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Statutory Instruments

2010 No. 279

National Health Service, England

The National Health Service (Quality Accounts) Regulations 2010

Made

8th February 2010

Laid before Parliament

11th February 2010

Coming into force

1st April 2010

The Secretary of State makes these Regulations in exercise of the powers conferred by sections 8, 9(5) and 10(3) of the Health Act 2009 M1 and sections 8(1), 272(7) and 273(4) of the National Health Service Act 2006 M2.

Marginal Citations

M22006 c. 41; the powers of the Secretary of State under this Act as exercised in these Regulations are exercisable only in relation to England, by virtue of section 271 of that Act. See section 275(1) for the definition of “regulations”.

Citation, commencement and interpretationE+W

1.—(1) These Regulations may be cited as the National Health Service (Quality Accounts) Regulations 2010 and shall come into force on 1st April 2010.

(2) In these Regulations—

“the 2006 Act” means the National Health Service Act 2006;

“the 2009 Act” means the Health Act 2009;

F1...

F2...

F3...

[F4“integrated care board” means an integrated care board established under Chapter A3 of Part 2 of the National Health Service Act 2006;]

[F5“NHS England” means the body corporate established under section 1H of the National Health Service Act 2006;]

“relevant document” means a document which must be published under section 8(1) or (3) of the 2009 Act.

(3) For the purposes of these Regulations—

(a)“[F6relevant health services]” does not include the services exempted by regulation 2;

(b)a body or person sub-contracts services where—

(i)in the case of a body listed in section 8(2) of the 2009 Act, they make arrangements for a person not listed in section 8(2) or (3) of that Act to provide those services; and

(ii)in the case of a person listed in section 8(3) of the 2009 Act, they make arrangements as mentioned in section 2(5)(a) of that Act for another person to provide those services; and

(c)references to [F7relevant health services] provided by a body or person are a reference to—

(i)in the case of a body listed in section 8(2) of the 2009 Act, any [F7relevant health services] provided by that body; and

(ii)in the case of a person listed in section 8(3) of the 2009 Act, any [F7relevant health services] provided by that person as mentioned in section 2(4)(a) or (b) of the 2009 Act, or which that person assists in providing as mentioned in section 2(4)(b) of that Act.

Textual Amendments

Exemption for [F8NHS Continuing Healthcare] and primary care servicesE+W

2.—(1) Section 8(1) and (3) of the 2009 Act (duty of provider to publish information) does not apply to [F9NHS Continuing Healthcare] and primary care services.

(2) For the purpose of this regulation—

[F10“NHS Continuing Healthcare” means a package of care arranged and funded solely by the health service for a person aged 18 or over to meet physical or mental health needs which have arisen as a result of illness;

“health service” and “illness” have the meanings given in section 275 of the 2006 Act;]

“primary care services” means [F11relevant health services]—

(a)

provided under a contract, agreement or arrangement made under or by virtue of the following provisions of the 2006 Act—

(i)

[F12section 83(2)] (arrangements made by [F13NHS England] for provision of primary medical services),

(ii)

section 84(1) (general medical services contracts),

(iii)

section 92 (other arrangements for the provision of primary medical services),

(iv)

section 100(1) (general dental services contracts),

(v)

section 107(1) (other arrangements for the provision of primary dental services),

(avi)

[F14section 115(4) (arrangements made by [F13NHS England] for provision of primary ophthalmic services),]

(vi)

section 117(1) (general ophthalmic services contracts),

(vii)

section 126(1) (pharmaceutical services),

(viii)

section 127(1) (additional pharmaceutical services), or

(ix)

Schedule 12 (local pharmaceutical services schemes); F15...

(b)

F16...

Textual Amendments

Exemption for small providers from duty to publish informationE+W

3.—(1) Section 8(1) and (3) of the 2009 Act does not apply to a body or person in respect of a reporting period, where paragraph (2) applies.

(2) This paragraph applies to a body or person—

(a)which on the relevant date employed no more than fifty full time equivalent employees; and

(b)whose total income in relation to the reporting period under all contracts, agreements or arrangements with [F17[F13NHS England] and [F18integrated care boards]] for the provision of [F19relevant health services], is not more than £130,000.

