The Care Quality Commission, or CQC, is the independent regulator of health and social care in England. They carry out inspections and monitor and regulate services.

• Frimley Health NHS Foundation Trust is rated good by the CQC
• Frimley Park Hospital has a rating of outstanding
• Heatherwood Hospital has a rating of good
• Wexham Park Hospital has a rating of good

Priority 1: Improving our pressure injury prevention and management in both our acute and community hospital settings

Partially achieved

Rationale for achievement rating

•  55% of patients at the end of quarter four met required risk assessment timeframe and documentation of care interventions – a 20% improvement from quarter one, however, the ambition of 85% was not met. Progress with this element of the quality account priority was delayed due to a requirement for a rebuild in Epic (our electronic patient record) of the assessment tool and care intervention order set.
• The Trust achieved a 65% reduction in the number of hospital acquired grade three and four pressure injuries compared to 2022/2023.
• There were 23 grade three pressure injuries in 2023/24 compared to 74 in 2022/23
• There were four grade four hospital acquired pressure injuries. This was equal to 2022/23 numbers.

Improvement actions in 2023/24

• Cross site Tissue Viability Lead appointed.
• Fundamental and Better Care Council – frontline staff, who are members of the council, initiated ward level quality improvement projects to support the reduction of pressure injuries.
• New pressure injury prevention protocol released.
• New immersive pressure relieving mattress across the trust with training for staff.

Further actions for 2024/25

• Extension of the quality account priority into 2024/25.
• Continue ward based quality improvement workstreams and oversight via the Fundamental and Better Care Council.
• Monitor pressure injury outcome data and include as a key performance metric within our clinical accreditation programme. 10
• Launch of the new national risk tool PURPOSE T by end of March 2025. •
• Launch of essential training programme – via e-learning to complement current face to face training sessions. •
• Work to ensure early risk assessments and care interventions are conducted in the Emergency Department

Priority 2: Improving our recognition and management of sepsis in our Emergency Department, Adult, Paediatric and Maternity wards and units

Partially achieved

Rationale for achievement rating

Whilst there have been improvements in most of our sepsis workstreams, we need to further embed our improvement work in order to consistently meet the targets for both screening and antibiotic administration. We also need to ensure there is a significant improvement for our recognition and management of neutropenic sepsis. During the first few months of the financial year, our improvement work focused on a re-build of our track and trigger systems listed below:

• National Early Warning Score (NEWS) 
• Paediatric Early Warning Score (PEWS) 
• Modified Early Obstetric Warning Score (MEOWS)

In addition, we re-built our sepsis bundles working with frontline staff to support understanding and ease of access. The rebuild work delayed our reporting/auditing capability. In terms of neutropenic sepsis, there needs to be increased focus on the recognition of this and door to needle times for intravenous (IV) antibiotics in this high-risk group of patients.

Emergency Departments – Adult Sepsis

• Our Emergency Departments have consistently maintained screening for sepsis in adult patients at 100% since October 2023. Performance in terms of antibiotics given within the hour, where patients were screened, has been variable and linked to challenges with patient attendance volumes, however, 100% of patients received antibiotics within the hour in March 2024.

Emergency Department Neutropenic Sepsis 

• Our Emergency Departments have not met the 90% target for intravenous (IV) antibiotics to be given within the hour for patients with suspected neutropenic sepsis

Emergency Departments – Paediatric Sepsis

• Our Emergency Departments screening of paediatric patients for sepsis and timely administration of IV antibiotics met both targets in three out of the seven months audited.

Inpatients – Adult sepsis

• Our sepsis screening performance was on or above target during the last quarter of the financial year, however, we have not consistently met target for both screening and antibiotics throughout the year

Inpatients – maternity

• Our maternity departments have not consistently met targets for either screening or antibiotics throughout the year.

