Quality Report. Quarter /17

Transcription

1 RCCG/GB/16/170 Quality Report Quarter /17 Page 1 of 44

2 Section Contents 1.0 Executive Summary Introduction Patient Safety Health Care Associated Infections Serious Incidents Person Centred Care Transforming Care Continuing Health Care Personal Health Budgets Special Educational Needs and Disability Provision of High Quality Care Provider Quality Care Home Quality Homecare Primary Care Quality Care Quality Commission Service Reviews Patient Experience Patient Advice and Liaison Service Complaints Patient Experience Activity Patient Stories Recommendation 40 Appendix 1 Summary of Complaints and MP Letters Quarter /17 41 Page Page 2 of 44

3 Quality Report Quarter / Executive Summary This Quality Report provides an update on the activity of the Quality and Patient Safety Team, acting on behalf of Nottingham North and East (NNE), Nottingham West (NW) and Rushcliffe Clinical Commissioning Groups (CCGs), collectively known as the South Nottinghamshire CCGs, during the period Quarter /17. The report also identifies any local or national initiatives or developments aimed at improving the quality of services. The following are included in this report: An update on Health Care Associated Infection position against limits at the end of quarter /17. This shows that NUH and all three South Nottinghamshire CCGs exceeded the limit for Clostridium difficile and NUH has not achieved zero tolerance for Methicillin Resistant Staphylococcus Aureus Blood Stream Infection (MRSA BSI). Page 5 An update on numbers and categories of Serious Incidents (SIs) reported to the end of quarter /17. This shows that a slight increase from quarter /17. This is in part as a result of an increase in pressure ulcers and Never Events. Page 10 An update on the Transforming Care Programme (the response to the Winterbourne View investigation) including progress against the requirement to reduce the number of inpatients over the next three years. The status of the current South Nottinghamshire funded inpatients as at the end of Quarter 2 (1 NNE, 1 NW and 1 Rushcliffe) is also provided. Page 15 An update on Continuing Health Care (CHC) including details of the financial recovery plan and performance against the 28 day standard from referral to assessment. Page 17 An update on the plans to expand Personal Health Budgets (PHB) along with current numbers. Page 18 An update on Special Educational Needs and Disability reforms including current numbers of Education Health and Care Plans and the outcome of the CCG self-assessment. Page 20 An update on provider quality including current Care Quality Commission ratings and quality visits undertaken during quarters 1 and 2. Page 23 An update on care home and home care quality including CQC ratings and CCG quality monitoring. Page 27 An update on primary care quality including CQC ratings and the CCG Quality Assurance and Support Framework. Page 34 An update on CQC inspection of Children Looked After and Safeguarding and the Joint CQC/Ofsted inspection of Special Educational Needs and Disability. Page 37 Page 3 of 44

4 Patient Experience activity including, complaints, PALS and patient stories. Page 38 A summary of Quarter 2 complaints and MP letters is included at Appendix 1. Page 41 The report is considered in detail at the South Nottinghamshire CCGs Quality and Risk Committee and presented to the Governing Bodies for information and assurance purposes. 2.0 Introduction Commissioning is a tool for ensuring high quality, cost effective care. Quality is a key thread that underpins the work undertaken by commissioning groups. The mission is to improve the health and wellbeing of people in Nottinghamshire with a specific aim to improve quality by delivering improvements across the three domains of quality: Patient Safety Patient Experience Clinical Effectiveness Quality is only achieved when all three domains are met; delivering on one or two is not enough. To achieve a good quality service the values and behaviours of those working in the NHS need to remain focussed on patients first. Our ambition is to commission excellent, safe and cost effective healthcare for Nottinghamshire. The Quality Strategy ( ) sets out how we will ensure quality is at the heart of commissioning. The Quality Framework sets out our Governance processes for achieving this. In March 2016 NHS England introduced a new Improvement and Assurance Framework for CCGs aimed at measuring the CCGs delivery of the Five Year Forward View and the Sustainability and Transformation Plans (STPs) for each area, which are all driven by the pursuit of the triple aim : 1. Improving the health and wellbeing of the whole population 2. Better quality for all patients through care redesign and 3. Better value for taxpayers in a financially sustainable system The framework comprises four domains; Better Health, Better Care, Leadership and Sustainability and six clinical priorities mental health, dementia, learning disabilities, cancer, diabetes and maternity. These documents set the context for this Quality Report which provides an update on the activity of the Quality and Patient Safety Team, acting on behalf of Nottingham North and East (NNE), Nottingham West (NW) and Rushcliffe Clinical Commissioning Groups (CCGs) during the period Quarter /17. The report also identifies any local or national initiatives or developments aimed at improving the quality of services. Page 4 of 44

5 3.0 Patient Safety Patient Safety will be our highest priority (Quality Strategy ). 3.1 Healthcare Associated Infections (HCAIs) The table below shows the position against HCAI limits as at end of Quarter /17. Organisation Clostridium difficile 2016/17 MRSA Blood Stream Infection (BSI) 2016/17 Full Year Limit (Limit to end Q2 Actual to end of Q2 2016/17 Pre/Post 72 hour Full Year Limit Actual to end of Q2 2016/ /17) NNE CCG 47 (16) 18 Pre 9, post cases NW CCG 21 (7) 9 Pre 3, post cases Rushcliffe CCG 24 (8) 17 Pre 8, post 9 cases 0 0 (1 CCG case later attributed to NUH Q1) NUH 91 (43) 50 All post 0 3 Clostridium difficile (C diff) Targets for CCGs are set nationally and population based. Cases are designated as pre or post 72 hours, using the Public Health England definition, which is: Pre 72 hour / Community Acquired = diagnosis confirmed by a stool sample taken within 72 hours of admission to hospital or diagnosis from a GP sample. Post 72 hour / Hospital Acquired = diagnosis confirmed by a stool sample taken 72 hours after admission to hospital. Regardless of pre or post 72 hour designation all cases are assigned to the CCG relevant to the GP that the patient is registered with. C diff associated deaths / complications and MRSA Blood Stream Infections (BSI) are usually defined as serious incidents and as such, are investigated by either a Root Cause Analysis (RCA) or a Post Infection Review (PIR). C diff toxin positive infections undergo a multi-disciplinary assessment to identify if there were any lapses in the quality of care provided. Action plans are developed as necessary to mitigate risk and learning is shared across the health community. Financial sanctions may be applicable to the Acute Trust if the number of lapses in care exceeds the overall limit. The national Objective assigned to all organisations for remains unchanged from the previous year. This is because there was a slight increase in the median rate from the year to November 2014 to the year to November 2015 and the affect this would have on the way new limits are calculated. The Department of Health states that this is not to be interpreted as a suggestion that the irreducible minimum has been reached and efforts must continue to reduce Clostridium difficile infections across the NHS. Page 5 of 44