(3) The number of full time equivalent employees is calculated by dividing the total number of hours worked by all employees on the relevant date by the average standard contracted hours for the employing body or person for that period.

(4) For the purposes of this regulation, “the relevant date” in relation to a reporting period is—

(a)for any body or person not providing or subcontracting [F20relevant health services] on 1st April, the first day in that period the body or person provides or sub-contracts [F20relevant health services]; or

(b)in all other cases 1st April in that period.

Textual Amendments

Prescribed information, content and form of documentE+W

4.—(1) A relevant document must consist of 4 parts as follows—

(a)Part 1, containing a statement summarising the provider's M3 view of the quality of [F21relevant health services] provided or sub-contracted by the provider during the reporting period and the statement referred to in regulation 6;

(b)Part 2, containing the information relevant to the quality of [F22relevant health services] provided or sub-contracted by the provider during the reporting period which is prescribed for the purposes of section 8(1) or (3) of the 2009 Act by [F23paragraphs [F24(2), (2A) and (2B)]] and the information required by regulation 7;

(c)Part 3, containing other information relevant to the quality of [F25relevant health services] provided or sub-contracted by the provider during the reporting period which is included in the document by the provider; and

(d)an annex containing the statements or copies of the statements referred to in regulation 5.

(2) The information prescribed for the purposes of section 8(1) or (3) of the 2009 Act is the information specified [F26in items 1 to 11 F27... of the table in the Schedule as presented in the way specified in column 2 of those items in that table].

[F28(2A) In relation to the bodies listed in subsection (2)(b) and (d) of section 8 of the 2009 Act who are under the duty in section 8(1) of that Act, the information specified in column 1 of items 12 to 26 of the table in the Schedule as presented in the way specified in column 2 of those items in that table is prescribed information for the purposes of those bodies carrying out that duty.]

[F29(2B) The information prescribed for the purposes of section 8(1) F30... of the 2009 Act includes the information specified in items 27.1 to 27.9 of the table in the Schedule[F31, presented in the way specified for those items in column 2 of that table,] for—

(a)National Health Service trusts specified in section 8(2)(b) of the 2009 Act; and

(b)NHS foundation trusts.

(2C) Paragraph (2B) does not apply in relation to any ambulance trust.

(2D) The quarterly information required in items 27.1 to 27.3 of the table in the Schedule may be taken from quarterly information published by providers in response to national guidance.]

(3) The annex referred to in paragraph (1)(d) is not required in a draft relevant document supplied under regulations 8 to 10

Textual Amendments

Marginal Citations

M3See section 9(1) of the Health Act 2009 for the meaning of “the provider”.

Written statements by other bodiesE+W

5.—(1) The statements or copies of statements referred to in regulation 4(1)(d) are—

F32(a). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

(b)a copy of any written statement relating to the content of the relevant document, which is no more than [F331000] words in length, provided prior to publication by [F34the appropriate Local Healthwatch organisation] in response to the draft received pursuant to regulation 9;

(c)a copy of any written statement relating to the content of the relevant document, which is no more than [F351000] words in length, provided prior to publication in response to the draft received pursuant to regulation 10 by—

(i)the appropriate Overview and Scrutiny Committee, or

(ii)a joint overview and scrutiny committee carrying out the functions of that Overview and Scrutiny Committee under regulations under section 245 of the 2006 Act (joint overview and scrutiny committees etc.); F36...

(d)a statement by the provider setting out any changes made to the relevant document following receipt of such written statements; [F37and,

(e)for the providers referred to in regulation 4(2B), a statement describing how information required in items 27.1 to 27.3 of the Schedule to these Regulations is being published each quarter by the providers.]

(2) For the purpose of this regulation, “[F38appropriate Local Healthwatch organisation]” and “appropriate Overview and Scrutiny Committee” have the same meaning as in regulations 9 and 10.

Textual Amendments

Signature by senior employeeE+W

6.—(1) The relevant document must include a written statement, at the end of Part 1, signed by the responsible person for the provider that to the best of that person's knowledge the information in the document is accurate.

