Quality Account 2016/17. Ambulance, Community, Hospital, Learning Disability & Mental Health Services.

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1 Quality Account 2016/17 Ambulance, Community, Hospital, Learning Disability & Mental Health Services

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3 Isle of Wight NHS Trust Quality Account 2016/17 03 Contents Part 1 Chairman and Chief Executive s Statement on Quality 05 Part Priorities for Improvement Progress against Key Priorities for Action 2016 / Key Priorities for Action 2017 / PRIORITY 1 (Patient Safety) PRIORITY 2 (Patient Experience) PRIORITY 3 (Clinical Effectiveness) 14 Part Statements of Assurance from the Board Review of Services Participation in Clinical Audits Research Goals Agreed with Commissioners What Others Say about the Provider Data Quality 34 Part Review of Quality Performance Implementation and monitoring the effectiveness of the sepsis care bundle Improve communication with patients and carers Improve the culture of the organisation to improve patient experience Improve the discharge planning process Reduce incidents of patient harm Further Performance Information Quality Indicators Healthcare Associated Infections (HCAI) Complaints & Compliments Patient Feedback (inc FFT) Learning from Serious Incidents / Never Events Dashboards & Scorecards Patient Safety Walkrounds Quality Action Plans Workforce 71 Part Statements provided by Commissioning PCT, LINks or OSCs 73 Part Statement of Directors Responsibilities 76 Part Changes made to the final version of the Quality Account 77 Part How to Provide Feedback on the Account 78 Appendix One Stakeholders engaged in the development of the Quality Account 79 Appendix Two Glossary 80 Appendix Three Independent Auditor 82

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5 Isle of Wight NHS Trust Quality Account 2016/17 05 Part 1 Chairman and Chief Executive s Statement on Quality The Isle of Wight NHS Trust aims to be one of the safest organisations within the NHS with our staff committed to providing safe, high quality care for everyone, every time % Harm free care within the hospital setting We are pleased to be presenting the Isle of Wight s Quality Account for 2016 / 2017 to both service users and the general public. It demonstrates our progress against those Quality priorities which are of particular importance to you, our stakeholders, and also sets out our intentions for 2017 / It is an open and honest account of the quality of services for which the Trust Board is accountable and acknowledge that this has been a very challenging year. The Trust was inspected by the Care Quality Commission (CQC) in November This was the first full inspection since Although some improvements have been made since 2014, there was concern that we have not made all the improvements we needed to have made during this time Furthermore, immediately after this inspection in November 2016, the CQC issued the Trust with an Enforcement Notice under Section 31 regarding safety concerns within the mental health services and a warning notice under Regulation 17 with regard to some staffing issues in the Emergency Department and some other governance items. The Trust started work to resolve these immediate issues in this year but had not concluded the actions that would enable the CQC to consider removing the warnings. The CQC s final report was received in April 2017 and showed the Trust to be inadequate overall. The detail of how the Trust will address the quality failings identified by the CQC and the progress made will therefore be addressed in our 2017 / 18 Quality Account. What is a quality account? A Quality Account is an annual report that is produced by the Isle of Wight NHS Trust to give the public details about the quality of healthcare services that we provide. The Quality Account gives a review of quality within our organisation over the last year, giving details of our outcomes against last year s priorities; and also looking forward to define our priorities for the next year and indicate how we plan to achieve these. There is a glossary of terms included within this Quality Account and is attached as Appendix Two. Our successes We continue to make improvements in performance against the quality indicators. During 2016 / 17 mortality monitoring has demonstrated an as expected performance by the NHS measure SHMI and a better than expected performance as measured by the Dr Foster measure the HSMR. This continues a pattern of sustained improvement over the last 3 years. We are continuing to see excellent performance against the NHS Safety Thermometer figure, which measures the percentage of patients receiving care with no harms. We now deliver an average of 98.29% harm free care within the hospital setting. We have reviewed the impact of continuing to measure falls, pressure ulcers, and infections on our quality outcomes and have decided that whilst we will continue to reduce

6 06 Quality Account 2016/17 Isle of Wight NHS Trust these, particularly in the community, the focus for the next year needs to be on improvements that will have a meaningful impact on our aim of reducing mortality and morbidity even further. For this reason, we have agreed to undertake the following national Commissioning for Quality and Innovation (CQUINs) which will be the focus for the next year: National / Local Isle of Wight NHS Trust CQUIN Schemes 2016 / 17 Total N N N N N N N N N N N N N N N 1.a Improvement of Health and Wellbeing of NHS Staff. 1.b Healthy Food for NHS staff, Visitors and Patients. 1.c Improving the Uptake of Flu Vaccinations for Front Line Clinical Staff. 2.a Timely identification of sepsis in emergency departments and acute inpatient settings. 2.b. Timely treatment of sepsis in emergency departments and acute inpatient settings. 2.c Antibiotic Review Assessment of clinical antibiotic review between hours of patients with sepsis who are still inpatients at 72 hours. 2.d Reduction in antibiotic consumption per 1,000 admissions. 3.a. Cardio metabolic assessment and treatment for patients with psychoses. 3.b. Collaboration with primary care clinicians. 4. Improving services for people with mental health needs who present at A&E. 5. Transitions out of Children and Young People s Mental Health Services (CYPMHS). 6. Offering Advice and Guidance (A&G). 7. NHS e-referrals CQUIN. 8.a. Supporting proactive and safe discharge Acute providers. 8.b. Supporting proactive and safe discharge Community providers. 8.c. Supporting proactive and safe discharge Care homes. 9.a. Tobacco screening. 9.b. Tobacco brief advice. 9.c. Tobacco referral and medication offer. 9.d. Alcohol screening. 9.e. Alcohol brief advice or referral. 10. Improving the assessment of wounds. 11. Personalised care and support planning. 12. A reduction in the proportion of ambulance 999 calls that result in transportation to a type 1 or type 2 A&E department. 13. Increasing the proportion of NHS 111 referrals to services other than to the ambulance service or A&E departments.

7 Isle of Wight NHS Trust Quality Account 2016/17 07 The Trust recognises that this year delivering Quality Improvement (QI) at a time when pressures have been high has been somewhat challenging; however, this has also continued to provide us with the opportunity to identify improvements that we can make to ensure our services remain high quality for everyone, every time / 17 saw a significant improvement in a number of Quality Indicators that have been difficult to improve for a number of months and years. We are pleased to have been able to balance our ambitious Quality Improvement priorities whilst continuing to deliver a number of key targets. We have achieved 13 of the 18 of our Commissioning for Quality and Innovation (CQUIN) goals and have excelled in reducing the most serious areas of harm. The Trust has welcomed the work of Healthwatch Isle of Wight and the local Clinical Commissioning Group (CCG) in supporting us with the on-going review of our services. Healthwatch have undertaken a number of reviews of Trust services this year. This included a review of the Emergency Department and the follow up of the Trust s complaints handling process, at the time of writing reports are still awaited. The Trust welcomes the opportunity to work with commissioners of health care services on the Island to deliver a smaller number of more ambitious quality improvement subjects. Significant improvements in 2016 / 17 have been seen in pressure ulcer prevention in the community, identification of patients who suffer with sepsis and the improved experience for people who use our services who have or care for someone with dementia. Our progress against the NHS Safety Thermometer which provides point of care surveying places the Trust in a better position for Pressure Ulcers and Falls. The Trust achieved its targeted reduction in community pressure ulcers of the most serious type. In fact, we significantly exceeded this. Whilst we continue to receive and learn from complaints about our services, we can confirm that formal complaints have reduced by 24% with a slight increase in concerns of 0.2% (950 in 15 / 17; 952 in 16 / 17). We will continue to work to reduce complaints further over the next year. Performance against the national stroke indicator for 80% of patients to spend 90% of their time in a hospital stroke unit was achieved consistently in the last three years with only one exception. It is important to note that the CQC have recognised the continued good work in our vulnerable groups, in particular both the Learning Disabilities and the Island Recovery Integrated Service (IRIS); both of whom achieved a good rating. The NHS 111 service has also achieved a good rating following its inspection in March Our challenges 2016 / 17 proved to be a challenging year for the Trust. Significant increases in emergency activity, staff vacancies in key clinical posts, the delivery of significant cost improvements and supporting our Clinical Business Units, who came in to play in November 2015 have meant for many of our senior leaders they have had to get to grips with how to monitor, manage and improve quality very quickly. This, coupled with a number of vacant posts, has meant 2016 / 17 has been a particularly difficult year. Throughout the past year the Trust has been forced to declare 16 full days of Black Alerts and on two occasions has declared a Critical Incident. During these challenging times patient safety and quality of care was maintained and internal monitoring did not see any notable rise in reported incidents (other than patients who endured unacceptable delays waiting for an in patient bed). The response from staff was commendable with staff working additional hours and shifts to support the delivery of care. It is important to note that many of the actions needed to improve performance in key areas have been in place from early in the year. These actions continue to have a positive impact but performance remains inconsistent with the Trust working hard to put sustainable improvements in place as part of its 2017 / 18 operational planning.

8 08 Quality Account 2016/17 Isle of Wight NHS Trust The prevention of infection whilst staying in hospital has been a real challenge for the Trust. People who used our services experienced a higher than normal rate of Clostridium Difficile Infections, (although lower than last year); and an unusually high number of patients with Methicillin Resistant Staphylococcus Aureus (MRSA). Following very robust investigations into many of these cases, we became aware that there was a clear link to the time patients spend in hospital especially whilst waiting for transfer to a more suitable location. However, we also know we must improve on our infection prevention and control practices. This will be a large driver for 2017 / 18 and will include a greater focus on patients who require urinary catheters. During the year we have seen unprecedented delays in patients leaving the organisation which has meant significant pressure on our teams and resources. Maintaining quality whilst under these pressures must be at the forefront of any decision making and we have had to make some difficult choices to achieve this. Unfortunately, this has resulted in the need to cancel operations at times, in order to ensure adequate care for our more acute patients and additional staff have been required to deliver this care. Getting the balance right is a challenge for us all but we have successfully worked together across the Island services to deliver the best possible care. Whilst recognising that 2016 / 17 has been a challenging year, significant progress has been made on a wide range of fronts and this Quality Account highlights some of the work that has been undertaken. It includes an overview of the improvements and achievements we have made in 2016 / 17 and sets out our priorities for 2017 / 18. Specific issues that have arisen The following control risks materialised in 2016 / 17: Failing to deliver key operational targets and constitutional standards Throughout 2016 / 17 the Trust failed to deliver on the following key targets and constitutional standards: Ambulance Emergency Department Referral to Treatment (RTT) Some cancer targets The Trust did not achieve national ambulance targets in 2016 / 17 due to workforce vacancies and worsening handover times in ED, meaning vehicles were slow to be released to attend other calls. The Trust is addressing these issues through 2017 / 18 targeting the timely release of these critical resources, described in more detail in the Annual Report. Emergency Care four (4) hour standard under-performed, also due to: workforce vacancies; delays putting in place best practice, and the impact of insufficient improvement to patient flow (across the health system). The Trust s Integrated Improvement Framework (IIF) sets out the key improvement actions to address these challenges. The Trust s performance against Referral to Treatment (RTT) has worsened due to reduced elective capacity, increases in gastroenterology and ophthalmology waiting lists over 18 weeks and under-utilisation of some theatre lists. Improvements to address this include: delivery of the 2017 / 18 demand plan; a standardised booking model; as well as through sub contracts with mainland independent providers. Non-achievement of the cancer 62 day target was due to inconsistent performance in the year because complex pathways required multiple diagnostic tests both at the Trust and at our healthcare partners. Key improvements to address these issues in 2017 / 18 are summarised in the annual report. The Trust monitors performance through the Board Assurance Committees and in a comprehensive performance report which is discussed at the regular Trust Board meetings held in public. The necessary redesign of arrangements together with our local health and social care partners and the fundamental underlying issues will be addressed by the My Life a Full Life new model of care initiative, and Hampshire and Isle of Wight Sustainability and Transformation Plan (STP), respectively

9 Isle of Wight NHS Trust Quality Account 2016/17 09 NHS Improvement and Care Quality Commission In November 2016, the Care Quality Commission (CQC) commenced an inspection of the Isle of Wight NHS Trust. This was published in April Through the Single Oversight Framework, NHS Improvement identifies how to help NHS providers attain, and maintain, Care Quality Commission ratings of Good or Outstanding. NHS Improvement identify Trusts potential support needs through reviewing a range of data, including CQC inspection findings of requiring improvement or inadequate in particular domains. NHS Improvement issue enforcement Undertakings where they have concern that a Trust will not achieve necessary improvement without accepting prescribed support. NHS Improvement opened an investigation on 23 September 2016 due to concerns around the operational, quality and financial performance and strategic direction of the Trust. The investigation considered whether the Trust s leadership, governance structures and delivery arrangements were appropriate to sufficiently address these. Accordingly, the Trust were issued with Undertakings on 28 November 2016, requiring robust plans to be put in place in respect of governance arrangements, operational performance, sustainability,, meetings and reports. A Performance Director was appointed. Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires providers have systems and processes that ensure that they are able to meet other requirements in this part of the Regulations (Regulations 4 to 20A). To meet this regulation; providers must have effective governance, including assurance and auditing systems or processes. These must assess, monitor and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service. The systems and processes must also assess, monitor and mitigate any risks relating the health, safety and welfare of people using services and others. Providers must continually evaluate and seek to improve their governance and auditing practice. The CQC can issue a Regulation 17 notice which requires an NHS provider to return, within 28 days, a written report setting out how, and the extent to which, in the opinion of the provider, the requirements above are being complied with, and any plans for improving the standard of the services provided to service users with a view to ensuring their health and welfare. The Trust was issued with a Regulation 17 notice and further NHS Improvement undertakings following the publication of the CQC report. Under Section 31 of the Health and Social Care Act 2008, the CQC can impose a condition on a health provider s registration whenever it has reasonable cause to believe that any person will or may be exposed to risk of harm in a service. The Trust was issued with a Section 31 notice of decision in respect of mental health services immediately following the inspection of the services in January The CQC also formally wrote to the Trust asking for a report on urgent action to address a number of other serious concerns across all services. The publication of the report in April resulted in the Trust being placed into special measures in April 2017 and receiving a further set of Undertakings from NHS Improvement. An NHSI Improvement Director has been appointed to work with the Trust by NHS Improvement. An Integrated Improvement Framework (IIF) is being developed to serve as an enabler for the Trust s quality improvement journey. A Quality Improvement Plan has been developed and will be submitted to the CQC on 2 June The aim of the plan is to ensure the Trust makes rapid improvements that enable it to be taken out of Special Measures as soon as possible. Although the most significant concerns of the CQC concerned the Trust s Mental Health Services, concerns also extended to a number of areas across the Trust including Ambulance, Acute and Emergency Care and Community, and can be grouped under the categories of Clinical Care, Governance, Workforce and Infrastructure.