6 Nottingham North & East CCG There has been an increase in community attributed cases over Q2. Monitoring is in place and analysis of the 6 patients has identified that 2 cases are as a result of relapsed disease and 1 case had no antibiotic exposure so it is unclear what led to the episode of infection. 5 patients had received antibiotics in the 3 months prior to the onset of disease and review of all of the episodes of antibiotic prescribing appear to have been appropriate with the exception of one case where the out of hours antibiotic prescribing was not appropriate for urinary tract infection; learning was also identified for the GP practice as the C diff was not suspected, no stool sample was requested and no treatment given until after the patient was admitted. Action has been taken to investigate the out of hours prescribing by Citycare and support with learning has been provided to the GP practice by the Community Infection Prevention and Control Team and the Prescribing Advisor. 50% of the patients were on a proton pump inhibitor at the time of the episode which is a known risk factor for C diff infection. Nottingham West CCG There has been a rise in both trust acquired and community attributed cases over Q2. Monitoring is in place and analysis of the 3 community cases has identified the following themes. 1 case had received no recent antibiotics but this case may be attributed to appropriate antibiotics that were issued 5 months previously. The other 2 cases had both received appropriate antibiotics, with 1 case being treated solely by the GP and the other by NUH. Rushcliffe CCG There has been a rise in both trust acquired and community attributed cases over Q2. Monitoring is in place and analysis of the 5 community cases has identified the following themes. 1 case has a long standing history of erratic bowel habits and weight loss which is being investigated and have experienced a prolonged hospital admission with no history of recent antibiotics; the patient is currently in a community hospital and has had no recent GP contact. Four cases have received antibiotics prior to the episode of C diff infection which is a known high risk factor. 1 patient had antibiotic treatment given in America, which did not follow the local prescribing guidance and the case is considered to be unavoidable, In 3 cases the prescribing appears appropriate and was jointly between the GP and hospital trust, the 4 th case was acute trust antibiotic prescribing for a complex surgical site infection. No cases were identified as lapses in local community care In summary It appears from the information provided that of the 14 community cases there are 2 with identified lapses in care and 1 episode of inappropriate antibiotic prescribing which was issued abroad. The other 11 cases appear to have been treated and managed appropriately and are considered unavoidable. Monitoring by the Community Infection Prevention and Control team continues in conjunction with the Practice Prescribing Teams and measures are in place to review and reduce inappropriate antibiotic prescribing. Nottingham University Hospitals NHS Trust (NUH) The C diff Objective ( ) assigned to the Trust is no more than 91 cases, set out in monthly and quarterly trajectories. The Q2 trajectory was not achieved as 27 cases were apportioned to the Page 6 of 44

7 Trust against a limit of 20. Overall position is RAG rated RED as 50 cases have been apportioned by the end of a Q2 limit of 43. Out of the 50 cases, six lapses in the quality of care provided have been confirmed:- Two incidents of cross contamination Three incidents of inappropriate antibiotics One incident of delayed diagnosis (did not contribute to the acquisition of the infection) Lapses for August and September 2016 are yet to be confirmed. The Trust s healthcare associated infection (HCAI) related reduction plan has continued to be revised on a six monthly basis and is a standing agenda item on the co-ordinating CCG led quarterly performance monitoring meetings. The irreducible minimum remains unknown. Some people carry C diff in their bowel and will develop symptoms due to their underlying clinical conditions or as a consequence of factors outside the control of the NHS organisation that detected it. Comparison with other similar organisations is helpful to gain contextual detail on trajectories against performance targets and this is supplied in the tables below for the 3 South Nottinghamshire CCGs. The peer groups shown below reflect those used within RightCare and are based on number of factors including deprivation scores, age distribution, population density and ethnicity. Categorisation of CCGs by RightCare has been linked to the Office of National Statistics (ONS) clusters. NNE and NW are within the same peer group named Manufacturing Towns. Rushcliffe is located within the Prospering Smaller Towns group. The tables below show comparative C diff data for the CCGs and NUH. Rushcliffe CCG Rating Peer Comparison to NHS Rushcliffe CCG C diff cases 1 NHS STAFFORD AND SURROUNDS CCG 15 2 NHS RUSHCLIFFE CCG 17 2 NHS SOUTH WEST LINCOLNSHIRE CCG 17 4 NHS HIGH WEALD LEWES HAVENS CCG 18 5 NHS GUILDFORD AND WAVERLEY CCG 18 6 NHS EAST SURREY CCG 21 7 NHS HORSHAM AND MID SUSSEX CCG 25 8 NHS WEST SUFFOLK CCG 34 9 NHS EAST LEICESTERSHIRE AND RUTLAND CCG 54 NNE and NW CCGs Rating Peer Comparison to NHS NNE and NW CCGs C diff cases 1 NHS NOTTINGHAM WEST CCG 9 1 NHS EREWASH CCG 9 3 NHS CASTLE POINT AND ROCHFORD CCG 14 4 NHS WYRE FOREST CCG 14 5 NHS NOTTINGHAM NORTH AND EAST CCG 18 6 NHS SOUTHPORT AND FORMBY CCG 19 7 NHS NORTH TYNESIDE CCG 21 Page 7 of 44

8 8 NHS FAREHAM AND GOSPORT CCG 24 9 NHS SOUTH EAST STAFFORDSHIRE AND 26 SEISDON PENINSULA CCG 10 NHS SOUTH EASTERN HAMPSHIRE CCG NHS SOLIHULL CCG 31 NUH Rating Peer Comparison to Nottingham University Hospitals NHS C diff cases Trust 1 ST GEORGE UNIVERSITY HOSPITAL NHS TRUST 12 2 GUYS AND THOMAS NHS FOUNDATION TRUST 21 3 UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST 31 4 THE NEWCASTLE UPON TYNE NHS FOUNDATION TRUST 39 5 OXFORD UNIVERSITY HOSPITALS NHS TRUST 43 6 UNIVERSITY HOSPITALS OF BIRMINGHAM NHS TRUST 47 7 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST 50 8 SHEFFIELD TEACHING HOSPITALS NHS TRUST 52 9 LEEDS TEACHING HOSPITALS NHS TRUST 59 MRSA Blood Stream Infections (BSI) The NHS Commissioning Board s planning guidance for Everyone Counts: Planning for Patients set out a Zero Tolerance approach. This was in response to approximately one sixth of Acute Trusts not reporting any cases. This indicated that a point had been reached where avoidable cases should not be accepted in NHS funded services. At the same time the Post Infection Review (PIR) replaced Root Cause Analysis (RCA) to assist with identifying why the infection occurred and how future cases can be avoided. NHS Nottingham North and East CCG No cases assigned. NHS Nottingham West CCG No cases assigned. NHS Rushcliffe CCG One case was assigned to NUH after completion of the post infection review in Q1, no cases in Q2. NUH Three cases were assigned to NUH in May Number PIR Clinical Outcome Clinically Avoidable / Unavoidable 1 Bacteraemia secondary to an unavoidable wound MRSA acquisition linked to a cluster on the Stroke Wards. Clinically avoidable Changes in practice were implemented to:- Strengthen compliance with hand hygiene Recruit permanent ward based staff Page 8 of 44