(2) For the purpose of this regulation “the responsible person” means, where the provider is—

(a)a body corporate or partnership, the most senior employee;

(b)an unincorporated body of persons other than a partnership, a member of the provider's governing body or the most senior employee of the provider; or

(c)an individual, that individual.

Priorities for improvementE+W

7.—(1) The relevant document must include, in Part 2, a description of the areas for improvement in the quality of [F39relevant health services] that the provider intends to provide or sub-contract for the 12 months following the end of the reporting period.

[F40(2) The description must include—

(a)at least three priorities for improvement indicating the relationship, if any, between the identification of these priorities and the reviews of data relating to quality of care referred to in item 1.1 of the Schedule;

(b)progress made since the last relevant document (if one has been published before);

(c)how progress to achieve the priorities identified in paragraph (a) will be monitored and measured by the provider; and

(d)how progress to achieve the priorities identified in paragraph (a) will be reported by the provider.]

Textual Amendments

[F41Document assurance by [F13NHS England] or the relevant [F18integrated care board] E+W

8.—(1) Where paragraph (3) applies, the provider must provide a copy of the draft relevant document to [F13NHS England] within 30 days beginning with 1st April following the end of the reporting period.

(2) Where paragraph (3) does not apply, the provider must provide a copy of the draft relevant document to the relevant [F18integrated care board] within 30 days beginning with 1st April following the end of the reporting period.

[F42(2A) But if the draft relevant document is for the reporting period ending with 31st March 2020 the provider may provide a copy of it as required by paragraph (1) or (2) later than 30 days beginning with 1st April following the end of the reporting period.]

(3) This paragraph applies where 50% or more of the relevant health services that the provider directly provides or sub-contracts during the reporting period are provided under contracts, agreements or arrangements with [F13NHS England] (calculated by reference to the full cost to the provider of providing, either directly or through sub-contractors, the services).

(4) For the purpose of this regulation, “relevant [F18integrated care board]” means—

(a)where all the relevant health services that the provider directly provides or sub-contracts under contracts, agreements or arrangements with [F18an integrated care board] are provided under contracts, agreements or arrangements with one [F18integrated care board], that [F18integrated care board];

(b)where all the relevant health services that the provider directly provides or sub-contracts under contracts, agreements or arrangements with [F18an integrated care board] are provided under contracts, agreements or arrangements with more than one [F18integrated care board], the [F18integrated care board] which has responsibility for the largest number of persons to whom the provider has provided relevant health services during the reporting period.

(5) For the purposes of paragraph (4)(b), [F18an integrated care board] has responsibility for a person receiving health services provided by a provider if, in relation to those services, it is responsible for that person under or by virtue of section 3 (duties of [F18integrated care boards] as to commissioning certain health services) or 3A (power of [F18integrated care boards] to commission certain health services) of the 2006 Act.

Textual Amendments

Document assurance by appropriate Local Healthwatch organisationE+W

9.—(1) The provider must provide a copy of the draft relevant document to the appropriate Local Healthwatch organisation within 30 days beginning with 1st April following the end of the reporting period.

[F43(1A) But if the draft relevant document is for the reporting period ending on 31st March 2020 the provider may provide a copy of it to the appropriate Local Healthwatch organisation later than 30 days beginning with 1st April following the end of the reporting period.]

(2) For the purposes of this regulation, “appropriate Local Healthwatch organisation” means the Local Healthwatch organisation in the local authority area in which the provider has its registered or principal office located.]

Textual Amendments

Document assurance by appropriate Overview and Scrutiny CommitteeE+W

10.—(1) The provider must provide a copy of the draft relevant document to the appropriate Overview and Scrutiny Committee within 30 days beginning with 1st April following the end of the reporting period.

[F44(1A) But if the draft relevant document is for the reporting period ending on 31st March 2020 the provider may provide a copy of it to the appropriate Overview and Scrutiny Committee later than 30 days beginning with 1st April following the end of the reporting period.]

(2) For the purpose of this Regulation—

“Overview and Scrutiny Committee” means an overview and scrutiny committee of any local authority to which section 244 of the 2006 Act applies (functions of overview and scrutiny committees);

“the appropriate Overview and Scrutiny Committee” means the Overview and Scrutiny Committee of the local authority in whose area the provider has its registered or principal office located.