10 10 Quality Account 2016/17 Isle of Wight NHS Trust Particular observations of the CQC relating to the Trust s internal control and governance arrangements were: There were deficiencies in organisational structures, processes and the Trust leadership which prevented staff from providing good services. The Trust did not have strong risk management and governance processes at all levels which affected the quality and safety of services and Executives were not properly sighted on some risks and issues. The Trust did not know whether all front line staff were reporting all incidents and whether learning from incidents was shared. Key groups of staff were not up to date with safeguarding training and there were shortcomings in reported incidents. Senior management were felt by staff to have insufficient knowledge and experience. There was found to be a top down culture with senior managers attempting to direct change. Senior managers did not appear to understand what was needed to make necessary changes or to implement their vision and strategies. Staff did not feel part of this process as the Board / Executive had sought a high number of external reviews. Ambulance One (whistleblowing) Following an investigation in respect of manipulation of Ambulance data, we cannot internally assure the accuracy of the data from last year but can assure systems going forward in 2017 / 18. Endoscopy In last year s Quality Account we advised that there was an issue affecting the booking of Endoscopy appointments. An investigation was launched following the discovery that an Administrator was potentially cancelling and re-booking patients outside of the 2 week pathway. The incidents covered a two year span. A robust investigation was undertaken throughout the organisation of systems and practices. The Trust benefited from external scrutiny, both clinical and non clinical to provide assurance around the methodology used. An action plan was compiled following receipt of the recommendations from the intensive support team (part of NHS Improvement). The action plan is due for completion by the end of July Changes are being rolled out to all bookings across the Trust. Additional training is being implemented for all booking staff which is being audited annually. The Serious Incident Requiring Investigation and safeguarding case are now closed. A member of staff has been dismissed.

11 Isle of Wight NHS Trust Quality Account 2016/17 11 Our Vision & Values Quality Care for everyone, every time remains our strategic vision and is threaded through all that we do. During 2016 / 2017 we recognised the need to strengthen our strategy and clearly communicate our direction to all our staff. The Trust Board have worked hard to be clear that all our quality priorities will be aligned to our wider organisational goals, as demonstrated in the following: Our goals for 2017 / 2018 are: 1. Excellent patient care. 2. To work with others to continually improve our services. 3. A positive experience for patients, carers, people who use our services and our staff. 4. Skilled and capable staff. 5. Cost effective, sustainable services. Our quality priorities for 2017 / 18 are linked to our organisational goals: Safe and secure handling of medicines. Improve the management of the nutrition and hydration needs of patients. Reduce the number of inpatient bed moves that are not related to clinical need. Our plans for continuing to improve and demonstrate quality over the next year are described in the Trust s Quality Improvement Plan that will be submitted to the CQC as a response to the findings of their inspection and monitored by NHSI as part of their oversight role. This framework supports our longer term, transformational clinical strategy: Beyond Boundaries. Our Quality Improvement Plan brings together all of our key planning and operational delivery documents, ensuring that they all work together to achieve our commitment of delivering safe, high quality care for all of our patients, as well as making our hospitals, modern and efficient places to work. Together, it will help us to realise our aspiration of making our hospitals great places to be cared for; and great places to work. We are committed to developing the Island s Health Care System as the preferred provider of sustainable care. This means we will continue to strive to deliver better care for patients with Dementia and look at how we deliver better care from Cradle to Grave. Our Quality Improvement Plan reiterates the Trust Board s commitment to delivering high standards of safe, quality care for everyone every time, as well as providing a working environment and culture which promotes and welcomes honesty, safety first, openness and compassion in everything we do. Progress described within this document is based on data and evidence collected locally and nationally, much of which is presented as part of our performance framework. Redesigning our services for the future During the year the Trust has commenced the Acute Service Redesign project which will deliver an overall blueprint for the Island s acute Services. The outcome of the redesign work will be a key part of all our work programmes for 2017 / The Trust will continue to work in partnership with our neighbouring mainland Trusts, Southampton and Portsmouth, to continue the Clinical Service Review. Development of this Quality Account This Quality Account has been developed with internal and external stakeholders and partner organisations, including the Patients Council, Healthwatch; Patient Representation Groups, Clinicians, Senior Managers, Commissioners from the Isle of Wight Clinical Commissioning Group (CCG) and the Local Authority s Overview and Scrutiny Committee (OSC) see full list in Appendix 1. This Quality Account has been approved by the Isle of Wight NHS Trust Board.

12 12 Quality Account 2016/17 Isle of Wight NHS Trust The Board are fully committed to the improvements that need to be made to the quality of our services, and our staff are equally committed to the provision of safe and effective care for all our patients. We look forward to making further improvements during 2017 / 18 and are confident that our aims are achievable. Our plans and priorities are all explained further in this account and our progress will continue to be overseen and supported by the Trust Board. We commend this report to you as an accurate assessment of the quality of care we have delivered at the Isle of Wight NHS Trust and to demonstrate our continued to commitment to improving the quality of care and treatment we deliver whist supporting our staff to continue to deliver this in a way that we can be proud of. Eve Richardson, Chair Date: 27 June 2017 Maggie Oldham, Interim Chief Executive Officer Date: 27 June 2017

13 Isle of Wight NHS Trust Quality Account 2016/17 13 Part Priorities for Improvement Progress against Key Priorities for Action 2016 / 17 Progress made in 2015 / 16 quality priorities that contribute to the delivery of the Trust s overarching priorities which were can be found in Part Three Review of quality performance on pages 35 to Key Priorities for Action 2017 / 18 The Trust Board in consultation with key stakeholders, including Patients Council; and staff groups has identified three overarching priorities for quality improvement during 2017 / 18. These priorities are derived the Trust s performance over the past year against its quality and safety indicators; national and regional priorities, and are outlined in the following sections. A full list of stakeholders that were given the opportunity to comment is included as Appendix One. Progress to achieve the quality goals will be measured via key performance indicators for each quality priority, and will be monitored by the Patient Safety; Experience & Clinical Effectiveness (SEE) Triumvirate who receive the Trust s Quality Report and Trust Board Performance Report and review these at the SEE Committee who report to the Quality Governance Committee (QGC). Assurance is provided to the Trust Board via QGC. Progress against priorities will also be reported to and / or discussed with key stakeholders, including the local Clinical Commissioning Group (CCG); NHS England, Healthwatch Isle of Wight and Health Overview Scrutiny Committee through our current governance reporting mechanisms and attendance at key meetings.

14 14 Quality Account 2016/17 Isle of Wight NHS Trust PRIORITY 1 (Patient Safety) Safe and secure handling of medicines. Prescribed medication is the most frequent treatment provided for patients in the NHS. It is vital that medicines are prescribed, dispensed and administered safely and effectively. Of equal importance is their storage and handling within NHS organisations which must be safe, secure and compliant with current legislation. It is vital that we consider all aspects of the safe and secure handling of medicines; in order to do this we will undertake the following: % compliance with daily fridge recording of maximum / minimum reset % compliance with locked drug storage % EPMA training for all hospital and mental health inpatient clinical staff PRIORITY 2 (Patient Experience) Reduce the number of inpatient bed moves that are not related to clinical need. We have experienced considerable difficulty in maintaining patient flow throughout the hospital over the past 12 months. In order to ensure patients have a bed, it has sometimes been necessary to move patients in existing beds to create capacity within a designated specialty, or to avoid mixing male and female patients in the same bay. Often patients are moved for clinical reasons (e.g. they develop an infection and need a side room), but we aim to reduce the amount of patient moves for non-clinical reasons (e.g. to create capacity). The three KPIs for this priority are: 1. 10% reduction in the number of non clinical transfers. 2. 5% reduction the number of patients transferred out of their speciality and as such changing their clinical management pathway. 3. No end of life patients to be moved unless requested by patient / carer / family or clinical need PRIORITY 3 (Clinical Effectiveness) Improve the management of the nutrition and hydration needs of patients. It is widely acknowledged that good nutrition and hydration play a fundamental role in people s health. For older adults, dehydration is the most common cause of fluid and electrolyte imbalance and one that can have long-term effects. Poor nutrition can affect healing, alertness and energy levels. In order to promote good nutrition and hydration with our patients, it is important to understand their needs when they come into hospital. One of the tools available to us is the Malnutrition Universal Screening Tool (MUST). MUST is a five-step screening tool to identify adults who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan. The three Key Performance Indicators for this priority are: % of patients admitted to the inpatient hospital wards will have an accurate MUST assessment done within 12hrs of admission % of patients identified at risk of malnutrition from the MUST assessment will have a plan of care in place within 24hrs of admission % of Registered Nurses who insert and check position of Fine Bore Nasogastric feeding tubes will have received formal training.

15 Isle of Wight NHS Trust Quality Account 2016/17 15 Progress to achieve the priorities identified will be monitored and managed by the identification of subject specialists who will lead the initiatives and develop three Key Performance Indicators (KPIs) for each priority. Reporting of progress against the KPIs will be on a quarterly basis through the Safety, Experience and Clinical Effectiveness Committee; the results of which will be fed through the Quality Governance Committee then on to Trust Board. The three quality priorities for the Trust as a whole will also be underpinned by specialty-specific quality priorities relevant to Ambulance, Community and Mental Health: All patients entering ED via Ambulance are handed over within the 15 minute time frame to a suitably qualified member of staff. The KPIs are: 1. Compliance with national standards of patient handover on a monthly basis. 2. ED staffing to reflect handover Nurse / practitioner in place by July Improved Ambulance response times to RED1 & 2 calls by 2% July For Mental Health, the quality priority is: All patients to have a risk / core assessment and care plan in place. The KPIs are: 1. 95% compliance with monthly Caseload Management requirement % of CPA patients to have a formal review within 12 months.

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17 Isle of Wight NHS Trust Quality Account 2016/17 17 Part Statements of Assurance from the Board Review of Services During 2016 / 17 the Isle of Wight NHS Trust provided and / or sub-contracted 74 NHS services. The Isle of Wight NHS Trust has reviewed all the data available to them on the quality of care in 68 of these NHS Services. The income generated by the NHS services reviewed in 2016 / 17 represents per cent of the total income generated from the provision of NHS Services by the Isle of Wight NHS Trust for 2016 / Participation in Clinical Audits During 2016 / 17, 57 national clinical audits and 5 national confidential enquiries covered NHS services that the Isle of Wight NHS Trust provides. During that period the Isle of Wight NHS Trust participated in 100% national clinical audits and 80% of national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that the Isle of Wight NHS Trust was eligible to participate in during 2016 / 17 are as follows: Audit title Child health clinical outcome review programme (NCEPOD) Child health clinical outcome review programme (NCEPOD) Child health clinical outcome review programme (NCEPOD) Diabetes (Paediatric) (NPDA) Elective surgery (National PROMs Programme) Falls and Fragility Fractures Audit Programme (FFFAP) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) National Joint Registry (NJR) National Joint Registry (NJR) National Nosocomial surgical Site Surveillance National Ophthalmology Audit National Neonatal Audit Programme (NNAP) Stress Urinary Incontinence Audit National Paediatric Pneumonia Audit The National Complicated Acute Diverticulitis (CADS) Project NHS Cervical Screening Programme UK Cystic Fibrosis Registry IBRA (implant based breast reconstruction audit National Adult Asthma Audit (BTS) Work Stream Chronic Neurodisability Young People s Mental Health Cancer in Children, Teens and Young Adults 2016 / 17 data collection 2016 / 17 data collection 3. National Hip Fracture Database 1. Perinatal mortality surveillance; 2. Perinatal mortality and morbidity confidential enquiries (term intrapartum related neonatal deaths) 3. Maternal morbidity and mortality confidential enquiries (cardiac (plus cardiac morbidity) early pregnancy deaths and pre-eclampsia, plus psychiatric morbidity) 4. Maternal mortality surveillance Knee replacement Hip replacement 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection Acute surgical services Paediatric 2016 / 17 data collection Carried over from 2014 ongoing national audit BTS Stop Smoking Champions Medical and Surgical Clinical Outcome Review Programme, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Non-invasive ventilation