Improvement actions in 2023/24 •

• Epic front-end build for MEOWS/PEWS and NEWS completed with Best Practice Advisories(BPAs) for screening (BPAs are prompts for interventions which pop up on the screen for frontline teams). 
• Sepsis screening tool re-built, and order sets set up and optimised for sepsis 6. This will need further optimisation. 
• Increase in training focusing on sepsis including: o
  • Trust-wide clinical skills blitz with over 400 staff attending to date. o
  • Sepsis recognition and response included in part of deteriorating patient training day. o
  • Programme of focused ward-based training taking place – this will continue on a rolling basis supported by practice development and deteriorating patient teams. o
  • Regular junior doctors training programme in place. •
• Quality walkabouts – with sepsis focus in November & December and Quality and Audit nursing team now visiting wards daily where NEWS of 5> identified via Epic NEWS dashboard to ensure sepsis screening has taken place. 
• Performance actions and actions required discussed at all clinical forums. •
• All wards/clinical areas asked to nominate sepsis champion to support delivery of the improvement actions at ward level. 
• New task force group for sepsis in place to lead on improvement work with plans to ensure oversight at the Deteriorating Patient Committee for 2024/25. •
• New Consultant Lead in place for the inpatient sepsis workstream, co-ordinating junior doctor involvement in quality improvement and providing clinical expertise. •
• Emergency Departments and oncology services working together to improve pathway for neutropenic sepsis. This will be a key area of focus for improvement in 2024/25. 
• Patient Group Directives in place in the Emergency Department for IV Antibiotics – these allow nursing staff under defined circumstances to administer certain IV Antibiotics, without having to wait for a prescription from a clinician. 
• Emergency Departments now have a Sepsis Call system to a nominated consultant to support more immediate reviews where sepsis is suspected.

Further actions for 2024/25 

• Launch new clinical guideline following release of new NICE (National Institute for Health and Care Excellence) guidance for recognition, escalation and management of sepsis. 
• Refresh education programme for all healthcare professionals to align with new clinical guideline. 
• Further engage junior doctors and ward teams in local quality improvement around sepsis; we need to further understand why the screening tool is not being used routinely and seek solutions from the frontline teams. 
• Share thematic findings and results from audits, ensuring changes in practice happen as a result. 
• Implement staff recognition programme for best practice relating to sepsis.
• Focus on ensuring that patients are reviewed post sepsis 6 interventions to ensure treatment plan is effective.
• Continue the work started to improve neutropenic sepsis pathway.
• Implement new obstetric sepsis management guidelines and paediatric guidelines. 
• Optimise Epic as a live system to help us prevent harm/missed sepsis.
• Establish a sepsis prevention strategy – e.g., reduce e-coli related to UTI’s from catheters, reduce hospital acquired pneumonia.
• Look at how we can support patients to reduce their risk of sepsis, recognise symptoms and also how we may support patients with long term issues associated with sepsis

Priority 3: Supporting our surgical patients to optimise their recovery – drinking, eating and mobilising after major elective surgery (DrEaM)

Fully achieved

Rationale for achievement rating

• The Trust participated in the national CQUIN programme to support this quality account priority. Our ambition was to achieve 80% or above which we did throughout all quarters of the year

Improvement actions in 2023/24

• The Trust has focused on ensuring patients are well prepared for surgery, ensuring they know what to expect and understand the importance of drinking, eating and mobilising early to enhance recovery times.
• Our surgeons, nursing teams and physiotherapists have worked collaboratively to improve goal setting with patients post-operatively to support early recovery.
• Our heads of nursing leadership were a significant driver for the clinical teams to take ownership for delivery of these improvements. Further actions for 2024/25
• To embed the principles of enhanced recovery across our emergency surgical pathways

Priority 4: Improve our antimicrobial stewardship, switching patients from IV (intravenous) antibiotics to oral when they meet the clinical criteria (IVOS)

Fully achieved

Rationale for achievement rating

• The Trust participated in the national CQUIN programme to support this quality account priority. Our ambition was to achieve 40% (or fewer) of patients still receiving IV antibiotics past the point at which they meet switching criteria. We exceeded our target throughout all quarters of the year.

Improvement actions in 2023/24

• Real-time use of Epic (our electronic patient record) was key to the delivery of this priority. The system enabled patients on IV antibiotics to be flagged to clinicians/pharmacists and our intravenous therapy team for review. Due to the nature of the system, the review could take place at either the bedside or remotely.
• Re-established Frimley Health Hospitals Antimicrobial Stewardship Group, with appointment of the Trust’s Chief Medical Officer as chair. Further actions for 2024/25
• The process for switching patients from IV antibiotics to oral when they meet the clinical criteria is now embedded into practice and will continue as routine practice.
• Antimicrobial stewardship will remain a key area of focus for the Trust.