Textual Amendments

Publication and provision of copiesE+W

11.—[F45(1)] By 30th June following the end of the reporting period—

(a)the relevant document must be published by making the document electronically available on the NHS Choices website M4, or another website if that website is not available at the time of publication; and

(b)a copy of the relevant document must be sent to the Secretary of State.

[F46(2) But if the relevant document is for the reporting period ending on 31st March 2020 the provider may take the action described in paragraph (1) later than 30th June following the end of the reporting period.]

Textual Amendments

Marginal Citations

M4See http://www.nhs.uk/Pages/HomePage.aspx.

[F47GuidanceE+W

12.  Providers must have regard to any guidance issued by the Secretary of State which relates to Chapter 2 of the 2009 Act.]

Textual Amendments

Signed by authority of the Secretary of State for Health

Mike O'Brien

Minister of State

Department of Health

Regulation 4

SCHEDULEE+WInformation to be contained in Part 2 of the relevant document

Prescribed InformationForm of statement (words in italics indicate information which must be inserted by the provider) [F48and the way that information must be presented]
1.

The number of different types of [F49relevant health services] provided or sub-contracted by the provider during the reporting period, as determined in accordance with the categorisation of services—

(a) specified under the contracts, agreements or arrangements under which those services are provided; or

(b) in the case of an NHS body providing services other than under a contract, agreement or arrangements, adopted by the provider.

During [reporting period] the [name of provider] provided and/or sub-contracted [number] [F49relevant health services].
1.1The number of [F49relevant health services] identified under entry 1 in relation to which the provider has reviewed all data available to them on the quality of care provided during the reporting period.The [name of provider] has reviewed all the data available to them on the quality of care in [number] of these [F49relevant health services].
1.2The percentage the income generated by the [F49relevant health services] reviewed by the provider, as identified under entry 1.1, represents of the total income for the provider for the reporting period under all contracts, agreements and arrangements held by the provider for the provision of, or sub-contracting of, [F49relevant health services].The income generated by the [F49relevant health services] reviewed in [reporting period] represents [number] per cent of the total income generated from the provision of [F49relevant health services] by the [name of provider] for [reporting period].
2.The number of national clinical audits M5 and national confidential enquiries M6 which collected data during the reporting period and which covered the [F49relevant health services] that the provider provides or sub-contracts.During [reporting period] [number] national clinical audits and [number] national confidential enquiries covered [F49relevant health services] that [name of provider] provides.
2.1.The number, as a percentage, of national clinical audits and national confidential enquiries, identified under entry 2, that the provider participated in during the reporting period.During that period [name of provider] participated in [number as a percentage] national clinical audits and [number as a percentage] national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.
2.2A list of the national clinical audits and national confidential enquires identified under entry 2 that the provider was eligible to participate in.The national clinical audits and national confidential enquiries that [name of provider] was eligible to participate in during [reporting period] are as follows: [insert list].
2.3A list of the national clinical audits and national confidential enquiries, identified under entry 2.1, that the provider participated in.The national clinical audits and national confidential enquiries that [name of provider] participated in during [reporting period] are as follows: [insert list].
2.4A list of each national clinical audit and national confidential enquiry that the provider participated in, and which data collection was completed for during the reporting period, alongside the number of cases submitted to each audit, as a percentage of the number required by the terms of the audit or enquiry.

The national clinical audits and national confidential enquires that [name of provider] participated in, and for which data collection was completed during [reporting period], are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

[insert list and percentages]

2.5The number of national clinical audit reports published during the reporting period that were reviewed by the provider during the reporting period.

The reports of [number] national clinical audits were reviewed by the provider in [reporting period] and [name of provider] intends to take the following actions to improve the quality of healthcare provided [description of actions].

The reports of [number] local clinical audits were reviewed by the provider in [reporting period] and [name of provider] intends to take the following actions to improve the quality of healthcare provided [description of actions].