18 18 Quality Account 2016/17 Isle of Wight NHS Trust Audit title National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme Diabetes (Adult) Diabetes (Adult) Diabetes (Adult) Diabetes (Adult) Sentinel Stroke National Audit Programme (SSNAP) Cardiac Rhythm Management (CRM) National Cardiac Arrest Audit (NCAA) National Heart Failure Audit Bowel cancer (NBOCAP) Work Stream Secondary care workstream Pulmonary rehabilitation workstream National Inpatient Audit National Pregnancy in Diabetes Audit National Diabetes Transition National Diabetes Audit (NDA) SSNAP Clinical Audit 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection 1. Admission; 2. Readmission (submitted for both) 2016 / 17 data collection 6 th National Audit Project of the Royal College of Anaesthetists Perioperative Anaphylaxis in the UK Case Mix Programme (CMP) National Head and Neck Cancer Audit (HANA) National Comparative Audit of Blood Transfusion programme National Comparative Audit of Blood Transfusion programme National Comparative Audit of Blood Transfusion programme National Comparative Audit of Blood Transfusion programme National Emergency Laparotomy Audit (NELA) Lung cancer (NLCA) National Prostate Cancer Audit Oesophago-gastric cancer (NAOGC) Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) National Audit of Cardiac Rehabilitation (NACR) Audit of Red Cell & Platelet transfusion in adult haematology patients Re-audit of Patient Blood Management in Scheduled Surgery Audit of Red Cell transfusion in palliative care 2017 Transfusion Associated Circulatory Overload Audit 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection Consultant sign-off (RCEM) Severe sepsis and septic shock care in emergency departments (RCEM) Asthma (paediatric and adult) care in emergency departments (RCEM) Major Trauma: The Trauma Audit & Research Network (TARN) Diabetes (Adult) 1. Adult and paediatric; 2. Prehospital care, acute care; 3. Secondary and tertiary care; 4. Processes of trauma care; 5. Outcomes after trauma care (submitted for all) 2016 / 17 data collection National Diabetes Footcare Audit BHIVA National Audit of Routine Monitoring of Adults with HIV NHIVNA National psychological audit 2015: Survey of HIV psychological support and emotional wellbeing National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH) Learning Disability Mortality Review Programme (LeDeR) Suicide, Homicide & Sudden Unexplained Death 2016 / 17 data collection 2016 / 17 data collection

19 Isle of Wight NHS Trust Quality Account 2016/17 19 Audit title Medical and Surgical Clinical Outcome Review Programme, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Prescribing Observatory for Mental Health (POMH) Prescribing Observatory for Mental Health (POMH) Prescribing Observatory for Mental Health (POMH) Work Stream Physical and mental health care of mental health patients in acute hospitals Prescribing of antipsychotics for people with dementia Monitoring of patients prescribed lithium Rapid tranquillisation National Dementia Audit (NAD) The national clinical audits and national confidential enquiries that the Isle of Wight NHS Trust participated in during 2016 / 17 are as follows: Audit title Child health clinical outcome review programme (NCEPOD) Child health clinical outcome review programme (NCEPOD) Child health clinical outcome review programme (NCEPOD) Diabetes (Paediatric) (NPDA) Elective surgery (National PROMs Programme) Falls and Fragility Fractures Audit Programme (FFFAP) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE UK) National Joint Registry (NJR) National Joint Registry (NJR) National Nosocomial surgical Site Surveillance National Ophthalmology Audit National Neonatal Audit Programme (NNAP) Work Stream Chronic Neurodisability Young People s Mental Health Cancer in Children, Teens and Young Adults 2016 / 17 data collection 2016 / 17 data collection 3. National Hip Fracture Database 1. Perinatal mortality surveillance; 2. Perinatal mortality and morbidity confidential enquiries (term intrapartum related neonatal deaths) 3. Maternal morbidity and mortality confidential enquiries (cardiac (plus cardiac morbidity) early pregnancy deaths and pre-eclampsia, plus psychiatric morbidity) 4. Maternal mortality surveillance Knee replacement Hip replacement 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection Stress Urinary Incontinence Audit National Paediatric Pneumonia Audit The National Complicated Acute Diverticulitis (CADS) Project Acute surgical services NHS Cervical Screening Programme UK Cystic Fibrosis Registry IBRA (implant based breast reconstruction audit) Paediatric 2016 / 17 data collection Carried over from 2014 ongoing national audit National Adult Asthma Audit (BTS) BTS Stop Smoking Champions Medical and Surgical Clinical Outcome Review Programme, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme Diabetes (Adult) Non-invasive ventilation Secondary care workstream Pulmonary rehabilitation workstream National Inpatient Audit

20 20 Quality Account 2016/17 Isle of Wight NHS Trust Audit title Diabetes (Adult) Diabetes (Adult) Diabetes (Adult) Sentinel Stroke National Audit Programme (SSNAP) Cardiac Rhythm Management (CRM) National Cardiac Arrest Audit (NCAA) National Heart Failure Audit Bowel cancer (NBOCAP) Work Stream National Pregnancy in Diabetes Audit National Diabetes Transition National Diabetes Audit (NDA) SSNAP Clinical Audit 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection 1. Admission; 2. Readmission (submitted for both) 2016 / 17 data collection 6 th National Audit Project of the Royal College of Anaesthetists Perioperative Anaphylaxis in the UK Case Mix Programme (CMP) National Head and Neck Cancer Audit (HANA) National Comparative Audit of Blood Transfusion programme National Comparative Audit of Blood Transfusion programme National Comparative Audit of Blood Transfusion programme National Comparative Audit of Blood Transfusion programme National Emergency Laparotomy Audit (NELA) Lung cancer (NLCA) National Prostate Cancer Audit Oesophago-gastric cancer (NAOGC) Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) National Audit of Cardiac Rehabilitation (NACR) Audit of Red Cell & Platelet transfusion in adult haematology patients Re-audit of Patient Blood Management in Scheduled Surgery Audit of Red Cell transfusion in palliative care 2017 Transfusion Associated Circulatory Overload Audit 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection 2016 / 17 data collection Consultant sign-off (RCEM) Severe sepsis and septic shock care in emergency departments (RCEM) Asthma (paediatric and adult) care in emergency departments (RCEM) Major Trauma: The Trauma Audit & Research Network (TARN) Diabetes (Adult) 1. Adult and paediatric; 2. Prehospital care, acute care; 3. Secondary and tertiary care; 4. Processes of trauma care; 5. Outcomes after trauma care (submitted for all) 2016 / 17 data collection National Diabetes Footcare Audit BHIVA National Audit of Routine Monitoring of Adults with HIV NHIVNA National psychological audit 2015: Survey of HIV psychological support and emotional wellbeing National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH) Learning Disability Mortality Review Programme (LeDeR) Medical and Surgical Clinical Outcome Review Programme, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Prescribing Observatory for Mental Health (POMH) Prescribing Observatory for Mental Health (POMH) Suicide, Homicide & Sudden Unexplained Death 2016 / 17 data collection 2016 / 17 data collection Physical and mental health care of mental health patients in acute hospitals Prescribing of antipsychotics for people with dementia Monitoring of patients prescribed lithium

21 Isle of Wight NHS Trust Quality Account 2016/17 21 Audit title Prescribing Observatory for Mental Health (POMH) Work Stream Rapid tranquillisation National Dementia Audit (NAD) The national clinical audits and national confidential enquiries that Isle of Wight NHS Trust participated in, and for which data collection was completed during 2016 / 17 are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. Audit Work Participation % Cases Child health clinical outcome review programme (NCEPOD) Chronic Neurodisability Yes Data collection still ongoing Child health clinical outcome review programme (NCEPOD) Young People s Mental Health Yes Data collection still ongoing Child health clinical outcome review programme (NCEPOD) Cancer in Children, Teens and Young Adults Yes Data collection still ongoing Diabetes (Paediatric) (NPDA) 2016 / 17 data collection Yes 100% Elective surgery (National PROMs Programme) 2016 / 17 data collection Yes Data collection still ongoing Falls and Fragility Fractures Audit Programme (FFFAP) 3. National Hip Fracture Database Yes 100% Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) 1. Perinatal mortality surveillance; Yes 100% Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) 2. Perinatal mortality and morbidity confidential enquiries (term intrapartum related neonatal deaths) 3. Maternal morbidity and mortality confidential enquiries (cardiac (plus cardiac morbidity) early pregnancy deaths and preeclampsia, plus psychiatric morbidity) Yes 100% Yes 100% Maternal, Newborn and Infant Clinical Outcome Review Programme (MBRRACE-UK) 4. Maternal mortality surveillance Yes 100% National Joint Registry (NJR) Knee replacement Yes 100% National Joint Registry (NJR) Hip replacement Yes 100% National Nosocomial surgical Site Surveillance 2016 / 17 data collection Yes Data collection still ongoing National Ophthalmology Audit 2016 / 17 data collection Yes Data collection still ongoing National Neonatal Audit Programme (NNAP) 2016 / 17 data collection Yes Data collection still ongoing Stress Urinary Incontinence Audit Yes National Paediatric Pneumonia Audit Yes Data collection still ongoing Data collection still ongoing The National Complicated Acute Diverticulitis (CADS) Project Acute surgical services Yes 100% NHS Cervical Screening Programme Colposcopy KC65 Yes 100% UK Cystic Fibrosis Registry Paediatric 2016 / 17 data collection Yes Data collection still ongoing IBRA (implant based breast reconstruction audit) Carried over from 2014 ongoing national audit Yes Data collection still ongoing National Adult Asthma Audit (BTS) Yes 88%

22 22 Quality Account 2016/17 Isle of Wight NHS Trust Audit Work Participation % Cases BTS Stop Smoking Champions Yes 100% Medical and Surgical Clinical Outcome Review Programme, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Non-invasive ventilation Yes 0% National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme Secondary care workstream Yes Data collection still ongoing National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme Pulmonary rehabilitation workstream Yes Data collection still ongoing Diabetes (Adult) National Inpatient Audit Yes 100% Diabetes (Adult) National Pregnancy in Diabetes Audit Yes Data collection still ongoing Diabetes (Adult) National Diabetes Transition Yes 100% Diabetes (Adult) National Diabetes Audit (NDA) Yes 93.8% Sentinel Stroke National Audit Programme (SSNAP) SSNAP Clinical Audit 2016 / 17 data collection Yes 100% Cardiac Rhythm Management (CRM) 2016 / 17 data collection Yes Data collection still ongoing National Cardiac Arrest Audit (NCAA) 2016 / 17 data collection Yes Data collection still ongoing National Heart Failure Audit 1. Admission; 2. Readmission (submitted for both) Yes Data collection still ongoing Bowel cancer (NBOCAP) 2016 / 17 data collection Yes 100% 6 th National Audit Project of the Royal College of Anaesthetists Perioperative Anaphylaxis in the UK Case Mix Programme (CMP) National Head and Neck Cancer Audit (HANA) Yes Yes Yes Data collection still Data collection still ongoing Data collection still ongoing National Comparative Audit of Blood Transfusion programme Audit of Red Cell & Platelet transfusion in adult haematology patients Yes 100% National Comparative Audit of Blood Transfusion programme Re-audit of Patient Blood Management in Scheduled Surgery Yes Nil return as we did not have any patients who met the criteria National Comparative Audit of Blood Transfusion programme Audit of Red Cell transfusion in palliative care Yes 100% National Comparative Audit of Blood Transfusion programme 2017 Transfusion Associated Circulatory Overload Audit Yes Data collection still ongoing National Emergency Laparotomy Audit (NELA) 2016 / 17 data collection Yes Data collection still ongoing Lung cancer (NLCA) 2016 / 17 data collection Yes National Prostate Cancer Audit 2016 / 17 data collection Yes Oesophago-gastric cancer (NAOGC) 2016 / 17 data collection Yes Data collection still ongoing Data collection still ongoing Data collection still ongoing Acute Coronary Syndrome or Acute Myocardial Infarction (MINAP) National Audit of Cardiac Rehabilitation (NACR) 2016 / 17 data collection Yes 2016 / 17 data collection Yes Data collection still ongoing Data collection still ongoing Consultant sign-off (RCEM) Yes 0% Severe sepsis and septic shock care in emergency departments (RCEM) Yes 100%

23 Isle of Wight NHS Trust Quality Account 2016/17 23 Audit Work Participation % Cases Asthma (paediatric and adult) care in emergency departments (RCEM) Major Trauma: The Trauma Audit & Research Network (TARN) 1. Adult and paediatric; 2. Prehospital care, acute care; 3. Secondary and tertiary care; 4. Processes of trauma care; 5. Outcomes after trauma care (submitted for all) 2016/17 data collection Diabetes (Adult) National Diabetes Footcare Audit Yes BHIVA National Audit of Routine Monitoring of Adults with HIV NHIVNA National psychological audit 2015: Survey of HIV psychological support and emotional wellbeing National Confidential Inquiry into Suicide and Homicide for people with Mental Illness (NCISH) Learning Disability Mortality Review Programme (LeDeR) Medical and Surgical Clinical Outcome Review Programme, National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Prescribing Observatory for Mental Health (POMH) Prescribing Observatory for Mental Health (POMH) Prescribing Observatory for Mental Health (POMH) Suicide, Homicide & Sudden Unexplained Death 2016 / 17 data collection Yes 100% Yes Yes 100% Yes 100% Yes 2016 / 17 data collection Yes Physical and mental health care of mental health patients in acute hospitals Prescribing of antipsychotics for people with dementia Monitoring of patients prescribed lithium Yes 100% Yes 100% Yes 100% Rapid tranquillisation Yes 100% National Dementia Audit (NAD) Yes Data collection still ongoing Data collection still ongoing Data collection still ongoing Data collection still ongoing Participation withdrawn after starting audit lead left with no-one to take over The reports of 17 national clinical audits were reviewed by the provider in 2016 / 17 and Isle of Wight NHS Trust intends to take the following actions to improve the quality of healthcare provided: The contribution of the NHS bowel cancer screening programme to the diagnosis of patients with early bowel cancer is demonstrated. All health professionals should be encouraged to actively promote participation in this service to increase service uptake. Clinicians and data managers should prioritise data completeness for: reason for no treatment, performance status, care plan intent and pre treatment M-stage. This will reduce the proportion of patients who do not undergo a major resection who are unassigned to a treatment pathway and therefore better describe the care and outcomes in this cohort. Improving the post-operative survival in patients undergoing emergency or urgent bowel cancer resection should remain a clinical priority. The provision of pre-operative resuscitation, adequate theatre access, post operative critical care, and early colorectal team involvement, including full radiological support and facilities for colonic stenting as a bridge to curative surgery or expediting palliative chemotherapy, is likely to improve survival. Efforts to reduce long length of stay may need to be more focused on improving the provision of, and reducing any regional disparity in, community and primary care services (as described in the length of stay short report). Potential delays to discharge, particularly in the elderly population, should be considered pre-operatively, to allow for the provision of community services if required, to reduce the risk of prolonged length of hospital stay.

