities from board to ward. Poor teamwork, either between management and clinicians or between clinicians themselves was another common factor.

  22.  It is crucial that Boards routinely receive key information on a range of risks such as rates of infection and medication errors so that they can act on safety concerns. The Commission was surprised that many boards involved in investigations did not have systems in place to ensure this. This meant that these boards were unable to spot problems and take steps to fix them.

Accountability at board level

  23.  We have recently conducted research looking at what information is reported to boards on safety and the level of priority given to safety at board meetings.

  24.  Early findings indicate that there has been increased attention given to safety, largely driven by Government priorities. However, the priority given and approach taken varies, and in most cases, detailed scrutiny of safety takes place at committee level with only key facts and exceptions reported to the board. Acute trusts (and in particular foundation trusts) tend to be more advanced in terms of systematic reporting, due to better information systems and perhaps because targets applied to the sector gave rise to a culture of collecting and acting on information. Conversely, reporting within PCTs is less developed, perhaps due to the disruption arising from organisational change as well as poor information infrastructure. There has been limited development of systematic processes by which PCTs monitor the safety of providers from whom they commission services.

Driving improvement

  25.  Trusts' analysis of their own position must be coupled with systematic action to drive improvements. However the national picture of performance across the past three years of the Annual Healthcheck has not changed. In 2007/8, only 62.7 per cent declared compliance for all safety standards, compared with 61.1% in 2006/7 and 62.8% in 2005/6.


  26.  The independent healthcare sector provides a considerable and increasing level of care to NHS-funded patients.

  27.  We undertook a review of ISTCs[313], and found that although contracts required ISTCs to return information on quality and safety[314], the level of returns and data quality were very poor. These were however new requirements of the independent sector and there has been some improvement since.

  28.  We receive "regulation 28" notifications from providers: these generally relate to incidents regarding safety. As for the NHS, data quality can be poor and the level of reporting from different providers of the same type varies greatly. Our assessors follow up on individual notifications, and we are working with providers to improve reporting and its consistency.

  29.  Whilst there is an anecdotal sense that the standards of safety and the development of safety management systems in the independent acute sector is good, this cannot currently be quantified. A key challenge for the regulator is the data available to permit meaningful cross-checking of providers' self-assessments. The Healthcare Commission has undertaken several initiatives to promote comparable patient level data but it will take several years before data quality is sufficient for valid use across the whole independent sector. However, a series of high-level indicators has been developed to help monitor the performance of acute providers, so an understanding of safety for these organisations will be available sooner.


  30.  The Commission has from its work a considerable amount of evidence relating to the major types of risk to the safety of patients. This is detailed in Appendix 3. Findings include:

    —  there have been advances in infection prevention and control, but almost all trusts we have visited are not compliant with all elements of the Code and a number have not met their individual MRSA targets. Systems to ensure all aspects of the code of practice are met reliably every time for every patient need to be strengthened.

    —  Although providers have taken steps to improve the management of controlled drugs, medication risks arising during handover and in certain settings (eg mental health care) are not well addressed

    —  staffing levels and absence due to stress, injury, violence and harassment need to be tackled

    —  delayed or inaccurate diagnosis in primary care is a major cause of complaint

    —  there have been improvements in the percentage of community mental health service users that have the number of someone to contact in a crisis, but 45% still do not

    —  inspections have highlighted the lack of priority given to children's safeguarding by some NHS trusts


  31.  Boards themselves need to embed safety culture, and drive improvement from within, to put safety at the heart of what they do. This can be supported by context set at a national level. A concerted effort to improve safety, such as has been seen for infection control, needs to be brought by all national-level parties, highlighting other risks.

  32.  There are a number of immediate and medium term opportunities to set a framework that establishes safety as of top priority.


Registration requirements

  33.  The regulator of quality plays a fundamental part in driving improvement in safety. Its work is underpinned by the standards against which it assesses performance. One critical consideration in preparations for the establishment of the new regulator, the Care Quality Commission, will be the registration requirements in relation to which it can take enforcement action, and the standards against which it can measure performance.

  34.  The proposed registration requirements need to go further. Currently, two proposed requirements address safety in general[315]. As currently worded these requirements are not as comprehensive as the Standards for Better Health, which not only require organisations to learn from ALL patient safety incidents, but require them to act upon national learning from incidents such as distributed in safety alerts. The bar for registration requirements and standards must not be lower than that currently set. Ideally, elements of the developmental standard for safety, which requires continuous and systematic review of safety and application of best practice, should be adopted.

Scope of regulation

  35.  The fact that the Care Quality Commission's remit will extend into primary care and covers social as well as NHS and independent health care should have a very positive impact. It will better enable CQC to look at what happens when people are transferred between organisations, or care is shared between organisations[316]. It is also important that at last, NHS and independent healthcare providers will be assessed under the same system, and so better comparison will be possible. CQC will be able to focus its programme on the areas of greatest risk across sectors.

  36.  CQC must be given appropriate powers to assess safety in general practice[317]: as discussed below, this is an area where risks are currently largely unquantified.

Scope of programme

  37.  On the basis of the Healthcare Commission's experience, and feedback from the NHS, the approach to assess and improve safety that works, that we recommend to CQC, is one that:

    —  Continues to out the onus on Boards to assess and assure themselves of their position on safety

    —  Assesses whether organisations learn from incidents and make improvements

    —  Tests organisations' approaches to managing a range of key risks

    —  Threads safety throughout its assessments, but supplements this with specific safety-themed work to ensure the major risks are addressed

    —  Prioritises a programme of work based on available information on risk

    —  Takes action where safety is at risk


Measures of safety

  38.  It is imperative that better information on safety is made available, building, for example, on the Commission's benchmark indicators.

