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 26 February 2019 with an overall rating of 'Good'.

Read our latest CQC inspection report.

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, which was developed with our staff, brings together multiple plans to improve delivery and efficiency of services.

In September 2015, the Care Quality Commission (CQC) inspected our hospitals and published a report that rated the Trust ‘inadequate’. NHS Improvement also recommended that the Trust was placed in special measures.

The Trust was subsequently asked to produce an Improvement Plan to set out how and by when we would address their concerns and reduce the amount of money spent by the Trust each week. It outlines our five priority areas for improvement:

  • Leadership and accountability
  • Strategy
  • Quality improvement
  • Operational capacity
  • Financial recovery

A comprehensive re-inspection was carried out in September 2016 with the findings published in January 2017. The CQC recommended that the Trust rating was improved to ‘good’ – a considerable achievement over a period of 18 months – and NHS Improvement recommended that the Trust was removed from special measures.

The Improvement Plan remains a dynamic document updated on a regular basis to demonstrate that we continue to build on the progress being made, and to ensure it remains fit for purpose and reflective of the priorities of the Trust.