2.6.A description of the action the provider intends to take to improve the quality of healthcare following the review of reports identified under entry 2.5.
2.7.The number of local clinical audit M7 reports that were reviewed by the provider during the reporting period.
2.8.A description of the action the provider intends to take to improve the quality of healthcare following the review of reports identified under entry 2.7.
3.The number of patients receiving [F49relevant health services] provided or sub-contracted by the provider during the reporting period that were recruited during that period to participate in research approved by a research ethics committee within the National Research Ethics Service M8.

The number of patients receiving [F49relevant health services] provided or sub-contracted by [name of provider] in [reporting period] that were recruited during that period to participate in research approved by a research ethics committee was

[insert number].

4.Whether or not a proportion of the provider's income during the reporting period was conditional on achieving quality improvement and innovation goals under the Commissioning for Quality and Innovation payment framework M9 agreed between the provider and any person or body they have entered into a contract, agreement or arrangement with for the provision of [F49relevant health services].

Either:

(a) A proportion of [name of provider] income in [reporting period] was conditional on achieving quality improvement and innovation goals agreed between [name of provider] and any person or body they entered into a contract, agreement or arrangement with for the provision of [F49relevant health services], through the Commissioning for Quality and Innovation payment framework.

Further details of the agreed goals for [reporting period] and for the following 12 month period are available [F50electronically at [provide a web link]].

Or:

(b) [name of provider] income in [reporting period] was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework because [insert reason].

4.1If a proportion of the provider's income during the reporting period was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework the reason for this.
4.2.If a proportion of the provider's income during the reporting period was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework, where further details of the agreed goals for the reporting period and the following 12 month period can be obtained.
5.Whether or not the provider is required to register with the Care Quality Commission (“CQC”) under section 10 of the Health and Social Care Act 2008 M10.

Either:

[name of provider] is required to register with the Care Quality Commission and its current registration status is [insert description]. [name of provider] has the following conditions on registration [insert conditions where applicable].

The Care Quality Commission (has/has not) taken enforcement action against [name of provider] during [reporting period].

Or:

[name of provider] is not required to register with the Care Quality Commission.

5.1.

If the provider is required to register with the CQC—

(a) whether at end of the reporting period the provider is—

(i) registered with the CQC with no conditions attached to registration,

(ii) registered with the CQC with conditions attached to registration, or

(iii) not registered with the CQC;

(b) if the provider's registration with the CQC is subject to conditions what those conditions are; and

(c) whether the Care Quality Commission has taken enforcement action against the provider during the reporting period.

6.F51. . .F51. . .
6.1.F51. . .
7.Whether or not the provider has taken part in any special reviews or investigations by the CQC under section 48 of the Health and Social Care Act 2008 during the reporting period.

Either:

[name of provider] has participated in special reviews or investigations by the Care Quality Commission relating to the following areas during [reporting period] [insert details of special reviews and/or investigations].

[name of provider] intends to take the following action to address the conclusions or requirements reported by the CQC [insert details of action].

[name of provider] has made the following progress by 31st March [insert year] in taking such action [insert description of progress].

Or:

[name of provider] has not participated in any special reviews or investigations by the CQC during the reporting period.

7.1.

If the provider has participated in a special review or investigation by the CQC—

(a) the subject matter of any review or investigation,

(b) the conclusions or requirements reported by the CQC following any review or investigation,

(c) the action the provider intends to take to address the conclusions or requirements reported by the CQC, and

(d) any progress the provider has made in taking the action identified under paragraph (c) prior to the end of the reporting period.

8.Whether or not during the reporting period the provider submitted records to the Secondary Uses service M11 for inclusion in the Hospital Episode Statistics M12 which are included in the latest version of those Statistics published prior to publication of the relevant document by the provider.

Either:

[name of provider] submitted records during [reporting period] to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data:

— which included the patient's valid NHS number was:

[percentage] for admitted patient care;

[percentage] for out patient care; and

[percentage] for accident and emergency care.

— which included the patient's valid General Medical Practice Code was:

[percentage] for admitted patient care;

[percentage] for out patient care; and

[percentage] for accident and emergency care.

Or:

[name of provider] did not submit records during [reporting period] to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data.

8.1.

