Agenda Item number: 8.1 Enclosure: 3. Discussion. Date reviewed. 22 nd September

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1 Board meeting date: 27 th October 2011 Agenda Item number: 8.1 Enclosure: 3 Title Quality Report Accountable Director: Authors(name & title): Maggie Bayley, Director of Nursing and Quality Dr Alastair Neale, Medical Director Maggie Bayley, Director of Nursing and Quality Peter Foord, Risk Manager; Tanya Kidson, Head of Infection Prevention and Control; Simon Savage, Clinical Audit Action required from the Board: Decision / Approval Gain assurance Discussion Information What other Trust Committee has considered this report? Committee Issues considered at Quality and Safety Committee Date reviewed 22 nd September Key points or recommendations Purpose of the report To provide a briefing to the Board on Quality and Safety Issues within the Trust and actions implemented to mitigate any risks Summary of Key Issues What are the key issues that the board needs to consider in this report? There has not been a Quality and Safety (Q&S) Committee since the last board meeting as the dates are being re-aligned to fit in with production of the performance dashboard. At the October meeting the Q&S committee will review the quality aspects of the performance dashboard content and agree the exception reports to go to the Board. There have been no mixed sex accommodation breaches reported There have been 4 serious incidents within the Community Trust in September, all of these relate to grade 3 or 4 pressure sores in patients cared for in their own homes/ nursing homes. There are plans to join the Safe Care Quality Innovation Productivity and Prevention (QIPP) work stream and work collaboratively with teams across the health economy to help tackle this harm No Never events have been reported by the Trust. The number of patient incidents has fallen for the second month running. The number of patient falls has increased on the previous month and is very slightly above average for the last 12 months. The number of pressure sores, both developed in Community Trust services and Patient transferred from other services is at the lowest level this year. Graph 1 shows incident trends by category for the last 12 months. Trust Board Quality Paper MB/AN/PF October, 2011 Page 1

2 The Regional Patient Experience Commissioning for Innovation and Quality baseline questionnaires has been issued, returned and analysed. The overall results for both community services in 4 specific pathway areas and inpatients is positive with 85% - 97% of patient s being satisfied with aspects of personal care considered. The challenge is however to focus on areas of improvement to ensure that boundaries are pushed and all patients are satisfied with the care and treatment received. A detailed analysis of qualitative feedback is being provided to service areas to ensure that have a clear understanding form patients of ways to improve. This will be tested again by quarter (Q) 4 January- March 2012 to assess the change and improvements made. Good progress is being made against all other CQUINs and a detailed report will be sent to the Quality and safety committee and form part of the dashboard for on-going review. There have been no significant issues in relation to safeguarding in the last month. Systems to identify potential issues in relation to adult safeguarding have been strengthened though amendment of the incident reporting form. Recommend ation(s) to Board The Board is asked to: Note the operational quality issues and actions being taken to maintain quality and safety Note the key risks identified and action being taken to mitigate those risks Discuss and question the report to ensure appropriate assurance is in place. Strategic Objective(s) to which this paper relates: / To increase quality, safety and productivity of the services we provide To explore every opportunity to innovate and improve To build financial strength and resilience To develop strong community links and a reputation for responsiveness Which key standards or State specific standard / outcome or BAF risk assurances does this report relate to? CQC Outcomes 1, 4, 5, 6, 8, 10, 13, 14, 16, 17 NHSLA Board Assurance Framework 956,958,991 IMPACTS & IMPLICATIONS Patient safety & experience Financial (revenue & capital) Equality & Diversity OD/Workforce What patient & public involvement has there been in this issue? The information contained in the report provides an overview of areas that may impact on experience and any safety issues that have occurred Nil No direct implications Action plans implemented through teams to ensure learning from incidents. The quality report is designed to provide assurance of quality and safety of services provided to patients/public Trust Board Quality Paper MB/AN/PF October, 2011 Page 2

