Bristol, North Somerset and South Gloucestershire CCGs Governing Body Quality Report

Transcription

1 Bristol, North Somerset and South Gloucestershire CCGs Governing Body Quality Report April 2017 February 2017 Data 1

2 s Introduction: BNSSG Quality Report Slide 3 Provider comparison: overview and comparison of quality indicators Slides 4-13 BNSSG Providers overview of CQC Status Slides Provider updates: Notable Practice, Hot Off The Press Key Risks (since February 2017) and Key Messages for February 2017 Slides CCG Information Slides BNSSG-wide reporting: National Safety Thermometer and Workforce Slides Exception reports: Acute services University Hospitals Bristol NHS Foundation Trust (UH Bristol) Weston Area Health Trust (WAHT) North Bristol NHS Trust (NBT) Mental Health Avon and Wiltshire Mental Health Partnership (AWP) Community services Bristol Community Health (BCH) Sirona Urgent Care South Western Ambulance Service Foundation Trust (SWAST) Care UK NHS 111 BrisDoc Slides Patient Advice and Liaison Service (PALS) Slides Serious Incidents Slides Areas for future development Slides Glossary Slide 109 Additional Assurance circulated to Committee: Evidence Briefing / Quality Dashboards Attached 2

3 Quality Exception Report Introduction and Context The purpose of this exception report is to update the Bristol, North Somerset and South Gloucestershire Clinical Commissioning Groups Quality Assurance Committee Group with details of any key quality issues that have arisen over the last month. Reporting will become increasingly aligned with the Quality Schedules which requires providers to report against national and local quality indicators on a periodic basis. 3

4 BNSSG Acute Provider Overview and Comparison of Quality Indicators 4

5 Utilising the Covalent System The following slides are produced using the system already used by the performance team. It is called the Covalent and it is an integrated system that allows users to collate, monitor and report on Performance Indicators and other key organisational metrics, with built in improvement plan tracking to improve overall performance. There are currently a limited number of consistent quality measures across the contracts and specifically in this report we have looked at acute services. For the contract the quality schedules have been aligned which will allow greater benchmarking, not only for acute services, but across the wider BNSSG health system. There is also an in-build report designer that allows the creation of templates for reports. Once set up, multiple reports can be easily generated using simple queries e.g. a full dashboard or an exception dashboard. Individual reports can be combined together into a dossier report, for example for urgent care, and a variety of different views can be generated and included in the reports. This can be done as a more routine report or as a bespoke report. 5

6 BNSSG Acute Provider Comparison Quality Indicators SHMI Org Indicator Nat. Control Limit Sep-15 Dec-15 Mar-16 Jun-16 DoT Value Value Value Value NBT Summary Hospital-level Mortality Indicator (SHMI) NBT SHMI Banding UHB Summary Hospital-level Mortality Indicator (SHMI) UHB SHMI Banding WAHT Summary Hospital-level Mortality Indicator (SHMI) WAHT SHMI Banding Key to SHMI Bandings Band 1 = SHMI is higher than expected Band 2 = SHMI is as expected SHMI Band 3 = SHMI is lower than expected 1.20 The NHS Safety Thermometer "Classic" allows teams to measure harm and the proportion of patients that are 'harm free' On 15 December 2016 NHS Digital published the quarterly statistics for Deaths Following Time in Hospital, England (July 2015 June 2016). WAHT was reported as being one of 11 higher than expected Trusts. UH Bristol, though rated lower than expected, the SHMI had slightly increased to above the national control limit NBT UHB WAHT Nat.Control Limit 6

7 Fractured Neck of Femur A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Percentage of patients with fractured neck of femur operated on within 36 hours 90% 80% 89% 86% 86% 74% 71% 86% 85% 81% 86% 86% UHB Percentage of patients with fractured neck of femur operated on within 36 hours 90% 87.50% 74.10% 72% 73.50% 61.30% 58.30% 73.70% 69.20% 51.70% 70% 61.90% WAHT Percentage of patients with fractured neck of femur operated on within 36 hours 90% 57% 70% 88% 76.20% 85% 90% 74% 85% 79% 96.70% Achieving the 90% compliance target for patients with fractured neck of femur being operated on within 36 hours remains a challenge for all the Trusts especially UH Bristol. WAHT s data is unavailable for February % 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% Fractured Neck of Femur NBT UHB WAHT Target 7

8 Friends & Family Test A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Friends & Family Test - Provider Response Rate (inpatient) 30% 21.30% 30% 26% 26% 28.30% 26% 23% 22.40% 20.30% 21.50% 25% UHB Friends & Family Test - Provider Response Rate (inpatient) 30% 35.20% 42.40% 40.50% 36.50% 36.80% 30.70% 33.70% 35.90% 30.60% 31.70% 34.80% WAHT Friends & Family Test - Provider Response Rate (inpatient) 25% 40.40% 41.90% 42% 44.10% 33.40% 35.70% 31.50% 34.60% 31% 34.10% 41.60% NBT Friends & Family Test - Provider Response Rate (ED) 15% 29.40% 17.50% 12.50% 16.10% 17.90% 15.50% 16.10% 15.10% 12% 13.20% 20.7% UHB Friends & Family Test - Provider Response Rate (ED) 15% 14.80% 13.50% 15.50% 12% 16.80% 15.50% 17.30% 18.90% 15.40% 21.20% 17.70% WAHT Friends & Family Test - Provider Response Rate (ED) 15% 4.90% 5.20% 4.50% 3.50% 5.20% 4.40% 2.90% 3.80% 1.60% 5.90% 5.70% The target threshold for Inpatient FFT response rates differs between acute providers (30% for NBT and UH Bristol and 25% for WAHT). This has been aligned to 30% in the BNSSG Quality Schedules for 2017/19. 8

9 Complaints A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Percentage of complaints responded to within agreed response time 90% N/A 66% 66.70% 85.40% 91.60% 87.80% 88.40% 82.80% 79.80% 68% 72.90% UHB Percentage of complaints responded to within agreed response time 90% 81.60% 73.10% 73.80% 86.60% 90.60% 86% 92.30% 93.40% 97.40% 87.50% 87.50% WAHT Percentage of complaints responded to within agreed response time 95% 71% 55% 87% 86% 55% 40% 67% 71% 63% 74% The target threshold for responding to complaints within the agreed response time currently varies (90% for NBT and UH Bristol and 95% for WAHT). This has been aligned to 90% in the BNSSG Quality Schedules for 2017/19. WAHT s data is unavailable for February % 90% 80% 70% 60% 50% 40% 30% Complaints Response Rate NBT UHB WAHT Target 9

10 HCAI A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Number of Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia (post 48 hours) UHB Number of Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia (post 48 hours) WAHT Number of Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia (post 48 hours) NBT Incidence of Clostridium difficile (Post 72 hours) UHB Incidence of Clostridium difficile (Post 72 hours) WAHT Incidence of Clostridium difficile (Post 72 hours) Healthcare-associated infections (HCAIs) are infections that are acquired as a result of health care. The burden of healthcare-associated infections has mainly been in hospitals where more serious infections are seen. NBT have failed to achieve the zero tolerance MRSA Bacteraemia standard, reporting a total of 6 cases of MRSA cases in the last year (since April 2016). The target threshold and the Rag rating criteria for Clostridium difficile is different for each acute provider. HCAI - MRSA HCAI - CDIFF NBT UHB WAHT Target NBT UHB WAHT 10

11 VTE Assessment A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Percentage of adult inpatients who have had a VTE assessment on admission to hospital 95% 91.50% 91.50% 93.80% 95.30% 95.30% 95.70% 95.60% 95.30% 96% 95% 95.23% UHB Percentage of adult inpatients who have had a VTE assessment on admission to hospital 95% 99.30% 99.10% 99% 99.10% 99.10% 99% 99% 99.40% 99% 99.10% 98.90% WAHT Percentage of adult inpatients who have had a VTE assessment on admission to hospital 95% 92.09% 85.50% 86.68% 75.24% 78.95% 68.88% 44.47% 53.90% 70.22% 60.52% Venous thromboembolism (VTE) is the formation of blood clots in the vein. When a clot forms in a deep vein, usually in the leg, it is called a deep vein thrombosis or DVT. If that clot breaks loose and travels to the lungs, it is called a pulmonary embolism or PE. Around half of all cases of VTE are associated with hospitalisation, with many events occurring up to 90 days after admission. The criteria for Rag rating is currently not aligned - NBT is rated amber at 93.80% whilst WAHT doesn t appear to have an amber rating. WAHT s data is unavailable for February % 90% 80% 70% 60% 50% 40% VTE Assessment Rate NBT UHB WAHT Target 11

12 Slips, Trips and Falls A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Rate of slips, trips and falls per 1,000 bed days 5.60% 7.17% 7.09% 6.29% 6.15% 6.68% 6.73% 7.30% 7.50% 5.70% 7.30% 6.00% UHB Rate of slips, trips and falls per 1,000 bed days 4.80% 4.24% 3.93% 4.57% 4.57% 3.81% 4.38% 4.76% 4.04% 3.74% 3.74% 4.90% WAHT Rate of slips, trips and falls per 1,000 bed days 5.60% 5.40% 4.30% 5.20% 5.90% 4.20% 5.50% 4.60% 4.20% 6.50% 4.50% The target thresholds for the rate of slips trips and falls per 1000 bed days are set internally by the providers and are different for each organisation. The criteria for Rag rating is currently not aligned - NBT is rated amber some months whilst WAHT doesn t appear to have an amber rating. WAHT s data is unavailable for February % 7.0% 6.0% 5.0% 4.0% 3.0% Slips, Trips & Falls per 1,000 Bed Days NBT UHB WAHT Target 12

13 Safeguarding Training - Children A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Percentage of staff completing safeguarding Level 1 children (rolling 12 months) 90% N/A N/A 82% N/A N/A 80% N/A N/A 86% N/A N/A UHB Percentage of staff completing safeguarding Level 1 children (rolling 12 months) 90% N/A 90% 90% 91% 91% 92% 92% 91% 91% 91% 91% WAHT Percentage of staff completing safeguarding Level 1 children (rolling 12 months) 90% 93.30% 93.90% 94.80% 94.50% 93.80% 94.30% 94.60% 94% 94.70% 94.70% 94.10% NBT Percentage of staff completing safeguarding Level 2 children (rolling 12 months) 90% N/A N/A 83% N/A N/A 83% N/A N/A 88% N/A N/A UHB Percentage of staff completing safeguarding Level 2 children (rolling 12 months) 90% N/A 88% 87% 87% 84% 87% 88% 89% 90% 90% 90% WAHT Percentage of staff completing safeguarding Level 2 children (rolling 12 months) 90% 83.40% 84.90% 86.40% 85.60% 84.80% 84.90% 85.30% 84% 83.40% 81.80% 83.30% NBT Percentage of staff completing safeguarding Level 3 children (rolling 12 months) 90% N/A N/A 79% N/A N/A 69% N/A N/A 81% N/A N/A UHB Percentage of staff completing safeguarding Level 3 children (rolling 12 months) 90% N/A 75% 76% 76% 75% 75% 72% 75% 76% 77% 76% WAHT Percentage of staff completing safeguarding Level 3 children (rolling 12 months) 90% 80.80% 73% 67.20% 74.20% 86.20% 85.50% 85.30% 83.20% 79.70% 79.10% 78.50% The frequency of reporting compliance with Safeguarding children currently varies from quarterly to monthly reporting. Adult Safeguarding training is currently not reported on as this is measured differently for each Trust. Reporting has been aligned to monthly as per the Safeguarding standards contained within the BNSSG Quality Schedules for 2017/ % 95% 90% 85% 80% Safeguarding - Childrens Level 2 NBT UHB WAHT Target 13

14 BNSSG Providers CQC Status 14

15 BNSSG Provider CQC Ratings The following tables provide an overview of CQC inspection ratings pertaining to providers within the BNSSG CCG locality. The CQC monitors, inspects and regulates health and social care services. Outstanding Good Requires Improvement Inadequate 15

16 Good Requires Improvement Inadequate Provider CQC Rating Date of Inspection Date of Report Link to Report Additional Information BCH Is the service safe? Good Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Outstanding 16-18/11/16, 27-28/11/16, 30/11/16 and 1/12/16 16/2/17 fault/files/new_reports/aaag0 260.pdf Several areas of outstanding practice were highlighted. There were also identified areas for improvement. NSCP Is the service safe? Requires Improvement Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Good November, 1,2, 13 and 14 December /03/17 fault/files/new_reports/aaag3 506.pdf Requirement notice around sufficient numbers of suitable qualified, competent, skilled and experienced persons Sirona Is the service safe? Requires Improvement Is the service effective? Good Is the service caring? Outstanding Is the service responsive? Good Is the service well-led? Good 18-21/10/ /03/17 site/sirona%20care%20%26 %20Health?location=&latitude =&longitude=&sort=default&la =&distance=15&mode=html A number of areas of good practice were identified in addition to areas requiring improvement. There were 2 Must Dos. BrisDoc CQC found that BrisDoc provided a service which was safe, effective, caring, responsive to people s needs and the service was well-led /2/14 and 14/2/14 7/5/14 efault/files/new_reports/aaaa 0496.pdf Inspection recently undertaken. Initial feedback has been positive; report is awaited. Care UK NHS 111 South West Is the service safe? Good Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Good 27-28/9/16 6/12/16 fault/files/new_reports/aaag0 065.pdf Some Outstanding features noted. 16