9 Promote consistency in allocation of Agency Staff Enhance role and responsibilities for the Infection Control Link Worker Enhance attendance by external cleaning contractors to infection prevention and control training 2 Bacteraemia secondary to an essential invasive medical device MRSA acquisition linked to a cluster on the Stroke Wards Clinically avoidable Changes in practice were implemented to:- Strengthen compliance with Screening and Decolonisation Strengthen knowledge and compliance with peripherally inserted central catheters which were being increasingly introduced 3 Bacteraemia secondary to an essential invasive medical device Clinically unavoidable Documented evidence that insertion and care followed best practice and staff screening for MRSA failed to identify any carriers Actions to strengthen compliance with hand hygiene were implemented. The Trust continued to have HCAI reduction plans in place which focus on:- Sustaining high level compliance with MRSA screening and decolonisation Enhancing Trust wide compliance with effective antimicrobial stewardship Strengthening and sustaining compliance with hand hygiene, decontamination, equipment and environmental cleanliness Improving infection control related communication and information sharing within the organisation and across the health economy. Following on from the quality visits during , NHS Improvement, Public Health England and the CCG visited both the QMC and City Hospital in September Findings were mixed:- Excellent examples of how the ward staff had taken on board the findings from previous visits Concerns remained regarding cleanliness, waste and linen which are the responsibility of estates and facilities Assured that the Board were addressing the issues identified. In response, the Trust put the following measures in place:- Immediate implementation of an enhanced recovery plan with the external contractors to raise and sustain standards of cleanliness Page 9 of 44

10 Daily afternoon walk round on each ward to record standards of cleanliness against a 15 point checklist for cleaning via an app on a smart phone / tablet. This is a short term measure. A fully qualified external assessor will be in post by November 2016 to lead on reporting to Trust Board Regular Trust wide communications including progress in addition to the acknowledgment of good practice. 3.2 Serious Incidents (SIs) and Never Events (NEs) The table below identifies the number of SIs reported by providers where the 3 South Nottinghamshire CCGs are Co-ordinating Commissioners. These providers consist of Nottingham University Hospitals Trust (NUH), Health Partnerships (HP), Circle, Nottingham (CN), Nottingham Woodthorpe Hospital (NWH) and BMI The Park. Primary Care (PC) SIs are also included due to delegated responsibility from NHS England to the CCGs for oversight and monitoring from 1 April The figures are up to the end of quarter /17 although due to the timescale of the Serious Incident framework some are still undergoing ratification and so the quarter 2 figures are provisional. 49 SIs were reported in the same period last year. Total Serious Incidents by Organisation by Quarter 2016/17 Organisation Concise 1 Comprehensive 2 Independent Total YTD Investigation 3 Total Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 NUH HP Circle NWH The Park South CCGs NNE PC NW PC Rushcliffe PC Total Concise internal investigation - Suited to less complex incidents which can be managed by individuals or a small group at a local level 2 Comprehensive internal investigation - Suited to complex issues which should be managed by a multidisciplinary team involving experts and/or specialist investigators where applicable 3 Independent investigation - Required where the integrity of the investigation is likely to be challenged or where it will be difficult for an organisation to conduct an objective investigation internally due to the size of organisation or the capacity/ capability of the available individuals and/or number of organisations involved The tables below show comparative data by theme. Pressure Ulcers (PU) Pressure Ulcers by Organisation by Quarter 2016/17 and comparison with 2015/16 Organisation Q1 15/16 Q1 16/17 Q2 15/16 Q2 16/17 Q3 15/16 Q3 16/17 Q4 15/16 Q4 16/17 NUH HP Page 10 of 44

11 Circle NWH The Park CCGs NNE Primary Care NW Primary Care Rushcliffe Primary Care The updated SI framework (March 2015) has been interpreted to exclude unavoidable stage 3 and 4 PUs as SIs. NUH have adopted a streamlined review of PUs initially to enable them to focus a more comprehensive review for avoidable PU damage. Primary Care PU damage is also only entered as an SI if it is deemed avoidable, following discussion between the GP practice and the Quality Team. Two stage 4 avoidable PUs were reported in Q2, (1 NUH and 1 HP). The HP RCA indicated avoidable stage 4 damage due to lack of oversight by the Case Manager to ensure appropriate visiting and care planning to prevent deterioration from stage 3 PU damage. As a consequence actions to address this have been developed to provide assurance of this incident not being repeated in Newark and Sherwood locality. This is the second stage 4 PU reported by NUH this year to date, the first one being reported in May although this was an unusual presentation in that it was on a hand and related to oxygen tubing causing pressure. Prior to May 2016 there had not been a stage 4 PU reported by NUH since April The RCA received by the CCG Quality Team indicates that whilst this was a patient with extremely complex needs, there were omissions around risk assessment, accurate care planning and review and documentation of care delivery and any changes in patient needs. Falls Falls by Organisation by Quarter 2016/17 and comparison with 2015/16 Organisation Q1 15/16 Q1 16/17 Q2 15/16 Q2 16/17 Q3 15/16 Q3 16/17 Q4 15/16 NUH Q4 16/17 One fall resulting in a head injury was reported in Q2 and occurred on Bramley Ward. A Root Cause Investigation report has been received and the key areas for learning are indicated as lack of appropriate escalation of a deteriorating patient by nursing and medical staff and patient choice to visit the toilet unaided by staff. A comprehensive action plan has been developed to address these issues for this area. The CCG Quality team are assured that NUH utilise a robust internal review process, led by a senior clinician for all investigations into falls with harm which enables multi-disciplinary oversight and debate. This process is overseen by a panel of CCG colleagues who review a random sample of falls which are not determined as SIs to ensure the reduction is valid and robust. Page 11 of 44

12 Infection Prevention and Control (IPC) Related Serious Incidents IPC Serious Incidents by Organisation by Quarter 2016/17 comparison with 2015/16 Organisation Q1 15/16 Q1 16/17 Q2 15/16 Q2 16/17 Q3 15/16 Q3 16/17 Q4 15/16 Q4 16/17 NUH HP NNE Primary Care NW Primary Care Rushcliffe Primary Care HCAI incidents were reported in Q2 by NUH: 1 x MRSAb (QMC AICU) 1 x C diff (Ward F21) The MRSAb was deemed an unavoidable 3rd party case as the patient was in a road traffic collision and was transferred to NUH from Derby. All appropriate measures had been in place and documented. There have been 2 MRSA cases this year and 2 last year on ICU, however there have been not identified links between these cases. The C diff case was deemed unavoidable due to no lapses in care being identified. Never Events (NEs) Never Events are a subset of Serious Incidents that are considered wholly preventable, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers. For a full list of Never Events go to Never Events by Quarter by Organisation /17 and comparison with 2015/16 Full Year Organisation 2015/16 Full Year Q1 2016/17 Q2 2016/17 Q3 2016/17 Q4 2016/17 Page 12 of 44 YTD Total 2016/17 NUH HP Circle NWH BMI The Park South CCGs NNE Primary Care NW Primary Care Rushcliffe Primary Care There have been 4 Never Events in Q2 at NUH which consist of the following, with progress identified in the table below: 1. Overdose of insulin due to abbreviation or incorrect device 2. Retained vaginal swab 3. Wrong site surgery - wrong sided anaesthetic block for wrist surgery patient