  39.  The Darzi Quality Framework provides an excellent opportunity to drive forward data availability and data quality in safety. Phase 1 of this work will use existing nationally-available data, and so is limited. Phase 2 will allow local and national organisations to together define new measures that reflect key aspects of safe care. Collecting some of this data on a national basis may be resource-intensive, but Government and healthcare providers should not be deterred.

  40.  The Healthcare Commission has recently concluded in-depth research[318] to determine what data is available locally, and what information boards would like to receive to drive local improvement in safety. Organisations put forward a list of key measures (see Appendix 4) that they would like to use. We are currently piloting their use with the NPSA, and want to see them taken forward in the Quality Framework and local Quality Accounts.

Incident reporting

  41.  The data on incidents reported to the NPSA is critical to safety. The NPSA draws out learning that may not be apparent at a local level, and shares this nationally. Systematic collection of this information across the healthcare sector as a whole (public and private) would be very powerful, highlighting potential risks and areas for improvement. The level of reporting from some sectors, and quality of reported data, is a barrier to this process.

  42.  Firstly, reporting levels must be improved. We have discussed above culture within trusts and how this impacts on reporting. There are things that could be done at a national level to help. Reporting routes for incidents are very complex (Appendix 5). The NPSA is beginning work to create a single, simplified reporting route for providers of all types, and for incidents of all types, from which all end-users[319] can extract the data they need. This work should be given the highest priority.

  43.  Secondly, the NRLS's dependence on data from local risk management systems means the quality of data reported is variable. Clear definitions need to be developed and used within local incident reporting systems, to introduce better consistency and increase the speed and comprehensiveness with which NPSA is able to extract learning from incidents.


  44.  There is clearly insufficient information on risks and safety in primary care and independent healthcare.

  45.  Very few incidents are reported from primary care and yet the largest number of complaints that we review relate to primary care (38.4%). The lack of information on risks[320] has caused a focus on the acute sector, where risks are better known, which may have created an assumption that primary and community care is safe. The avoidable harm caused by wrong, missed and delayed diagnosis, or medicine errors, is likely to be significant.

  46.  Improved measures of safety are needed in primary care, along with systematic local and national analysis of complaints[321]. And a concerted effort is needed to increase levels of reporting from general practice, and to promote a culture of learning from incidents and safety improvement.

  47.  As stated above the information available on safety in the independent sector is poor, although information on acute care is improving.

  48.  Until data availability and quality improve, if data to target or assess is not readily available, CQC may need to use random inspection methods and should also focus reviews on these providers, to improve knowledge and data on risks.

  49.  CQC also covers social care. Increasingly, the NHS commissions long term care from care homes and delivers health care through domiciliary and care home staff. Little data is available on risks in social care and debate is needed to determine if or how the dataset should be improved.


  50.  There are many national players in the realm of safety, and joined-up working has sometimes been difficult. It can provide real benefits: for example, the Healthcare Commission and the NPSA now work closely together, with NPSA information on incidents used to prioritise the Commission's programme of work on safety. This also allows the Commission to reinforce national learning (such as alerts) distributed by the NPSA. We are working with the Health and Safety Executive to prioritise areas of work on staff safety and the Academy of Royal Colleges to come to a shared understanding of what it is important to measure and assess in safety and quality.

  51.  National organisations need to recognise each others' distinct contributions—whether as information providers, assessors, enforcers, improvement agencies or national representative bodies—and work together in a coordinated manner to make the best use of the levers available to improve safety and support boards in driving improvement.


  52.  There has been increased attention to safety in recent years, with some improvements in the areas of healthcare-associated infection and reporting of incidents by many acute trusts. However:

    —  there is a considerable variation in the level of reporting of incidents from different organisations, even those of the same type; and some types of services (notably general practice and independent healthcare) have poor levels of reporting;

    —  the link between incidents and systematic analysis to identify common factors and action required is often missing;

    —  the information routinely reported to boards does not cover a broad enough range of risks but often concerns single issues or exceptions;

    —  there has been limited development of processes by which PCTs monitor the safety of the providers from whom they commission services;

    —  Performance on safety standards is highly variable, with certain safety standards having some of the lowest compliance rates of all standards; furthermore overall performance on safety standards across the past three years of the Annual Healthcheck has not improved.

  53.  In summary, there is much to be done within trusts to embed a culture of safety and underpin it with information and systems of governance that ensure that safe care is delivered for every patient; enable learning to be implemented systematically and improvement to be monitored.

  54.  Boards must assure themselves that their organisations are operating safely. A range of national-level levers must be used to support and promote such change:

    —  Changes to regulation will bring benefits in terms of joined-up coverage but requirements of trusts must not slacken;

    —  The Darzi Quality Framework must be used to improve information on safety;

    —  Incident reporting routes should be simplified and data quality must be improved;

    —  Better information on risks in general practice and independent healthcare is needed; and

    —  National bodies should further improve their partnership working to promote safety.