17 Good Requires Improvement Inadequate Provider CQC Rating Date of Inspection Date of Report Link to Report Additional Information SWAST Is the service safe? Requires Improvement Is the service effective? Requires Improvement Is the service caring? Outstanding Is the service responsive? Good Is the service well-led? Requires Improvement 7-10 June, 17, 20 and 22 June 6/10/16 sites/default/files/new _reports/aaaf7807.p df Following the CQC visit SWAST invited commissioners and SCWCSU to a presentation to feedback the findings of the inspection. Engagement was sought from commissioners and SCWCSU in a workshop session to consider ways for improving the weaker areas identified. SWAST has since produced an action plan which will be reviewed/monitored via the IQPMB. AWP Is the service safe? Requires Improvement Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Requires Improvement 16/5/16 8/9/16 sites/default/files/new _reports/aaaf7896.p df A Quality Summit took place on 2 November 2016 following the announced Trust-wide CQC inspection. The Warning Notice relating to illegal detentions in the Place of Safety Units, issued in December 2014, remains in place. Overall the CQC reported improvements from the 2014 inspection. The CQC highlighted 21 Must Dos and 33 Should Do actions and AWP will devise locality based quality improvement plans to address these with one overarching quality improvement plan for Trust wide actions. The CQC has informed AWP they will re-inspect the Trust on 26 June 2017, particularly the 136 suites. 17

18 Good Requires Improvement Inadequate Provider CQC Rating Date of Inspection Date of Report Link to Report Additional Information Nuffield Health Is the service safe? Good Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Good 14/8/16 4/8/16 Purpose of this inspection was to follow up on the last inspection in February 2015 where CQC found concerns with the services for children and young people. Care UK Emersons Green NHS Treatment Centre Is the service safe? Good Is the service effective? Good Is the service caring? Good Is the service responsive? Good Is the service well-led? Good 30 & 31 March and 11 April July /reports New Medical Systems Ltd Service not yet inspected. Provider is registered with the CQC. Spire Bristol Hospital There's no need for the service to take further action. Note: The last CQC inspection undertaken was under their previous inspection regime whereby each type of service was not rated 4/3/14 29/3/16 Recent CQC inspection undertaken on September 2016; expecting receipt of report. 18

19 Good Requires Improvement Inadequate Provider CQC Rating Date of Inspection Date of Report Link to Report Additional Information Circle Hospital (Bath) Ltd No need for the service to take further action. Note: The last CQC inspection undertaken was under their previous inspection regime whereby each type of service was not rated 7/2/14 19/2/14 ult/files/old_reports/ _circle_hospital_bat h_limited_t- a_circle_bath_ins _responsive_- _Follow_Up_ pdf The CQC reinspected the hospital at the end of The report is currently awaited. Somerset Surgical Services No need for the service to take further action. Note: The last CQC inspection undertaken was under their previous inspection regime whereby each type of service was not rated 14/2/14 19/3/14 ult/files/old_reports/ _weston_area_healt h_trust_weston_general_ins _scheduled_ pdf 19

20 Provider Updates: Notable Practice, Hot Off The Press Key Risks (Since February 2017) and Key Messages February

21 Notable Practice CQC Rating - UH Bristol were commended by commissioners for their CQC rating of Outstanding. It was noted at the Quality Group that this is significant for staff morale, recruitment and retention of staff. Accessible Information Standard - The Trust has undertaken some excellent work to meet the Accessible Information Standard (AIS) including training of staff, and changes to alerts in Medway patient administration system to human readable definitions. The work plan that has been developed by the AIS steering group is being shared across the Trust to continue the work in 2017/18. Hot off the Press Key Risks (Since February 2017) Nil to report. UH Bristol Key Messages for February 2017 Emergency General Surgery report - The report identifies some areas that are red rated. UH Bristol agreed that an update on the work being undertaken to address these areas will brought to the next Quality Sub Group meeting in April. Verita report - The report was received by the Bristol and South Gloucestershire Overview and Scrutiny Committee in February. The Overview and Scrutiny Committee agreed to close the plan and the Quality Sub Group will also formally close the plan. Paediatric Cardiac Action Plan - The Overview and Scrutiny Committee have requested that a report on the impact of the delivery of the recommendations is brought back to the Overview and Scrutiny Committee in March The Quality Sub Group has also have requested to see the impact report next March. Fractured Neck of Femur (#NOF) - Performance improved this month (61.9%) however remains below the 90% threshold. The actions from British Orthopaedic Association Review have been shared with the BNSSG MSK group assigned to look at #NOF. The longer term solution sits with the MSK group. 21

22 WAHT The Trust data available at the time of writing this report is for January 2017 from the WAHT Integrated Performance Report (IPR); updates have been provided from the Quality Sub Group & Integrated Contract, Quality and Performance Meeting Board (ICQPMB) meetings in March. The Quality Sub Group and ICQPMB monthly meetings have been changed to take place on the third Thursday of the month from the previous first Thursday of the month; this will take effect from 1 April Notable Practice MRSA Bacteraemia - There has been zero cases of hospital acquired MRSA Bacteraemia reported since October Key Messages February 2017 Norovirus - Two outbreaks of Norovirus in March impacted on two wards. Contract Performance Notices (CPNs) - The Trust were sent a second CPN in March 2017 from North Somerset CCG detailing areas of concern where assurance has not been met. CQC - The CQC undertook an unannounced follow up visit on 9 March 2017 to complete the areas they were unable to inspect at their previous visit. Senior Management Team several posts are changing at the Trust during March and April. Never Event - one Never Event was reported in February. Safety Thermometer - harm free care is 85.27% in February. All pressure ulcers are 12.79% of which 3.10% are new plus 0.78% are new falls with harm. Total new harm in February 2017 was 3.88%. Summary Hospital level Mortality Indicator (SHMI) - The SHMI has shown a slow improvement, current data available on Dr Foster is for Quarter /17 = 115. The Trust have in place several quality improvement processes they are working through. The focus aims to produce measurable reductions in mortality which is monitored through the Mortality Review Group. Monthly mortality updates are provided at the Quality Sub Group & ICQPMB. There are two external reports outstanding, the fractured neck of femur pathways and the management of colorectal patients; the Trust will share these with the CCG on receipt. Time to surgery compliance for fractured neck of femur is improving and was at 96.7% in January. 22

23 WAHT 4 hour Emergency Department (ED) performance - Performance has continued to decline against the trajectory with performance in December 2016 reported as 66.85; January showed a decline to 63.7%. The 95% national standard is not expected to be achieved during 2016/17. NHS England has set a national target for all Acute Trusts to achieve 90% for ED performance by the end of the week commencing 27 March 2017; a trajectory has been set for WAHT that is being monitored through the A & E Delivery Board. Daily Green to Go (G2G) meetings continue with daily system calls. Decision to admit (D2A) Pathway 2 is in place and is being further developed. Out Patient Pending List - The Out Patient Pending list has been the subject of a CPN since September The latest update provided to the Quality Sub Group and discussed on 9 March 2017 was incomplete as it did not provide an update on progress against patient`s overdue in 2015 or The CCG are not assured and have escalated with a further CPN and requested a Remedial Action Plan (RAP) as per criteria within the CPN. Venous Thromboembolism (VTE) Risk Assessment - The Trust have provided a trajectory to achieve the 95% compliance rate by April January data showed a decline at 60.52% from an improved figure in December of 70.22%. On review of the agreed action plan and the January performance against trajectory, the CCG are not assured of progress. An explanation of remedial actions and progress has been requested. 62 Day Cancer standard - A RAP with trajectories has been provided by the Trust following the exception letter issued by the CCG in December This is monitored through the Quality Sub Group and ICQPMB meetings as well as the BNSSG Cancer Group. An improved figure of 86.7% was noted for January 2017 compared to 75.01% in December. Electronic Patient Discharge letters - Following progress monitoring against the e-discharge plan at the Quality Sub Group, the CCG is not assured due to the lack of compliance with the Trust s contractual requirements in respect of all discharge templates. Given the lack of progress in addressing this issue, the CCG now require the Trust to provide a RAP together with an improvement trajectory which addresses all discharges. General Dementia Training - General Dementia training in November was 82% and Level 3 was 66%. A plan was requested for review at the January Quality Sub Group meeting demonstrating how the Trust will improve this position. The plan tabled at the contract meeting has been reviewed and deemed to be not acceptable. An updated plan has been requested which also incorporates the actions from the SI PU action plans. This is monitored at the SI panel and escalated through the Quality Sub Group. 23

24 WAHT Serious Incidents (SI s) - Following the CPN issued in December 2016 with regard to the number of outstanding open SI`s the Trust have a Serious Incident Management plan in place which continues to be monitored by the CCG at the fortnightly SI panels and the Quality Sub Group. Progress was noted at the Quality Sub Group held in March. One Never Event was reported in February that pertained to a retained chest drain guide wire. The patient required surgery to remove the wire. Immediate equipment checks took place to ensure all chest drains of this kind were removed from wards until safety checks on the equipment could be undertaken. National Safety Standards of Invasive Procedures (NaTSSIPs) were in place in the Trust and a safety checklist poster was disseminated to all wards reminding staff that for all invasive procedures a checklist must be completed. A full investigation has commenced in line with national SI guidance and the event will also be used as a learning tool for junior doctors at the Trust. Friends and Family Data Collections - Friends & Family Test (FFT) response rate in ED continues to be very low at 5.9% in January with only 86% of those who responded would recommend the department to family and friends. The initial thoughts were potentially due to the long waits experienced in the department. The Trust has undertaken a visit to Clevedon Hospital to discuss how they capture their FFT information and a business plan was developed based on those findings. The Trust have since agreed to purchase three ipads which, once the software has been loaded, will be wall mounted in the department and ready to use. Complaints Response Rates - January saw a slight improvement in response rate compliance at 74% but remains below the 90% trajectory. Weekly meetings remain in place with the Complaints Manager and the Associate Directors of Nursing at the Trust. The CCG have requested a plan to reach trajectory with detail on how this will be achieved and data for number of complaints received and number of overdue cases. Staff Training/Appraisal data - Concern has been raised as staff training continues to track below a 90% trajectory; this is the same for the annual staff appraisals against an 85% trajectory. Statutory/Mandatory Training has remained below the 90% compliance rate and tracks at between 85.9% in November 2015 to 84.8% in January General Dementia Training is currently performing in the low 80% compliance since February 2016 against the 90% trajectory. Level 3 Training is at 62.6% in January Information Governance Training has dropped to 70.5% the lowest it has been in the last 12 months. Staff appraisals saw a decline in January 2017 to 80.8% from previous months and below the 85% trajectory. 24

25 WAHT Safeguarding Notable Practice Modern Slavery/trafficking - A case of Modern Slavery/trafficking was correctly identified in ED and referred appropriately following staff training. Safeguarding referrals - North Somerset Council have reported that adults safeguarding referrals from WAHT have a conversion rate to over 60%, indicating good quality referrals. Key Messages February 2017 Safeguarding matrix - Revision of Level 3 safeguarding children Matrix has indicated that 22 additional staff need to be included in this level, reducing the Trust s compliance to 72% (from 78.5%) with a trajectory to meet the required compliance level of 90% by July CDOP an action plan for the care of severely ill children in ED, following a CDOP case, had not been updated and is now being monitored at Quality Sub Group. SI There has been concern regarding an SI not being reported to the CCG pertaining to a 17 year old child registered under Children and Adolescents Mental Health Services (CAMHS) who had run out of a clinical meeting in August 2016, and was seriously harmed following a fall from a motorway bridge. No notice had been provided to the CCG regarding this incident. It has since been added as an SI by the Trust. Adult Safeguarding lead for Mental Capacity Act (MCA) & Deprivation of living standards (Dols) - Concern was raised during the CCG pre visit and the CQC visit in February on the staff dependence on the Trusts Adult Safeguarding lead for Mental Capacity Act (MCA) & Deprivation of living standards (Dols) information and how they would access this information when this person was not on site. This is being addressed at the monthly QPSG meeting. 25