13 4. Wrong route administration of medication - patient incorrectly received Fentanyl/Levobupivicaine mix intravenously and Syntocinon epidurally. Summary of Never Events, Analysis and Actions Taken: Overdose of insulin (July 16) 10mls of insulin (1000 units) prescribed and administered rather than intended 10units. The patient became hypoglycaemic and required treatment. (Low patient harm) Dextrose & insulin for hyperkalaemia was subject to prescribing error (prescribed as mls not units). Prepared by nurse using an ordinary IV syringe - checked by second nurse & administered. Resulted in patient receiving 10ml of Actrapid which equals 1000 units of insulin in place of 10 units. Noticed when patient became hypoglycaemic. Investigation in progress. Due for completion October Retained swab after childbirth (August 16) Maternity / theatre swab retained Swab counting process & (Moderate patient harm) documentation not robust. Maternity swab counting guidance does not align with trust swab counting policy & is not robust - it is still a guideline not a policy (action in AP from previous incident is to review content & convert to policy). Both staff members continued to administer oral medication without further training or education. With regards to IV preparation and administration- staff members started as second checkers, followed by reintroduction of administration of IV medication. RCA received by CCG Quality Team on and currently being reviewed RCA investigation in progress and due to CCG Quality Team for review. Investigation in progress. Due for completion November Wrong site surgery (September 16) Medial nerve (wrist) block partially administered by an experienced consultant anaesthetist on the wrong side (in theatre). No Stop Before you Block moment (human error). Investigation in progress. Due for completion December Wrong route administration of medication (September 16) Midwife disconnected IV Syntocinon No track back of line to point of & epidural to change patient into connection. theatre gown & reconnected the wrong way round. Error realised Investigation team being established. approx an hour later. RCA investigation in progress and due to CCG Quality Team on Early ( ) communication sent to midwifery, obstetrics and anaesthetic services. Midwives informed they cannot connect, disconnect or bolus epidurals. RCA investigation in progress and due to CCG Quality Team on Page 13 of 44

14 Given the increase in Never Events additional assurance has been requested and received by the Co-ordinating Commissioner, which will be part of forthcoming Quality Scrutiny Panel, although the additional information included: The Clinical Support Division has an active action log in response to safe surgery Never Events. In response to the increased incidence of Never Events this has been reviewed to provide a current reflection of progress with initiatives which consist of Safety Dashboard, Pre-list briefings and de-briefings, culture survey, effective incident response, education and training, implementation of NatSSIPs and specific action plans for wrong site block. NUH have a Medicines Optimisation Strategy with a medicines committee structure to aid governance and learning both across the Trust and externally. The Medicines Safety Group has an audit plan aligned to the medicines safety risk register and there is a medicines safety work stream for Sign up to Safety. NUH have applied a taxonomy to the Never Events which have occurred since September 2015 and the contributory factors in order of frequency cited are: 1. Human error 2. Clarity of policy/guidance 3. Physical connection, design (designing out error) 4. Second checking process 5. Process i.e. deviation from the norm 6. Handover / Handoffs 7. Knowledge base 8. Clarity of prescribing NUH have focused their patient safety improvement work on system based solutions as well as considering interventions such as second checking and rules, policies, guidelines and education. Implications for staff involved in Never Events: No staff have been referred to professional bodies as a result of these incidents and their root causes after investigations. After the medicines-related incidents it was common for staff (nurse and doctors) to be paused from undertaking relevant procedures until investigation. Several staff were instructed to undertake (or repeat) relevant training packages and/or include a written reflective practice report for their training portfolio and PDP, and discuss this with their educational supervisor / appraiser. (NUH does not have electronic prescribing or administration) After the incorrect pairing of surgical implants and retained swabs the focus was on improved storage, systems and procedures to support individual clinician practice. Maternity incidents (NUH only) From 20 May 2015, STEIS SI categories changed. There are now only 3 maternity categories (baby only; mother and baby; mother only) The unexpected admission to NICU, unexpected neonatal death, intrauterine and unplanned admission to ITU categories were in use on STEIS from 1 April mid May 2015 and are therefore included in this report; however they are no longer in use. Page 14 of 44

15 NUH Maternity SIs by Quarter 2016/17 and comparison with 2015/16 Category Q1 15/16 Q1 16/17 Q2 15/16 Q2 16/17 Q3 15/16 Q3 16/17 Q4 15/16 Q4 16/17 Unexpected 2 N/A N/A N/A N/A N/A N/A admission to NICU Unexpected neonatal 1 N/A N/A N/A N/A N/A N/A death Intrauterine death 1 N/A N/A N/A N/A N/A N/A Unplanned admission 1 N/A N/A N/A N/A N/A N/A to ITU Maternity Obstetric: baby only (foetus, neonate and infant Maternity Obstetric: mother and baby (foetus, neonate and infant) Maternity Obstetric: mother only Maternity SI was reported in Q2 by NUH - an inter-uterine death. This was initially reported as a High Level Incident and not as an SI. However following further investigation by NUH an external review by an independent midwife has been requested and the incident was escalated to SI status and the RCA investigation is expected to come to the CCG Quality team for review. 4.0 Person Centred Care We will commission patient centred services that meet patient expectations (Quality Strategy ). 4.1 Transforming Care (Learning Disabilities) Following the publication of the Department of Health s report, Transforming Care: A national response to Winterbourne View Hospital in December 2012, and subsequent reports including the Bubb Report in November 2014, and Transforming Care for People with Learning Disabilities Next Steps in January 2015, a significant amount of work has been undertaken to make improvements in the care and services available for people with learning disabilities and/or autism spectrum disorders. NHS England, the Local Government Association and Association of Directors of Adult Social Services announced on 12 June 2015 that five fast track areas were being established that would be the forerunners of transformation of services for people with a learning disability and/or autism and challenging behaviours, or a mental health condition. The fast track areas were asked to submit a transformation plan by 7 September 2015 which described how they would strengthen community services, reduce reliance on in-patient beds (non-secure, low and medium secure) and close some in-patient facilities. Nottinghamshire (including Bassetlaw) was one of the areas identified as a fast track area and the Nottinghamshire Transforming Care Partnership (TCP) plan aims to transform care and support for individuals with a learning disability and/or autism who also have, or are at risk of developing, a mental health condition or behaviours described as challenging so that their care is focused on Page 15 of 44