24 24 Quality Account 2016/17 Isle of Wight NHS Trust Further work is required into investigating regional variation in rates of two-year survival. This is a priority for the audit moving forward and access to the chemotherapy dataset and cause of death data will facilitate this. Patients presenting with stage IV bowel cancer should be referred to multi disciplinary teams (MDTs) to optimise timing of resection of both the primary tumour and metastases as well as advising on neo-adjuvant and adjuvant treatment. In the future the audit will correlate radiotherapy use to rates of positive circumferential resection margins and local recurrence in rectal cancer patients undergoing major resection. To facilitate this, clinicians should aim to ensure complete data for circumferential resection margin. Clinicians should ensure that patients undergoing an anterior resection are aware that data suggests that in a significant proportion of patients a temporary stoma may not be reversed within 18 months. Networks / SCNs and commissioners should monitor adherence to their guidelines for treatment in early larynx cancer and confirm that patients are being offered appropriate choice in determining their treatment. MDTs are encouraged to record current status to allow future disease specific survival to be calculated. The improvement of multi professional submission continues an encouraging trend and should be built upon by MDTs to provide a more comprehensive assurance to patients and commissioners. MDTs are encouraged to ensure that outcome data is recorded to enable analysis of disease free survival data in a cumulative cohort as clinical trials are unlikely to answer these questions. Focused effort is required in some SCNs / networks and their contributing MDTs, who have consistently failed in adequately recording stage. We would encourage each MDT to review their own results and appraise their methods for ensuring accurate recording of risk adjustment factors. To facilitate risk adjustment, improved completeness of co morbidity is required. The MDT discussion remains central to the recording of this information. We would encourage each MDT to review their own results and appraise their methods for ensuring accurate recording of risk adjustment factors. The information currently available suggests that of the casemix variables proposed, co morbidity and deprivation are likely to be the most sensitive predictors. Deprivation is calculated independently from the post code recorded at diagnosis. MDTs are encouraged to focus specifically on developing strategies to ensure the robust collection of co morbidity data. Promote the use of the sepsis 6 care bundle and referral to CCOS for tracking to improve recognition and treatment of sepsis. Remind Nursing staff of the importance of recording their actions in relation to sick and deteriorating patients. Promote early appropriate discussion around DNACPR to increase it use and prevent unnecessary resuscitation attempts. The reports of 17 local clinical audits were reviewed by the provider in 2016 / 17 and Isle of Wight NHS Trust intends to take the following actions to improve the quality of healthcare provided: Need to improve documentation on IOL page of maternity case notes. Proper categorization caesarean section should be done. Use of regional anaesthesia should not delay the section. Consultant should be informed and documented [of section]. Written consent can be omitted to avoid delay [for section]. Ensure the [Vancomycin] protocol is easily accessible. When weight is taken for the patient, to be transcribed onto JACS system as well as the nursing notes. Educating the new incoming junior doctors to familiarise them with the hospital vancomycin guidelines. Create GRACE sticker for logging the risk scores. Increase awareness and utilisation of GRACE score online via ecarelogic. Incorporate teaching on GRACE score for FY1 junior doctors during induction. Need to assess the risk of patients presenting with NSTEMI to determine the accepted transfer times to PPCI center. Patient presenting with NSTEMI and high risk features should be transferred on the same day. First line 2nd antiplatelet agent should be Ticagrelor or Prasugrel. All patients presenting with NSTEMI or suspected NSTEMI should have their Lipids measured on the first set of bloods taken in A&E.

25 Isle of Wight NHS Trust Quality Account 2016/ Research Participation in Clinical Research The Research and Development Committee continues to receive research proposals for approval. During 2016 / 17, 23 studies were granted research governance approval. A central annual allocation of 394,006 was made available by the Local Clinical Research Network: Wessex to provide NHS infrastructure support to studies within the National Institute for Health Research Clinical Research Network (NIHR CRN) portfolio, which covers clinician sessions, research nurses and associated staff, NHS service support (pathology, radiology and pharmacy) and research set-up and management. The number of patients receiving NHS services provided or sub-contracted by the Isle of Wight NHS Trust in 2016 / 17 that were recruited during that period to participate in research approved by a research ethics committee was Participation in clinical research demonstrates the Trust s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. Through active participation in research, our clinical staff stay abreast of the latest possible treatment possibilities. There were 23 clinical staff participating in research approved by a research ethics committee at the Trust during 2016 / 17. These staff participated in research covering the clinical specialties of cancer, cardiovascular disease, children, dementia & degenerative diseases, diabetes, gastroenterology, haematology, hepatology, mental health, metabolic & endocrine disease, ophthalmology, ENT, reproductive health & childbirth, respiratory disorders and stroke. The impact of research activities of the David Hide Asthma & Allergy Centre continues to be substantial, delivering high impact publications and facilitating the development of further funding applications. The Centre has managed to review over 70% of the 89 / 90 Birth Cohort at 26 years of age, alongside recruitment to the 3 rd Generation Study with reviews at 2 and 3 years of age. The team has also recruited MAPS / ITEC children at 3 years for follow-up and children have been recruited to the second phase of the Asthma UK ItsMyAsthma trial. Further grant funding has been secured from the Asthma, Allergy and Inflammation (AAIR) Charity funding to conduct a sub-study to assess Bronchial Hyper-reactivity in 150 of the Birth Cohort at 26 years, together with Wellcome Trust funding to study pulmonary epithelial barrier and immunological functions at birth and in early life in 200 children over the next 2½ years. Two 5-year grants have also been secured from the National Institute for Health (NIH) USA which will enable the team to continue follow-up of the 3 rd Generation at 6 years in collaboration with the University of Memphis and also to assess the MAPS / ITEC children at 6 7 years of age. Their collaboration with the University of Manchester continues with the provision of data from our IOW cohort for a 4 year MRC-funded network of all UK-based birth cohorts designed to study asthma (STELAR consortium). Our engagement with clinical research shows our commitment to transparency and desire to improve patient outcomes and experience across the NHS but equally demonstrates our commitment to testing and offering the latest medical treatments and techniques. 394,006 made available by the Local Clinical Research Network

26 26 Quality Account 2016/17 Isle of Wight NHS Trust Goals Agreed with Commissioners A proportion of Isle of Wight NHS Trust s income in 2016 / 17 was conditional on achieving quality improvement and innovation goals agreed between Isle of Wight NHS Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through Commissioning for Quality and Innovation payment framework. A summary of the CQUIN achievement for 2016 / 17 can be seen in the table below. Details of the agreed goals for 2017 / 18 are available from the Quality Governance Team; Isle of Wight NHS Trust, St. Mary s Hospital, Parkhurst Road, Newport, Isle of Wight, PO30 5TG or via quality@iow.nhs.uk CQUIN 2016 / 17 NHS Staff health and wellbeing Sepsis Mental Health Antimicrobial Resistance and Antimicrobial Stewardship Falls Holistic Health Care in Community Settings 1a Health and wellbeing initiatives 1b Healthy food for NHS Staff, visitors and patients 1c Improving the uptake of flu vaccinations for front line staff within Providers 2a Screening 2b Treatment 3a Cardiometabolic assessment of patients with Schizophrenia 3b Communication with General Practitioners 4a Reduction in antibiotic consumption 4b Empiric review of antibiotic prescriptions 5 Falls Prevention of Slips, Trips and Falls in In-patient settings 6a Safer staffing Direct care staff within Community Nursing, Community Mental Health and Ambulance service 6b Innovation and Technology to enable holistic patient care and service delivery Achieved / not achieved Not achieved Achieved Partially achieved Achieved Achieved Achieved Partially Achieved Achieved Achieved Achieved Achieved Achieved 6c Holistic Risk Assessment and Care Planning N/A An option if 6b was discontinued

27 Isle of Wight NHS Trust Quality Account 2016/ What Others Say about the Provider Statements from the CQC Isle of Wight NHS Trust is required to register with the Care Quality Commission and its current registration status is registered with conditions. The Care Quality Commission has taken enforcement action against Isle of Wight NHS Trust during 2016 / 17. Isle of Wight NHS Trust has the following conditions on registration: Regulated Activity Diagnostic and screening procedures Treatment of disease, disorder or injury Regulation Section 31 HSCA Urgent procedure for suspension, variation etc. The CQC issued a s31 Notice of decision to urgently impose conditions on the registered provider as they had reasonable cause to believe a person would or may be exposed to the risk of harm unless we did so. The notice of decision was in respect of Isle of Wight NHS Trust. 1. The registered provider must carry out an urgent assessment of the physical environment on the inpatient mental health wards at St Mary s Hospital. The Trust must ensure there is a comprehensive ligature assessment and an action plan to mitigate the risks. The action plan must include a stated time for completion. The assessment must cover all inpatient mental health wards and environments. There should be effective leadership, and the necessary resources and support to ensure changes have appropriate governance, are appropriately supported and are implemented with the necessary pace and urgency. The action plan must be produced by Wednesday 28 December The registered provider must immediately review its policy and procedures and governance arrangements to ensure there is appropriate assurance to identify, assess, manage, mitigate and monitor all environmental risks to patients care and safety across all inpatient mental health services. This includes where patient privacy and dignity may be compromised. The governance arrangements need to identify where additional resources and support are required and how staff will be supported to understand what actions need to occur to effectively manage all environmental risks. The Trust must provide a copy of the revised governance arrangements by Wednesday 11 January The Registered Provider must ensure that the Commission receives the following information every two weeks. A risk register that includes all environment risks in inpatient mental health services. The action(s) taken to mitigate the risks. Risks mitigated through individual patient assessment. The controls that are in place. The ongoing dated review and specified actions of how these risks are being managed. Both wards had multiple ligature risks. There had not been a full comprehensive assessment of ligature risks on either ward since An assessment had been completed that focused only on some risks within the ward areas and did not contain information relating to the mitigation of risks or levels of severity. The courtyards on both wards had not been assessed. The courtyard on the Osbourne ward was vast with hidden areas that were not in view of staff. These areas contained fixtures that could be used to tie ligatures, for example piping and fencing. Internal doors that had exposed hinges and bar closures were not included on the assessment. One door had no anti barricade defences, which would restrict staff being able to access patients in the event of an emergency. This had not been highlighted on the assessment.

28 28 Quality Account 2016/17 Isle of Wight NHS Trust Regulated Activity Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury Regulation Section 31 HSCA Urgent procedure for suspension, variation etc. The CQC issued a Notice of decision to urgently impose conditions on the registered provider (under section 31 HSCA 2008) as they had reasonable cause to believe a person would, or may be, exposed to the risk of harm unless we did so. The following conditions were imposed for the regulated activity Treatment of disease, disorder or injury: Community Mental Health Service A. The Registered Provider must operate an effective escalation protocol in community mental health services. This escalation protocol will need to ensure patients are prioritised appropriately in response to service demands and pressures. There should be appropriate governance and leadership arrangements, and appropriate resources and support to the service and staff. The use of the escalation protocol should be on the corporate risk register and there should be clear mitigation and monitoring arrangements. The Trust should ensure the escalation procedures are adhered to. The Trust must provide the Commission with a report on the escalation protocol. B. The Registered Provider must ensure that every patient who has received a letter, as part of the current action taken under the business continuity plan, is risk assessed and appropriately managed. Each patient must have a documented risk assessment and a clear date for review. The Trust must provide the Commission with a report of actions taken. C. The Registered Provider must complete the review of the current caseload of each clinician. Each patient must be identified, have a full assessment of their needs and patients should be allocated for CPA according to the set criteria and guidelines. The Trust must provide a report to the Commission on this work. D. The Registered Provider should agree a comprehensive community mental health services improvement plan. There should be the necessary external advice and agreement for this improvement plan. The plan should ensure demands on the service are appropriately escalated, assessed and managed. There should be structures that ensure national guidance and best practice is followed; that promote effective leadership, and review capacity and capability of staff; there should be sufficient resources and support to the service. Staff must be effectively supervised and supported to review their caseloads. The improvement plan should be adhered to and the necessary changes must be implemented at the appropriate pace and urgency. The Trust must provide the Commission with a report on the improvement plan and the action taken in response.