26 Notable Practice Emergency General Surgery Review of Acute Trusts in the South West this was published by the NHS South West Clinical Senate in February All 14 Trusts in the South West were assessed on their performance against Emergency General Surgery Standards and NBT was found to be the second highest performing Trust. Backlog of Endoscopy surveillance cases - NBT had been failing the six week diagnostic target and had a significant Endoscopy surveillance recall backlog. The Trust are currently on track to meet the improvement trajectory outlined in RAP and the backlog should be cleared by the end of March All affected patients have been reviewed and those requiring treatment have received it. Hot Off the Press Key Risks (since February 2017) None identified. NBT Key Messages February 2017 MRSA - A CPN was issued to the Trust in November 2016 in response to the 6 cases of MRSA Bacteraemia reported by NBT since September NBT is implementing an MRSA RAP. Never Events - NBT have reported five Never Events for the year to date 2016/17. A CPN was issued to the Trust in November NBT is implementing the Never Events RAP. Overdue complaints - the number of overdue complaints has reduced to 26 in February Of the cases closed in February 2017, 73% of them were completed within the agreed timescale (against a target of 90%). Backlog of discharge letters - Delays in the receipt of discharge letters following outpatient consultations at NBT have been highlighted by GPs. The CCG has requested a Trust wide action plan to provide assurance that action is being taken. FFT NBT has verbally reported an improvement in response rates for Inpatient FFT however it remains below target (25% February 2017). NBT has verbally reported an improvement in the FFT ED response rate (20.6% February 2017) now above target. 26

27 Safeguarding NBT Notable Practice Management of Deprivation of Liberty Standards within Intensive Care Unit revised approach have been developed and approved by NBT Safeguarding Committee and commissioners. Hot Off the Press Key Risks (since February 2017) Managing challenging behaviour - Delivery of safe physical intervention, restriction, restraint in managing challenging behaviour is Included on NBT s risk register (15). NBT have met with the training company to develop bespoke training to be piloted in the Neuro directorate during May Allegation Management - Clarity is required in the HR process of management of staff when an allegation is made by patients. NBT processes are being reviewed with HR. Safeguarding RCAs these do not always demonstrate robust investigation processes. NBT is reviewing UH Bristol s template and considering revisions. PREVENT There is limited awareness of the PREVENT agenda; training, safeguarding and HR policies require revision. Training has been revised and competencies included in Level 1 and Level 2 training. Key Messages February 2017 ED referrals to children's social care - Risks associated regarding a robust process for ED referrals to children's social care; the development of a revised referral form for ED is in progress; there are plans to revise ED training to enhance the quality of referrals and increase the positive conversion rate to section 47 investigations; a process for quality assurance of referrals in place. FGM mandatory recording - NBT is now submitting FGM mandatory recording information to DoH although there is an issue with Lorenzo being compatible with Euro King which still needs resolving. Safeguarding Adult Boards and Safeguarding Children Boards - NBT have provided representation at Safeguarding Adult Boards and Safeguarding Children Boards and Sub Groups; there is now a Head of Safeguarding in post. MCA and DOLs in Midwifery - Training for midwives on has been undertaken; updates are planned to support maintenance of competencies. 27

28 BCH Notable Practice Pressure Ulcers - BCH have reported a decrease in the number of pressure ulcers (all grades) from 112 in December 2016 to 63 in February. BCH is making changes to community teams working arrangements. This should increase the continuity of care provided and further support reduction in pressure ulcers. Infection Control - BCH continue to improve on their hand hygiene audit results with 98% compliance reported in February, of which 70% of the audits being observed opposed to self assessment. Hot Off The Press Key Risks (Since February 2017) Complaints - BCH recently identified that staff were using personal vehicles to transport Learning Difficulty service users to and from health care appointments. BCH have requested that staff no longer do this and alternative transport arrangements have now been arranged for service users. This has resulted in an increased number of complaints from both service users and staff in the Learning Difficulties team as this change is accepted. Key Messages February 2017 FFT - Response rates for the Walk in Centre (3.4%) and the Urgent Care Centre (12.1%) have declined further for the month of January and are not in line with the improvement trajectory target of 14%. The Walk in Centre is of particular concern with figures significantly below target demonstrating that FFT is not embedded practice within the service. Bristol CCG has requested an action plan to address this. 28

29 NSCP The NSCP data available at the time of writing this report is for January 2017, month 10, updates have been provided where conversations were held at Quality and Performance review meeting. Review meetings take place the 2 nd Thursday of the month. Notable Practice CQC - The CQC have published their report following an inspection visit in November 2016 as part of their scheduled inspection programme. The overall rating was Good with a Requires Improvement for Safety. Training for staff in dementia and delirium this continues to be a priority for NSCP. A mental health training day (to include dementia and delirium) for NSCP staff has been arranged for Thursday 2 March 2017 and is being provided by Avon and Wiltshire Mental Health Trust (AWP). Key Messages February 2017 FFT - NSCP has a range of measures in place to ensure that the FFT is accessible to all service users and are rolling out a programme to capture the FFT responses from housebound patients managed by the Integrated Care Teams ( ICT). In January % of people would recommend NSCP to a friend or family and that 97% of patients said that they were satisfied with the standard of care they received and 96% said that staff treated them with respect and dignity. Pressure Ulcers - In January there were twenty-eight pressure ulcers reported seven were acquired and twenty one were inherited. The number of category two acquired pressure ulcers has fallen from fifteen in December to four in January. Staff turnover - This is at 14.47% in January, there were eleven starters and ten leavers spread across Bands 3-6; there are no specific hotspots or concerns identified. Sickness absence This increased in January to 5.6% which is higher than the comparators NSCP use. 34% related to cough/cold/flu and Gastro related illness related to 19%. 29

30 NSCP Safeguarding Notable practice Training - A mapping exercise of NSCP safeguarding adults training shows that their Level two training equates to the competencies required at Level three, so all staff are currently receiving a higher level of training. Safeguarding referrals - North Somerset Council have advised that conversion rates of Safeguarding adults referrals to agreed Section 42 / other inquiry is 43% compared with 21% nationally for all referrals. Key areas of risk School nursing establishment This remains fragile due to long term sick and compassionate leave. The service is being supported by the wider management team in order to ensure safeguarding case conferences and strategy meetings are quorate with health representatives. NSCP Funded Healthcare Team - There is a capacity issue for the NSCP Funded Healthcare team to manage safeguarding concerns in North Somerset homes, where patients receive Continuing Health Care or Mental Health funding. The team does not currently have the capacity to respond within the timescales required. NSCP safeguarding adult lead is reviewing and monitoring this issue. 30

31 Sirona 2017 Notable Practice Overall Sirona perform well in most areas however areas of concern namely cleaning standards at Thornbury Hospital and FFT at Thornbury (inpatients) are contained within the report. Pressure Ulcers - the incidence of new grade 2 pressure ulcers has reduced in February from 33 (January) to 26 in February. FFT - The FFT response rate at Yate MIU has increased significantly to 20% in February. Hot Off The Press Key Risks (Since February 2017) CQC - Sirona received an overall rating of good following the CQC s inspection of services undertaken in October The report, published at the end of March 2017 found that in terms of caring the organisation was outstanding. Key Messages February 2017 Environmental cleanliness - hospital cleaning at Thornbury has improved to 93%, just below the 95% target. An action plan has been implemented and is being monitored. FFT - The response rate at Thornbury inpatients was low in February 2017 (5%) however Sirona have provided an explanation for the variance in FFT response rates in this area. 31

32 Safeguarding Sirona (1) Notable Practice New Head of Safeguarding Adults lead professionals in post, attended Adult Safeguarding Boards and met with Commissioners. S Glos MASH commenced Sirona providing Safeguarding Nurse Specialists to provide health expertise. Hot Off The Press Key Risks (Since March 2017) CQC the report was published on 28 March The overall rating for Safeguarding was Requires Improvement and a must do action set as must improve its compliance rates for level two and level three adults and safeguarding training and ensure that safeguarding training is received at the right level for the role. There were adult and children s safeguarding systems in place to keep patients safe. Policies were in place and staff were aware of their responsibilities in relation to safeguarding. There was a PREVENT strategy in development but this was not yet embedded or included in training. Safeguarding arrangements in the community health services for children, young people and families rated as Good There were arrangements in place to safeguard children from abuse that reflected the relevant legislation and local requirements. Staff were completing training that was being audited and monitored. Staff understood their responsibilities and were aware of the provider s policies and procedures Support staff working within the Lifetime service were being trained to safeguarding level two when the national recommended level for staff lone working in this type of situation is level three. Not all staff were up-to-date with adult safeguarding training, Staff must complete their adult safeguarding updates within the required timescales. Safeguarding children's policy had been reviewed in April 2016 and during induction all staff members received safeguarding children training at level 1. Health visitors received regular feedback on serious case reviews through team meetings and safeguarding training 32

33 Safeguarding Sirona (2) Staff were supported through a structured approach to safeguarding supervision. This was provided regularly and from appropriately qualified professionals. The Sirona lead safeguarding nurse provides group supervision session for nurses working in the family nurse partnership teams Safeguarding was regularly discussed at team meetings and learning from serious case reviews could be discussed. Safeguarding in Community mental health services for people with learning disabilities or autism was rated as Good - As Safeguarding was managed well. Staff displayed good knowledge of safeguarding. The service referred appropriately to the local authority safeguarding team and kept a log of all issues. People were protected from abuse and avoidable harm. Staff had good knowledge of safeguarding vulnerable people were supported to have responsive, safe and effective care; to ensure level three child safeguarding has been updated by all nursing staff when this was relevant to their role. Safeguarding in urgent care services was rated as Good - Staff were clear about their responsibilities for reporting any suspicion of abuse of a vulnerable person. It was recognised that urgent care services would often see people who were vulnerable, or not having regular healthcare or other support in their community. All staff we met had experience of reporting any suspicions of abuse, and clearly described Sirona s process for keeping people safe. Staff were clear about their responsibilities for reporting any suspicion of abuse of a vulnerable person. Safeguarding in of End of life care was rated as Good - Staff were knowledgeable about safeguarding processes for vulnerable adults and children and were clear about their responsibilities. Staff demonstrated an understanding of what kind of issues might alert them to consider possible safeguarding issues, and what they could do to respond to the patient in a safe and supportive manner. An action was made to Ensure all staff has in date mandatory safeguarding children and vulnerable adults training. 33

34 AWP Trust-wide (1) Notable Practice Agency utilisation - Use of agency staff is beginning to show an improving trajectory. Workforce - Information shows some improvement in appraisal and mandatory training. Out of area placements Whilst variable this is significantly improved on this time last year as a result of new and improved processes impacting on inpatient flow. DTOC This has improved in several localities and improved slightly overall at 11% against a trajectory of 5%. To achieve the 5% target would require approximately 20 patients to be moved to settings more suitable to their needs. Hot off the Press Key Risks Red rated scorecard measures - A significant number of scorecard measures remain Red rated for up to 6 months or longer. It has been agreed that AWP will embed a process where any score rated red for 2 months or more will be reviewed and reported to the Quality Sub Group. Capacity and demand Concerns continue about matching capacity with demand (inpatient and community services). An action plan is in progress, monitored via the CQPM, Quality Sub Group and local contract performance meetings. Safer staffing, recruitment, retention - challenges are ongoing particularly with retention and use of temporary staff. Action plans are also ongoing, monitored via the CQPM, Quality Sub Group and local contract performance meetings. CAMHs issues also relate to staff sickness rates, mandatory training and supervision requirements, waiting times and Choice waits. 136 breaches 1 breach of the 72 hour standard was reported at the end of January. The total length of stay at the Bristol Place of Safety was 83 hours 40 minutes. An RCA is in progress. CQC The Warning Notice relating to illegal detentions in the Place of Safety Units remains in place. The CQC has informed AWP they will re-inspect the Trust on 26 June 2017, particularly the 136 suites and has requested detailed pre inspection feedback from commissioners re all issues and in particular regarding the well led requirements. Monitoring of CQC actions is via the Quality Sub Group SIs - despite some improvements concerns remain regarding evidence of learning from SIs. The CCGs facilitated a second workshop with AWP in March where agreement was reached on best practice and on what is required in terms of reporting and evidencing learning. 34

35 AWP Trust-wide (2) Key Messages February 2017 The Caring Solutions report commissioned by Bristol CCG to review unexpected deaths Mental Health commissioners and Quality Team members have met and developed an action plan to address the commissioner actions. AWP has been asked to respond to the report and to include their approach to zero tolerance to suicides. The AWP report will be discussed at April 2017 Quality Sub Group. Rapid tranquilisation - Clinical practice relating to management of patients requiring rapid tranquilisation remains a focus for commissioners - data this month shows an improvement. The CCGs are monitoring monthly via the Quality Sub Group and locality meetings with the expectation that this will continue to improve. 35