16 keeping them healthy, well and supported in the community. Achieving this will minimise the need for inpatient care with the objective of reducing the number of beds we have available over a period of time as the redesign of services and implementation of more community based provision takes effect, for example better provision around addressing crises as they occur including accommodation options. The CCGs within the TCP are being monitored both in terms of the number of inpatients and the number of inpatient beds. Trajectories have been set for TCP populations rather than individual CCGs or organisations. The Nottinghamshire trajectory for the number of inpatients for the next three years is as follows (please note this includes the numbers of inpatients in services commissioned by specialised commissioning (medium and high secure)): April 16 April 17 April 18 April 19 (Baseline) Specialised CCG Total The table below shows actual performance to date which is broadly on track. May 16 June 16 July 16 August 16 Sept 16 Specialised CCG Total We have put a number of measures in place to manage admissions to hospital which include having an at risk of admission register and a Care and Treatment Review (CTR) process. We carry out a Care and Treatment review on anyone that is considered at risk of admission. We also carry out a CTR on anyone that is in hospital every 6 months. CTRs take a whole day and involve 3 people (a commissioner, expert by experience and clinical expert) plus an advocate reviewing the care of an individual in order to try and prevent a hospital admission where appropriate or expedite discharge if the person is already in hospital. We are also planning to commission a number of services to help reduce inpatient numbers. These services are as follows: A step-down unit for people leaving hospital. This will be a community provision that can meet the needs of more challenging individuals to expedite discharge. A crisis service. This will be a service that people can use as an alternative to a hospital admission when it is thought a hospital admission is not necessary but that the person does need to leave their current accommodation for a period of time. (Pilot for one year) A respite service that can meet the needs of more challenging individuals. (Pilot for one year). An enhanced Intensive Community Assessment and Treatment Team. (Pilot for one year). As the aim of the TCP is to ensure that care for individuals is focused on keeping them healthy, well and supported in their local community so that in-patient services are only used where community settings cannot provide safe and suitable alternatives we anticipate that this will significantly reduce the need for inpatient care. Within Building the Right Support (BRS) which was published in October 2015, NHSE set out their expectation that as a minimum, in three years time no area will need capacity for more than inpatients per million Page 16 of 44

17 population in CCG commissioned beds and inpatients per million population in NHS England-commissioned beds. As a TCP we are required to report monthly on the progress of these Nottinghamshire inpatients, and how this will affect the numbers of beds that are being commissioned for our patient population. There is recognition that we only commission a proportion of the 199 beds that are physically in Nottinghamshire and that this means that Nottinghamshire does not have control over the movement of these patients or closure of beds but as all TCPs have the same reporting requirements this will be captured in other TCP reports. However, we need to ensure that can accurately forecast population need by 2019 in order that Nottinghamshire residents have access to care and treatment close to home. The table below provides information regarding the three South Nottinghamshire CCG inpatients as at end September Pt. Admitted/ Transferred Type of Unit Nottingham North and East Acute Hospital Ward Nottingham West (transferred out of area) Locked Rehab Rushcliffe Assessment & Treatment Unit *Deprivation of Liberty Safeguards Mental Health Act Last Care &Treatment Review (CTR) CTR Outcome Section Not ready for discharge Section Appropriately placed for a defined period of time Informal Not ready for discharge needs hospital bed for care and treatment Planned Discharge Date Comments Admitted in response to psychotic episodeimproving Working towards August 2017 Transferred to be closer to family until ready for discharge DOLS* request made Continuing Health Care (CHC) NHS Continuing Health Care refers to packages of care (in a care home setting or in the patient s own home) that are arranged and/or funded by the NHS following assessment using a nationally recognised Decision Support Tool (DST) to identify if the individual has a primary health care need. CityCare currently provide the CHC assessment service on behalf of the five Nottinghamshire County CCGs. For more information about NHS continuing healthcare including who is eligible please use the following link Patients referred for assessment for CHC eligibility will fall into one of the following categories: Fully funded- a primary health care need is evidenced and therefore the care package is fully funded by the NHS. Page 17 of 44

18 Jointly funded- a primary health care need is not evidenced but the individual has a combination of both health and social care needs. The package is funded jointly by the NHS and social care (if the individual meets eligibility for social care funding if not the individual meets the cost). The percentage splits are recommended based on a review of the DST scores and agreed at a multi- agency panel held weekly. Funded Nursing Care (FNC) - a primary health care need is not evidenced and the care needs are predominantly social care in nature. Health needs can be met by registered nursing oversight in a care home setting. A health contribution of 112 per week is paid by the NHS and the remainder of the package costs are paid by social care (if the individual meets eligibility for social care funding if not the individual meets the cost). Not eligible- the care needs are entirely social care in nature. The costs are paid by social care (if the individual meets eligibility for social care funding if not the individual meets the cost). If a patient is deemed to have a rapidly deteriorating condition, is thought to be in the end of life phase and requires a new care package or placement they can be referred for fast track funding which will result in their care package being fully funded without the need for a DST. Patients who require aftercare (in the form of a placement or care package) following admission under a section of the Mental Healthcare Act are eligible for Section 117 funding which is joint funding by the NHS and social care. The percentage splits are recommended following a review of the individuals diagnosis, presentation and care needs and agreed at a multi- agency panel held weekly. New referrals and fast track cases are reviewed within three months and existing cases are subject to annual review. CityCare have a threshold for median time from referral to assessment for new referrals (excluding fast track) of 10 days as at August they were over-achieving with median time from referral to assessment of only 7 days. As a result of a significant level of growth in CHC expenditure a recovery action plan has been developed and a turnaround group comprising CCG and CityCare finance, contracting and quality representatives are meeting fortnightly to oversee implementation. Actions to control costs include: Implementation of a cap on 1 to 1 hourly rates of 12 per hour Review of 1 to 1 provision Review of high cost packages Review of fast track referrals to ensure appropriateness Raising awareness of fast track eligibility amongst referrers Management of accruals 4.3 Personal Health Budgets (PHB) From 1 October 2014 people who are eligible for NHS continuing health care, including children and young people have had the right to be considered for a personal health budget. The NHS wants more people with complex long term needs to benefit from the option of a personal health budget. Locally the Nottinghamshire Clinical Commissioning Groups (Mansfield & Ashfield, Newark and Sherwood, Nottingham North & East, Nottingham West and Rushcliffe) are committed to Page 18 of 44

19 increasing the proportion of people eligible for NHS continuing health care who hold personal health budgets, as well as the number of children and young people eligible for an education, health and care plan benefiting from an integrated care budget offering flexibility and choice and incorporating funding for health care from the NHS. The teams involved in assessing people eligible for NHS continuing health care and children and young people eligible for an education, health and care plan have now been trained in personal health budgets and will now routinely discuss this option as part of the assessment process. As well as expanding the number of personal health budgets for those eligible for NHS continuing care the Nottinghamshire Clinical Commissioning Groups will be working closely with Nottinghamshire County Council to improve and expand access to personal health budgets for other groups of individuals with suitable high level needs but who are not eligible for NHS continuing care. It is important to understand that developing personal health budgets is not about finding new money for additional services but about spending some of the money currently being spent on existing services in a different way. This approach represents a major shift in the way the NHS works and will require comprehensive engagement, careful planning and testing, so as not to compromise the financial sustainability of the NHS or destabilise existing services for other people. It is likely that early implementation will initially be prioritised for a relatively small group of individuals with suitable high level needs for whom current service offers do not always work well but who are not eligible for NHS continuing care e.g. People with learning disabilities or autism in high cost residential placements, or those with high support needs who are frequently using inpatient services, or are at high risk of using inpatient services In the longer term (i.e. over the next 3-5 years) Nottinghamshire Clinical Commissioning Groups will consult on and further develop processes to enable more people with suitable high level long term needs to benefit from the flexibility, choice and control offered by the personal health budget process, such as: Those with complex long term conditions (including neurological conditions) for whom current services do not work well resulting in frequent relapse or crises and access to acute services People receiving mental health services who frequently use A&E services Young people receiving mental health services transitioning to adult services The numbers of patients with a PHB as at the end September 2016 are shown in the table below. CCG CHC (fully funded) Non CHC (joint funded) Newark and Sherwood 8 0 Nottingham North and East 9 2 Nottingham West 7 1 Mansfield and Ashfield 7 2 Rushcliffe 8 2 TOTAL 39 7 Page 19 of 44