September 2008

Appendix 1

The most common types of safety incidents reported to national organisations, and examples of the Healthcare Commission's related work

Top 10 incident types[322] Reported incidents, 2007/8Healthcare Commission recent and current programme—examples
Patient accident (largest category of which is falls) 271,230Annual Healthcheck core standard assessment (C1a) National study of falls
Treatment or procedure error* (Broad category) 78,104 + 329 = 78433Annual Healthcheck core standard (C3) Proactive and reactive inspections of radiology and radiography departments Investigations and review of maternity care Coverage in various service-based reviews
Infection control incident***13,386 + 59831 = 73217 Annual Healthcheck assessment of progress on national targets for MRSA and C Difficile Annual Healthcheck core standards (C4a, C4c, C21) Inspections of compliance with the Hygiene code at all acute and some non-acute NHS trusts Investigations of infection control Study of infection control across health and social care boundaries
Medication error70,178 Annual Healthcheck core standard (C4d) Review of medicines management following discharge across the acute/primary care boundary Monitoring compliance with controlled drugs legislation
Access, admission, transfer, discharge error 58,116Annual Healthcheck core standard (C6) Review of medicines management following discharge across the acute/primary care boundary Study of infection control across health and social care boundaries
Infrastructure (incl staffing, facilities, environment) 53,491Annual Healthcheck core standards (C10, C11, C20a, C21) Staffing covered in a number of reviews
Documentation error40,329 Annual Healthcheck core standard (C9)
Clinical assessment error36,258 Annual Healthcheck core standard (C3)
Medical device error**25,341+8,634 = 33975 Annual Healthcheck core standard assessment (C1a) National study of medical device management
Disruptive aggressive behaviour32,886 Recent reviews of community and acute mental health services

  *  this sums data reported to the NPSA with ionising radiation incidents reported to the Healthcare Commission which may not be valid

  **  this sums data reported to the NPSA with device incidents reported to the MHRA which may not be valid

  ***  this sums incidents reported to the NPSA with those reported to the HPA, which may not be valid. NB HPA data only includes C Difficile and MRSA cases reported to the HPA—other infections are not represented in these figures

Appendix 2

Core standards for better health that relate to patient safety, and performance on them

  The safety-related core standards are as follows:

  C1a Health care organisations protect patients through systems that

    (a)  identify and learn from all patient safety incidents and other reportable incidents, and make improvements in practice based on local and national experience and information

derived from the analysis of incidents; and

    (b)  ensure that patient safety notices, alerts and other communications concerning patient safety which require action are acted upon within required time-scales.

  C2 Health care organisations protect children by following national child protection guidance within their own activities and in their dealings with other organisations.

  C3 Health care organisations protect patients by following NICE Interventional Procedures guidance.

  C4 Health care organisations keep patients, staff and visitors safe by having systems to ensure that

    (a)  the risk of health care acquired infection to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year-on-year reductions

in MRSA;

    (b)  all risks associated with the acquisition and use of medical devices are minimised;

    (c)  all reusable medical devices are properly decontaminated prior to use and that the risks associated with decontamination facilities and processes are well managed;

    (d)  medicines are handled safely and securely; and

e) the prevention, segregation, handling, transport and disposal of waste is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment

  C11b) Health care organisations ensure that staff concerned with all aspects of the provision of health care participate in mandatory training programmes

  C20a) Health care services are provided in environments which promote effective care and optimise health outcomes by being a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisation

  C21 Health care services are provided in environments which promote effective care and optimise health outcomes by being well designed and well maintained with cleanliness levels in clinical and nonclinical areas that meet the national specification for clean NHS premises.

  Trusts' compliance with core standards, as self-assessed in their declarations relating to 2007/8, is as shown in graph 1 and table 1:

Graph1: Percentage of trusts compliant with each core standard

Table 1: Percentage compliance with each core standard relating to safety, and change from 2006/7


Increasing declared compliance

    —  98 per cent (384 trusts) declared compliance for C1a (learning from patient safety incidents). This was a 3.8% increase from last year.

    —  97 per cent (383 trusts) declared compliance for C2 (child protection). This was a 1.2% increase from last year.

    —  97 per cent (165 trusts, of 170) declared compliance for C3 (NICE guidance on interventional procedures). This was a 5.4% increase from last year.

    —  91 per cent (356 trusts) declared compliance for C4a (infection-control). This was a 5.0% increase from last year.

    —  94 per cent (369 trusts) declared compliance for C4d (safe handling of medicines). This was a 2.7% increase from last year.

    —  94 per cent (369 trusts) declared compliance for C4e (handling and disposal of waste). This was a 1.0% increase from last year.

Decreasing declared compliance

    —  98 per cent (383 trusts) declared compliance for C1b (acting upon safety notices). This was a 0.3% decrease from last year.

    —  88 per cent (345 trusts) declared compliance for C4b (use of medical devices). This was a 1.1% decrease from last year.

    —  78 per cent (252 trusts, of 322) declared compliance for C4c (decontamination of medical equipment). This was a 7.5% decrease from last year.

Appendix 3

The Commission's findings in relation to key risks to safety


"Patient accidents" including falls

  "Patient accident" is the single largest category of incident reported to the NPSA, with slips, trips and falls a major proportion of these incidents. There is sometimes complacency with respect to falls, due to an assumption that falls cannot be prevented where patients are frail or confused. However, falls are a major cause of harm, leading to injury, increased lengths of stay in hospital, and sometimes death. There are many risk factors that can be improved for individual patients—relating to their medication, their continence control or their footwear, for example. The Commission is carrying out research in this area, following up on the NPSA's "Slips, trips and falls" report, and will publish findings in the new year.

Risks associated with treatment: surgery and anaesthetics

  Our 2008 survey of inpatients found that 81% of respondents who underwent an operation or procedure said they were "completely" informed about the risks and benefits of surgery. Full comparative information about risk is patchy but increasingly available[323].

  Incidents that arise during surgery are, however, potentially under-reported. The NPSA is promoting specialty-specific reporting with the Royal College of Anaesthetists, and has issued a range of "safer surgery" guidance. Surgery is one of the Commission's priorities for work in 2009.

Risks associated with treatment: Diagnostic and therapeutic use of ionising radiation

  Organisations are required by regulations to notify the Healthcare Commission when patients receive an exposure of ionising radiation "much greater than intended". The most common cause for notification is that the wrong patient has been subjected to an x-ray or CT scan[324]. There is however a considerable variation in the rates of notification made by individual organisations, with some regularly making notifications, but many more which have made none at all.