29 Isle of Wight NHS Trust Quality Account 2016/17 29 Regulated Activity Regulation E. The Registered Provider must ensure that the Commission receives the following information every two weeks: Number of patients known to the service. Numbers of patients who have risk assessment. Numbers of patients appropriately identified as requiring CPA. Number of patients who are on CPA. Number of patients who have CPA review date. Numbers of patients identified on the BCP. Management outcomes for patients on the BCP. Actual and expected caseloads numbers for clinical teams. Any complaints about the service or incidents involving staff and/or patients of the community mental health service. F. The first report should be received on 28 December 2016 and every two weeks thereafter. Mental Health Inpatient Services G. The registered provider must carry out an urgent assessment of the physical environment on the inpatient mental health wards at St Mary s Hospital. The Trust must ensure there is a comprehensive ligature assessment and an action plan to mitigate the risks. The action plan must include a stated time for completion. The assessment must cover all inpatient mental health wards and environments. There should be effective leadership, and the necessary resources and support to ensure changes have appropriate governance, are appropriately supported and are implemented with the necessary pace and urgency. The action plan must be produced by Wednesday 28 December H. The registered provider must immediately review its policy and procedures and governance arrangements to ensure there is appropriate assurance to identify, assess, manage, mitigate and monitor all environmental risks to patients care and safety across all inpatient mental health services. This includes where patient privacy and dignity may be compromised. The governance arrangements need to identify where additional resources and support are required and how staff will be supported to understand what actions need to occur to effectively manage all environmental risks. The Trust must provide a copy of the revised governance arrangements by Wednesday 11 January I. The Registered Provider must ensure that the Commission receives the following information every two weeks. A risk register that includes all environment risks in inpatient mental health services. The action(s) taken to mitigate the risks. Risks mitigated through individual patient assessment. The controls that are in place. The ongoing dated review and specified actions of how these risks are being managed. J. The first report should be received on 28 December2016 and every two weeks thereafter. The Isle of Wight NHS Trust has participated in special reviews or investigations by the Care Quality Commission relating to the following areas during 2016/17.

30 30 Quality Account 2016/17 Isle of Wight NHS Trust CQC Inspections The Isle of Wight NHS Trust was subject to a Care Quality Commission inspection on 22 nd, 23 rd and 24 th November The inspection covered Ambulance, Mental Health, Patient Transport Service and the Well Led Key Line of Enquiry. This has resulted in the Trust being placed in Special Measures. This means that: An improvement director can be appointed to provide assurance of the Trust s approach to performance. A review of the capability of the Trust s leadership is undertaken. A buddy Trust may be chosen to offer support in the areas where improvement is needed. Progress against action plans is published monthly on the Trust s website and NHS Choices. The Isle of Wight NHS Trust intends to take the following action to address the conclusions or requirements reported by the CQC: Following receipt of the Section 31 and Regulation 17 notices, the Trust set up a Mental Health Improvement Group, focussing primarily on issues raised by the CQC in both notices. The group reports progress to the CQC on a fortnightly basis. The remainder of the Regulation 17 issues are monitored and managed through the Operational Management Group which meets weekly to review progress and address areas of concern. Summary of findings Overall rating for this Trust Are the services at this Trust safe? Are the services at this Trust effective? Are the services at this Trust caring? Are the services at this Trust responsive? Are the services at this Trust well-led? An Improvement Director has been appointed to assist the Trust, and current systems and processes are under review to ensure that they are more effective going forward. The Isle of Wight NHS Trust was subject to a further Care Quality Commission on 7 th and 8 th March, looking specifically at the Urgent Care Service and NHS 111. NHS 111 is a telephone based service where patients are assessed, given advice and directed to a local service that most appropriately meets their needs. For example that could be an out of hours GP service, walk-in centre or urgent care centre, community nurse, emergency dentist, emergency department, emergency ambulance or late opening chemist. NHS 111 services are usually area specific, but on occasion will take calls from all parts of England. St. Mary s Hospital no longer offers a Walk-in GP service. The Beacon Health Centre has been Inadequate Inadequate Requires improvement Good Inadequate Inadequate redesigned into the Urgent Care Service (UCS) which is co-located with the Emergency Department at St Mary s, and treats urgent care needs. Those attending the Urgent Care Service will have been advised to do so by a health professional doctor, dentist, optician, pharmacist, nurse, paramedic, etc. or the NHS 111 service. Those attending the Urgent Care Service, depending on their needs, will be seen by a nurse, a community practitioner or a GP. The Urgent Care Service will redirect individuals to other services where the individual does not have an urgent care need and their problem can be better dealt with by another service.

31 Isle of Wight NHS Trust Quality Account 2016/17 31 The outcome of the inspections of these services are detailed below: What is a Mental Health Act monitoring visit? Overall rating for Urgent Care Service Are the services at this Trust safe? Are the services at this Trust effective? Are the services at this Trust caring? Are the services at this Trust responsive? Are the services at this Trust well-led? Overall rating for this NHS111 Are the services at this Trust safe? Are the services at this Trust effective? Requires Improvement Requires Improvement Inadequate Good Good Requires Improvement Good Good Good By law, the Care Quality Commission (CQC) is required to monitor the use of the Mental Health Act 1983 (MHA) to provide a safeguard for individual patients whose rights are restricted under the Act. They do this by looking across the whole patient pathway experience from admissions to discharge whether patients have their treatment in the community under a supervised treatment order or are detained in hospital. Mental Health Act Reviewers do this on behalf of CQC, by interviewing detained patients or those who have their rights restricted under the Act and discussing their experience. They also talk to relatives, carers, staff, advocates and managers, and they review records and documents. Are the services at this Trust caring? Good Are the services at this Trust responsive? Good Are the services at this Trust well-led? Requires Improvement Mental Health Act monitoring visits have taken place as detailed below. 16 th June 2016 Afton Ward The findings from the report are: Afton ward was a 12 bed ward for older people with functional mental health problems. It was in the Sevenacres unit on the St Mary s Hospital site in Newport on the Isle of Wight. On the day of our visit there were eight patients allocated to the ward. One of these patients was detained under the Mental Health Act (MHA). There were no patients on leave and no patients were absent without leave.

32 32 Quality Account 2016/17 Isle of Wight NHS Trust Nursing staff worked on early, late and night shifts. On the day of our visit staffing comprised two qualified nurses and two health care support workers. The manager and deputy manager were also working that day. This was the agreed staffing compliment. All staff were employed by the Trust rather than being agency staff. The ward had no dedicated psychology input and limited occupational therapy input; however, one member of staff took on an activity worker role. There were three consultant psychiatrists who admitted to the ward. They saw patients both in hospital and in the community. The ward comprised a communal living, television and eating area. There were two small lounges. There was a further seating area at the back of the ward. Patients had separate rooms but they shared toilet and shower rooms. There was one bathroom. The ward manager and deputy manager had a separate office but the main staff office area was a desk and computer hub divided from the ward by frosted glass screens. The lack of opportunity for confidential discussion that this afforded was raised at our last visit and was raised with us by staff on this visit also. The rooms had King s Fund beds, clothes rails and cupboard handles that presented obvious ligature risks. Clinical equipment was stored in the corridor near to the bedrooms, due to lack of alternative space. We asked for a recent local ligature audit and a ligature risk management plan. We were advised that a ligature audit for the building was done three years ago and that the team were aware of and managed the environmental risks but that there was no recent documented plan. The ward had a beautiful tiered garden, which had been designed to offer male and female spaces if segregation was required. However, this area presented obvious fall risks for those unsteady on their feet. The walls separating the unit from the rest of the hospital and the acute adult ward next door appeared to be climbable. It should be noted that the positive aspect of the outdoor space was commended in the comprehensive inspection of the Trust in 2014, but the risks inherent in the environment had not been commented on. We were told that occasionally the ward was asked to admit overflow patients from either the adult acute ward or the dementia ward. The environment, given the ligature and falls risks, was not dementia-friendly or suitable for someone at high risk of self-harm. 17 th June 2016 Woodlands The findings from the report are: Woodlands was a standalone 11 bed rehabilitation unit for adults of working age, provided by the Isle of Wight NHS Trust. On the day of our visit there were nine patients allocated to the unit, six of whom were detained under the Mental Health Act (MHA), including section 37 / 41. There were no patients on overnight leave and no patients were absent without leave. Nursing staff worked on early, late and night shifts. On the day of our visit staffing comprised the team leader, a qualified nurse and a health care support worker. We were told that staffing had been problematic in recent months, with two vacancies for qualified staff and significant amounts of long term sickness. We were told that a calculated safe staffing ratio for Woodlands was two qualified and one health care support worker per shift. This was not always being adhered to. The team leader told us that it was difficult to use agency or bank staff at Woodlands because of the complex patients, some of whom had significant forensic histories. Two consultant psychiatrists were responsible for medical care of Woodlands patients. The unit had sessional occupational therapy input. There was no dedicated psychology input, apart from a weekly psychologist-facilitated reflection group for staff. A reablement team had recently been established, with the aim of offering short term support to patients who were trying to establish their independence. Feedback from patients about this team was very positive. This team was housed within the Woodlands building and was managed by Woodlands team leader. The unit was on a residential street. It comprised en suite bedrooms and shared bath facilities. There was a large patient lounge, a kitchen, a dining room, a conservatory that could be used as a female lounge, a gym and a large garden. The ward office was in a central part of the building.

33 Isle of Wight NHS Trust Quality Account 2016/17 33 Isle of Wight NHS Trust There was a small desk reception space to the side of this office. We were told that space was so limited that patient reviews had to take place in the ward office. This compromised patient confidentiality because there was patient identifiable information on the walls. The goal of admission was to prepare patients for living in the community. As such, the environment was more homely and less hospital like. There were some ligature risks in the environment, as there might be in community homes. We asked for a recent local ligature audit and a ligature risk management plan. We were given a one page ligature risk document that was last dated May There was no evidence of a comprehensive ligature risk management plan for the building or for individuals. The following table contains details of the accreditation status from the Royal College of Psychiatrists: Programmes MSNAP: Memory Services National Accreditation Project PLAN: Psychiatric Liaison Accreditation Network QNCC ED: Quality Network for Community CAMHS (Child and Adolescent Community Mental Health Services) Eating Disorders QNLD: Quality Network for Learning Disability Wards QNOAMHS: Quality Network Older Adults Mental Health Services AIMS-WA: Working Age Adult Wards ECTAS: Electro Convulsive Therapy Accreditation Service EIP Self-Assessment (English Teams only): EIP Self-Assessment (English Teams only) Perinatal: Perinatal In-Patient & Community settings QNCC: Quality Network for Community CAMHS (Child and Adolescent Community Mental Health Services) QNFMHS: Quality Network for Forensic Mental Health Services QNIC: Quality Network for Inpatient CAMHS (Child and Adolescent Community Mental Health Services) QNPMHS (Prison): Quality Network for Prison Mental Health Services AIMS PICU: Psychiatric Intensive Care Units Participating services in the Trust Accreditation status Isle of Wight Memory Service Accredited as excellent 107 None N / A 74 None N / A 18 None N / A 40 Afton Not accredited 67 Osborne Ward, St. Mary s Hospital Accredited 136 Sevenacres (Isle of Wight) Accredited as excellent 101 Isle of Wight Early Intervention in Psychosis N / A 153 None N / A 43 None N / A 32 None N / A 125 None N / A 127 None N / A 40 Seagrove PICU Not yet assessed 38 AIMS Rehab: Rehabilitation Wards None N / A 65 HTAS: Home Treatment Accreditation Service QED: Quality Network for Eating Disorders Services APPTS: Accreditation Project for Psychological Therapy Services Isle of Wight Crisis Resolution Home Treatment Team Accredited as excellent 49 None N / A 32 None N / A 22 CofC: Community of Communities None N / A 8 AIMS-AT: Assessment Triage None N / A 5 Number of services participating nationally EIPN: Early Intervention in Psychosis Network QNLD: Quality Network for Learning Disability Wards ACOMHS: Accreditation for Community Mental Health Services Prescribing Observatory for Mental Health (POMH) None N / A 5 None N / A 1 None N / A 12 The Trust is participating in the following Quality Improvement Programmes (QIP) POMH POMH POMH QIP 16a: Rapid tranquillisation QIP 17e: Monitoring of patients prescribed lithium QIP 11c: Prescribing antipsychotics in people with dementia

34 34 Quality Account 2016/17 Isle of Wight NHS Trust Data Quality Statement on relevance of Data Quality and actions to improve data quality The Isle of Wight NHS Trust will be taking the following actions to improve data quality: A vital pre-requisite to robust governance and effective service delivery is the availability of high quality data across all areas of the organisation. The organisation requires high quality data to support a number of business objectives, including safe and effective delivery of care, and the ability to accurately demonstrate the achievement of key performance indicators. The Trust Data Quality Policy sets out the specific roles and responsibilities of staff and management in ensuring that data is managed effectively from the point of collection, through its lifecycle until disposal. In order to monitor adherence to the Data Quality Policy the Isle of Wight NHS Trust will, as a matter of routine, monitor performance in collecting and processing data according to nationally and locally defined standards, and provide appropriate feedback to all staff, this activity will be coordinated by the Deputy Director of Information, and reported through the Information Steering Group. The Information Steering Group will provide regular reports on indicators of performance for senior operational managers to review and develop targeted improvement plans. These reports will be further utilised as part of Business Units Performance Reviews. Where outcomes are unsatisfactory, root causes will be reviewed and performance management measures implemented at Business Unit, team or individual level, as required to deliver a level of performance which supports the Trust s duty of care to service users, as well as statutory performance and financial targets. Action plans for all areas identified as a concern will be developed and delivery will be overseen by the Information Steering Group. In addition a data quality report is provided on a monthly basis to the Finance, Investment, Information and Workforce Committee and a subset of this report is also included within the Trust Board Performance report. Furthermore an annual report is provided for the Trust Board to examine the quality of data underpinning Key Performance Indicators. Data quality is included regularly on the internal audit programme and has been assessed by external audit. NHS Number and General Medical Practice Code Validity The Isle of Wight NHS Trust submitted records during 2016 / 17 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data: which included the patient s valid NHS number was: 98.7% for admitted patient care; 99.6% for out patient care; and 98.2% for accident and emergency care. which included the patient s valid General Medical Practice Code was: 100% for admitted patient care; 100% for out patient care; and 99.9% for accident and emergency care Information Governance Toolkit Attainment Levels The Isle of Wight NHS Trust s Information Governance Assessment Report score overall score for 2016 / 17 was 68% and was graded green Clinical Coding Error Rate The Isle of Wight NHS Trust was subject to an Information Governance audit during the reporting period as part of the Information Governance Toolkit instigated by the Department of Health and the error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were 3.5% (96.5% accurate) for primary diagnosis and 2% (98% accurate) for secondary diagnosis; 3.4% (96.6% accurate) for primary procedure and 7.9% (92.1% accurate) secondary procedures.