20 Within the Nottinghamshire Sustainability and Transformation Plan an interest was expressed in becoming an early adopter of the Integrated Personal Commissioning (IPC) model. The IPC is one of the pillars of the Five Year Forward View. It empowers people and communities to take an active role in their health and wellbeing with greater choice and control over the care they need. It supports the improvement, integration and personalisation of services, building on learning from personal budgets in social care and driving bold expansion plans for personal health budgets. In Nottinghamshire developmental work for an integrated budget and process for people with health and social care needs is underway, and the IPC aligns to this work. The next stage is to apply to NHSE, by submitting a Project Initiation Document by the 26 th October. If successful being an early adopter will provide: financial assistance to develop the model; support from specialists at NHSE e.g. finance, decommissioning block contracts and access to a range of support from the Voluntary sector to develop the model. For more information on personal health budgets including responses to frequently asked questions please use the following link Special Educational Needs and Disability (SEND) The Special Educational Needs and Disability (SEND) reforms outlined in the Children and Families Act 2014 are focused on outcomes for children and young people (CYP) with SEND and how education, health and social care work together to help CYP aged 0-25 achieve their outcomes. The reforms include a move from children having a statement of special educational need and disability to having an integrated education, health and care plan which has been developed in partnership with the child, their family and relevant leads from health, education and social care. This integrated working across sectors leads to better commissioning of services with a more transparent and efficient process of assessment and planning. It removes duplication of effort, by bringing different commissioners together at an early stage, pools or aligns resources, and involves children, their families and carers in decision making about services they receive. During 2016/17 joint inspections undertaken by the Care Quality Commission (CQC) and Ofsted are due to commence. For more information about the Special Educational Needs and Disability Code of Practice please use the following link The table below shows the work undertaken by the Children s Integrated Commissioning Hub on behalf of the CCGs to ensure that they meet their statutory duties in the Children and Families Act In May 2016 the Nottinghamshire County and City CCGs funded a permanent Designated Clinical Officer (DCO) post working within the hub to ensure that the CCGs continue to meet these statutory duties. An Associate DCO post also joined the team in September Page 20 of 44

21 Statutory Duties for CCGs Commission services jointly for 0-25 year old CYP with SEND, including those with Education, Health and Care Plans (EHCP) Ensure that procedures are in place to agree a plan of action to secure provision which meets CYP reasonable health needs in EVERY case Work with the LA to contribute to the local offer Ensure mechanisms are in place to ensure practitioners and clinicians will support the integrated education health and care assessment within 20 weeks. Work undertaken by the DCO and ICH Joint Education, Health and Care Plan Pathway has been established Re-commissioning of children s community services Integrated Community Children and Young People s Healthcare Programme (ICCYPH) A CYP panel for continuing health care established Joint resolution and mediation process developed between CCGs and the LA Work underway to ensure data on CYP is captured at a CCG level not just LA district level, so CCGs can clearly see the numbers of CYP who have been referred or who have an EHCP-this includes capturing the no to assessment for an EHCP decisions, as this cohort of CYP will still have need, and this can inform the commissioning cycle. Quality assurance report developed for CCGs presented twice annually to Quality and Risk Committee CCG diagnostic checklist for CQC/OFSTED inspection framework completed ahead of joint inspection which commenced on 20 June 2016 (see section 5.4 for details) Non-core commissioned services panel commenced March 2016 Clinical oversight and scrutiny provided for all new requests for an EHCP Quality Assurance Strategy being developed in partnership with social care and education This is now part of new provider contracts going forward All CYP community service specifications include this and it is an indicator in performance monitoring. This also includes adult community services specifications which cover transitions and up to age 25 where appropriate (as part of the current community services re-tender, from April 2016). On-going work with clinicians to embed the EHCP pathway including training The table below shows the total number of EHCP requests for Q1 and Q2, which has increased by 19% on Q1 and Q2 of 2014/5. The national increase over the same time period was 18% (however this was based on a small sample base of only 4 Local Authority areas).south Notts had 75 EHCP requests in that time frame, with 48 of those being a yes. There were 207 transfers from a statement of education or a Learning Disability 139a to an EHCP. Page 21 of 44

22 EHCP activity from initiation April 2015-Sept 2015 (Q1 and Q2) SCHOOL BOROUGH YES NO TOTAL Number of EHCP requests (first stage of information gathering) Bassetlaw Newark Ashfield * Mansfield Mid Notts Broxtowe Gedling Rushcliffe South Notts Total NUMBER OF TRANSFERs * Ashfield includes the figures for Hucknall, however in terms of CCG boundaries it falls into a South Notts CCG (NNE). The CCG diagnostic checklist self-assessment for the CQC/OFSTED inspection provides a framework for CCGs to capture evidence of compliance with statutory requirements and best practice and enables identification of areas for further development. The framework includes key indicators across a number of domains. This was completed in June 2016, the table below summarises the results. An action plan has been developed in response to the assessment and the self-assessment will be repeated on an annual basis. Domain No of red indicators (Non- compliant) No of amber indicators (Partially compliant) No of green indicators (Compliant) Leadership Joint Arrangements Commissioning Education, Health and Care Plan Engagement Monitoring and Redress Totals Page 22 of 44

23 5.0 Provision of High Quality Care 5.1 Provider Quality Our ambition is to commission excellent, safe and cost effective healthcare for Nottinghamshire (Quality Strategy ). Care Quality Commission (CQC) Ratings The tables below show the current CQC ratings for main providers where one of the South CCGs are either the co-ordinating commissioner or the associate to a contract coordinated by another CCG. CQC ratings for providers where one of the South CCGs are the coordinating commissioner Provider CQC Rating Date Comments NUH Good September 2015 Overall outstanding in well-led, requires improvement in safe, good in all other domains. City, QMC and Ropewalk House all good overall. Critical Care at City outstanding and end of life services at City and QMC requires improvement. Recommendations in relation to Do Not Attempt to Resuscitate, Mental Capacity Act, staffing (levels and training) and equipment checking were made. The Trust continues to implement their improvement action plan which is monitored by the Trust s Quality Assurance Committee with Commissioner oversight via the Quality Scrutiny Panel. Circle Good May 2015 Good in all domains. Outstanding in surgery and requires improvement in termination of pregnancy service. Recommendations were made in relation to termination of pregnancy services and complaint handling. Circle has implemented its improvement action plan and was revisited by the CQC to review these areas in May The outcome of this follow up visit is not yet known. HP (as part of NHCT) Good July 2014 Outstanding in caring, requires improvement in safe and good in all other domains. Recommendations for HP included medicines management policies and audits in the Children s Development Centre and ensuring people know how to complain. These areas were addressed and continue to be monitored internally with oversight via the Quality Scrutiny Panel NWH Good May 2016 Good in all domains, surgery and outpatients. Some areas for improvement noted (mandatory training rates, dementia friendly environment) but no formal recommendations made. BMI The Park Compliant September 2016 Inspected under the old regime in July 2014 and found to be complaint in all areas, no recommendations made. Inspected under the new regime in September 2016 report awaited- no immediate concerns identified. CQC ratings for providers where the South CCGs are associate commissioners Provider CQC Rating Date Comments SFHFT Inadequate October 2015 Inadequate in safe and well-led, requires improvement in effective and responsive, good in caring. A warning notice was issued and the Trust has been in special measures since the CQC inspection. A quality improvement plan continues to be implemented overseen by Mansfield and Ashfield CCG as Page 23 of 44