36 AWP: Bristol CCG Locality Notable Practice Out of Area placements There has been an positive impact of opening Larch with the reduction in the number of Out of Trust and Out of Area placements. Hot Off The Press Key Risks (Since February 2017) Callington Road Hospital - There are concerns regarding the quality of care on the inpatient wards including AWPs response/lack of action following coroner recommendations issued in There are also concerns regarding general staffing levels/skill mix all underpinned by lack of leadership at a local level. A meeting was held on 23 March with representation from Bristol CCG, CQC, LA and AWP colleagues. Actions and next steps were agreed and will be monitored locally and via the LCQPM and Quality Sub Group. Key Messages February 2017 Bristol Delayed Transfer of Care (DTOC) This remains a significant challenge and increased again in February 2017 to 13.5%. This was the 6 th consecutive month s increase. Staff sickness rate this increased in January to 5.3% (target 4.6%), with higher rate of sickness within the inpatient services. Staff turnover - pressures persist. Recruitment is in process with a good response. Safeguarding training Community staff levels 2 & 3 is below the 90% target at 74% and 66% respectively. Inpatient staff levels 1, 2 & 3 are all below 90% target at 89%, 82% and 40%. Level 3 performance relates to small numbers overall but the majority being new starters. AWP were asked to look at ways of proactively booking sessions for new starters. FFT response rate This remains below the 15% target for RBP at 6%, however, the inpatient rate is above target at 20%. Quality administrators are now in post so should see a greater response rate going forward. Data source: AWP Bristol MH Services Month 11 Performance and Quality report 36

37 AWP: North Somerset CCG Locality Key Messages February 2017 Quality reporting - The local Quality and Performance report is very performance driven, the CCG have requested that exception reporting against the quality schedule should be included in the monthly locality Quality and Performance report, a meeting was held following the North Somerset Quality and Performance meeting to agree the format. Pressure Ulcers and Falls - There have been two pressure ulcers reported and sixty five falls reported in the last six months. Further information was requested at the February Quality and Performance meeting. The CCG are organising a meeting with the Clinical Matron to discuss the detail behind the data. Sickness absence this showed very little change in January at 5.50% from 5.51% in December both exceeding the 4.6% trajectory; there was no February data available at the time of the report. Although the Trust are working with both Human Resources and Team Managers the CCG have requested a further breakdown of the data, for example, long and short term sickness. Mandatory Training This remains non compliant in seven areas: Basic Life Support, CPA and Risk, Food Safety awareness, PERT, Practical Patient Handling, Safe assistance of moving patients and Safeguarding Children Level 3. An update was given in the Quality and Performance report. The locality confirmed that there had been a big push on training through March and would expect compliance to improve in April. Cardiac arrest support at Juniper WAHT are withdrawing their Service Level Agreement (SLA) to attend Juniper Ward with cardiac arrest support as from the 31 st March The CCG have requested assurance that a new processes will be in place from 1 April 2017 when the SLA is withdrawn. 37

38 SWAST Notable Practice Right Care Event 9 February SWAST organised an event in February for Commissioners, Quality Colleagues, SWCSU and representation from Minor Injury Units (MIUs), GP Out of Hours (OOH) and Care UK NHS 111. This was a very productive session the feedback from this session will be reviewed and analysed for any future learning. Hot Off The Press Key Risks (Since February 2017) Thematic Call Review The session planned for February 2017 had to be cancelled due to the fact that no identified cases were forwarded to the SCWCSU from any provider. A letter has been drafted to be sent to SWAST and the CCGs detailing the SCWCSUs position moving forward and is being commented on by senior staff within the SCWCSU before dissemination. Move to St. James North - SWAST have moved to St James North and a visit is planned by the SCWCSU for the end of April along with representation from the BNSSG CCG Quality team. Key Messages February 2017 Performance February performance of Purple responses within 8 minutes was 73.96%%, which is below SWAST s target of 75%.This continues to show an increase on the previous month and is an improving picture. Handover delays This continues to be a challenge for SWAST, detailed later in this report Serious Incidents (SIs) Previously identified themes of spinal management and No Clinical Decision in Isolation. arising from SIs continue to be monitored. Staying on the line and Audit Prioritisation and Explicit Consent have been identified as developing themes and have been discussed with the Deputy Medical director of SWAST in a meeting with the SCWCSU on the 24 March SCWCSU are planning on visiting SWAST to look at the process of audit both in the North and the South, due to the planned move to St. James North this has been delayed as the priority is ensuring a smooth transition from one building to another. 38

39 Care UK NHS 111 Notable Practice ED validation line The ED validation line was in operation at peak times on all but one day in February, with a related improvement in ED referral rates (although still above the 5% standard). Of those calls subject to validation, circa 70% are redirected to an alternative service. However, the total number of calls validated is small as this is a very resource intensive model. Commissioners have provisionally agreed maintaining an ED validation line CQUIN for and the SCWCSU is preparing the paperwork. Hot Off The Press Key Risks (Since February 2017) CCG Safeguarding lead The safeguarding lead issue has not yet been resolved. It is anticipated that this will be addressed prior to end April. Once roles have been agreed by commissioners, SCWCSU will prepare a Memorandum of Understanding between commissioners to formally clarify responsibilities. Thematic Call Review The session planned for February 2017 had to be cancelled due to the fact that no identified cases were forwarded to the SCWCSU from any provider. A letter has been drafted to be sent to Care UK NHS 111 and the CCGs detailing the SCWCSUs position moving forward and is being commented on by senior staff within the SCWCSU before dissemination. Key Messages February 2017 Clinical Advisor (CA) capacity CA establishment (23.74 WTE) remains below the required establishment (42.47 WTE). However, this is the best clinical staffing level reported in over a year. Care UK NHS111 advise that as the clinical workforce is predominantly part time they are able to use overtime, as well as agency staff and the network, to support clinical capacity. 60 seconds call answering This standard was not achieved in February, ending the month at 93.4% for BNSSG. This has been attributed to two issues: firstly, the ED validation pilot increases the total call handling time, which reduces the staff available to pick up new calls; secondly, a number of new staff have come on board. The total call handling time of new staff tends to be a bit longer, and again this reduces the pool of staff available to pick up new calls.however, unvalidated data for March shows recovery as the new staff and processes have bedded in. 39

40 BrisDoc Notable Practice Urgent Clinical Advice Performance (93%) has improved 8% when compared to the same period as last year (85%). BrisDoc attribute this improvement to increasing the hours in the weekend rota that are dedicated to telephone advice. Hot Off The Press Key Risks (Since February 2017) CQC BrisDoc were inspected by the CQC during the week 13 March SI The coroner's inquest was held in March and the coroner gave a narrative verdict. The CGG will facilitate a debrief meeting with all relevant stakeholders to review the learning from the serious incident investigation and external independent reviews. Key Messages February 2017 Quality Report A meeting is to be held with the BrisDoc Quality Lead to review the quality report in light of changes made to the report last year and the agreement of the new quality schedule. BrisDoc has been asked by commissioners to provide more assurance in relation to quality in their monthly report. 40

41 CCG Information 41

42 Bristol CCG Infection Prevention and Control February 2017 Clostridium Difficile The table below shows the number of C. Difficile cases against threshold for April February The number of C. Difficile infection cases for Bristol CCG was below the monthly threshold. There were 6 cases against a threshold of 9. Overall there have been 116 cases recorded to the end of February 2017 against a threshold of

43 MRSA The table below shows the number of MRSA pre 48 hour bacteraemia cases (3) assigned to Bristol CCG from April to February MRSA cases reported in brackets in February 2017 have been submitted for third party arbitration by NHS England. Cases in brackets for March are under investigation. Third Party The number of MRSA cases assigned to third party (9) from April to February 2017 is shown in the table below. E.Coli Bristol CCG has been set a threshold of 229 cases for the year 2017/18. The Medicines Management Team has commenced a review of 30 cases that occurred this year to identify if there is any key learning that can feed into the Healthcare Associated Infection Group work plan to meet the required threshold. 43

44 April May June July Aug Sept Oct Nov Dec Jan Feb YTD North Somerset CCG Infection Prevention and Control / Health Care Acquired Infections (HCAI`s) NS CCG HCAI Escherichia Coli (Ecoli) ALL Methicillin-resistant Staphylococcus aureus (MRSA) TRUST Methicillin-resistant Staphylococcus aureus (MRSA) COMMUNITY Methicillin-resistant Staphylococcus aureus (MRSA) 3 rd PARTY Clostridium difficile (C-diff) TRUST Clostridium difficile (C-diff) COMMUNITY (WAHT) microbiology) Clostridium difficile (C-diff) COMMUNITY (NBT/UHB microbiology) 2016/17 Trajectory n/a Acute inclusive of Community and Acute Assurance Two cases of MRSA Bacteraemia were reported in March and were provisionally assigned to North Somerset CCG as community acquired cases. Following post infection root cause analysis investigations undertaken one case has remained assigned to the CCG and the second case is undergoing third party arbitration with NHS England. North Somerset C-difficile cases in the Acute Trust and in the Community are currently tracking below the Department of Health NSCCG trajectory for the year. 44

45 North Somerset CCG Quality Incidents All Incidents reported by month Apr 2016 May 2016 Jun 2016 Jul 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 Total AWP (Avon & Wilts Mental Health Partnership) NBT (North Bristol NHS Trust) NSCP (North Somerset Community Partnership) Other Secondary Provider Taunton & Somerset NSH FT UHB (University Hospitals Bristol NHS Trust) WAHT (Weston Area Health Trust) Total Reports continue to be generated on the CCG Datix system to share concerns for North Somerset patients and the Health Care provided to ensure Patient Safety is central to all patient contact. The chart above indicates that a high percentage of cases do relate to WAHT as the main Acute health service provider for North Somerset residents. All reported cases are shared with the applicable provider for information/action and to monitor specific themes requiring provider actions to take place. 45

46 North Somerset CCG Quality Incidents Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Weston top 15 incident themes listed by month Total Discharges- Discharge planning failure Discharges- Patient discharged with IV Cannula in situ Pressure Ulcer Incidents Discharges- Patient discharged without any discharge letter Discharges- Requests for dosset boxes at discharge from hospital Discharges- Other problems with medication at discharge Discharges- Inappropriate or unsafe discharge Discharges- Patient discharged with inaccurate discharge letter Discharges- Incorrect medication provided to patient at discharge Documentation (including records, identification) other Outpatients- Other problems with medication at an outpatient appointment Discharges- No medication provided to patient at discharge Test results / reports - failure / delay to receive Failure to refer to appropriate team following discharge from hospital Other - please specify in description Total The top 15 themes as reported onto the North Somerset CCG DATIX reporting system are discussed at the monthly Quality Sub Group meetings held with the Trust. The management of discharges in various forms remains the top themes inclusive of discharge letters not received by GP s.

47 CCG HW PALS SI MP North Somerset CCG Complaints/Compliments from all Patient Experience Resources No formal complaints were received by the CCG in February Patient Experience sources in February 2017 Patient Experience Source Total Issues, Mitigation and Actions Discharged from hospital unable to walk - was not supplied with crutches. Still on crutches 6+ weeks after the operation and has been unable to get a follow up appointment in outpatients. The reason given for not able to get an appointment was because the person responsible was away so the follow up appointment request will not be looked at till February 2017 Orthopaedic Team Appointment at the Eye Clinic at 4pm but was not seen until 5.30pm. Said there is often a long wait in this clinic. There was no information on the information board about how long and why delays were. Patient found out that most outpatients receive a text or auto phone message reminding them of their outpatient appointment. Patient advised did not get either reminder but it would be really useful as forgetful some days. Consultant Obstetrics and Gynecology was brilliant. Fast tracked into surgery and given excellent care Feedback received by Weston Area Health Trust Feedback received by Weston Area Health Trust Feedback received by Weston Area Health Trust Feedback received by Weston Area Health Trust. 47

48 North Somerset CCG Patient and Public Involvement Overview of key work streams for February 2017 BNSSG PPI work on STP The North Somerset Sustainability STP Spotlight Project (Weston) Engagement commenced on 9 February. There has been engagement with 20 community groups throughout February including Practice Patient Groups, local councillors, condition specific groups such as Parkinson s, Supportive Parents and staff groups. Also work has been undertaken to prepare for three open public meetings. Over 350 people were engaged with face to face. 360 degree stakeholder survey Field work continued and the process closed; awaiting report due April 17. North Somerset Health Overview and Scrutiny Panel (NS HOSP): Liaison continues to prepare for informal briefing meetings and full meeting in March. Chair of HOSP is leading some community engagement events in their role of overview and gathering views. Healthwatch North Somerset (HWNS) - Liaison continues. Healthwatch staff are supporting the engagement process by taking information materials out to community groups, for example the foodbank in Weston. NS Voluntary Sector Liaison: Voluntary Action North Somerset (VANS) liaison there is a further meeting to discuss progress on SLA. Black and Minority Ethnicities (BME) Engagement there is planning for a BME conversation group for the Weston Engagement. Lesbian, Gay, Bisexual and Transgender (LGBT) Engagement there has been continued liaison with a focus on the Weston Engagement and planning for Weston Pride. North Somerset Patient Participation Group (NS PPG) Chairs there is a meeting and tour of Weston Hospital as part of the engagement process. STP - Prevention, Early Intervention and Self-care PPI is focussed on how to engage with the various schemes that form this work stream. Particularly social prescribing and self-care, Making Every Contact Count and how best to engage with the Voluntary and Community Sector. Gluten free consultation PPI support provided to this project with help to submit a paper to HOSP. 48