35 Isle of Wight NHS Trust Quality Account 2016/17 35 Part Review of Quality Performance Implementation and monitoring the effectiveness of the sepsis care bundle Sepsis is defined as an overwhelming response to infection in which the immune system initiates a potentially damaging systemic inflammatory response syndrome (SIRS) which can manifest in a number of physiological changes, recognised by worsening vital signs or SIRS criteria (temperature, respiratory rate, heart rate). Severe sepsis is defined as sepsis leading to dysfunction of one or more organ systems according to current criteria. Last year, international consensus definitions have been amended to focus on physiological changes of organ dysfunction, including hypotension, tachypnoea and altered mental state. Sepsis is already recognised as difficult to diagnose and it can only be hoped that a new definition will aid this process. What we know locally is that our mortality associated with patients with a primary diagnosis of sepsis is 12% and the national average is 7%, although there are many factors that also influence that mortality outcome for patients with a primary diagnosis of sepsis such as age and other relevant morbidity. With all the current improvement work being undertaken and continued with regard to sepsis we have seen improvement. See Run Chart below: We also know from the Sepsis CQUIN for 2015 / 16, we still need to make improvement on our compliance with sepsis screening and giving antibiotics within the hour as per the sepsis 6. The local pre hospital initiative for sepsis recognition and response by Paramedics led by Dr Pike and Dr Andrews in the Emergency Department has led to high risk groups of patients in the community getting antibiotics before they arrive to hospital. The data is currently being reviewed to confirm if this is having any statistical relevance to patient outcomes.

36 36 Quality Account 2016/17 Isle of Wight NHS Trust Compliance The KPIs that have been used for this quality improvement have included the following 3 measures; 1. 95% of hospital admissions will be screened for Sepsis if they are MEWS positive Achieved 2. Antibiotics are given within 1 hour of recognising potential or actual sepsis in 95% of patients. ED has Achieved / In-patient areas Not Achieved (91%) 3. 95% compliance with the sepsis 6, once sepsis is being suspected and treated Achieved We have a baseline data set from 2015 / 16 for the first 2 KPIs and the data for the third KPI has been collected as from April 2016 from a random selection of 30 sets of notes from across the organisation that relate to patients with the sepsis diagnosis code. The data collection for all 3 KPIs will be 1 month in retrospect. 50 sets of notes are reviewed for ED each month and 50 sets of notes from in-patient areas are reviewed each month for the screening element and antibiotics given within 60 minutes. Results Emergency Department July 2016 % of those requiring screening that received it Count of screening needed & NOT Received Count of screening needed & received Count of screening not needed Emergency Department July 2016 % of those requiring ABX that received <60 mins August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March % 100% % 100% 100% 100% 100% 98% August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March % 93.3% 96.6% 100% 96.7% 100% 100% 100% 100% Count of not indicated Count of <60 min Count of others including time of arrival / time of antibiotic administration unclear for exclusion In patient areas July 2016 % of those requiring screening that received it Count of screening needed & NOT Received Count of screening needed & received Count of screening not needed In patient areas July 2016 % of those requiring ABX that received <60 mins August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March % 90.7% 88.9% 96.3% 87% 88% 87.5% 89.3% 92% August 2016 September 2016 October 2016 November 2016 December 2016 January 2017 February 2017 March % 92.2% 96.2% 81% 92.3% 100% 93.8% 93.2% 92% Count of not indicated Count of <60 min Count of others including time of arrival / time of antibiotic administration unclear for exclusion

37 Isle of Wight NHS Trust Quality Account 2016/17 37 Sepsis 6 Compliance (Random 30 sets of notes per month from across the acute in-patient Trust) Sepsis 6 Compliance Headline (by month) Sepsis 6 compliance Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 YTD yes no total % compliance 98.9% 97.8% 94.4% 98.3% 97.8% 98.9% 100% 99.4% 98.9% 98.9% 98.3% Issues identified Issues that will be addressed within this area of quality improvement will include and address the following areas of concern; The new integrated sepsis policy has been out for consultation and will be formally approved during May 2017 and now includes mental health services. Revised sepsis screening tool for adults and paediatrics within the Emergency Department, in-patient areas for direct admissions and for existing in patients was implemented from 31 st January 2017 Revised sepsis 6 treatment stickers. Staff prompt cards for screening and treatment of sepsis. The need for embedded sepsis champions within each clinical service. Revision of the current sepsis e-learning module once the above improvements have occurred. Visual prompts in clinical areas to emphasize the need for IV antibiotics to be given within 1 hour. 98.3% Sepsis 6 compliance, year-to-date

38 38 Quality Account 2016/17 Isle of Wight NHS Trust Improve communication with patients and carers The Trust is committed to delivering a positive experience to both patients and carers, and one the key themes that continues to be raised through concerns and patient / carer feedback, relates to poor communication. One of the key objectives within the Trust s Patient Experience Strategy ( ), clearly identifies the need to work with staff to ensure that all patients and their families are treated with kindness and compassion, have clear co-ordination of care and clear communication to ensure patients / families and carers feel involved in the patients care, treatment and decision making. The Trust acknowledged that we still have some way to go to ensure that all patients and carers receive clear and concise communication, and are fully involved in the care and treatment and the number of negative comments in relation to this are reduced. During 2016 / 17 the Trust has continued to work with staff, patients and carers to improve our communication, and has been monitored through quarterly reports against the following key performance indicators (KPIs): A reduction of 20% for 2016 / 17 in the number for formal complaints received relating to communication. A reduction of 40% for 2016 / 17 in the number of concerns received relating to communication. A reduction of 40% for 2016 / 17 in the number of negative comments about communication left via the Friends and Family Test. Below is the achievement against these key performance indicators. The Trust has seen improvements in the complaints, concerns and comments in relation to poor communication; and whilst we have not achieved the initial improvement targets met, we are continuing to see an improvement in all areas, and will continue to implement mechanisms to improve the communication with our patients and carers. During the year the Trust has implemented a Patient Experience Steering Group chaired by the Deputy Director of Nursing; and this group regularly reviews patient experience feedback to ensure action is taken in response to feedback. During the year the Trust has implemented customer service training, Patient Experience Excellence Training. The aim of this externally delivered training is to ensure that Trust staff put themselves in the shoes of our customers and how to effectively communicate with patients and carers. Further training sessions will continue in 2017 / 18 to ensure we continue to see an improvement in the complaints, concerns and comments regarding poor communication. KPI Baseline Q1 Q2 Q3 Q4 A reduction of 20% for 2016 / 17 in the number for formal complaints received relating to communication () 2015 / 16 6 (6) 50% 6 (4) 30% 7 (10) 14 (14) A reduction of 40% for 2016 / 17 in the number of concerns received relating to communication () 2015 / 16 35% 20 (77) 5% 62 (65) 15% 54 (64) 152% 134 (53) A reduction of 40% for 2016 / 17 in the number of negative comments about communication left via the Friends and Family Test 66% Qtr 1 15 / 16 9% Qtr 1 16 / 17 3% 75% Qtr 2 15 / 16 9% Qtr 2 16 / % 74% Qtr 3 15 / 16 10% Qtr 3 16 / % 92% Qtr 4 15 / 16 22% Qtr 4 16 / %

39 Isle of Wight NHS Trust Quality Account 2016/ Improve the culture of the organisation to improve patient experience The Trust identified three key areas to assist in improving the culture of the organisation: Appraisal All staff will have had a behaviours based appraisal by 31 March The latest figures up to 28 th February 2017 show that 2158 staff (83.88%) had an appraisal in the 2016 / 17 year. The reporting of this was changed to a zero base on 1 April 2016 as the paperwork was amended to incorporate values and behaviours discussions to take place. From 1 April 2017 this will return to reporting on a rolling year basis. Training was changed with more of a focus on values and behaviours discussions and to equip staff with using the new paperwork. Success has been highlighted through the 2016 Staff Surveys where it has been reported that the number of staff having received an appraisal during 2016 has increased in all 3 sectors compared with the previous year as shown below: Acute: 90% 80% Mental Health: 92% 76% Ambulance: 66% 56% Results were equivocal with other questions in relation to appraisal of the staff survey where improvements have been made in some areas and a declined in others. Examples of this are; Appraisal helped staff to improve how they did their job, Mental Health results suggest a slight decline in this, whereas the Acute sector remains the same as 2015, however a considerable improvement 68% 2016 compared with 57% 2015 for Ambulance has been reported. Appraisal left staff feeling that their work is valued by their organisation. Both Acute and Mental Health sector scores have remained the same for this question for both years. Ambulance sector has reported an increase 72% 2016 compared with 63% Research (M West) has proven that effective appraisal and human resources management have a direct impact not only on staff experience but patient experience and outcomes. Coaching for Performance 80% of spaces of Coaching for Performance courses to be filled by 31 March Since 1 April 2016, 88 places were made available for staff to book onto the coaching for performance. Of these, 78 places were booked and 63 people attended. Therefore this target was met with 89% of places filled (booked) with a total of 72% actually attended. Communications courses 30% increase in the number of staff attending communication courses by 31 March For the purposes of these quality priorities, the education department will report on those courses co ordinated and reported by them, namely Communications and Teamwork and Challenging Conversations. It should be noted that additional courses may be run by others and not recorded through the education department, also that many of the leadership development and team interventions that take place throughout the year have elements of communication within them. Figures available to date (8 March 2017) show that there were 250 places made available for both courses. Of these, 195 places were booked and (to date) 150 have attended. It should be noted that this results in 88 places having been made available during the year that have not been filled. Many staff report to the education team that black alerts and other conflicting priorities affect their ability to attend. This is not the most effective use for those facilitating the training whereby they may have been able to run fewer sessions during the year and focus more time on 121 coaching interventions which they are currently unable to meet demand.

40 40 Quality Account 2016/17 Isle of Wight NHS Trust Improve the discharge planning process Effective and robust early discharge planning and implementation improves outcomes for patients, and when implemented consistently, effective discharge planning should reduce the number and length of delayed discharges and result in patients being successfully transferred to services or support arrangements where their needs for health and care support can be met. The need to improve the discharge planning, process was identified in the 2014 / 15 quality account which, acknowledged that the process within the Trust was requiring further planning and organisation. With increased pressure on the system the need for a robust discharge process is fundamental in improving patient s experience, reducing length of stay, and ensuring patient flow is not compromised, with the results that ensure the patients are directed to the most appropriate area to meet their clinical needs in an optimised way. The continued implementation of a multi-agency pathway navigation team, and regular workshops to discuss improvement plans have highlighted the need for early discharge assessments initiated at the point of admission to clearly identify the individual s needs, with a clear pathway and plan that the patient, relatives and carers are involved with and understand, which will result in safer discharges and reduce the number of readmissions. Key performance indicators were identified to demonstrate how effective the discharge process is, these included: Reduction in length of stay. Improvement in pre midday discharges. Follow up calls. Improving length of stay has been seen as a key driver in managing capacity within the Trust and enabling stability and sustainability over the long term. Average LOS for period 2016 to January 2017 were under 4.5 days, which is currently about the same as figures for February show that this has reduced to 3.5 days for the month. Plans are now in place with regards to ward areas having a new discharge planning process which include ward, multi-disciplinary team huddles to agree, revise or confirm estimated date of discharge. It also enables the team to identify issues and agree actions which will ensure patient s discharge will be appropriate and safe, and this approach will help to improve patient discharge before lunch. The table shows the number of patients discharged before midday by ward and clinical business units over the past year and although numbers were higher during the first, second and third quarters there is a noticeable decline in the numbers for the last quarter.