24 coordinating commissioners. A partnership between SFHFT and NUH is currently in development. NHCT Good July 2014 Outstanding in caring, requires improvement in safe and good in all other domains. Recommendations for the local and forensic services included recording physical health needs of patients within MH units, single sex accommodation and recording risk assessments and care plans. Improvement action plans were monitored internally with oversight by City CCG as coordinating commissioners. The CQC have inspected a number of NHCT locations during June 2016, the outcome is not yet known. EMAS Requires Improvement November 2015 Good in caring and responsive, requires improvement in effective and well-led and inadequate in safe. Warning notice issued in relation to staffing (levels and training), medicines management and insufficient vehicles. An improvement action plan has been developed and must show progress by November This is being monitored internally with oversight by Hardwick CCG as coordinating commissioners and Mansfield and Ashfield as leads for the Nottinghamshire contract. NEMS Good April 2016 Good in all domains. No recommendations made. Quality Visits The Quality Team co ordinates quality visits to providers for which their CCGs are coordinating commissioners, in line with contractual agreements. The provider organisations which receive scheduled, responsive and unannounced visits by the Quality team are Nottingham, University Hospitals (NUH), County Health Partnerships (HP), Circle, Ramsay Nottingham Woodthorpe Hospital and BMI The Park Hospital (visits to the latter two providers commenced from Quarter 2 onwards). The aims of the visits are to: gain a contextual understanding of the services which are commissioned develop effective working relationships between staff in provider and commissioner organisations facilitate triangulation and exploration of indicators of service delivery and enhance intelligent interpretation and analysis identify awareness and action of provider in relation to key areas of concern and enable staff and service users to share their perspective on these Lay members from the CCGs take part in the quality visits to providers (once their code of conduct is signed and the Disclosure and Barring approval is received). CCG Governing Body members and CCG officers are encouraged to take part in these visits and can contact Liz Owen (elizabeth.owen@nottinghamnortheastccg.nhs.uk) to arrange attendance. The details of all quality visits undertaken year to date are shown below. Visits undertaken during the last quarter are shown in bold. Those scheduled to take place in the coming quarter are shown in italics. CIRCLE, NOTTINGHAM Date Area Reason for Visit Outcome IPC - Unannounced Seek assurance on IPC standards. Staff welcoming and helpful. Very positive visit, assurance of Gateway B Seek assurance on quality of service. IPC standards provided. Strong assurance gained of the quality of service being Page 24 of 44

25 December 2016 Safeguarding Seek assurance on safeguarding culture and processes. provided. The team were found to be informed, motivated and empowered to deliver a safe and effective service. HEALTH PARTNERSHIPS Date Area Reason for Visit Outcome Safeguarding To understand safeguarding arrangements due to soft intelligence and CQC verbal feedback in relation to capacity within the safeguarding team Team appeared to have high level of knowledge and skills however had been stretched to capacity over recent years. Issues with newly qualified staff for children s services not receiving 1-1 and group supervision. Concern that safeguarding audits and quality monitoring systems may not be effectively identifying gaps. Further clarity of the Safeguarding Link role is required and how this will be embedded Newark Health Centre A quality visit undertaken in March 2016 highlighted concerns relating to staffing levels, clinical leadership, and staff morale. This was a follow up visit to enable the provider to share with the CCG s the changes that have been made to address the concerns previously identified Paediatric Focus on therapies service Recommendations were given. Evidence of a hardworking and committed workforce that was embracing the recent additions to the clinical leadership of the team following an extended period with insufficient senior clinical staff (qualified District Nurses). Senior managers agreed the existing caseloads remain too large and requires further cleansing. NOTTINGHAM UNIVERSITY HOSPITALS Date Area Reason for Visit Outcome Maternity - City Routine visit Joint visit with representation from NHS Improvement, City CCG, Mid Notts CCGs and South Notts CCGs. Effective leadership, service improvement initiatives evident. Staff were welcoming, open and friendly, patient feedback was good. Assurance on the safety and Page 25 of 44

26 E15, A23, E12 Kitchen - QMC Paediatrics - QMC Seacole, Newell, Winifred 2 wards City QMC and City Hospitals Unannounced visit to follow up on environmental cleanliness concerns Routine visit Announced visit to follow up on environmental cleanliness concerns. NHS Improvement, Public Health England and the CCG visited both the QMC and City Hospital on 20 September Findings were mixed:- Excellent examples of how the ward staff had taken on board the findings from previous visits Concerns remained regarding cleanliness, waste and linen which are the responsibility of estates and facilities Assured that the Board were addressing the issues identified Safeguarding Seek assurance on safeguarding culture/processes HCOP Seek assurance on quality and safety quality of service provided by visit Good assurance of sustained actions to ensure environmental cleanliness and IPC practice. Joint visit with representation from Integrated Community Children and Young People s Hub and South Notts CCGs. Awareness of key challenges in the provision of safe quality care for children and their families and effective leadership. Investment in enhancing patient engagement and experience. Proposed merger with SFHFT was viewed as posing limited risks and seen as an opportunity for the Nottinghamshire paediatric service. Staff approachable and engaged and patient experience good. Joint visit by NHS Improvement and CCG which indicated lack of sustained improvements in environmental cleanliness and IPC practice. Poor assurance and NUH providing response. For ongoing monitoring. Trust had implemented a daily afternoon walk round on each ward an input standards of cleanliness against a 15 point checklist for cleaning via an app on a smart phone / tablet. This is a short term measure. A fully qualified external assessor will be in place by November 2016 and will lead on reporting to Trust Board. Regular communications to all staff regarding the situation, also celebrate the good. Try to keep staff positive and engaged as well as aware of the importance. Page 26 of 44

27 Ramsay Nottingham Woodthorpe Hospital Date Area Reason for Visit Outcome 4/8/2016 Various Safeguarding focus in order to gain assurance of the organisation s safeguarding policies, procedures and culture. Good assurance that robust safeguarding policies and procedures are in place and are supported by an informed and knowledgeable workforce who feel empowered to report and escalate any safeguarding concerns. BMI The Park Hospital Date Area Reason for Visit Outcome 12/7/2016 Various Safeguarding focus in order to gain assurance of the organisation s safeguarding policies, procedures and culture. Assured of a strong safeguarding culture with appropriate safeguarding policies and procedures. Staff demonstrated good knowledge and understanding and knew how to deal with any safeguarding issues. 5.2 Care Home Quality South Nottinghamshire Quality and Patient Safety Team is committed to enhancing the quality and delivery of nursing care within care homes by supporting their staff and managers to achieve the optimum levels of care delivery which aligns to the NHS standard contact. The duties of the team are to: Monitor the quality of care of Any Qualified Provider (AQP) homes in conjunction with Local Authorities (LA) Provide regular activity and monitoring reports for CCGs Ensure that all AQP homes are audited at least once a year, reports and findings from these audits are shared with LA and individual AQP providers Escalate and manage any issues or concerns raised during an audit or whistleblowing The table below shows the main changes since the last report. Quality monitoring processes have been revised and shared across Mid-Notts CCGs to ensure consistency across the county. Legend: Low History of concerns that are resolving but require some monitoring to ensure progress maintained Moderate On-going concerns around quality of care delivery / lack of compliance with CQC standards home requires regular monitoring of standards of care and action plans by CQC/LA/CCG High Serious concerns raised/contract suspensions in place/non-compliance with CQC standards home required frequent monitoring of standards of care and action plans by CQC/LA/CCG Noted Care homes noted to have low level concerns / CQC compliance issues but not requiring CCG input Page 27 of 44

