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Quality, assurance and performance

We believe in being transparent and accountable about the care and treatment we provide.

Care Quality Commission

Our Trust is assessed periodically by the Care Quality Commission on quality standards and on a range of performance indicators.

Our latest CQC inspection report for Addenbrooke's and the Rosie hospitals was published on 24 June 2022 with an overall rating of 'Good'.

In Spring 2022, the CQC conducted an inspection into the urgent and emergency care services in Cambridge and Peterborough, across a range of health and social care services in the area covered by the Cambridgeshire and Peterborough Integrated Care System.

Our performance

We are proud to promote our achievements and we also want to be open about what we could do better.

Performance is measured against guidelines and targets set by The Department of Health and Social Care and local commissioners. They relate to waiting times and key standards of care for a range of conditions and diseases.

Our board of directors meets in public six times a year and receives updates on a range of performance measures and targets from different areas of the Trust. The papers from each meeting are published on this site.

Guidelines and targets

The Department of Health and Social Care and local commissioners set guidelines and targets for all NHS trusts relating to waiting times and key standards of care for a range of conditions and diseases.

National targets include:

  • No more than two hospital-acquired MRSA bacteraemias
  • No more than 41 cases of Clostridium difficile
  • 93% of patients with symptoms of cancer seen within two weeks
  • 31-day wait for subsequent cancer treatment
  • 90% of patients receive treatment with 18 weeks from GP referral
  • 95% of non-admitted patients receive treatment with 18 weeks from GP referral
  • 85% of patients referred with suspected cancer treated within 62 days
  • No more than 11 patients per week occupying an acute bed whose transfer of care was delayed
  • 95% of A&E patients treated, admitted or discharged within four hours
  • The Trust is one of 14 sites to pilot new emergency department standards from 22 May 2019 and therefore will be monitoring the four hour target internally (but not reporting externally) during this period

In addition, the Trust receives extra payments or incentives from local commissioners if we meet certain improvement goals – called CQUINS (Commissioning for Quality and Innovation). These change yearly and are also related to quality of care and patient experience for the treatment of conditions such as dementia and pressure ulcers.

Each month the board of directors hears how we are meeting these targets in the quality and performance report.

Our Trust's improvement plan

Our Improvement Plan (2022-24), was developed with our staff, considers the changing landscape of regulation, learning and brings together multiple quality and safety goals to monitor and continually improve delivery and safety of services.

In September 2018, the Care Quality Commission (CQC) inspected our hospitals and published a report that rated the Trust ‘Good’.

A subsequent CQC inspection was anticipated in early 2020, although due to the covid-19 pandemic, this inspection was cancelled and specific visits to the Trust in relation to the CQC’s Emergency Monitoring Framework were carried out during 2020-21, and a system wide review (including CUH urgent & emergency care and medicine. The Trust has also participated in a provider collaboration review (Cancer Services), and a national review of services for those with a learning disability and/or autism.

The Trust carried out an internal self- assessment against the CQC ’Well-Led’ and core service frameworks in 2021. These frameworks set out the expectations to meet the required standards in healthcare, which continue to evolve.  The Trust has subsequently produced a plan or goals to continue to drive and monitor improvement against these standards going forward in addition to specific CQC feedback.

The Improvement Plan remains a dynamic document reviewed and updated on a regular basis in response to feedback from patient’s, partners and regulators. It will enable us to monitor and communicate the progress being made, and to ensure it remains fit for purpose and continues to be reflective of the overall strategy and priorities of the Trust.