49 North Somerset CCG- Primary Care Quality Improvement Working with the AHSN the CCG has been working with practices in the following areas:- NEWS- recognising the deteriorating patient. Building on the work started 3 years ago the use of the National Early Warning Score (NEWS) has become embedded in primary care with education sessions being held at the GP Forum and Clinical Governance Leads forums. The CCG has also assisted with the role out of the EMIS NEWS template to GP practices to facilitate calculation and recording of the score during patient consultations. A story of a patients journey from a North Somerset GP into ED at UHB illustrating the use of NEWS can be found on the AHSN website and was shown at the recent NEWS event Primary Care Collaborative North Somerset practices have expressed an interest in joining Cohort 2 of this work New Court Surgery The Cedars Surgery Tyntesfield Medical Group Further practices are being encouraged to join. CCG Engagement with practices to improve quality:- DATIX reporting of clinical quality issues. The CCG have implemented a DATIX computer reporting tool to record and follow up quality concerns reported by organisations across North Somerset in both community and primary care. This has enabled the CCG to monitor themes and issues with providers as well as promoting engagement with practices and sharing any learning identified. Primary Care engagement with Health Care Acquired Infections investigations (HCAI), learning and patient outcomes. The CCG has continued to foster engagement with primary care in the investigation of Clostridium difficile HCAI. There is now a well embedded process where GPs complete Root Cause Analysis (RCAs) for each community attributed case. These are then shared with the community teams and Trust Microbiologist who reviews every case. The CCG write to each GP with the learning outcomes from each case. Since this process was started there has been a consistent reduction in community C.difficile infection and at present there have been zero avoidable instances within the current year. 49

50 BNSSG provider comparison: National Safety Thermometer and Workforce Information 50

51 March April May June July August September October November December January February % March April May June July August September October November December January February March April May June July August September October November December January February % % BNSSG Safety Thermometer The NHS Safety Thermometer "Classic" allows teams to measure harm and the proportion of patients that are 'harm free' from pressure ulcers, falls, urine infections (in patients with a catheter) and venous thromboembolism during their working day, for example at shift handover or during ward rounds. Same day monthly reporting of data provides an overview of how well patients are receiving Harm Free Care (taken direct from the National Safety Thermometer website). Acute Harm Free Care Community Harm Free Care WAHT UHB NBT Acute Average NSCP BCH Sirona Community Average AWP Harm Free Care AWP Average 92 51

52 March April May June July August September October November December January February March April May June July August September October November December January February % % March April May June July August September October November December January February March April May June July August September October November December January February % % BNSSG Safety Thermometer Acute NEW Harm NEW Harms in Acute Trusts Acute New Harms - UHB WAHT UHB NBT Acute Average Pressure Ulcers Falls with harm Catheters and New UTI VTE All Acute Average Acute New Harms - WAHT Acute New Harms - NBT Pressure Ulcers Falls with harm Catheters and New UTI VTE Pressure Ulcers Falls with harm Catheters and New UTI VTE 0 All Acute Average 0 All Acute Average 52

53 March April May June July August September October November December January February March April May June July August September October November December January February % % March April May June July August September October November December January February March April May June July August September October November December January February % % BNSSG Safety Thermometer Community NEW Harm 'New' Harms Community Providers Community New Harms BCH BCH NSCP Sirona All Average Pressure Ulcers Falls with harm Catheters and New UTI VTE All Community Average Community New Harms NSCP Community New Harms - Sirona Pressure Ulcers Falls with harm Catheters and New UTI VTE Pressure Ulcers Falls with harm Catheters and New UTI VTE 0 All Community Average 0 All Community Average 53

54 March April May June July August September October November December January February % BNSSG Safety Thermometer Mental Health Harm Free Care and Adult Ward NEW Harm AWP All New Harms AWP ALL Average 0 New Harm that was highlighted the BNSSG area was from Laurel ward in the Callington Road facility in Bristol and Cove ward in Long Fox Unit, North Somerset who both recorded Falls with Harm. Both wards are Later Life mental health units. The Matron from Long Fox Matron is formulating a falls action plan to share with the CCG. 54

55 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 BNSSG Workforce Information Staff Sickness / absence A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Percentage of staff sickness / absence 4% 4.59% 4.10% 4.10% 4.30% 4.12% 4.40% 4.50% 4.50% 5.10% 5.17% UHB Percentage of staff sickness / absence 4% 3.90% 3.70% 3.80% 3.80% 3.80% 3.70% 4.60% 4.80% 4.90% 5.00% 4.50% WAHT Percentage of staff sickness / absence 4% 4.40% 3.65% 3.30% 3.70% 3.90% 3.70% 3.70% 3.70% 4.40% 3.80% Staff Turnover A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Percentage staff turnover (rolling 12 months) 12% 9.8% 10.3% 15.4% 15.3% 15.4% 15.5% 15.4% 15.4% 15.5% 15.5% 15.2% UHB Percentage staff turnover (rolling 12 months) 11% 13.6% 13.3% 13.1% 13.4% 13.2% 13.3% 13.1% 12.7% 12.7% 12.4% 12.5% WAHT Percentage staff turnover (rolling 12 months) 12% 13.4% 13.0% 12.4% 12.4% 12.3% 12.6% 13.0% 12.9% 13.5% 13.5% 6% 5% 4% 3% Staff Sickness / absence 18% 13% 8% Staff Turnover NBT UHB WAHT Target NBT UHB WAHT Target 55

56 Vacancy Rate A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Vacancy rate (%) N/A 6.50% 8.91% 10.00% 10.30% 10.50% 9.30% 9.13% 8.91% 9.73% 9.13% 9.51% UHB Vacancy rate (%) 5% 3.8% 4.7% 5.3% 6.0% 5.5% 4.9% 4.9% 4.6% 4.6% 4.7% 4.6% WAHT Vacancy rate (%) (nursing) N/A 4.75% 5.18% 5.76% 5.48% 6.95% 3.80% 7.12% 7.05% 8.57% 9.51% 9.77% NBT Vacancies as whole time equivalents N/A UHB Vacancies as whole time equivalents N/A WAHT Vacancies as whole time equivalents (nursing) (%) N/A 20.88% 22.83% 25.51% 24.27% 31.26% 30.33% 31.75% 31.46% 37.55% 43.92% 45.12% Targets are not stated except for UHB vacancy rate. Vacancy rates as a whole in NBT and UHB appear stable, whilst WAHT appears to be increasing. Vacancy Rate (%) Vacancies as whole time equivalents 12% 10% 8% 6% 4% 2% NBT UHB WAHT NBT UHB 56

57 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Apr-16 May- Jun-16 Jul-16 Aug- Sep-16 Oct-16 Nov- Dec- Jan-17 Feb-17 Staff Appraisals A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Percentage of staff having had an annual appraisals (rolling 12 months) (non-medical) 90% 58.6% N/A 25.0% 63.0% 60.5% 55.0% 52.0% 55.0% 57.0% 56.0% 57.0% UHB Percentage of staff having had an annual appraisals (rolling 12 months) 90% 83.9% N/A 84.9% 85.1% 85.3% 84.9% 86.5% 87.1% 85.5% 85.5% WAHT Percentage of staff having had an annual appraisals (rolling 12 months) 85% 86.7% 85.5% 85.9% 81.8% 80.5% 77.9% 82.3% 82.1% 81.3% 80.8% Percentage of staff receiving appraisals has been below target since June Information Governance Training A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17 Org Indicato r T arget Value Value Value Value Value Value Value Value Value Value Value Value DoT NBT Percentage of staff completing information governance training N/A 85.1% 85.1% 76.6% 76.7% 75.7% 70.2% 69.5% 73.5% 76.1% 72.3% 76.7% UHB Percentage of staff completing information governance training N/A 97.0% 58.0% 65.0% 65.0% 70.0% 70.0% 76.0% 73.0% 76.0% 76.0% 77.0% WAHT Percentage of staff completing information governance training 90% 77.6% 78.4% 78.1% 80.3% 77.9% 77.3% 77.5% 75.5% 73.7% 70.5% 67.6% Information Governance training is consistently below 80% across the acute trusts which is below target for WAHT and the target unstated for UHB and NBT. 100% 80% 60% 40% 20% Staff Appraisals 100% 50% Information Governance Training NBT UHB WAHT Target NBT UHB WAHT Target 57

58 Exception Reporting Acute Services: UH Bristol, WAHT and NBT 58

59 UH Bristol Fractured Neck of Femur February 2017 The Issue Performance for fractured neck of femur (FNF) improved this month (61.9%) however remains below the best practice tariff standard (90%). Time to theatre within 36 hours performance was 81%. The Trust advise that this was due to lack of theatre capacity (1), complex hip fractures requiring specialist surgeon (2) and not prioritised over another clinically urgent case (1). Six patient did not receive an ortho-geriatrician review due to sickness and the clinician being required to cover the Older Persons Unit. Provider Actions The Trust has advised that the posts for the middle grade ortho-geriatric support, specialist fracture nurse and physiotherapist have been put on hold pending completion of the business case of investment to service following the British Orthopaedic Association report and recommendations. The Trust has submitted proposals to split the wards into one elderly trauma and fractured neck of femur ward and one young trauma and elective ward. Assurance & CCG Response Fractured Neck of Femur performance against the best practice tariff is monitored by Bristol CCG through the Quality Sub Group The CCG will continue to review performance with the expectation that this will improve UH Bristol has shared the work arising from the British Orthopaedic Association Review into the BNSSG group looking at FNF. The longer term solution for FNF sits within the MSK work stream Recovery timescales Ongoing since Data Source: UH Bristol Quality & Performance Report (March 2017) 59

60 WAHT Mortality The Issue The Dr Foster Summary Hospital-level Mortality Indicator (SHMI) remains a concern however a slight improvement is noted. The Trust data suggests continued stabilisation and some marginal improvement in the mortality indicators for the second quarter Q = 115 Provider Actions The Trust have shared two action plans The Mortality Reduction Plan and Ensuring Effective Learning from Mortality Reviews, which have been accepted by the CCG. These will be monitored through the monthly Quality Sub Group. There are two external reports outstanding that consider the # Neck of Femur pathway and the Management of Colorectal patients. Compliance in time to surgery has improved month on month. Assurance & CCG Response Following a review of the two action plans and discussion at the recent Quality Sub Group and ICQPMB meetings on 9 March 2017, the CCG are not assured and have concerns regarding changes to the plans, the latest version having changed in many areas from the plans agreed, and areas that were previously on track have been changed to now be at risk. A CPN was issued in March and an updated position has been requested. Recovery timescales Time-Frame to achieve as in Action Plans. WAHT Oct- 15 Nov- 15 Dec- 15 Jan- Feb Mar- 16 Apr- 16 May- 16 Dr Foster Data National guide <100 <100 <100 Jun

61 WAHT 4 Hour ED Performance The Issue 4 hour Emergency Department (ED) performance has continued to underperform against and the national standard which is not expected to be achieved during 2016/17. Performance for December was 66% with a further decline to 63% in January. Provider Actions Continued implementation of an agreed plan with phasing of initiative, as part of the Emergency Care Improvement Project. This combines the actions required of the Trust by the BNSSG ED Delivery Board and includes work plans for an ED Clinical streaming pilot commissioned by NHS England to improve patient flow at the front door. Evaluations are currently underway. The Trust have provided an updated Remedial Action Plan (RAP) linked to the national reset actions, with new trajectories for 4 hour performance in response to the Exception Report letter issued by the CCG on 20 December Daily Alamac calls continue across BNSSG care providers and commissioners. Assurance & CCG Response Daily Green to Go (G2G) meetings continue to take place with care navigators and brokerage teams having a consistent presence. A continual regular review of information that clearly identifies blocks and any Commissioning gaps are identified. A new BNSSG governance structure is now in place with clear lines of accountability for working groups. NSCP and WAHT Integrated Discharge Teams take forward further system actions as they are highlighted. NHS England has set a national target for all Acute Trusts to achieve 90% for ED performance by the end of the week commencing 27 March 2017; a trajectory has been set for WAHT that is being monitored by the Urgent Care control centre. Recovery Timescales Daily monitoring plus an STP trajectory to achieve 93% by March is in place but has not been achieved since June 2016.er Timescales 61

62 WAHT Out Patient Pending List The Issue The Trust have been unable to provide the continual requested monthly assurance that the Out Patient pending list is being addressed as numbers continue to grow. The Trust have been unable to confirm the current size of the backlog pending list and the risk involved. Provider Actions Providing clarification on numbers up to the end of February 2017 inclusive of all backlog figures according to each specialty demonstrating clinical validation used. Providing assurance as to no patients have been harmed due to the delays. Confirmation of entry onto the Trusts strategic risk register. The Standard Operation Procedure (SOP) is implemented to prevent re-occurrence of a backlog. Assurance & CCG Response Following the second CPN which was issued in March 2017 the CCG have requested a RAP inclusive of an Assurance improvement trajectory by specialty from the Trust to be provided. Recovery timescales A full review will take place at the Quality Sub Group in April and then monthly review of progress actions to continue at Quality Sub Group/ICQPMB meetings. 62