Infection prevention and control and hygiene

  The Commission has undertaken a range of work in this area, reflecting national priorities as well as the level of risk involved.

  Since 2005/2006, acute trusts have been measured on the Healthcare Commission's "MRSA bacteraemia" performance indicator, which measures each trust's progress towards achieving the national target of halving the number of MRSA bacteraemias in NHS acute and specialist trusts in England by March 2008. The indicator shows that MRSA levels have reduced each year of our assessments, and as a whole, across the country, there MRSA targets have been met. However, individual trusts' performance varies: many have not reduced their MRSA numbers in line with their individual agreed targets.

  NHS organisations in England have been required to report C. difficile infections since January 2004. Initially this was just in cases affecting people over 65 (which accounts for around 80% of all known cases) but since April 2007 reporting requirements cover all ages over 2 years old. The absolute number of infections in England fell in 2007, the first annual decrease since the collection began in 2004. For over 65s, there were 50,392 cases in 2007, compared with 55,635 the previous year. The rate of infection has also fallen, though it is too early to tell whether this is the start of a long-term trend.

Three core standards relate to infection prevention and control and hygiene[325]. The standard for decontamination of reusable medical equipment features for the third year running in the list of standards that trusts most struggle to meet. It is also the standard that showed the greatest decrease in compliance this year. By contrast the standard for overall infection prevention and control was one of the standards where trusts have shown the most improvement this year. Overall, one in four trusts are non-complaint with at least one of the standards related to the Hygiene Code.

  The Healthcare Commission is this year inspecting all acute trusts to check compliance with the Hygiene Code. Between January and July, 87 visits were carried out. Of the 39 inspections undertaken between January and March 2008, there were only 5 trusts where no breaches of the code were identified: the other 34 trusts all breached the code for one or more sub-duties, and all were issued with recommendations. To date we have issued four improvement notices where significant breaches of the code were identified (see box 1).


  The healthcare commission has issued 4 improvement notices since April 2007

    Trust 1—inadequate resources and training for infection control, poor risk management, inadequate provision of antibacterial hand rubs, and lack of compliance with isolation policy (duties 2c,2d,3,4e and 8)

    Trust 2—problems with arrangement for decontamination of equipment and cleanliness (duty 4c and 4f)

    Trust 3—problems with arrangement for decontamination of equipment (duty 4f)

    Trust 4—problems with arrangements for decontamination of equipment (duty 4f) an drisk management (duty 3)

  Patient and staff surveys show encouraging signs of improvement in infection control but more needs to be done to make hand-washing equipment available in some trusts[326].

  Overall, there have been advances in improving infection prevention and control as evidenced by the falling MRSA rate, but almost all trusts are not compliant with all elements of the Hygiene Code. The NHS can and must do much more to ensure safe procedures are systematically followed. All NHS trusts will need to make a declaration of compliance with a regulation requiring them to minimise the risk of infection, in order to be registered with the Care Quality Commission in April 2009. The regulations will be supported by a code of practice. All trusts, but in particular non-acute trusts which have thus far not been the focus of monitoring and targets for infection prevention and control, will need to continue to improve in this area. Systems to ensure that all aspects of the code of practice are met reliably every time for every patient need to be strengthened. In autumn 2008 we will be extending our programme of inspection to non-acute trusts.

Medicines management

  Medicines are given because it is believed that the benefits outweigh the associated

risks, but trusts need to apply appropriate controls to ensure that these risks are minimised. 94 per cent (369 trusts) declared that they handles medicines safely in 2008/9 (core standard C4d). This was a 2.7% increase from the previous year.

  A key area of risk is when a patient is given new medication. Patients should be given clear information on how to take their medicine and the side-effects to watch out for. A range of evidence points to the fact that this is not done comprehensively. Our 2008 survey of patients' experience of local health services found there was a decrease in the percentage who said that they got enough information on any side effects the medicine might have. In 2005, 61% said that they got "enough" information regarding side effects, but this decreased to 59% in 2008. A reduced percentage said they received enough information about how to use their medicine—85% in 2008 compared with 86% in 2005. Our 2008 survey of inpatients shows similar results: the number of respondents saying they were not told about possible side effects when taking medicines home rose to 46% from 45% in 2006 and 42% in 2005. However, only nine per cent of respondents said they were not told how to take their medicine in a way they could understand. Just less than one-third (32%) of mental health service users who had been prescribed new prescriptions said that they had not been told about the possible side effects. However, this proportion has been improving (35% in 2004 and 2005, 34% in 2006 and 33% in 2007).

  Our reviews of medicines management (2007) showed that in 98% of trusts, less than half of audited patients had a complete medicine history from their GP on admission to hospital, and only 30% of PCTs reported that GPs thought they received adequate information on patients' medicines on discharge.

  The Healthcare Commission monitors that both NHS and independent healthcare organisations have controlled drugs Accountable Officers in place to take responsibility for all aspects of safer management of controlled drugs. Providers have taken positive steps to improve the monitoring and management of controlled drugs following the Shipman Inquiry[327]. And our review of substance misuse services in 2006 found that the majority of services had procedures in place for the prescription and administration of Methadone. But more work is necessary to ensure all concerns in relation to controlled drugs are picked up, investigated and, where appropriate, action is taken.

  It is our belief that medication safety has not been subject to concerted improvement. In particular, risks arising during the process of discharge or handover and risks in certain settings (for example, mental health care) are not well addressed. We are currently conducting a review of medicines management when a patient is discharged from hospital back to the care of their GP to assess performance in one of these areas.