If the provider submitted records to the Secondary Uses service for inclusion in the Hospital Episodes Statistics which are included in the latest published data:

(a) the percentage of records relating to admitted patient care which include the patient's—

 (i) valid NHS number; and

 (ii) General Medical Practice Code;

(b) the percentage of records relating to out patient care which included the patient's—

 (i) valid NHS number; and

 (ii) General Medical Practice Code;

(c) the percentage of records relating to accident and emergency care which included the patient's—

 (i) valid NHS number; and

 (ii) General Medical Practice Code.

[F529. The provider’s Information Governance Assessment Report overall score for the reporting period as a percentage and as a colour according to the IGT Grading scheme. [name of provider] Information Governance Assessment Report overall score for [reporting period] was [percentage] and was graded [insert colour from IGT Grading Scheme].]
10.Whether or not the provider was subject to the Payment by Results clinical coding audit at any time during the reporting period by the Audit Commission M13.

Either:

[name of provider] was subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission and the error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were [percentages].

Or:

[name ofprovider] was not subject to the Payment by Results clinical coding audit during [reporting period] by the Audit Commission.

10.1If the provider was subject to the Payment by Results clinical coding audit by the Audit Commission at any time during the reporting period, the error rates, as percentages, for clinical diagnosis coding and clinical treatment coding reported by the Audit Commission in any audit published in relation to the provider for the reporting period prior to publication of the relevant document by the provider.
[F5311. The action taken by the provider to improve data quality. [name of provider] will be taking the following actions to improve data quality [insert actions].]
[F5412.

The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to—

(a)

the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and

(b )

the percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period.

The [name of trust] considers that this data is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve the indicator and percentage in (a) and (b), and so the quality of its services, by [insert description of actions].

Present, in a table format, the SHMI value for at least the last two reporting periods including the banding for each value.

13.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric in-patient care during the reporting period.

The [name of trust] considers that this percentage is as described for the following reasons [insert reasons].

The [name of trust] [intendsto take/has taken] the following actions to improve this percentage, and so the quality of its services, by [insert description of actions].

Present, in a table format, the percentage for at least the last two reporting periods.

14.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of Category A telephone calls (Red 1 and Red 2 calls) resulting in an emergency response by the trust at the scene of the emergency within 8 minutes of receipt of that call during the reporting period.

The [name of trust] considers that this percentage is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this percentage, and so the quality of its services, by [insert description of actions].

Present, in a table format, separately for Red 1 and Red 2 calls, the percentage for at least the last two reporting periods.

14.1.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of Category A telephone calls resulting in an ambulance response by the trust at the scene of the emergency within 19 minutes of receipt of that call during the reporting period.

The [name of trust] considers that this percentage is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this percentage, and so the quality of its services, by [insert description of actions].

Present, in a table format, the percentage for at least the last two reporting periods.

15. The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of patients with a pre-existing diagnosis of suspected ST elevation myocardial infarction who received an appropriate care bundle from the trust during the reporting period.

The [name of trust] considers that this percentage is as described for the following reasons [insert reasons].

The [name of trust] [intendsto take/has taken] the following actions to improve this percentage, and so the quality of its services, by [insert description of actions].

Present, in a table format, the percentage for at least the last two reporting periods.

16.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of patients with suspected stroke assessed face to face who received an appropriate care bundle from the trust during the reporting period.

The [name of trust] considers that this percentage is as described for the following reasons [insert reasons].

The [name of trust] [intendsto take/has taken] the following actions to improve this percentage, and so the quality of its services, by [insert description of actions].

Present, in a table format, the percentage for at least the last two reporting periods.

17.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting period.

The [name of trust] considers that this percentage is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this proportion, and so the quality of its services, by [insert description of actions].

Present, in a table format, the percentage for at least the last two reporting periods.

18.

The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the trust’s patient reported outcome measures scores for—

(i)

groin hernia surgery,

(ii)

varicose vein surgery,

(iii)

hip replacement surgery, and

(iv)

knee replacement surgery,

during the reporting period.

The [name of trust] considers that the outcome scores are as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve these outcome scores, and so the quality of its services, by [insert description of actions].

Present, in a table format, the scores for at least the last two reporting periods.

19.

The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of patients aged—

(i)

0 to 14; and

(ii)

15 or over,

readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period.

