The National Health Service (Quality Accounts) Regulations 2010

Regulation 4

SCHEDULE E+W Information to be contained in Part 2 of the relevant document

Prescribed Information		Form of statement (words in italics indicate information which must be inserted by the provider) [F1 and the way that information must be presented]
1.	The number of different types of [F2 relevant 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] [F2 relevant health services].
1.1	The number of [F2 relevant 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 [F2 relevant health services].
1.2	The percentage the income generated by the [F2 relevant 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, [F2 relevant health services].	The income generated by the [F2 relevant health services] reviewed in [reporting period] represents [number] per cent of the total income generated from the provision of [F2 relevant health services] by the [name of provider] for [reporting period].
2.	The number of national clinical audits M1 and national confidential enquiries M2 which collected data during the reporting period and which covered the [F2 relevant health services] that the provider provides or sub-contracts.	During [reporting period] [number] national clinical audits and [number] national confidential enquiries covered [F2 relevant 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.
2.2	A 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].
2.3	A 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].
2.4	A 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]
2.5	The 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 M3 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 [F2 relevant 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 M4 .	The number of patients receiving [F2 relevant 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 M5 agreed between the provider and any person or body they have entered into a contract, agreement or arrangement with for the provision of [F2 relevant 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 [F2 relevant 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 [F3 electronically 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].
4.1	If 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 M6 .	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.	F4 . . .	F4 . . .
6.1.	F4 . . .
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 M7 for inclusion in the Hospital Episode Statistics M8 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.
[F5 9.	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 M9 .	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.
10.1	If 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.
[F6 11.	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].]
[F7 12.	The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre 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 the Health and Social Care Information Centre, 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).]
[F8 27.1.	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

F1 Words in Sch. inserted (4.2.2013) by The National Health Service (Quality Accounts) Amendment Regulations 2012 (S.I. 2012/3081), regs. 1(2), 10(b)

F2 Words in Sch. substituted (1.4.2013) by The National Health Service (Quality Accounts) Amendment Regulations 2012 (S.I. 2012/3081), regs. 1(2), 10(a)

F3 Words in Sch. Item 4 substituted (1.4.2011) by The National Health Service (Quality Accounts) Amendment Regulations 2011 (S.I. 2011/269), regs. 1, 2(5)(a)

F4 Sch. Items 6, 6.1 omitted (1.4.2011) by virtue of The National Health Service (Quality Accounts) Amendment Regulations 2011 (S.I. 2011/269), regs. 1, 2(5)(b)

F5 Sch. Item 4 substituted (1.4.2011) by The National Health Service (Quality Accounts) Amendment Regulations 2011 (S.I. 2011/269), regs. 1, 2(5)(c)

F6 Sch. Item 11 added (1.4.2011) by The National Health Service (Quality Accounts) Amendment Regulations 2011 (S.I. 2011/269), regs. 1, 2(5)(d)

F7 Sch. Items 12-26 added (4.2.2013) by The National Health Service (Quality Accounts) Amendment Regulations 2012 (S.I. 2012/3081), regs. 1(2), 10(c)

F8 Sch. Items 27.1-27.9 inserted (1.11.2017) by The National Health Service (Quality Accounts) (Amendment) Regulations 2017 (S.I. 2017/744), regs. 1(2), 2(4)

Marginal Citations

M1 See http://www.dh.gov.uk/en/Healthcare/Highqualitycareforall/Qualityaccounts/index.htm.

M2 See http://www.npsa.nhs.uk/.

M3 See http://www.hqip.org.uk/what-is-local-clinical-audit/.

M4 See http://www.nres.npsa.nhs.uk/.

M5 See http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_091443.

M6 2008 c. 14.

M7 See http://nww.connectingforhealth.nhs.uk/susreporting/dataquality/registration.

M8 See http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937.

M9 See http://www.audit-commission.gov.uk/health/audit/paymentbyresults/assuranceframework/pages/default.aspx.