3 QUALITY AND SAFETY REPORT 1. INTRODUCTION This report focuses on operational issues affecting quality / safety and patient experience and builds upon the information provided to the Quality and Safety (Q&S) Committee at its meeting in September, Additional pertinent information is enclosed that has not been discussed at the Q&S committee due to the re-alignment of meetings to synchronise with the production of the Trust performance dashboard. The information contained is current data for the Trust since 1 st July and retrospective to the previous individual provider organisations. 2. CURRENT OPERATIONAL ISSUES 2.1 MINOR INJURIES UNITS ( MIU) The Care Quality Commission (CQC) have contacted the Trust and will undertake a site visit on 3 rd November to review the new facilities. Relocation of MIU is still being planned and has been primarily delayed due to installation of radiological equipment. 2.2 Sub Groups of Q&S Committee Progress is being made in establishing and structuring the sub-groups of the committee. The Clinical Advisory Board has met and following discussion recommends that the Board agree to change the title of the group to Clinical Advisory Group. 3. INCIDENTS & RISK 3.1 Serious Incidents(SIs) As detailed in the August Board paper a number of SIs transfer to the community Trust on 1 st July, in addition there have been reported incidents as detailed below Current SIs 4 SIs have been reported by the Trust in September. These are all grade 3 or 4 pressure sores. Three of the 4 have had root cause analysis completed, and closure has been requested to the commissioners. Predominant issues raised have been the patient s physical condition and use of equipment by patients and carers. Areas for improvement for the Trust have been identified as communication between services, improvements in holistic patient assessment, grading of pressure sores. As detailed last month number of SIs have been carried over from the providers arms of the PCTs to the community trust as they are related to Trust services. An update is provided in relation to the status of the SIs currently. Incident Position Update October unexpected death, care given by Community Hospital 3 deaths in custody, 1 natural causes, 2 selfinflicted Investigation completed and recommendations being implemented, including introduction of an early warning score system. All awaiting coroner s inquest Commissioners have been asked for closure Natural cause inquest set for November 29 th / 30 th Trust Board Quality Paper MB/AN/PF October, 2011 Page 3

4 Incident Position Update October pressure sore Investigation Completed. Actions implemented relating to training, identification of key workers and assessment recording 1 unexpected death Investigation and actions complete. Follow up review by Care Quality Commission completed. Commissioners have been asked for closure Coroner s inquest booked 22 nd November Never Event Category No Never Events have been reported in September or since trust Authorisation. 3.2 Incident Trends Graph 1 details the incidents from the two provider arms and current position of the Trust from October 2010 to September 2011, thus providing a high level overview of trend. It shows a breakdown of all risks by incident type. There were 133 reported patient incidents in September. This is the second month where the number of patient s incidents has decreased. However, the number of falls has increased from 26 the previous month to 38. This is slightly above the last 12 months average of 34. The number of reported pressures sores in September was 37, the lowest number for the last 12 months. The average has been 52. The decrease is in both those developed in service and received into community services from other care settings. This decrease is encouraging indicating that the initiatives introduced in the last few months may be having an effect. There has however been a monthly increase in the number of in service grade 3 and 4 incidents reported. This increase is a cause of concern for the Trust whilst recognising these were all developed in patients either being cared for in their own homes, or in nursing homes. The Trust will be joining phase 2 of the Safe Care Quality Innovation Productivity and Prevention (QIPP) work stream and will ensure a target focus in this are to reduce harm to patients through collaborative working. Other types of incidents remain low numbers. Graph 1: Incident Trends Trust Board Quality Paper MB/AN/PF October, 2011 Page 4

5 3.2 RISK MANAGEMENT Risks relating to the Provider arms of Telford & Wrekin and Shropshire County PCTs have been transferred to the Community Trust Risk Register. The Audit Committee agreed at its meeting in October to the development of a Corporate and Directorate Risk Registers within the Trust. 4. INFECTION PREVENTION AND CONTROL The root cause analysis of the pre 48hr MRSA bacteraemia diagnosed in August involving Shropshire Community Health Trust was reviewed at the Infection Prevention and Control Group meeting on 23 September The service improvement plan is currently being implemented by the district nurse team involved with the patient prior to diagnosis and the lessons learnt shared across all localities. In September 2011 no cases of MRSA bacteraemia involving Shropshire Community Health Trust were recorded and no cases of Clostridium difficile were diagnosed in Community Hospitals or Prisons. 5. PATIENT EXPERIENCE 5.1 Eliminating Mixed Sex Accommodation No breaches have been reported in July or August. 5.2 Patient Experience Commissioning for Quality and Innovation (CQUIN) - Outpatients As outlined in the last Board report the patient experience CQUIN questionnaire was undertaken been undertaken during July 2011, for patients who had recently been on the following pathways: Continence, Diabetes COPD and Wound care. High level results are detailed in table 1 below. Further analysis of qualitative feedback is being undertaken and fed back to teams to facilitate on-going improvements. Table 1 Number of questionnaire sent out Number of replies received Continence (39%) Wound care (44%) Diabetes (38%) COPD (52%) Although, the response rates were low this is not dissimilar to those received annually by acute hospital trusts as part of the national survey. Table 2 details the results and shows that overall, 95% of patients were satisfied with the personal care and treatment they received. However 5% were not happy and this is an area where work is required to address the concerns and strive for continuous improvement. A further area for development is ensuring that patients have key contact details on discharge and are not left in a vulnerable position. 27% of our patients stated they did not know who to contact. Work is progressing with teams to review discharge information and address this issue. Trust Board Quality Paper MB/AN/PF October, 2011 Page 5