41 Isle of Wight NHS Trust Quality Account 2016/17 41 Over the year the average is around 170 patients per month inclusive of mental health, emergency department, theatres and day surgery. Medical ward discharges before lunch, have an average of 31 patients per month. Surgical ward discharges before lunch, have an average of 69 patients per month which include the elective wards who are more likely to have early discharges. With work continuing on wards to improve the estimated date of discharge this will then have a positive impact on when other agencies can be involved to actively work towards earlier discharges. Further work still needs to be done to clear the current backlog of discharge summaries. These are the forms that are sent to GPs giving them details of diagnosis and treatment that has taken place whilst the patient was in hospital, together with any changes to medication etc. Business Unit Disch Ward Name APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR Grand total COO Winter Poppy COO Total A, UC & C Medical Assessment & Admit Un Ambulatory Emergency Care Unit A, UC & C Total S,W & CH Alverstone Luccombe Mottistone Suite St Helens Whippingham S,W & CH Total CC, C & DS Coronary Care Acute Ward Coronary Care Unit Ward Day Surgical Unit Intensive Care Unit Theatre IOW CC, C & DS Total MS Colwell General Rehab & Stepdown Unit Stroke & Neuro Rehab Unit Appley MS Total Afton Ward Osborne Ward Sevenacre MH & LD Seagrove Ward Sevenacre Shackleton Woodlands 1 1 MH & LD Total Grand Total

42 42 Quality Account 2016/17 Isle of Wight NHS Trust As part of the discharge improvement plan there are now twice weekly multi-agency meetings to discuss patients medically fit for discharge in a proactive, whole system, integrated approach. This allows all aspects of the individual s needs to be discussed and plans put in place to create a safe and robust discharge plan. Another initiative piloted in 2016 to provide patients discharged from hospital with a follow up call the next day was carried out over a month. During the pilot the clinical capacity and pathway team were not able to manage the number of calls required and were targeting those patients deemed as having an increased potential risk of requiring further support post discharge. There was also no robust monitoring and reporting of the results and outcomes of the discharge follow up calls, which if the notes were available could easily be added following the call. A new pilot has been agreed which will be carried out by the discharging ward, who have the patients information, notes. Two medical wards have been identified to undertake the trial, and this will be started on April 1 st 2017 for a period of one month. This will be audited, and any issues raised, will be reviewed with further discussions to take place on introducing this on all wards. Patients, relatives or carers will be asked prior to discharge if they would appreciate the follow up calls, and if requested any problems identified at the time of call, will then be forwarded to the navigation team. From this process it is hoped that all inpatients will be offered this service. From the pilot scheme there was a positive response received from recipients of calls with onward referrals / signposting identified / provided in a number of cases. The Age UK team following referrals from the wards will do follow up calls which have proved successful, and continue daily, with up to 6 referrals per day from wards, and they currently have 23 patients that they are actively working with.

43 Isle of Wight NHS Trust Quality Account 2016/ Reduce incidents of patient harm All patients who are admitted to the care of the Trust should have a reasonable expectation that all practicable steps are taken to avoid harm or complications during their care. The Trust relies on honesty and openness in the reporting of clinical incidents which may or may not result in harm. By encouraging the reporting of clinical incidents, the Trust has the opportunity to examine the circumstances in which these incidents occurred, learn from them, and employ appropriate preventative strategies to minimise their reoccurrence. To this end, it has been a target for 2016 / 17 to encourage the reporting of clinical incidents. The Table right demonstrates how the trend is increasing. Whilst the reporting of incidents is clearly encouraged, it is also obviously desirable that the harm that patients experience is reduced as much as is possible. The percentage of patients who have been reported as experiencing any form of harm as a result of a clinical incident is demonstrably falling over the past year (see table right). Clinical incidents that result in moderate harm or above usually require additional treatment, in some circumstances surgery, in order to correct harm or injury experienced by the patient. Whilst there has been a small increase in reporting of this level of harm near the end of 2016, the percentage of patients experiencing this level of harm has overall improved this year since the previous year % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 100% 80% 60% 40% 20% 0% Number of incidents reported month by month Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Percentage of patients experiencing harm Percentage of patients experiencing moderate harm or above. Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 No. Of incidents Linear (No. Of incidents) Percentage of patients experiencing harm Linear (Percentage of patients experiencing harm) Percentage of patients experiencing moderate harm or above.

44 44 Quality Account 2016/17 Isle of Wight NHS Trust During 2016 / 17 the management of patient harm has increasingly been centred around the employment of quality improvement collaboratives to support clinical teams in their efforts to reduce patient harm. The implementation of the quality improvement collaborative methodology for pressure ulcers has been based on three core principles: Weekly downloading and validation of the incident data, and circulation of this data to senior nurses and allied healthcare professionals. Weekly meeting by senior nurses and allied healthcare professionals from hospital and community to identify key themes and develop actions to address these. Regular involvement of professionals from across healthcare boundaries to ensure collaborative methodology brings in experts from all clinical settings to inform practice change. The experience of collaboratives was that once the key personnel involved were present and engaged in the process, that there was an initial increase in reporting of incidents due to raising awareness of the issues, but then this changed to a noticeable and persistent reduction week by week in the occurrence of incidents. of moderate harm and above. By clustering incidents of minor harm and identifying the key themes that arise from them, that this would start to improve the clinical teams understanding of the clinical incidents and therefore inform a more proactive rather than reactive strategy for prevention. The community nursing teams have established a weekly governance meeting which includes the peer review of incidents and root cause analyses by the locality leads and senior nurses. This has already identified key themes through the peer review of serious incidents and the ongoing monitoring of key actions that have arisen from the recommendations of these plans. Key performance indicators for pressure ulcers: Pressure ulcers Pressure ulcers are areas of skin that breakdown under the stress of prolonged pressure, or pressure in association with shearing or friction. Older, immobile patients with one or more long term conditions are commonly at risk of these types of skin damage. As there are a number of ways of preventing pressure ulcers such as using the right pressure relieving equipment, and encouraging patients to reposition, pressure ulcers are in many circumstances partially or wholly preventable. The Trust has committed to reducing the likelihood of pressure ulcers occurring whilst patients are under the care of the Trust. The targets for reduction of pressure ulcers and achievement during 2016 / 17 is summarised below. 80% reduction in grade 4 pressure ulcers Partially achieved 50% reduction in grade 3 pressure ulcers Achieved 30% reduction in grade 2 pressure ulcers Partially achieved. Each collaborative focuses on analysing the key themes related to incidents. The Trust already has a mandatory responsibility to perform a root cause analysis for incidents

45 Isle of Wight NHS Trust Quality Account 2016/17 45 The community nursing teams continue to show solid progress in eliminating these serious harms. The table below shows quarterly improvement in reduction of grade 3 and 4 pressure ulcers. Without exception the community nursing teams have achieved reductions over the last 7 quarters / / 17 Community Grade 3 and 4 pressure ulcers Q1 Q2 Q3 Q4 Q1 Q2 Q3 Baseline Performance Percentage reduction on baseline 27% 55% 80% 92% 88% 80% 33% Despite an initial rise in reporting of grade 2 pressure ulcers due to the additional focus of a quality improvement collaborative, the trajectory overall however has been downward with the work that has been ongoing around the clustering and thematic analysis of grade 2 pressure ulcer incidents, with consistent reductions below baseline over the last 3 quarters. In only one month over the last nine months did the community nursing teams fail to achieve any reduction in reported grade 2 pressure ulcers. Quarter on quarter improvement has become positive over the last 12 months. The table below depicts this trajectory in terms of percentage improvement in grade 2 pressure ulcers. Community acquired Grade 2 pressure ulcers 2015 / / 17 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Baseline Performance Percentage reduction on baseline 35% 90% 50% 26% 13% 14% 24% It is tempting to expect that initiatives such as quality improvement collaboratives will result in improvements relatively quickly. In actual fact, the process usually results in raised awareness and therefore raised incident reporting whilst clinical teams are getting to grips with the underlying issues surrounding the quality improvement focus. This then, in the longer term, after an initial dip in performance, leads on to a consistent improvement trajectory. Key issues identified by the community nursing teams as part of the clustering of grade 2 pressure ulcers in the community settings include: Patients choosing not to use the pressure relieving equipment. Patients choosing not to follow the advice given. Making lifestyle choices that are not in line with preventative recommendations. Deterioration of physical condition. Declining to be physically examined. The highlighted findings point to the fact that the predominant reasons patients are presenting with pressure ulcers whilst under the care of district nursing teams is the fact that whilst equipment, advice, and the opportunity to have checks of their skin are regularly offered, that it is the patient s right to choose not to participate in these activities. This clearly does not take account of the patients whose mental capacity does not allow them to make informed decisions around consenting to treatment, and this is a separate issue that is regularly discussed as part of the clustering reviews.

46 46 Quality Account 2016/17 Isle of Wight NHS Trust The hospital s clinical teams have employed the same collaborative methodology since January All the ward sisters have been visited by the Tissue Viability team and Quality Assurance lead to go through the process of clustering pressure ulcers. Regular reports are circulated to highlight progress with clustering pressure ulcers in the hospital setting. The trends in the hospital setting are still concerning, but may be showing signs of improvement. The table below sets out quarter on quarter comparison since the April Hospital acquired Grade 3 and 4 pressure ulcers 2015 / / 17 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Baseline Performance Percentage reduction on baseline 0% 63% 40% 50% 67% 0% 67% Whilst generally the trend is reducing, with 4 out of the last 7 quarters showing reductions, there are still glaring peaks in this data. With grade 2 pressure ulcers, there appears to be signs of improvement since the start of the collaborative with the trend starting to move downward. The table below depicts quarterly percentage reduction on baseline since April / / 17 Hospital acquired Grade 2 pressure ulcers Q1 Q2 Q3 Q4 Q1 Q2 Q3 Baseline Performance Percentage reduction on baseline 92% 75% 100% 72% 52% 17% 4% Whilst no improvement is initially apparent, as all of the reductions are negative (i.e. growth not reduction), when this is depicted pictorially it becomes more obvious. Hospital acquired Grade 2 pressure ulcers - Percentage reduction on baseline 40% 20% 0% -20% -40% Q Q Q Q Q Q Q % -4% -60% -52% -80% -100% -92% -75% -100% -72%

47 Isle of Wight NHS Trust Quality Account 2016/17 47 Whilst still in negative figures the trend is going upward. This coincides with the experience of the community PU collaborative and it is a fair expectation if focus continues to be applied in this area that we would continue to see the improvements into positive percentage reductions during the next quarters. From what has already been clustered the following themes have been identified in the hospital setting, both in terms of care and service delivery issues: Documentation standards require improvement. Information giving needs recording. Equipment or advice not followed. Deterioration of physical condition. Reduction in overall mobility. Falls The same quality improvement methodology has also been applied to Inpatient Falls prevention during 2016 / 17. Falls in hospital are often associated with frailer patients with poor balance, poor eyesight or poor mobility. They may be confused or disorientated due to their illness or a mental health issue. Key performance indicators for inpatient falls prevention All of these factors singularly or together contribute to putting this patient group at more serious risk of harm. Work around Inpatient falls prevention not only focusses on mitigating the risk of the patient falling, but also on understanding how the resilient the patient is to harm, such as understanding their osteoporosis risk which may contribute to increased rates of bone fractures. 0% reduction in falls causing harm against 2015 / 16 baseline Partially achieved 100% of patients over 65 will have a lying standing blood pressure as a patient 100% of patients over 65 will have a lying standing blood pressure as a patient Partially achieved Achieved There continues to be improvement in overall harm resulting from falls. In quarter / 17 there were 103 falls reported as causing harm to patients, as opposed to 107 for the same period in 2015 / 16. This is a 4% decrease on baseline for the previous year / / 17 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Baseline Performance Percentage reduction 4% 18% 4% 32% 16% 25% 4%

48 48 Quality Account 2016/17 Isle of Wight NHS Trust All patient slips, trips and falls that occur in the Trust are expected to be reported via the Datix reporting system and are graded according to harm including falls where no obvious harm has occurred. This allows for analysis of conversion to harm. The figure below indicates that as a proportion of falls overall patients are increasingly less likely to come to harm as a result of a fall, and this trend continues throughout 2016 / % 70% 60% 50% 40% 30% 20% 10% 0% Percentage of falls converting to harm Percentage of falls converting to harm Percentage of falls converting to harm over time Of particular note was the National Audit figures that suggested that the Isle of Wight NHS Trust was significantly above national average for falls causing moderate or severe harm. The figure below depicts monthly data for falls causing moderate or severe harm between April 2014 and December Falls causing moderate or major harm monthly incidence since April Falls causing moderate or major harm Falls causing moderate or major harm A quarter by quarter analysis comparing 2016 / 17 performance to baseline shows significant improvements in 3 out of the last 5 quarters. The falls concerned continue to be under review as part of the local review process / / 17 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Baseline Performance Percentage reduction 75% 0% 82% 69% 133% 67% 0%

49 Isle of Wight NHS Trust Quality Account 2016/17 49 Patients who are at risk of postural hypotension need a lying standing blood pressure to be performed to check whether their blood pressure drops on standing up, as this can have implications for their risk of falling when stood up. This may lead on to further diagnostic tests to determine whether the blood pressure drop is symptomatic and may require further treatment. During 2016 / 17 the target was 100% of patients over the age of 65 would require a lying standing blood pressure during their admission. Quarterly performance during 2016 / 17, as evidenced by audit, is in the table right. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Measurement of lying and standing blood pressure Quarter 1 Quarter 2 Quarter 3 Quarter 4 measurement of lying and standing blood pressure Whilst clearly this target wasn t achieved, the Trust achieved its target of all patients having a falls risk assessment consistently performed during admission. The trajectory for lying standing blood pressures is of significant improvement in this area, which the Patient Safety Lead will continue to drive through the Patient Safety Working Group which meets weekly with the ward sisters and clinical team leaders. Identified actions to continue to embed improvement in Inpatient falls risk management have been identified as: Trust participation in National Audit of Inpatient Falls round 2 in May Patient Safety Working Group meeting weekly with ward sisters and matrons, feeding back to Director of Nursing team meeting, and Operational Management Group. Weekly Patient safety walk arounds by Patient Safety Lead, feedback to ward sisters and updating of handover sheets. Regular feedback to clinical teams to update them on their performance. Peer audit by ward sisters and clinical team leaders of falls care planning in other wards during 2017 / 18.