28 Nottingham North and East CCG Name of Home Current RAG Victoria Cottage Eden Lodge Nottingham West CCG Name of Home Beeston Lodge The Gables Rushcliffe CCG Name of Home Eton Park Church Farm at Skylarks Pelham Lodge Current RAG Current RAG Previous RAG Previous RAG Previous RAG Summary Residential service, currently suspended by LA and CQC substantiated concerns; consultancy appointed by the provider to lead work to resolve concerns. Recent CQC inspection identified a number of concerns. LA contract suspension in place but some improvement noted. Summary Concerns raised regarding nutritional support for residents were unsubstantiated but the home continues to be monitored. Recent quality monitoring visit highlighted areas for improvement, action plan not met LA and CCG suspension in place. Summary The home remains in administration and continues to receive quality monitoring visits. Meeting taken place with provider. Improvement notice lifted. LA and CCGs continue to monitor the home. Provider taken decision to voluntary close the home due to low occupancy, unable to recruit manager and permanent staff and environmental issues. A collaborative approach to support home by LA, CCG and CQC. Care Quality Commission (CQC) Ratings The Care Quality Commission (CQC), the independent regulator of health and adult social care services in England ensures health and social care services provide people with safe, effective, compassionate, high-quality care, and encourage care services to improve. Their role is to monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety which include: Is it safe? Is it effective? Is it caring? Is it responsive to people's needs? Is it well led? Based on the outcome of the inspection, CQC gives an overall rating as well as one for each of the key questions. There are four levels of rating: outstanding the service is performing exceptionally well good the service is performing well and meets CQC's expectations requires improvement the service isn't performing as well as it should and CQC has told the service how it should improve inadequate the service is performing badly and CQC has taken action against the person or organisation that runs it Page 28 of 44

29 A full inspection report and all ratings for a service are published on the CQC website Nottingham North and East Care Homes: 2-8 Orchard Street NNE CCG Care Homes Date of Last Inspection Outcome Not Yet Inspected Albemarle Court (Nottingham) Ltd T/As Albemarle Court Nursing Home 17/06/2015 Good Albemarle Hall Nursing Home 04/11/2015 Requires Improvement Aldercar Residential Care Home 16/02/2016 Good Annesley Lodge Care Home Good Beeches Care Home (Nottingham) 27&28/01/16 Good Bestwood Hospital (Winslow) 21/07/2015 Not Rated Braywood Gardens 1&2/12/15 Good Bridle Lodge 30/09/2015 Requires Improvement Camellia House 15/03/2016 Good Carlile House Good Carlton Care Home 24/10/2014 Good Charnwood 3&4/02/16 Requires Improvement Coppice Lodge 26&27/11/15 Requires Improvement Eden Lodge Residential Care Home 06/04/2016 Requires Improvement Elm Tree House Good Elmbank Care Home 24/03/2016 Good Ernehale Lodge Care Home 28/07/2014 Compliant Gedling Village Care Home 06/01/2015 Good Page 29 of 44

30 Gedling Village Court Hawthorne Nursing Home Hazelgrove Care Home Heathcotes (Arnold) Heathcotes (Hucknall & Watnall) Hucknall Hope Lea Project Ivy Leaf Jubilee Court Leen Valley Care Home Leivers Court Residential Care Home For Older People Loreto Cottage Manor Residential Home (Arnold) Limited Millbeck House Moriah House Limited Nottingham Care Village Nottingham Neurodisability Service Hucknall - Millwood Nottingham Neurodisability Service Hucknall - Rosewood Nottingham Neurodisability Service Hucknall -Fernwood Oakleigh Lodge Orla House Oxclose Lane Care Home Parker House Nursing Home Sheepwalk House Sherwood House Residential Care Home Shortwood House Springwater Lodge Care Home Stoke House Care Home The Firs Residential Care Home The Orchard Care Home The Spinnies The Vines Valley Road Care Home Victoria Cottage Residential Home Westwolds Willow Brook Care Home Woodthorpe Manor Nursing Home Woodthorpe View Care Home 05/01/2015 Requires Improvement 05/11/2015 Requires Improvement 30/11&01/12/15 Requires Improvement 14/03/2016 Good 26/11/2014 Good 21/10/2015 Good 20/08/2015 Good 6&7/01/15 Good 17/03/2015 Requires Improvement 11/02/2016 Good 2&5/10/15 Requires Improvement 9&10/02/15 Good 19/03/2015 Good 30/03/2016 Good Not Yet Inspected 20&21/01/16 Good 15/11/2013 Compliant 15/07/2014 Good Not Yet Inspected 26&27/03/15 Good 30/03/2016 Good Requires Improvement 12/02/2016 Good 25/03/2015 Good 30/10/2015 Good 3&4/03/15 Good 26/11/2015 Inadequate 02/03/2016 Good 01/12/2015 Good Good 09/04/2014 Compliant Good 13,14&19/01/16 Inadequate 26/11/2013 Compliant 26/03/2015 Good 06/01/2015 Good Good Page 30 of 44

31 Nottingham West Care Homes: 1 Devonshire Avenue Acer Court Care Home Alder House Care Home Alexandra House - Eastwood Ashton Court Residential Home Beech Court Care Home Beeston Lodge Nursing Home Bramcote Hills Care Home Bramwell Broadgate Care home Church Street Care Home Eastwood House Edward House Falcon House Care Home First Class Care Limited Giltbrook Care Home Kingsbridge Way Landermeads Care Home Lawrence Mews Little Acres Meadow lodge Moorlands Care Home Queenswood Ryland Residential Home NW CCG Care Homes Date of Last inspection Outcome Good 16&17/12/14 Good Good 25/02/2016 Good 02/04/2015 Good Good 3&4/12/14 Good 30&31/07/15 Good 3&4/02/15 Good 11/10/2015 Good 09/01/2014 Good 14/12/2015 Requires Improvement 11/06/2015 Good 26&27/08/15 Good Not Yet Inspected 18&19/05/15 Requires Improvement 10/04/2013 Compliant 23/03/2015 Requires Improvement 16/12/2014 Good 12/01/2016 Good 09/02/2016 Requires Improvement 08/12/2014 Requires Improvement 23/02/2016 Requires Improvement 23&24/09/15 Good Page 31 of 44