6 Table 2: Results Have you been involved as much as you wanted to be in decisions about your care and treatment? Were you given enough time to discuss your condition with healthcare professionals? Did staff clearly explain the purpose of any medication and side effects in a way that you could understand? Do you know what number/who to contact if you need support out of hours (after 5pm)? Overall, are you satisfied with the personal care and treatment you have received from community services? Yes No Yes No Yes No Yes No Yes No Continence Wound care Diabetes COPD Totals % 6% 94% 6% 93% 7% 73% 27% 95% 5% 5.3 CQUIN - Community Hospital In-Patient Survey In July 2011 patient experience questionnaires were sent out to patients who had recently been in one of the Community Hospitals. Generally, patients were very satisfied (84.5%), with the personal care and treatment they received as detailed in table 3. However, it is clear that a number of patients (17%) were not welcomed to the ward; 17% were not given enough time to discuss their condition; 20% did not have their medication explained in a way that could be understood and 5.7 patients felt that hospital staff may not have taken their family/home situation into account. As a result although the overall position is positive there are clear areas for improvement. A detailed report for the individual hospitals will be taken to the quality and safety committee for review. Table 3: In-Patient Survey results Question Response Yes Response No On your arrival were you welcomed, introduced to people on the ward and given information about your stay? Were you given enough time to discuss your condition, worries and fears with healthcare professionals? Did staff clearly explain the purpose of any medication and side effects in a way that you could understand? As far as you know, did hospital staff take your family or home situation into account when planning discharge from hospital? Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital? Trust Board Quality Paper MB/AN/PF October, 2011 Page 6

7 Question Response Yes Response No Totals 720 (84.5%) 132 (15.5) 6. COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) 2011/12 Progress is being made against all CQUINs for 2011/12, with detail provided to the September Quality and Safety committee. There are no exceptions to report at this stage. 7. ADULT AND CHILDREN S SAFEGUARDING 7.1 Children s safeguarding There are no new serious case reviews (SCR) in September; however, previous SCR review action plans continue to be progressed and implemented via the relevant services. A detailed plan of actions has been requested by the Q&S committee following its meeting in September. This will be presented to the October meeting. The safeguarding training strategy has now been incorporated into the overall training strategy; the safeguarding policy has now been completed and is going to the October Q&S committee for ratification. All other safeguarding guidelines and policies are in the process of being reviewed with a view to completion by the end of November. The Named Nurses continue to be active members of the Multi-agency Telford & Wrekin and Shropshire Safeguarding Children Boards sub-groups as well as representing the Trust on the multiagency MARAC (Multi-agency risk assessment conference), for victims of domestic abuse. 7.2 Adult Safeguarding In relation to adult safeguarding there have been no specific issues reported in regards to the protection of vulnerable Adults (POVA).Staff work within and adhere to multi-agency guidelines as appropriate. A specific piece of work with the Risk manager has been undertaken to amend the incident reporting forms to include a specific question re safeguarding to tighten procedures and ensure appropriate action and referrals are occurring. Throughout 2010 to 2011 an extensive audit of practice in relation to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLs), was carried out across Shropshire funded by the Department of Health. This has generated an Action Plan which will be monitored by the Vulnerable Adult Safeguarding Board for Shropshire, Telford and Wrekin and includes actions for Community Trust Staff. Included in this audit was an audit of Consent to Treatment decisions in Community Hospitals. A competency framework has been developed as a result of the audit and will be submitted for approval, to the safeguarding Board. Training sessions are available on a regular rolling programme, including. MCA Awareness DoLS Awareness MCA/DoLS Awareness In addition, bespoke training sessions have been provided by The MCA lead for District Nurses in Wem on MCA and Consent and for Community Hospital doctors on DNAR decision making. Trust Board Quality Paper MB/AN/PF October, 2011 Page 7

8 8. QUALITY MONITORING The Trust continue to meet regularly to monitor quality issues with the Primary Care Trust s (PCT s) to provide assurance in relation to delivery of key targets including, complaints, incidents, serious Incidents and CQUINs for example. However, there was no meeting in September. The dashboard for Q&S was discussed along with PCT s requirements and will be further debated at Q&S meeting in September to agree the final content. There has been a requirement to re-align the Q&S committee in line with production of the dashboard and report in a consistent manner with the resources and performance committee. Dates have been re-issued for agreement at the next Q&S committee meeting on 28 th October. 9. RECOMMENDATIONS The Board is asked to: Note the operational issues and actions being taken to maintain quality and safety Agree to re-name the Clinical Advisory Board and call it Clinical Advisory Group Note the key incidents reported and action taken to mitigate those risks Discuss and question the report to ensure appropriate assurance is in place. Maggie Bayley Director of Nursing and Quality Dr Alastair Neale Medical Director Trust Board Quality Paper MB/AN/PF October, 2011 Page 8