Infrastructure: staffing levels and training, and staff safety

  Having the right number of competent staff is key to safety. A number of commission reviews have looked at this area.

  For example our recent review of maternity services found that levels of staffing were well below the average, indicating that they may have been inadequate; that consultant obstetricians did not spend the time recommended by their professional body on labour wards; and that doctors and midwives did not attend in-service training courses consistently across trusts. Our 2007 review of children's hospital services found that in a small number of hospitals (12%), there was insufficient cover during the day to ensure that effective paediatric life support was available in serious emergencies. At night, this figure rose to 18%. Our review of day surgery found it was common that a child trained nurse was not always available when children were being treated.

  One cause of under-staffing is sickness, and sickness absence levels in the NHS are particularly high. Our survey of NHS staff (year) found that 17% of staff had been injured or felt unwell in the past 12 months as a result of problems at work, slightly down from 19% in 2005. Seventeen percent of staff had suffered a work-related injury due to moving and handling, needlestick and sharps, slips, trips or falls injuries, or exposure to dangerous substances. A third of staff (33%) still reported suffering from work-related stress, although this too had reduced slightly from 36% in 2005.

  Research has shown that a major cause of stress at work is bullying and harassment. Over the past three years, there has been little change in the proportion of staff who have been physically attacked or abused at work in the preceding 12 months, despite campaigns to tackle these issues. Nationally, 13% of staff in the 2007 survey reported that they had been physically attacked by patients or their relatives. Twenty six per cent reported that they had been harassed, bullied or abused compared with 28% in 2006[328]. However only around half of staff felt that their trust took effective action after incidents of violence, harassment, bullying or abuse. A surprisingly high proportion of staff also reported that they have been harassed, bullied or abused at work by managers or team leaders (8%) and other colleagues (13%).

  Trusts are providing training for staff to deal with violence and abuse. In 2007, 26% of staff said they had received training in this area in the 12 months prior to the survey and a further 23% said they received the training, although it was more than 12 months ago. This is an improvement of four percentage points on the previous survey but still demonstrates room to improve. NHS trusts must renew their efforts to tackle violence and abuse and encourage greater reporting by staff.

Errors of clinical assessment and other errors of omission: Inaccurate or delayed diagnosis; failure to recognise or respond to deterioration; failure to provide proper nutrition

  Our two "Spotlight on Complaints" reports indicate that delayed / inaccurate diagnosis in primary care is a major cause of complaint[329]. 23% of complaints about GPs were around failure or delay in diagnosing a condition: many complainants told us their GP had missed signs that may have led to an earlier diagnosis of cancer. As mentioned above, however, GPs are not regular reporters into incident systems, and therefore risks in general practice are largely unquantified. In addition, it is comparatively hard to measure errors of omission, leading to deterioration or hospital admission, as diagnosis can be complex and sometimes certain only with the benefit of hindsight.

  One area amenable to analysis is the extent to which patients are prescribed correct medicines once they have a diagnosis. Our review of heart failure services in 2007 found that nationally, 85.2% of patients registered with a diagnosis of heart failure were prescribed ACE inhibitors, one of the key treatments to reduce symptoms and prolong life. In 2003/04 this figure was less than 50%. However, at a local level, access to such medication varied significantly (0% to 100%) and not all patients were getting access to additional drugs, for example beta-blockers, proven effective for the treatment of heart failure.

  In mental health services, provision of crisis support is key to avoiding deterioration and admission to acute care. Our survey of users of community mental health services in 2008 found provision of out-of-hours emergency telephone services had increased to 55% from 49% in 2006 and 52% in 2007: but this still leaves 45% of service users without access to out of hours crisis care. Meanwhile, of service users who did not receive counselling, almost a third (32%) said they would have liked to have counselling sessions.

  Our survey of inpatients in 2008 found that of those who needed help from staff to eat their meals, a fifth (20%) said that they did not get enough help. This shows no improvement from 2006 and a decline since 2002 (18%). In the lowest scoring trust, 42% of respondents who needed help to eat said they did not receive it, while in the highest scoring trust this figure was 3%.

Management of medical devices

  The management of medical devices is one of the core standards with the lowest levels of declared compliance, and this compliance is decreasing. (88 per cent (345 trusts) declared compliance with C4b in 2007/8: this was a 1.1% decrease from last year.) The Commission is carrying out research in this area to determine factors behind non-compliance, and will be reporting in the new year.

Violence and self-harm

  Nationally, on average 11% of all inpatient mental health service users were assaulted in 2006 according to their care records. Our 2008 review of these services found that one in six trusts were significantly above this average. Staff need to have the appropriate skills—supported by good role models, awareness of different models of recovery, and effective training and supervision—to identify the signs and causes of aggressive and violent behaviour and to intervene to prevent and manage incidents. Nearly a third of trusts (30%) said that none of their ward-based nursing staff had received training in sexual safety awareness over a two-year period. And despite the high levels of co-morbid mental health and substance misuse problems, only 26% of clinical staff reported having had training from their trust at any time in how to ask service users about their use of alcohol or drugs (including illegal drugs) and only 22% reported having had training in how to handle patients who are drunk or under the influence of drugs.

  In acute trusts, by comparison, few respondents to our 2007 survey (4%) felt threatened by other patients or visitors during their stay in hospital.

  Violence and self-harm remain key risks in mental health settings and trusts need to put far more in place to improve safety.

Protection of vulnerable individuals

  Poor understanding of adult protection procedures and responsibilities was a serious underlying problem in the two investigations into learning disability services that we have conducted, and is the reason behind a number of interventions that we have made at other trusts. Staff need good training to understand their crucial role in protecting vulnerable adults.