The [name of trust] considers that these percentages are as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve these percentages, and so the quality of its services, by [insert description of actions].

Present, in a table format, the percentages for at least the last two reporting periods.

20.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the trust’s responsiveness to the personal needs of its patients during the reporting period.

The [name of trust] considers that this data is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this data, and so the quality of its services, by [insert description of actions].

Present, in a table format, the data for at least the last two reporting periods.

21.

The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.

The [name of trust] considers that this percentage is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this percentage, and so the quality of its services, by [insert description of actions].

Present, in a table format, the percentages for at least the last two reporting periods.

22.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the trust’s “Patient experience of community mental health services” indicator score with regard to a patient’s experience of contact with a health or social care worker during the reporting period.

The [name of trust] considers that this indicator score is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this indicator score, and so the quality of its services, by [insert description of actions].

Present, in a table format, the score for at least the last two reporting periods.

23.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period.

The [name of trust] considers that this percentage is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this percentage, and so the quality of its services, by [insert description of actions.

Present, in a table format the number and rates for at least the last two reporting periods.

24.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the rate per 100,000 bed days of cases of C.difficile infection reported within the trust amongst patients aged 2 or over during the reporting period.

The [name of trust] considers that this rate is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this rate, and so the quality of its services, by [insert description of actions].

Present, in a table format the number and rates for at least the last two reporting periods.

25.The data made available to the National Health Service trust or NHS foundation trust by [F55NHS England] with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death.

The [name of trust] considers that this number and/or rate is as described for the following reasons [insert reasons].

The [name of trust] [intends to take/has taken] the following actions to improve this number and/or rate, and so the quality of its services, by [insert description of actions].

Report the rate as per 100 patient admissions or per 1000 bed days, where data is available.

Present, in a table format the number and rates for at least the last two reporting periods.

26.

Where the necessary data is made available to the trust by [F55NHS England], a comparison of the numbers, percentages, values, scores or rates of the trust (as applicable) in items 12 to 25 with—

(a)

the national average for the same; and

(b)

with those National Health Service trusts and NHS foundation trusts with the highest and lowest of the same,

for the reporting period.

Present the comparisons in a table or graph format (as seems most appropriate).]
[F5627.1.The number of its patients who have died during the reporting period, including a quarterly breakdown of the annual figure.

During [reporting period] [number] of [the provider] patients died.

This comprised the following number of deaths which occurred in each quarter of that reporting period:

[number] in the first quarter; [number] in the second quarter;

[number] in the third quarter;

[number] in the fourth quarter.

27.2.The number of deaths included in item 27.1 which the provider has subjected to a case record review or an investigation to determine what problems (if any) there were in the care provided to the patient, including a quarterly breakdown of the annual figure.

By [date], [number] case record reviews and [number] investigations have been carried out in relation to [number] of the deaths included in item 27.1. In [number] cases a death was subjected to both a case record review and an investigation.

The number of deaths in each quarter for which a case record review or an investigation was carried out was:

[number] in the first quarter; [number] in the second quarter;

[number] in the third quarter;

[number] in the fourth quarter.

27.3.An estimate of the number of deaths during the reporting period included in item 27.2 for which a case record review or investigation has been carried out which the provider judges as a result of the review or investigation were more likely than not to have been due to problems in the care provided to the patient (including a quarterly breakdown), with an explanation of the methods used to assess this.

[Number] representing [number as percentage of number in item 27.1]% of the patient deaths during the reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient. In relation to each quarter, this consisted of:

[Number] representing [number as percentage of the number of deaths which occurred in the quarter given in item 27.1]% for the first quarter;

[Number] representing [number as percentage of the number of deaths which occurred in the quarter given in item 27.1]% for the second quarter;

[Number] representing [number as percentage of the number of deaths which occurred in the quarter given in item 27.1]% for the third quarter;

[Number] representing [number as percentage of the number of deaths which occurred in the quarter given in item 27.1]% for the fourth quarter.

These numbers have been estimated using the [name, and brief explanation of the methods used in the case record review or investigation].