63 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 % WAHT VTE The Issue VTE Risk assessment had previously shown a gradual improvement in December of 70.22% but decreased in January to 60.52% compliance. Provider Actions A new VTE clerk has been appointed in the Trust which should ensure continuity and resilience for reporting with manual data collection from ward areas. The leadership and governance of the process will move to the Critical Care and Resuscitation Committee in order to integrate the VTE assessment with other clinically led documentation. Following the CPN issued in December there is an action plafollowing the CPN issued in December there is an action plan in pe which is monitored at the QPSG and the Trust have provided a trajectory to achieve the 95% compliance r Assurance & CCG Response Following the CPN issued in December and a second one issued in March there is an action plan in place which is monitored at the Quality Sub Group and the Trust have provided a trajectory to achieve the 95% compliance rate by April Due to a fall in performance in January an explanation of remedial actions being taken and progress on the action plan is required. Recovery timescales Monthly trajectory s shared with a goal to reach 95% compliance by the end of April % 80.0% 60.0% 40.0% WAHT VTE Compliance VTE Trajectory 63

64 WAHT E-Discharge Letters The Issue NSCCG have raised a concern due to the Trust being unable to meet contractual requirements to issue a discharge letter for every patient within 48 hours. Incidents continue to be reported from GP s pertaining to discharge letters, onto the CCG DATIX system and remains one of the leading themes. Provider Actions E-discharge committee meetings are undertaken at the Trust on a monthly basis. E-Discharge Action Plan has been developed and is reviewed monthly. The Trust report limitations of their Cerner Millennium computer system as a reason for poor compliance. Assurance & CCG Response Following the CPN issued in December there is an action plafollowing the CPN issued in December there is an action plan in p which is monitored at the QPSG Following the second CPN issued in March 2017 the CCG have requested RAP and an improvement trajectory from the Trust. The CCG have also written to the CEO at the Trust seeking assurance that the Trust Board is sighted on this issue.. Assurance. Recovery timescales Awaiting trajectory and RAP. 64

65 WAHT Serious Incidents The Issue There is a backlog of SI`s open on the STEIS reporting system. The CCG are required to provide assurance to ensure that learning from the root cause analysis investigations has taken place Trust-wide. Progress was noted in the March Quality Sub Group. Provider Actions The Trusts Internal Governance structure has changed with a Governance lead for each directorate been allocated to assist in obtaining the assurance of learning from SIs and to ensure that reporting compliance is in line with national guidance. A review continues of all open cases with the support of the CCG to obtain the required assurance to close cases. Meetings are held every two weeks with the CCG either in person or by phone. From February there will be two SI panels per month to reduce the backlog of SI`s. The Trust have a SI Management Plan in place which was created in December. The Never Event reported in January is under investigation and will be used as a learning event for Junior Doctors. Assurance & CCG Response The CCG are working closely with the Trust with meetings arranged every two weeks to review progress and obtain the necessary assurance Assurance as to the learning and embedding of the learning from SI s. Monitoring of the Trust-wide Improvement Plan. Recovery timescales To close backlog on STEIS as per action plan. 65

66 January February March April May June July August September October November December January % January February March April May June July August September October November December January % WAHT Staff Training/Appraisal Data The Issue It is highlighted that key Mandatory Training for staff remains non-compliant as shown in graph below. Annual Appraisals are also non-compliant with a steady decline from 82.3% in October 2016 to 80.8% in January against an 85% trajectory. Provider Actions A breakdown as per directorate has been requested to show how the Trust are planning on compliance improvements The quality of appraisals is being reviewed by the Trusts. Human Resource Advisors in March and April 2017 to identify where improvements can be made with managers to improve on compliance and standards % 90.00% 80.00% 70.00% WAHT Staff Training Stat/Man General Dementia Information Gov Trajectory Assurance & CCG Response An action plan detailed per directorate to improve staff training figures with trajectory on how this will be achieved will be presented at the April Quality Sub Group. Recovery timescales Assurance 90.0% 88.0% 86.0% 84.0% 82.0% 80.0% 78.0% 76.0% 74.0% 72.0% WAHT Annual Staff Appraisals Apprasials Trajectory Monthly monitoring at Quality Sub Group meetings and monitoring of action plan on receipt. 66

67 NBT - MRSA Remedial Action Plan The Issue The number of MRSA Blood Stream Infection cases reported by NBT remains at six, the last reported case was in January A CPN was issued to the Trust in November 2016 and a RAP has been approved by the CCG and NHS Improvement. Provider Actions NBT is implementing the MRSA RAP devised from key learning from each case with a focus on screening and the management of indwelling devices (in particular vascular catheters and cannulae). The NBT Infection Control Team will be linking and working with the Director of Public Health to work towards reducing the incidence of MRSA Bacteraemia. Assurance & CCG Response The CCG s Director of Nursing and Quality has met with South Gloucestershire s Director of Public Health to discuss providing the Trust with further support to deliver the action plan. The implementation, progress and completion of the RAP will be monitored by the CCG via the Quality Sub Group. Recovery timescales Assurance NBT Attributed MRSA cases 2016/17 Sept Oct Nov Dec Jan Feb YTD Recovery is expected by 31 March Data Source: NBT IPR 67

68 NBT - Never Events Remedial Action Plan The Issue NBT has reported five Never Events for the year to date 2016/17. A CPN was issued to the Trust in November 2016 in response to the Trust s failure to ensure Never Events do not occur. Provider Actions NBT has submitted a RAP in the form of a Driver Diagram to the CCG for approval; this has now been approved by the CCG. Assurance & CCG Response The CCG has requested the final Action Plan and completed observational audits identified within the Action Plan to be submitted to the Quality Sub Group for review. The CCG has also requested the Stop Before You Block SOP along with feedback from the Trust s visit to NHS Plymouth. NHS Improvement will be carrying out a follow up visit. NBT Never Events 2016/17 Recovery timescales Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb YTD Recovery is expected by 31 March Data Source: NBT IPR / STEIS 68

69 NBT - Administration Backlog The Issue Issues have been raised with Bristol and South Gloucestershire CCGs by GP Practices around the delays in receiving discharge letters following outpatient consultations. The issues relate to the quality and timeliness of the discharge summaries and delays in the receipt of discharge letters following outpatient consultations at NBT. Provider Actions Following a request from the CCG, NBT is to devise an improvement plan to include internal targets, targets currently being met by NBT and how improvement will be achieved against trajectory. The NBT GP Liaison Officer will undertake a review to establish the nature and extent of the administration issues within the Trust. Both the quality and timeliness of correspondence will be addressed in relation to discharge summaries and outpatient clinic letters. Assurance & CCG Response The CCG has requested a Trust-wide action plan to address the timeliness and quality of correspondence with Primary Care colleagues. The CCG will continue to monitor NBT s administrative turnaround times via the Quality Sub Group. Recovery timescales Recovery is expected by 30 April

70 NBT - Complaints Management The Issue The number of overdue complaints has reduced from 42 in January down to 26 in February Of the cases closed in February 2017, 73% of them were completed within the agreed timescale; the target is 90%. Provider Actions NBT continues to work at reducing the number of overdue complaints at any one time and have devised an improvement plan for complaints management with the Head of Patient Experience focusing on overdue complaints. NBT is confident in continuing to improve its position on overdue complaints and aim to reduce this number further to below 10 by the end of April NBT anticipate that the introduction of the Datix system later this year will help sustain improvement. Assurance & CCG Response The CCG has requested an improvement action plan be presented to the Quality Sub Group. The CCG will continue to monitor NBT s management of complaints via the Quality Sub Group. Recovery timescales Recovery is expected by 31 March Data Source: NBT IPR 70

71 NBT - Gastroenterology Surveillance The Issue NBT were highlighted as failing the six week diagnostic target and had a significant Endoscopy surveillance recall backlog. This backlog was attributed to an ineffective recall process employed by the Trust. A RAP was developed in response to the backlog and is currently being implemented. Provider Actions The Trust has reviewed its recording systems and processes and all information is now recorded on PAS. The Trust is currently on track to meet the improvement trajectory outlined in the RAP and the backlog should be cleared by the end of March The Trust has confirmed that all affected patients have been reviewed and those requiring treatment have received it. Assurance & CCG Response The CCG has requested NBT provide assurance that each case has been clinically validated and patients are being reviewed with appropriate clinical action taken where required. The implementation, progress and completion of the RAP will be monitored by the CCG via the Quality Sub Group until completed. The Cancer Working Group will ensure patients are not managed off the system. Recovery timescales Assurance Recovery is expected by 31 March Data Source: NBT IPR 71

72 NBT - Friends and Family Test (FFT) The Issue The FFT response rates for Inpatients and the ED remain below target with the latest figures (January) from NHSE reporting 22% response rate for Inpatients and a 13% response rate for the ED. Provider Actions NBT has provided a verbal report of improvement in the response rates for inpatients and the ED for the month of February 2017 through the Quality Sub Group. NBT s Head of Patient Experience is looking at Directorates which are performing well with FFT in order to replicate good practice throughout the Trust to further improve the response rate. Assurance & CCG Response FFT Response Rates for Inpatients and ED July 16 January 16 NB NHSE data 2 months in arrears The CCG will continue to monitor FFT via the Quality Sub Group. Recovery timescales Recovery is expected by 31 March Data Source: NBT IPR / NHSE/NBT Quality Sub Group 72

73 NBT Emergency General Surgery Review Update The Issue A review of Acute Trusts in the South West was published by the NHS South West Clinical Senate in February The aim of the review was to find out how Trusts deliver their Emergency General surgery service, to identify common themes relating to the delivery of the service and to identify areas of good and excellent practice in a set of standards and recommendations. All 14 Trusts in the South West were assessed on their performance against Emergency General surgery standards. NBT was found to be the second highest performing Trust though did not meet all the standards relating to 7 day working. Provider Actions The Trust will use the results of the Emergency General Surgery Review together with information from the next seven day working audit to determine actions to be taken. Data Source: NHS South West Clinical Senate. 73

74 Exception Reporting Mental Health: AWP and Local Mental Health Services 74

75 AWP Trust-wide Workforce The Issue Trust-wide statutory/mandatory training remains rated amber at 83.2% (below the threshold of 85%). Supervision is rated green at 86.1% (85% threshold). Appraisal remains rated red at 88.4% (below the threshold of 95%). Sickness remains rated red at 4.95% (threshold 4.6%). Safeguarding training rates: level 1 amber at 88%, level 2 amber at 81% and level 3 red and a further decrease at 72.4% (threshold 90%). S Glos level 3 training has dropped to 62% and North Somerset to 50%. The vacancy rate has increased and is reported at 7%. Trust-wide turnover remains unchanged and is reported at 14%. Agency/temporary staff usage shows a slight increase this month from 25% to 27% at Trust-wide level. Provider Actions The Trust reports that action plans are in place. Any measure rated red for 2 or more consecutive months will be reviewed via the Performance meeting and reported to commissioners via the Quality Sub Group. Assurance & CCG Response The CCGs are monitoring monthly via the Quality Sub Group and locality meetings with the expectation that this will improve. Recovery timescales Issue Highlighted April Recovery is expected in June Month 8 (Nov 2016) % Trust wide Bristol CCG (RBP) S Glos CCG North Somerset CCG Appraisal rate Supervision rate Sickness rate Statutory/mandatory training rate Vacancy rate Turnover rate Agency/temp staff x No data this month X No data this month Safeguarding AWP training rate - level VCS Safeguarding training rate - level AWP 93.5 VCS Safeguarding training rate - level AWP 87 VCS Source: AWP IPR Board paper 75

76 AWP Rapid Tranquilisation The Issue Clinical practice relating to management of patients requiring rapid tranquilisation continues to be monitored with recording of physical health measures showing an improvement against trajectory this month. Clinical practice relating to use of restraint/restrictive practices is monitored monthly since high levels of the use of restrictive practices and physical restraint were reported in September Guidance recently published reiterates that face down restraint should not be used. There is a query as to whether the restrictive practice information links in any way to the lower levels of training (Prevention and Management of Violence and Aggression - PMVA) which has been rated red for 6 + months); assurance from AWP is pending. Provider Actions AWP will update the Quality Sub Group regarding the Trust s policies and procedures and use of this practice with a written report in April The Trust has action plans in place. Assurance & CCG Response The CCGs are monitoring monthly via the Quality Sub Group and locality meetings with the expectation that this will improve. Recovery timescales Issue highlighted September Recovery is expected in June Source: AWP Clinical Executive Report Board paper 76