  The children's safeguarding report for 2008[330] found the priority given to safeguarding across agencies has increased since the first Safeguarding review was completed in 2002. Joint working has particularly improved in some areas, including arrangements between children's services, the police and the health service aimed at preventing domestic violence. But the report finds that not all agencies are meeting their statutory duties, and lines of accountability and responsibility for child protection are still not always clear. In particular, inspections have highlighted the lack of priority given to children's safeguarding by some NHS trusts. This reflects earlier findings of our 2007 review of children's hospital services which found that although 60% of nurses had relevant training in basic child protection, 58% of the services used by children did not meet the necessary training standards.

Appendix 4

Summary of potential safety-related benchmark indicators by sector


    National— data available at national level for all relevant organistions

    National—caution—data available at national level for all relevant organistions but caution regarding use (eg due to perverse incentives or poor data quality)

    For potential development—indicators that trusts think would be useful at a national level but require development and national collection

    Local use only—indicators that trusts think would be useful at a local level

Classification Broad description AcuteMental Health PCT Providers AmbulanceComments
NationalPatient experience (safety related) YY YN Source = patient survey
NationalCleanliness YY ? Source = PEAT or patient survey. Readily available for acute and mental health sectors, but no national collection mechanism for PCTs
NationalIncident reporting YY YY Source = Identification of low levels of reporting on NRLS or reporting culture composite from staff survey.
NationalMortality—SMRs Y Suggest use NCHOD methods
NationalMortality low risk HRGs Y
NationalReadmission rates—general YY Suggest use NCHOD methods for acute. See IP mental health review for mental health sector
NationalNHSLA level achieved YY YY
Nationalservice users who have been involved in an assault NY NN Current data source is count me in census, but needs to be integrated with mental health MDS. Caution of zero levels—could be non-recording issue
NationalRIDDOR vs. non-RIDDOR YY YY
NationalFalls Y Process measures available via RCP Falls audit
NationalMRSA YY Y incidence and trends
NationalC diff Y Y incidence and trends
National30 day mortality—AMI Y
National30 day mortality—post procedure Y Suggest use NCHOD methods
NationalReadmission rates—heart failure Y Would need to pool years for sufficient volumes
NationalWomen only day areas Y May be shared by more than one ward within a hospital site
NationalEnvironment YY PEAT framework to be modified for 2009, which may enable more specific measurement of issues relating to maintenance and security
National—caution Violence against staff YY YY (Source = staff survey or CFSMS) Issues re reliability of staff survey data and potential for perverse incentives in using CFSMS data.
National—caution number of complaints returned unresolved by the Healthcare Commission Yy YY
National—caution Hip fracture mortality rate Y Numbers may be low
National—caution Post operative hip fracture Y Some validity, but variability in depth of coding
National—caution Selected infections due to medical care (ARHQ/OECD) Y Variation in recording on HES. Suggest restrict to central line infections?
National—caution Post operative sepsisY Need to ascertain current view from Veena
National—caution Obstetric trauma (various) Y Need to ascertain current view from Veena
National—caution Iatrogenic pneumothorax Y Need to ascertain current view from Veena
National—caution Decubitus ulcerY Y Would require major data quality drive to be a useful measure for benchmarking purposes
National—caution Single sex accommodation Y difficult to compare findings over the years due to changes in definition, and reliability of data based on one day
National—caution Participation in antipsychotic POMH-UK audits Y Not all trusts participate in Royal College of Psychiatry accreditation schemes
National—caution availability of handwashing/cleaning facilities Y? YY Ambulance indicator would also need to refer to cleaning cf. washing
National—caution Training in how to prevent or handle violence and aggression to either staff, patients or service users in the last 12 months YY YY however robust data may be dependent upon review of local training records
National—caution Training in assessing use of alcohol and drugs, and how to handle patients who are drunk or under the influence of drugs Y robust data may be dependent upon review of local training records
For potential development Cleanliness of vehicles Y Needs more work to define measure and establish data collection mechanisms. May need to focus on process rather than outcomes, eg deep cleaning frequency (DG comments 210808)
For potential development Medication errors (requires further work up) YY YY May vary by sector depending on availability of suitable metrics/data. May also be related to actual events, reconciliation or patients understanding
For potential development survival rates YAlready used by some ambulance trust boards (N.B. query if all cause or just cardiac)
For potential development sickness absence rates (staff survey or national stats?) YY YY Would need to explore how to obtain from ESR. Useful proxy, but beware confounding factors and variations in methods of calculation. Separate for long and short term?
For potential development DVT/VTEY Needs more work to define measure and establish data collection mechanisms.
For potential development Post operative haemorrhage Y
For potential development Detained patients going missing Y Needs more work to define measure and establish data collection mechanisms
For potential development manual handling incidents Y Needs more work to define measure and establish data collection mechanisms
For potential development vehicle accidents YNeeds more work to define measure and establish data collection mechanisms
For potential development ventilator acquired pneumonia Y Needs more work to define measure and establish data collection mechanisms
For potential development Ward pressures—occupancy/agency staff etc (needs further exploration) YY May be some pointers to methodology in old health service indicator approach. Royal college of psychiatrists suggest rate of 85% bed occupancy for safe and effective care, but difficulty setting thresholds for other specialties. Issue over whether to include or exclude leave. High bed occupancy a significant trigger issue for unrest in mental health settings.
For potential development Mandatory training YY YY Requires definition of mandatory training by sector/service type
Local use onlySUIs YY YY Not suitable to compare across organisations
Local use onlyNever events YY YY Still to be defined but not suitable to compare across organisations
Local use onlynumber of adverse incidents reported by seriousness (including near misses) reported via local systems YY YY inconsistencies of reporting and potential perverse incentives mean that this level of detail is not suitable for benchmarking at national level
Local use onlyrate of adverse incidents as identified by global trigger tool yY Y? too onerous to conduct on routine basis at national level and issues of consistency
Local use onlypatients experiences of adverse events management YY YY Availability of data and confidentiality issues means that this information is only suitable for reporting at a local level
Local use onlyuser surveys yY YY
Local use onlynumber of complaints yY YY
Local use onlyannual report on fire safety YY YY
Local use onlyannual report on health and safety Yy yY
Local use onlyannual report on radiation protection Y
Local use onlyexception report on risks yY YY
Local use onlyaudit of antipsychotic doses Y based on POMH-UK audit. However, could use proportion of eligible wards/community teams participating in audit of antispychotics as measured by the Royal College of Psychiatry accreditation scheme as a national benchmark
Local use onlylevels, quality and consistency of incident reporting by type/staff group/specialty/service YY YY inconsistencies of reporting mean that this level of detail is not suitable for benchmarking at national level
Local use onlyvolumes of activity compared with national clinical guidelines Y national guidelines are set at consultant level, so data only available at local levels
Local use onlycentral line infections Y ? would require local audit
Local use onlyrate of adverse drug events relating to specific high alert medications Y Y inconsistencies of reporting and potential perverse incentives mean that this level of detail is not suitable for benchmarking at national level
Local use only% service users for whom appropriate risk assessments have been undertaken yy Y service specific would require local audit
Local use only% patients with 4 or more ward moves Y data only available at local level and will depend upon local models of service
Local use onlypatients informed about an adverse incident by staff YY YY Availability of data and confidentiality issues means that this information is only suitable for reporting at a local level
Local use onlycomplaints and claims YY YY
Local use onlyNumber of documents that meet corporate clinical standards as a percentage of all reports YY Y? would require local audit
Local use onlyNumber of reported incident investigations hampered by poor clinical records YY Y? would require local audit
Local use onlyproportion of staff who have received relevant risk management training in the last twelve months yY Yy data only available at local level as it depends on individual training needs assessment in relation to job role
Local use onlyassessment of safety culture YY YY various tools available eg MAPSAFF, RCN tools
Local use onlyproportion of bank and agency staffing YY data not available at national level
Local use onlytraining in sexual safety awareness Y data not available at national level
Local use onlyNPSA 7 steps self assessment yy yy data not available at national level