27.4.A summary of what the provider has learnt from case record reviews and investigations conducted in relation to the deaths identified in item 27.3.Present the information required as a narrative.
27.5.A description of the actions which the provider has taken in the reporting period, and proposes to take following the reporting period, in consequence of what the provider has learnt during the reporting period (see item 27.4).Present the information required as a narrative.
27.6.An assessment of the impact of the actions described in item 27.5 which were taken by the provider during the reporting period.Present the information required as a narrative.
27.7.The number of case record reviews or investigations finished in the reporting period which related to deaths during the previous reporting period but were not included in item 27.2 in the relevant document for that previous reporting period.[Number] case record reviews and [number] investigations completed after [date] which related to deaths which took place before the start of the reporting period.
27.8.An estimate of the number of deaths included in item 27.7 which the provider judges as a result of the review or investigation were more likely than not to have been due to problems in the care provided to the patient, with an explanation of the methods used to assess this.[Number] representing [number as percentage of number in item 27.1 of the relevant document for the previous reporting period]% of the patient deaths before the reporting period, are judged to be more likely than not to have been due to problems in the care provided to the patient. This number has been estimated using the [name, and brief explanation of the methods used in the case record review or investigation].
27.9.A revised estimate of the number of deaths during the previous reporting period stated in item 27.3 of the relevant document for that previous reporting period, taking account of the deaths referred to in item 27.8[Number] representing [number as percentage of number in item 27.1 of the relevant document for the previous reporting period]% of the patient deaths during [the previous reporting period] are judged to be more likely than not to have been due to problems in the care provided to the patient.]

Textual Amendments

Marginal Citations

M5See http://www.dh.gov.uk/en/Healthcare/Highqualitycareforall/Qualityaccounts/index.htm.

M6See http://www.npsa.nhs.uk/.

M7See http://www.hqip.org.uk/what-is-local-clinical-audit/.

M8See http://www.nres.npsa.nhs.uk/.

M9See http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443.

M11See http://nww.connectingforhealth.nhs.uk/susreporting/dataquality/registration.

M12See http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937.

M13See http://www.audit-commission.gov.uk/health/audit/paymentbyresults/assuranceframework/pages/default.aspx.

Explanatory Note

(This note is not part of the Order)

These Regulations make provision about quality accounts. Under section 8 of the Health Act 2009 individuals or bodies who provide, or make arrangements for others to provide, NHS services must publish a document each year which sets out information relation to the quality of those services (a “quality account”).

Regulation 2 makes exemptions from the requirement to produce quality accounts for community health services and primary care services. Regulation 3 also exempts providers with small numbers of staff and a relatively low level of income derived from the provision of NHS services.

Regulations 4 to 7 and the Schedule set out the prescribed information, general content and form of quality accounts. This includes provision requiring the accounts to be in four parts with Part 1 containing a general statement about the quality of NHS services, Part 2 containing prescribed information, Part 3 containing other information about the quality of NHS services provided and the fourth part comprising an annex containing statements of assurance under regulation 8. The Schedule sets out the detail of the prescribed information and the form the information should take. Regulation 6 ensures that a senior employee verifies the accuracy of the account. Regulation 7 requires information to be included about the provider's priorities for improvement.

Regulation 8 makes provision for the draft accounts to be checked and commented on prior to publication by a Primary Care Trust (“PCT”) or Strategic Health Authority (“SHA”). Where the provider provides NHS services to a number of PCTs or SHAs provision is made to identify one body that the accounts must be sent to. Any statement provided by the PCT or SHA must be included in the published account (regulation 4(1)(d) and 5).

Regulations 9 and 10 require the accounts to be sent, prior to publication, to any Local Involvement Network (“LINK”) and Overview and Scrutiny Committee (“OSC”) in the local authority area where the provider is located. If any LINK or OSC provides a statement about the quality account which is less than 500 words provision is made to ensure that the statement is included in the published account (regulation 5).

Regulation 11 requires the quality account to be published by 30th June each year by making the document available on the NHS Choices website, or other website if this is not available. A copy of the account must also be sent to the Secretary of State.

A full impact assessment of the effect that this instrument will have on the costs of business, the voluntary sector and public sector is available from the Department of Health website (http://www.dh.gov.uk) and is annexed to the Explanatory Memorandum which is available alongside the instrument on the OPSI website.

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