77 AWP CQC Update The Issue The Warning Notice relating to illegal detentions in the Place of Safety Units remains in place. Following the CQC inspection in May the CQC highlighted 21 Must Do and 33 Should Do actions and AWP have devised locality based quality improvement plans to address these with one overarching improvement plan for Trust-wide actions. The CQC has informed AWP they will revisit the Trust on 26 June 2017, particularly the 136 suites. There have been reported cases of s hour breaches (illegal detentions) reported in the interim, but such incidents are much reduced. Provider Actions An action plan is in place for the Place of Safety actions. The Trust have developed locality based improvement plans to address the Should Do and Must Do actions. All reported s136 detention breaches are subject to RCA investigation. Assurance & CCG Response The Quality Sub Group has taken over monitoring compliance with the CQC actions from March The Trust has shared their improvement plans with NHSI/NHSE and the CCGs. Monitoring will be monthly with the expectation that this will improve. The CQC has requested detailed pre inspection feedback from commissioners re all issues and in particular regarding the well led requirements. Recovery timescales Recovery is expected in March 2017 for the place of safety actions. Further improvements are expected over time via the Crisis Concordat Group (work with wider stakeholders) and as a result of implementation of the Acute Care Pathway Programme. Timescales for completion of the Should Do and Must Do actions will be incorporated within the improvement plans. Source: Quality sub group and StEIS database 77

78 AWP Bristol CCG Locality The Issue Callington Road issues there are concerns regarding the quality of care on the inpatient wards including AWPs response/lack of action following issue of coroner recommendations in There are also concerns regarding general staffing levels/skill mix all underpinned by lack of leadership at a local level. Provider Actions A meeting was held including Bristol CCG, CQC, LA and AWP colleagues on 23 March. Actions were agreed. AWP acknowledged current staffing challenge, but have recruited to the modern matrons posts and are nearly at their target of 50:50 qualified to unqualified staff. As this is a new structure the trust were requested to share the quality impact assessment for this change Trust re-establishing their training around supervision. Commissioners suggested a space for reflective practice was vital to developing a learning culture. Agreed to include service user monitoring on the later life wards and to share with CQC as part of the are services responsive? domain. Assurance & CCG Response Agreed that LA safeguarding, commissioning and quality to all share information so there was a global view of what Commissioners was happening. have been meeting regularly with Laurel ward staff to agree discharge planning processes. Future management of the work around inpatient wards will come to the Bristol Quality/LCQPM meeting and the group can consider widening to include LA safeguarding in the discussions. Recovery timescales Issue highlighted February Recovery is expected in June Source: CQC, LA, StEIS database 78

79 Exception Reporting Community Services: BCH and Sirona 79

80 BCH Friends and Family Test (FFT) The Issue FFT response rates for the Walk in Centre (3.4%) and the Urgent Care Centre (12.1%) have declined further for the month of January and are not in line with the improvement trajectory target of 14%. The walk in centre is of particular concern with figures significantly below target demonstrating that FFT is not embedded practice within the service Provider Actions The PPE team are working with staff in the Walk in Centre to improve results All staff have been briefed on the targets and results and have been reminded of the importance of collecting this information. Assurance & CCG Response Bristol CCG has requested that an action plan is completed to address the poor response rates. The action plan will be monitored through the IQPM. Recovery timescales T March Data Source: BCH monthly Assurance Report 80

81 BCH Pressure Ulcers The Issue BCH reported 63 pressure ulcers this month, a reduction on the 112 reported in December. Four Grade 3 pressure ulcers were reported as Serious Incidents on STEIS. 72 hour reports have been received and 2 cases have been closed on receipt of the 72 hour report and the other 2 cases are currently undergoing a full RCA. Provider Actions The Tissue Viability Nurse reviewed 17 pressure ulcer incidents of which 12 were reported to have been identified correctly and a further 5 were re-categorised as moisture lesions or friction wounds. BCH reported that the Wound Care Team have been providing training to all community nursing teams to support nurses in correctly identifying and managing pressure ulcers and have commenced the training of the final three teams this month. BCH are developing a web page and leaflets for patients to help support the public in the prevention of pressure ulcers Assurance & CCG Response Pressure ulcers are monitored at the monthly Quality Group by Bristol CCG. BCH is a member of the Pan Bristol Pressure Ulcer Strategy Group. Bristol CCG agreed a CQUIN for 2016/17 to support the improvement in pressure ulcers. Pressure Ulcers December 2016 January 2017 February 2017 Total all grades Grade Grade Grade Grade Recovery timescales Ongoing Data Source: BCH monthly Assurance Report 81

82 Sirona Thornbury Inpatients FFT February 2017 The Issue The FFT response rate for Thornbury inpatients reduced to 5% in February, from 33% in January Provider Actions Sirona has advised that the variance in inpatient FFT response rates at Thornbury is due to the timing in the month that the response cards are collected and collated. Sirona has advised that the yearly average is taken in order to determine the FFT response rate. Therefore the average over the last 7 months (Aug 16 to Feb 17) is 34.5%. Assurance & CCG Response The CCG will continue to monitor all FFT response rates via the Quality and Performance meetings. FFT Response Rates Thornbury Inpatients August 16 February 17 Recovery timescales Recovery is expected by 31 March Data Source: Sirona s South Gloucestershire Performance Report 82

83 Sirona - Pressure Ulcers The Issue The incidence of community acquired grade 2 pressure ulcers has reduced to 26 in the month of February; this compares to 33 reported in January Two grade 3 pressure ulcers were reported in February Provider Actions Sirona attend the BNSSG-wide Pressure Ulcer Steering Group and are working to reduce the incidence of pressure ulcers. A full Root Cause Analysis (RCA) will be carried out for the two grade 3 pressure ulcers. Assurance & CCG Response The CCG monitors Sirona s incidence of pressure ulcers via the Sirona Performance Meetings. The CCG attends the BNSSG Pressure Ulcer Steering Group. Sirona Community Acquired Grade 2 Pressure Ulcers August 2016 February 2017 Recovery timescales Recovery is expected by 31 March Data Source: Sirona s South Gloucestershire Performance Report 83

84 Sirona - Thornbury Hospital Cleaning The Issue The cleaning standard at Thornbury Hospital has increased to 93%; an improvement towards the 95% target. Provider Actions Sirona have implemented the Cleaning Improvement Action Plan and are monitoring this going forward. Sirona s Head of Service is working with the Ward Manager and Facilities team to ensure further improvement continues and the 95% target is reached. Assurance & CCG Response The CCG will continue to monitor Thornbury Hospital s cleaning rates via the Quality and Performance meetings. Thornbury Hospital Cleaning Rates August 2016 February 2017 Recovery timescales Recovery is expected by 31 March Data Source: Sirona s South Gloucestershire Performance Report 84

85 Exception Reporting Urgent Care: BrisDoc, SWAST and Care UK NHS

86 SWAST - Performance The Issue Purple (previously known as Red) performance Trust-wide for SWAST continues to be a challenge in February 2017 as it is for other Ambulance services during the Winter period. February performance of Purple responses within 8 minutes, in the Bristol area, was 82.73%, which is above SWAST s target of 75%. February performance of Purple responses within 8 minutes, in the South Gloucestershire area, was 78.17%, which is above the target of 75% and is a noticeable increase from the previous month. February performance of Purple responses within 8 minutes, in the North Somerset area, was 79.72%, which is above SWAST s target of 75% and a slight decrease on the previous month. There continues to be an improvement in performance for Category 1 in the more urban areas. Provider Actions Work is ongoing work to look at current rota provision and changes in the Rapid Response/ Double Crewed Ambulance (RRV/DCA) mix. Work continues with NHSE and Sheffield University evaluating the ARP project a further meeting is arranged for May Assurance & CCG Response SCWCSU/CCGs continue to review at the bi-monthly IPQMG meetings. Recovery timescales Ongoing. 86

87 SWAST Handover Delays The Issue Handover delays continue to be a challenge for SWAST. The total handovers taking more than 15 minutes at the Bristol Royal Infirmary in February 2017 was 707, with hours resource lost due to these delays, this is a decrease on the previous months figures. The total handovers taking more than 15 minutes at Southmead Hospital in February 2017 was 642, with 81.8 hours resource lost due to these delays. This is an improving picture from January s figures. The total handovers taking more than 15 minutes at the Weston General Hospital in January 2017 was 372, with 61.1 hours resource lost due to these delays. This figure has improved from last month. Provider Actions SWAST, Commissioners and SCWCSU discuss these delays at the IQPMG. Assurance & CCG Response SCWCSU/CCGs continue to review at the bi-monthly IPQMG meetings. Recovery timescales Ongoing. 87

88 SWAST Staff Sickness, Turnover and Appraisals The Issue Sickness was 5.99% for February 2017 and 5.24% year to date, a slight decrease from January (6.04%). Turnover is at 13.48% in February 2017, a marginal increase from January (13.17%). To date the percentage of appraisals completed is 74.05% against the target of 85% for the year, showing steady improvement. Provider Actions SWASFT management continue to monitor and manage sickness; the staying well service is supporting those individuals identified as suffering from muscular-skeletal injury or mental health related illnesses. The Trust continues to monitor the declining level of turnover seen over the past few months. Following on from previous months there continues to be a significant focus to complete overdue career conversations. Alternative methods for ensuring these are completed such as the use of overtime are being considered. There has been a drive in the North hub to ensure that those which work part-time still receive a timely appraisal. Assurance & CCG Response SCWCSU/CCGs continue to review at the bi-monthly IPQMG meetings. Recovery timescales Ongoing. 88

89 SWAST Serious Incident Themes February 2017 The Issue Monitoring of the serious incident themes within SWAST SIs are Spinal management and No Clinical Decision in Isolation, continues via the IQPMG. Two other potentially developing themes, namely Staying on the line and Hub Resourcing/Audit Prioritisation have been discussed with the Deputy Clinical director as well as Explicit Consent. Adherence to Non-Conveyance policy has also been noted as a potential theme and SCWCSU are in discussion with the Trust regarding this. It has been noted that delays have been evident on cases which necessitate a time sensitive response (CVE & MI) and further evaluation of these is underway against the backdrop of ARP. Provider Actions The Trust is currently undertaking it s first concise RCA investigation after previous agreement with commissioners. Consideration for a presentation on the ACQIs by the Audit team of SWAST at the next Quality Workshop to be set up for May Assurance & CCG Response SCWCSU is to meet with Deputy Clinical Director at SWAST on 24 March, as this is the first available date to discuss these issues. SCWCSU are organising a meeting to North Hub to look at the 999 call audit process. Being organised for April 2017 post the move to St. James North. Recovery timescales Ongoing. 89

90 Care UK NHS 111 Performance The Issue Ambulance dispatch rates improved from 10.6% in January to 10.4% in February (against the 10% target). Warm transfer performance is at 33.1%. This is affected by the clinical prioritisation model operated locally which ensures that clinical resource is prioritised according to patient acuity (ensuring patient safety). However, Care UK NHS 111 continues to perform well for combined clinical contact (warm transfers plus call backs in 10 minutes) at 74.9%. Ninety five percent of calls answered within 60 seconds was below target (93.4% for BNSSG). This has been attributed to increases in call handling times due to the ED validation line and a new cohort of health advisors becoming operational. Provider Actions The ambulance validation line continues to be operational 7 days a week. Individual ambulance dispatch rate performance is discussed with staff in one to ones and addressed in staff development plans where appropriate. Training sessions have been put in place to develop staff skills in Probing relating to the red triggers in Pathways to reach safe and appropriate outcomes for patients. Care UK NHS 111 report that clinical training days are in place to improve management of urgent conditions and understanding of alternative pathways to ED. The ED validation line will operate more frequently during peak times in Q4, staffed by agency clinicians. Latest figures suggest that of those calls validated, circa 70% are redirected to an alternative service. However, the total number of calls validated is small as this is a very resource intensive model. Assurance & CCG Response The CPNs for ED referrals and ambulance referrals remain open. The associated action plans are monitored monthly. Ambulance referral rates remain broadly flat, but we are seeing a reduction in referral rates for ED. Care UK NHS 111 perform in line with national average for ambulance and ED referral metrics. CQUIN payments are adjusted accordingly for the underperformance for ED referrals and ambulance referrals, in line with the contract. Commissioners have suggested that Care UK NHS 111 liaises with Healthwatch to obtain an independent review of its services. Recovery timescales Care UK NHS 111 is showing positive progress, but there is no definitive timescale for performance improvement as this is heavily dependent on clinical workforce. 90