Appendix 5

Current reporting routes

SUI mapping V2.4

Explanatory Table for SUI Mapping

RecipientReporting Source Type of SUI
DH Estates NHS Providers (non FTs) Incidents involving fires
SHAsNHS Providers All types of SUIs typically via STEIS
ISTCsAll types of SUIs typically via STEIS
Patients and the public SUIs specifically maternity care
NPSANHS Providers All types of patient safety incidents via NRLS
Patients and the public All types of patient safety incidents via telephone/website
HPANHS Providers Mandatory HAI data via web based system
DH CFSMNHS Providers (non FTs) Incidents of violence, fraud, corruption and security
MonitorNHS Providers (FT) All SUIs
HSEPatients and the public RIDDOR: legal duty to report work related deaths, major injuries, over-three-day injuries, work related diseases and dangerours occurances (near misses).
NHS Providers
Independent Contactors (all)
IHC Providers
Commissioning PCTsIndependent Contractors (GPs) Under QOF, Significant Event Reviews: events that are significant for clinician/ team/ unit/ organisation
NHS Providers (non FTs and FTs) All types of SUIs, reporting is dependent on what has been specified in the contract.
ISTCsAll types of SUIs, reporting is dependent on what has been specified in the contract.
MHRAPatients and the public Medicines, devices & blood: Suspected adverse drug reactions, suspected defects in medicinal products. Any adverse incident involving a medical device or its instructions for use (especially if it led to, or could have led to, death, life-threatening illness or injury). Serious adverse events and serious adverse reactions related to blood/blood components.
NHS Providers
Independent Contractors (all)
IHC Providers
HCIHC ProvidersRegulation 28 and Regulation 41.9 notifications
DH Commercial Directorate (Central Contract Management Unit) ISTCsUnintended/ unexpected incident on a site providing NHS-funded care involving patients, visitors, staff, contractors, equipment, building or property.
GMC & NMCAll sources Concerns about the conduct/care provided by a healthcare professional
MHACNHS Providers (Non FT) For patients under section, expected and unexpected deaths. If on part III of the Act and go AWOL.
NHS Providers (FT)
IHC Providers

There are 44 part-standards in all. Local stakeholders (public and patient involvement forums (and now their successors, LINks), overview and scrutiny committees and for foundation trusts, the board of governors) are invited to comment and then the Commission visits 10% of trusts selected on a risk basis through its analysis of the information it holds. In addition, a further 10% of trusts are selected randomly for a follow-up visit. Back

297   Information on our findings is in the next section relating to term of reference 2a and Appendix 2. Back

298   Reference "Making a difference?", Healthcare Commission, July 2008 Back

299   For example, if there were no medication incidents reported from a hospital in a month (seemingly a good outcome) this could be due to high levels of safety; however, more likely, it could be because the hospital is not reporting incidents properly, or it could be luck-with the seemingly good outcome not generally replicable Back

300   Information on our findings is in the next section relating to term of reference 2a and in Appendix 3. Back

301   Investigations are undertaken where patient safety is seriously at risk. Back

302   Information on our findings is in the next section relating to term of reference 2a. Back

303   Note that not all investigations would have been relevant for all trusts and this question was asked before the report on the Maidstone and Tunbridge Wells investigation which probably had the highest profile of all investigations, was published. Back