Priority 5: Improve our waiting times in the Emergency Department

Fully achieved

Rationale for achievement rating

• During 2023/24 attendances to our Emergency Departments increased by 5.5%. We were, however, able to meet the national 76% target for patients being seen within 4 hours by the end of March 2024.

Improvement actions in 2023/24

• We established an Urgent and Emergency Care Improvement programme, overseen by the Urgent Care Board.
• Worked with the Frimley Integrated Care System (ICS) to promote and signpost patients to the new dedicated urgent care centres in Aldershot and Slough.
• We expanded our same day emergency care services.
• We advanced the use of our Frailty in-reach service and virtual wards for admission avoidance.
• Tested new ways of working during initiatives such as ‘Mega March’ to improve the number of patients discharged home before 5pm. ‘Mega March’ brought together volunteers & external system colleagues to work with our frontline teams, with a number of prizes and recognition awards given for the best performers with the discharge process.

Further actions for 2024/25

• The Trust will be working to further improve Emergency Department waiting times, aiming for a minimum of 78% of patients to be seen within 4 hours by March 2025, as identified within the FHFT 2024/25 operating plan.
• Implementing new ways of working. One example is Criteria Led Discharge, where a doctor identifies a criteria or goals for individual patients that will determine when they are medically ready to safely go home or to another care setting. This can help tackle discharge delays and help offer a patient a better experience. 15
• Collaboration with the Frimley Integrated Care System (ICS) will be vital to achievement of the new 78% target to ensure: o Appropriate alternative pathways for treatment are sought as an alternative to the Emergency Department. o Timely discharge for patients who are medically stable.

Priority 6 - Improve trust and confidence in our nurses and doctors

Partially achieved

Rationale for achievement rating

• The National Inpatient Survey Results published in 2021 showed the Trust in the bottom 20% of the country (88% for nurses and 89% for doctors). Our ambition was to move our performance to the top 10% of organisations in the 2023 National Inpatient Survey. The 2023 National Inpatient Survey results have not yet been published, therefore the achievement rating for this priority is based on our local patient survey results (around 350- 400 surveys are conducted per month).
• Although trust and confidence in nurses scores reported from our local patient experience survey were above our ambition of 92% for most of the year, we dipped below that in both July 2023 and March 2024. 
• Trust and confidence in doctors scores reported from our local patient experience survey did not meet our ambition of 93% during the year.

Improvement actions in 2023/24

• Focus groups held with staff and patients to better understand what gave people trust and confidence and what matters most to them. 
• Customer care training was commissioned from NHS Elect. This was attended by a range of staff and feedback was very positive. 
• We have focused on the ‘basics’, ensuring staff introduce themselves and utilise the ‘Hello my name is’ yellow badges. 
• We have continued to progress our shared decision making workstream. Shared decision making supports a ‘partnership’ approach between a healthcare professional and a patient to offer a more personalised approach to understanding and making decisions about care and treatment. 
• We have included communication as part of our Fundamental and Better care walkabouts, observing and supporting frontline teams to foster positive interactions with our patients, carers and families.

Further actions for 2024/25

• We will continue to progress our shared decision making workstream. 
• We will be one of the hospital trusts to participate in Phase 1 of the implementation of Martha’s Rule.
  The 3 proposed components of Martha’s Rule are:
  1. All staff in NHS trusts must have 24/7 access to a rapid review from a critical care outreach team, who they can contact should they have concerns about a patient. 
  2. All patients, their families, carers, and advocates must also have access to the same 24/7 rapid review from a critical care outreach team, which they can contact via mechanisms advertised around the hospital, and more widely if they are worried about the patient’s condition. 
  3. The NHS must implement a structured approach to obtain information relating to a patient’s condition directly from patients and their families at least daily. In the first instance, this will cover all inpatients in acute and specialist trusts. 
• Our clinical accreditation scheme will focus on communication as a key element and also take into account patient feedback such as local patient experience survey results and the Friends and Family Test.