91 Care UK NHS 111 Workforce The Issue Health Advisor (HA) staffing levels are good (75.8 WTE) against an establishment of 115 WTE, a small deterioration on the previous month. Clinical Advisor (CA) staffing levels remain low, with the Bristol call centre operating at WTE against a clinical establishment of WTE. Staffing levels for clinicians remain broadly static despite provider actions to increase applications. It should be noted that this is the best staffing level reported in 12 months and despite the clinical shortfall, Care UK performs well for the combined clinical contact metrics. Provider Actions A new rota has been implemented with improved work patterns, aimed at making roles more attractive. A Recruitment Partner is focusing on South West clinical recruitment, including attendance at recruitment fairs. The Care UK Network offers additional resilience i.e. clinicians from other sites are able to handle calls where required and demand is managed on a real time basis by The Bridge Team (commended by the CQC in their inspection report). Home working posts are being advertised nationally. The clinical prioritisation model in operation locally ensures that clinical resource is prioritised according to patient acuity. A clinical referral bonus is in place. Due to the workforce being predominantly part time, the provider is able to flex its existing workforce through overtime as appropriate, or agency staff for clinicians. Assurance & CCG Response Commissioners continue to monitor workforce planning at the monthly IQPMB. Recovery timescales There is no specific recovery timescale, but Care UK NHS 111 is working to meet its clinical establishment as soon as possible. 91

92 BrisDoc The Issue The Quality report provided minimal assurance this month. The BrisDoc quality lead was not at the IQPM and therefore a meeting is being set up to review the quality reporting in light of the changes made to the report during 2016 and the agreement of the new Quality Schedule for 2017/18. Provider Actions BrisDoc will report against the new quality KPI and items agreed within the new Quality Schedule from April BrisDoc produce a monthly quality & performance report that is discussed at the monthly meetings with commissioners. Assurance & CCG Response Commissioners discuss quality performance at the monthly contract meetings. Bristol CCG is meeting with BrisDoc Head of Quality to review the quality report. Recovery timescales May

93 Patient Advice and Liaison Service (PALS) 93

94 Summary of PALS activity in February 2017 for BNSSG CCGs In February 2017 a total of 119 new cases were recorded. BNSSG PALS contacts by type February Top five areas: Acute services access less of an issue than previously with more contacts regarding admin and clinical treatment. Mental health admin - predominantly in Bristol, with many people calling PALS in error wanting to make an appointment with Improved Access to Psychological Therapies. Primary care a significant number of people needing signposting to their local practice or NHS England to raise concern mainly about poor admin processes. Funding four enquiries about IVF funding and the others requiring advice and/or information regarding applications for funding and/or appeals. Commissioning concerns raised regarding gluten free prescribing consultation, carers access to healthcare, maternity care and diabetes education. Compliments There were seven compliments received in the month; all were about PALS. 94

95 Acute services contacts by provider February Out Of Area 12% Hospital Outside Area North Bristol NHS Trust University Hospitals Bristol Cumulative figures for 2016/17 South Gloucestershire CCG 37% North Somerset CCG 7% Bristol CCG 44% 95

96 Serious Incidents 96

97 BNSSG Serious Incidents Overview - March 2017 March 2017 Summary UH Bristol reported 5 SIs involving 2 Bristol patients, 2 North Somerset patients and a South Gloucestershire patient. WAHT reported 13 SIs. NBT reported 8 SIs involving 2 Bristol patients, 1 North Somerset patients and 4 South Gloucestershire patients (1 Wiltshire). BCH reported 3 SIs. NSCP reported 0 SIs. Sirona reported 1 SI. AWP reported 9 SIs involving 6 Bristol patients, 2 North Somerset patients and a South Gloucestershire patient. SWAST reported 1 SI concerning a Bristol patient. St Peter s Hospice (SPH) reported no SIs. Care UK NHS 111 reported no SIs. BrisDoc reported no SIs. Spire reported 1 SI concerning a Bristol patient BNSSG SIs March 2017 Themes Even though 12 Hour Trolley Breaches was a theme across the BNSSG area in 2017, the number of incidents have decreased further over the last month, with March s numbers accounted for 3.85% of all acute SIs reported. There was only one incident involving a total of 2 patients, 93.5% drop from last month. 97

98 UH Bristol Summary Within March 2017, UH Bristol reported 5 SIs. These pertained to 2 diagnostic incidents, 1 surgical/invasive procedure, 1 pressure ulcer and 1 slips, trips and falls incident (see graph to the left below). These incidents concerned 2 Bristol patients, one patient from South Gloucestershire and two from North Somerset involved in the two diagnostic cases reported (see graph to the right below). This brings the total number of incidents for the year (from April 1st onwards) to 68 SIs Child Death Environmental Incident Medication Incident Pressure Ulcer Sub-optimal care for deteriorating patient Treatment Delay Diagnostic Incident Maternity Pending Review Slip, trips, and falls Surgical/Invasive procedure incident Trolley breach Bristol CCG South Gloucestershire CCG North Somerset CCG Other CCGs Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Compliance In March 2017, UH Bristol had a 100% compliance rate for reporting SIs with all 5 SIs being reported within the expected timeframe of 2 working days (in accordance to national policy). The Trust also achieved 100% compliance with 72 hour reports due in March, all being received within the deadline of 3 working days. From the beginning of April 2016 to date, the Trust s SI compliance stands at 96% for incident reporting and 78% for 72 hour report submissions. NB - monthly numbers are small which impacts on percentages Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

99 WAHT Summary Within March 2017, WAHT reported 13 SIs. These pertained to 1 reported 12 Hour Trolley Breaches (involving 2 patients), 6 pressure ulcers, 2 slips, trips and falls, 1 treatment delay, 1 sub-optimal care incident, 1 screening issue and 1 safeguarding child incident (see graph to the left below). These incidents concern 14 North Somerset patients (see graph to the right below). This brings the total number of incidents for the year (from April 1st onwards) to 124 SIs Compliance Safeguarding Child Screening Issue Surgical/invasive procedure incident Abuse/alleged abuse of adult patient by staff HCAI/infection control incident Maternity Medication Incident Pressure Ulcer Slip, trips, and falls Sub-optimal care for deteriorating patient Treatment Delay Trolley breach Unexpected Death (general) Unexpected Injury causing potential harm Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar In March 2017, WAHT had a 92% compliance rate for reporting SIs with 12 of the 13 SIs being reported within the expected timeframe of 2 working days (in accordance to national policy). The Trust achieved 58% compliance with 72 hour reports with only 5 of the 12 due in March being received by their expected deadline of 3 working days. There are 3 outstanding 72 hour reports due in March. From the beginning of April 2016 to date, the Trust s SI compliance stands at 95% for incident reporting and 36% for 72 hour report submissions Bristol CCG South Gloucestershire CCG North Somerset CCG Other CCGs Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

100 NBT Summary Within March 2017, NBT reported 8 SIs. These pertained to 3 treatment delays, 1 slips, trips and falls incident, 1 maternity, 1 medical equipment failure, 1 medication incident and 1 pressure ulcer (see graph to the left below). These incidents involved 4 South Gloucestershire patients, 2 Bristol patients, 1 North Somerset patients and 1 Wiltshire patient (see graph to the right below). This brings the total number of incidents for the year (from April 1st onwards) to 111 SIs Unexpected Injury causing potential harm Commissioning Incident Diagnostic Incident HCAI/Infection Control incident Maternal Death Maternity Medical equipment failure Medication Incident Pressure Ulcer Screening Issue Slip, trips, and falls Sub-optimal care for deteriorating patient Surgical/Invasive procedure incident Treatment Delay Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Bristol CCG South Gloucestershire CCG North Somerset CCG Other CCGs Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Compliance In March 2017, NBT had an 88% compliance rate for reporting SIs with 1 of the 8 SIs not being reported within the expected timeframe of 2 working days (in accordance to national policy). The Trust achieved 44% compliance with 72 hour reports with 4 of the 9 due during March being received by their deadline of 3 working days. From the beginning of April 2016 to date, the Trust s SI compliance stands at 84.7% for incident reporting and 52% for 72 hour report submissions. NB - monthly numbers are small which impacts on percentages. 100

101 BCH Summary BCH reported 3 SIs in March 2017 which pertained to pressure ulcers (see graph below). This brings the total number of incidents for the year (from April 1st onwards) to 39 SIs Medication Incident Sub-optimal care for deteriorating patient Pressure Ulcer Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Compliance In March 2017, BCH had 100% compliance rate for reporting SIs within the expected timeframe of 2 working days (in accordance to national policy). BCH had 75% compliance for 72 hour reports, with 1 of the 4 due in March still being outstanding. From the beginning of April 2016 to date, the provider s SI compliance stands at 95% for incident reporting and 74% for 72 hour report submissions. NB - monthly numbers are small which impacts on percentages. 101

102 NSCP Summary Within March 2017, NSCP reported no new SIs (see graph below). Therefore the total number of incidents for the year (from April 1st onwards) remains 24 SIs Confidential Information Leak Diagnostic incident Medication Incident Slip, trips, and falls Pressure Ulcer Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Compliance In March 2017, NSCP did not report any new SI s. The Trust achieved 100% compliance with 72 hour reports with one report due in March being received within the deadline of 3 working days. From the beginning of April 2016 to date, NSCP s SI compliance stands at 63% for both incident reporting and 72 hour report submissions. NB - monthly numbers are small which impacts on percentages. 102

103 Sirona Summary Within March 2017, Sirona reported 1 SI which concerned a South Gloucestershire patient. This pertained to a pressure ulcer incident (see graph below). This brings the total number of incidents for the year (from April 1st onwards) to 20 SIs. 4 3 Pressure Ulcer Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Compliance In March 2017, Sirona had a 100% compliance rate for reporting SIs with the one SI being reported within the expected timeframe of 2 working days (in accordance to national policy). Sirona also achieved 100% compliance with 72 hour reports with all reports due in March being received within the deadline of 3 working days. From the beginning of April 2016 to date, the provider s SI compliance stands at 100% for incident reporting and 90% for 72 hour report submissions. NB - numbers are small which impacts on percentages. 103

104 AWP Summary Within March 2017, AWP reported 9 SIs relating to BNSSG patients. These pertained to 5 apparent self-harm incidents, 2 violent behaviour incidents, a slip, trip or fall and a HCAI (see graph to the left below). These incidents concerned 6 Bristol patients, 2 North Somerset patients and a South Gloucestershire patient (see graph to right below). This brings the total number of incidents affecting BNSSG patients this year (April ) to 75 SIs Compliance Apparent/actual/suspected self-inflicted harm Abuse/alleged abuse of adult patient by staff Disruptive/ aggressive/ violent behaviour meeting SI criteria HCAI/Infection control Homicide by Outpatient Medication incident Other Pending Review Slip Trips & Falls Sub-optimal care of the deteriorating patient Unexpected Death Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar In March 2017, AWP had a 100% compliance rate for reporting SIs with all 9 SIs being reported within the expected timeframe of 2 working days (in accordance to national policy). The Trust achieved 73% compliance with 72 hour reports with 3 of the 11 due in March being received after their deadline of 3 working days. For the year , the Trust s overall SI compliance was 91% for incident reporting and 83% for 72 hour report submissions. AWP continue to have several RCA reports overdue and this is being followed up with both the Trust and Commissioners Bristol CCG South Gloucestershire CCG North Somerset CCG Other CCG Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

105 SWAST Summary Within March 2017, SWAST reported 1 SI relating to the BNSSG locality. This pertained to a treatment delay and concerned a Bristol patient (see graph to below). The total number of incidents affecting BNSSG patients this year (from April 1st onwards) is 10 SIs Bristol CCG North Somerset CCG South Gloucestershire CCG Other CCG Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Compliance In March 2017, SWAST achieved 100% compliance rate for reporting SIs with all SI s being reported within the expected timeframe of 2 working days (in accordance to national policy). The Trust had 100% compliance with 72 hour reports, with all 5 which were due, being received within their deadline of 3 working days. For the year , the Trust s SI compliance for incidents was 97% for incident reporting and 56% for 72 hour report submissions. NB - numbers are small which impacts on percentages. 105

106 Other Providers St Peter s Hospice (SPH) SPH have reported no SIs in March Therefore the total number of incidents, to date, in 2016/17 is 4. Care UK NHS 111 Care UK NHS 111 have reported no SIs in March Therefore the total number of incidents, to date, in 2016/17 remains 2. BrisDoc BrisDoc have reported no SIs in March Therefore the total number of incidents, to date, in 2016/17 remains 3. Spire Spire have reported 1 SI in March Therefore the total number of incidents, to date, in 2016/17 is

107 Areas for Future Development 107

108 The content of the BNSSG Quality Report will continue to evolve over the coming months to include standardised quality measures reflected within the Quality Schedules for 2017/19 which will allow the opportunity for benchmarking. Going forward the report will include new sections pertaining to AQPs and Safeguarding and will also explore SI themes. Other possible areas currently being discussed include the Children s Community Health Partnership and Care Homes. Consideration is also being given as to how the CCGs can quality assure other healthcare services pertaining to patients from the BNSSG area who receive care outside of the locality e.g. RUH. 108

109 Glossary UHB University Hospitals Bristol NHS Foundation Trust WAHT Weston Area Healthcare NHS Trust NBT North Bristol NHS Trust BCH Bristol Community Health NSCP North Somerset Community Partnership Sirona South Gloucestershire Community Services AWP Avon and Wiltshire Mental Health Partnership SWAST South West Ambulance Service NHS Foundation Trust 109

110 Finance Finance Month Creating the Healthiest Community Together