304   The Department of Health states that organisations should have complied with the standards from their introduction in 2004. Overall, 12 of the 44 part-standards are safety-related Back

305   decontamination-C4c, use of medical devices-C4b, and acting on safety alerts-C1b Back

306   NRLS quarterly data summary issue 9, August 2008, NPSA Back

307   73% of incidents were reported by acute trusts, 14% by mental health trusts and 8% by PCT-provided community services Back

308   The largest number of complaints that we review relate to primary care (38.4% of total) Back

309   Organisations are required to inform the Healthcare Commission of incidents where patients receive a "much greater than intended" exposure of radiation as part of their diagnosis or treatment because of a failure to follow local procedures. The average number of incidents reported to us each month is consistently higher than under the previous regulatory structure. However there is a considerable variation in the rates of notification made by individual organisations, with many which have made none at all. Ionising Radiation (Medical Exposure) Regulations 2000-A report on regulation activity from 1 November 2006 to 31 December 2007, Healthcare Commission, March 2008. Back

310   For example, Billings C. Incident reporting systems in medicine and experience with the aviation reporting system. In Cook RI, Woods DD, Miller CA, eds. A tale of two stories: contrasting views of patient safety. North Adams, MA: US National Patient Safety Foundation, 1998:52-61. Back

311   Three-quarters of staff (75%) felt that they were encouraged to report incidents, and only a comparatively small proportion (12%) felt that reporting of errors would lead to blaming of those involved. However only around half felt that action was taken to prevent similar errors in the future (50%) and, staff were much less likely to say they were informed about (31%) changes made as a result of incidents that occurred in their trust. Back

312   Learning from investigations report, Healthcare Commission. The report reviewed all investigations undertaken by the Commission under its statutory powers from August 2004 to April 2007 Back

313   Independent Sector Treatment Centres: A review of the Quality of Care, Healthcare Commission July 2007. Back

314   In line with what is returned within NHS Hospital Episode Statistics Back

315   The proposed registration requirement 13 says organisations must: "|Have systems in place to manage, assess and report upon the safety and quality of care and treatment provided, and do so regularly [and]|systematically, identify and assess risks and take action to manage risks to health, safety and welfare [and] |use reports about the quality of care and treatment provided and learn from events to inform decisions about action needed to secure people's health, safety and welfare." And the first registration requirement says that safety must be taken into account when assessing, planning and delivering care for individual patients. This includes where care is unsafe for a person's needs, or errors of omission, when services fail to respond to that person's needs. Back

316   These are key points of risk, where errors (due to poor exchange of information, or unclear responsibilities, for example) often occur. Back

317   The Healthcare Commission has powers to collect evidence from general practice but only assess the PCTs that contract with them Back

318   Clinicians, senior managers and board members in over 30 trusts participated Back

319   including the NPSA, MHRA and regulator Back

320   The Quality and Outcomes Framework (QoF) requires GPs to complete twelve significant event audits in three years, but this cannot compare to the potential number of incidents and near misses that occur. Back

321   there is a risk that there will be no national reporting of the findings from complaints when the Parliamentary and Health Service Ombudsman takes over the appeal process from the Commission. Back

322   These categories are somewhat overlapping, and some of them are types of harm, some of them contributing factors. Back

323   For example our cardiac surgery website has provided comprehensive information to patients about the rates of survival for patients who have had certain types of heart surgery at different surgical units across the UK. It also provides general information about different operations, the benefits of having heart surgery, and details about what to expect after you have had an operation. The website was developed by the Healthcare Commission, the Society for Cardiothoracic Surgery in Great Britain and Ireland and patients who have had experience of heart surgery. Back

324   Ionising Radiation (Medical Exposure) Regulations 2000-A report on regulation activity from 1 November 2006 to 31 December 2007, Healthcare Commission, March 2008. Back

325   C4a (infection-control), C4c (decontamination of reusable equipment), C21 (healthcare environment and hygiene) Back

326   Our 2008 national survey of patients' experiences of local health services found that 72% of people who had visited their GP practice or health centre in the past year rated it as "very clean"-and a further 26% said it was "fairly clean". And the majority of inpatients responding to out 2007 survey (93%) said their room or ward was "very clean" or "fairly clean. However in some trusts, only a third of respondents described their room or ward as "very clean". A smaller proportion of respondents than in 2006 reported that, as far as they knew, health professionals "always" washed or cleaned their hands between patients. Sixty eight per cent of patients said doctors "always" washed their hands between patients, down from 69% in 2006. This compared with 70% for nurses, down from 71% in 2006. At the trust with the lowest score, a quarter of respondents (25%) said, as far as they knew, doctors did not wash or clean their hands between touching patients. In response to our 2007 survey of recent mothers, 63% of women said that the labour and delivery rooms were "very clean", but less than half (49%) reported this about the toilets and bathrooms they used and only 46% of women said that the hospital room or ward they were in after the birth was "very clean". The survey of NHS staff in 2007 showed a considerable improvement in the views of staff about their trusts' focus on hand washing. In 2007, 82% of acute hospital staff agreed that their trust was doing enough to promote the importance of hand washing to staff and 71% to patients. There is a continued slight upward trend in the proportion of staff reporting that hot water, soap and paper towels, or alcohol rubs were available "always" or "most of the time" when they needed them (91% compared with 88% in 2005). However, looking just at acute trusts, the number of staff that said hand-washing equipment was always available varied from 39% to 82%. Back

327   The safer management of controlled drugs-Annual report 2007, Healthcare Commission Back

328   Both of these figures are higher for staff working in ambulance services and mental health settings. Back

329   Spotlight on Complaints 2008 and 2007, Healthcare Commission Back

330   The third joint chief inspectors' report on arrangements to safeguard children, July 2008. Back

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