50 50 Quality Account 2016/17 Isle of Wight NHS Trust Catheter Acquired Infections Key performance indicators for catheter acquired infections 100% compliance with key standards for EPIC 3 catheter care planning audit tool Trials without catheter prior to discharge 100% of patients who are eligible have their catheter removed Partially achieved Partially achieved 100% compliance with IPC catheter care tool Partially achieved Catheter acquired infections (CAUTI) account for around 80% of hospital acquired infections (source: Nursing Times). For some patients, the insertion of a catheter is justifiable for their medical management. Where there are viable alternatives to being catheterised these should be explored as catheterisation exposes patients to a significant risk of acquiring a urinary tract infection and ultimately potentially extending the length of time they have to stay in hospital. Improving care for these patients depends on good education, robust audit pathways, and effective devices and treatment. During 2016 / 17 the Trust implemented a new catheter care plan, the format for which is aligned with national EPIC 3 guidance with regard to catheter care. The Trust has continued to analyse the reasons for insertions of catheters and the rate of successful removals of catheters whilst still inpatients. The actions undertaken during this year to address this issue included: Review of the care pathway with Matrons and infection control. Presentation of audit results to junior doctors. Ongoing work with the Emergency department on Catheter insertion as this is often where many are originally inserted. Catheter care posters to be put up in every ward promoting best practice Wards undertake monthly auditing of catheter care and catheter insertion, using tools aligned with the EPIC 3 guidance for infection control. The table below demonstrates monthly organisational compliance with ward clinical audit standards for catheter insertion. The target for 2016 / 17 was 100% in this area, whilst the compliance limit was at or greater than 90%. During 2016 / 17, the compliance standard was achieved in all but one of the months audited. The Trust continue to aspire to achieve 100% consistently in this area. Monthly Ward Clinical Audit of Catheter Insertion Catheter Insertion

51 Isle of Wight NHS Trust Quality Account 2016/17 51 The table right summarises the organisational performance in relation to monthly ward clinical audits of catheter care. Clearly further work is required to achieve the aspiration of 100% in this area, but in the majority of months the compliance standard was achieved. Deeper analysis of diagnostic and procedural information in order to ensure that it is clear whether catheters are inserted because of the Urinary Tract Infection (UTI) or that the UTI was in fact a consequence of the insertion of the catheter. This emphasis on data accuracy will then inform further quality improvement initiatives in this area. Education to continue within all in-patient departments regarding the completion of the Catheter Care Plans and completion of Trial Without Catheter (TWOC) information. Monitoring of the rate of successful trials without catheter in eligible patients using coding information and detailed notes audit. Infection Prevention & Control (IP&C) team, and Development & Training teams to continue with current education programmes for IP&C and Aseptic Non-Touch Technique (ANTT) training Monthly Ward Clinical Audit of Catheter Management Catheter Management

52 52 Quality Account 2016/17 Isle of Wight NHS Trust Infection, Prevention and Control Key performance indicators for infection, prevention and control Peripheral Intravenous Cannula Care (PVAD) >90% compliance with monthly audit Urinary Catheter Care ongoing management (see previous section) Cleaning & Decontamination of Equipment (including commodes) >90% compliance with monthly audit Partially achieved Please see previous section Achieved Infection prevention and control is everyone s responsibility. Robust infection prevention practice will provide sustainable reductions in Health Care Acquired Infection (HCAI) rates. To support HCAI improvement, during 2016 / 17, the Trust continued to focus on its departmental monthly audit programme to drive compliance with key standards of equipment cleanliness, and invasive device care. Ward areas are expected to audit a variety of infection control areas on a monthly basis. The standard is that clinical areas should achieve greater than 90% compliance. Where compliance falls below the expected standards, clinical areas are expected to produce an action plan detailing how issues will be resolved, and this will be driven until consistent improvement is noted. Many patients require the insertion of peripheral venous access devices (PVAD), for the administration of medication, fluids and other therapies as part of their medical management. Any device, particularly a PVAD, introduces a portal through which infective pathogens and organisms can enter the body of a vulnerable individual. Therefore the safe insertion and care of these devices is of the utmost importance in preventing infections or other avoidable harm related to this particular type of medical intervention. The table below summarises the organisational compliance with the monthly ward audit of PVAD care The trend has improved over 2016 / 17 in the care of these devices, and further work is being undertaken to ensure that where devices are inserted their insertion is correctly documented, and the ongoing review of the devices themselves and the flushing of the devices to maintain patency is continuing. Monthly Ward Clinical Audit of Peripheral Venous Access Device Care PVAD

53 Isle of Wight NHS Trust Quality Account 2016/17 53 In addition to the insertion of devices, the overall cleanliness of equipment in the clinical areas and bed spaces clearly has a significant impact on the risk of a patient developing an infection. Equipment that is not clean poses a risk of cross transmission of potentially harmful organisms. Wards undertake monthly checks of their equipment cleanliness standards as an assurance mechanism that they are meeting this important element of patient safety. The table right summarises the monthly average compliance across all ward areas for departmental equipment cleanliness audits Departmental Equipment Cleanliness Audits Departmental Environmental Cleanliness Audits Vigilance is still required to ensure that equipment that is no longer fit for purpose is not continuing to be used in clinical areas. This may include equipment surfaces delaminating and making them difficult to decontaminate. This alone would constitute a reason to remove equipment from patient use. A great deal of work this year has also gone into the decontamination, storage and maintenance of beds and mattresses as they are large items of equipment which every inpatient requires in their bed space as part of their ongoing care. Their cleanliness and fitness for purpose is a particular priority as these are the types of equipment that are going to be in the closest proximity to the patient, and therefore most likely to expose the patient to unnecessary risk if they are not maintained and cared for effectively Monthly commode cleanliness audits Commode cleanliness Although introduced during 2016 / 17, the audit standard has remained consistently above the compliance requirement. Similarly, commode cleanliness as a separate area is also audited on a monthly basis by wards and departments. The table right summarises the overall compliance across all wards with these standards. There is slightly more variability in compliance than the departmental equipment cleanliness audits, but nevertheless compliance above 90% has been achieved. Commode cleanliness is a particular contributor to preventing the spread of Clostridium Difficile and Norovirus and so the monitoring of this standard clearly supports reducing the likelihood of the spread of these infectious pathogens. Compliance with audit standards is monitored monthly through Infection Prevention and Control Committee, and the Infection Prevention and Control team completely spot audits to validate the results submitted by wards and clinical areas.

54 54 Quality Account 2016/17 Isle of Wight NHS Trust Further Performance Information Quality Indicators Set out in the table below are the indicators that NHS Trusts and non NHS Bodies are required to report in their Quality Accounts. Additionally, where the necessary data is made available to the NHS Trust and non NHS Bodies by NHS Digital, a comparison of the numbers, percentages, values, scores or rates of the Trust and non NHS bodies (as applicable) should be included for each of those listed in the table with: a) The national average for the same; and b) With those NHS Trusts and NHS Foundation Trusts with the highest and lowest of the same, for the reporting period. Quality Accounts 2016/17 - Isle of Wight NHS Trust Ref Indicator Description Period Data from Health & Social Care Information Centre - Indicator Portal Latest Performance National Target National Worst National Best National Average Our latest Performance National Average Performance Worst Quartile Performance Median Range Best Quartile Performance Performance 12. a) Summary Hospital-level Mortality Indicator (SHMI) Jul 15 - Jun n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- All inpatient activity is now coded from full casenotes rather than discharge summaries this has considerably improved the data quality of our SHMI score The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to implement improvements in the quality of its clinical coding. Fully utilise the monitoring tools and other benchmarking data to help identify areas to improve clinical practice and regulare reviews by the Executive Medical Director of patients dieing in hospital. 12 b) The % of patient deaths with palliative care coding Oct 14 - Sep n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- Current palliative care coding encompasses a wide variety of pathways and due to a misinterpretation of clinical terminology in relation to the strict national coding standards there have been some instances where Palliative care has been coded inappropriately. In order to assign the palliative care code the patient must have received specialised palliative care support, in some instances a patient was receiving palliative support as described on the discharge summary yet on further investigation this was not specialised therefore the Z51.5 ICD-10 code was not appropriate and a Z51.8 should have been utilised. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to implement improvements in the quality of its clinical coding by coding based on information contained within the patients notes as opposed to a discharge summary, this allows the clinical coders to more accurately reflect the appropriate clinical codes. 13 Patients on Care Programme Approach (CPA) followed up within 7 days of discharge from psychiatric inpatient stay. Q / % 95.0% 59.5% 99.5% 96.6% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The organisation has exceeded the national target of 95% for 2015/16 The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to monitor performance to achieve the required performance standards and undertake the actions outlined in our improvement plan. 14 Category A telephone calls (Red 1 and Red 2 calls) ; emergency response within 8 minutes. M / % 75.0% 53.7% 74.0% 62.6% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- Although the organisation is below the Ambulance Red 1 & Red 2 target of 75% for 2016/17, we are aware of the challenges we have faced delivering this standard and an improvement plan is in place. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to monitor performance to achieve the required performance standards and undertake the actions outlined in our improvement plan Category A telephone calls (Red 1 and Red 2 calls) ; emergency response within 19 minutes. M / % 95.0% 84.1% 96.4% 90.3% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- Although the organisation is below the Ambulance 19 minute target of 95% for 2016/17, we are aware of the challenges we have faced delivering this standard and an improvement plan is in place. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to monitor performance to achieve the required performance standards and undertake the actions outlined in our improvement plan. 15 Patients with suspected ST elevation myocardial infarction who received an appropriate care bundle. M / % n/a 60.5% 90.8% 79.3% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- Patient numbers relating to this quality indicator are very low (potentially only 4 or 5 patients per month). Performance can therefore fluctuate significantly month to month. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Actively monitoring all incidents of myocardial infarction and addressing any shortfalls in clinical practice that may be identified.

55 Isle of Wight NHS Trust Quality Account 2016/17 55 Data from Health & Social Care Information Centre - Indicator Portal Ref Indicator Description Period 16 Patients with suspected stroke assessed face to face who received an appropriate care bundle. Latest Performance National Target National Worst National Best National Average M / % n/a 94.4% 99.6% 97.6% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The range in performance nationally for this indicator is small and our performance continues to compare well against other Ambulance Trusts. Performance The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to monitor performance and maintaining the high levels of performance. 17 Admissions to acute wards gatekept by Crisis Resolution Home Treatment Team. Q /17 95% 95.0% 89.0% 100.0% 99.0% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The organisation has achieved the national target of 95% for 2015/16 The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to develop existing good practice and further enhancing communication between services. 18 (i) Patient reported outcomes measures for elective procedures - (i) Groin Hernia Surgery. 2016/17 (Apr - Sep) 0.16 n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The organisation has higher than average participation rates due to the robust system in place within Pre Assessment & Admissions Unit, where participants are informed and consulted about completing PROMS data returns. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to ensure that as many hernia patients participate as possible. 18 (iii) Patient reported outcomes measures for elective procedures - (iii) Hip Replacement Surgery 2016/17 (Apr - Sep) 0.36 n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The organisation has lower than average participation rates; we continue to have a robust system in place within Pre Assessment & Admissions Unit, where participants are informed and consulted about completing PROMS data returns, however, the number of cancelled joint surgeries during this period has impacted on completion rates. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to ensure that as many hip replacement patients participate as possible. 18 (iv) Patient reported outcomes measures for elective procedures - (iv) Knee Replacement Surgery 2016/17 (Apr - Sep) 13.2 n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The organisation has lower than average participation rates; we continue to have a robust system in place within Pre Assessment & Admissions Unit, where participants are informed and consulted about completing PROMS data returns, however, the number of cancelled joint surgeries during this period has impacted on completion rates. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to ensure that as many knee replacement patients participate as possible. 19 (i) 19 (ii) Emergency readmissions to hospital within 28 days of discharge : indirectly standardised percent, 16+ years Emergency readmissions to hospital within 28 days of discharge : indirectly standardised percent, <16 years 2011/12 8.8% n/a 17.2% 4.9% 11.5% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- Despite a small percentage rise in readmissions during 2013/14 compared with 2011/12 our internal monitoring shows that our number of readmissions is now reducing over time. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuoulsy reviewing the data in particular to identify common causes of avoidable re-admissions and where appropriate taking actions to address these for example the introduction of the Crisis Intervention Team. 2011/ % n/a 14.9% 5.1% 10.0% * * * The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The Trust has an open access policy for a cohort of children who need quick access to the childrens ward. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Reviewing the management of open access patients. Data from Health & Social Care Information Centre - Indicator Portal Ref Indicator Description Period Latest Performance National Target National Worst National Best National Average Performance 20 Responsiveness to the personal needs of it's patients (Score out of 100) 2013/ n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The Trust continues to review outcome of patient surveys and implement actions to improve services based on results. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Encouraging patients feedback on the quality of services, making feedback mechanisms more accessible and discussing feedback from patients at Trust Board. 21 Staff who would recommend the trust to their family or friends. Q / n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The Trust continues to go through a period of organisational change which has immpacted on staff morale, as indicated in the wider staff survey results. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- The Trust continues to review outcomes from the staff surveys and implements actions to improve performance based on the results. Also, the Trust has implmented the staff Friends & Family survey so that it can review findings more regularly than from the annual survey and from a wider number of staff to more regularly inform service improvements. 22 Patient experience of community mental health services n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- Patient experience now forms part of the monitoring undertaken by the Mental Health & Learning Disabilities Quality Group and actions taken to address performance issues. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Encouraging patients feedback on the quality of services, making feedback mechanisms more accessible and discussing feedback from patients at Trust Board. 23 Patients admitted to hospital who were risk assessed for venous thromboembolism. Q / % 95.0% 78.7% 100.0% 95.6% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The organisation is currently exceeding the national target of 95% for 2016/17. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- Continuing to monitor performance to achieve the required performance standards and to continually improve the quality of its service. 24 The rate per 100,000 bed days of cases of C.difficile infection that have occurred within the trust amongst patients aged 2 or over. 2016/ n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The information includes incidentes reported across Acute, Mental Health, Ambulance and Community services, so the figure will be higher compared to other Trusts and therefore the national average. This means the figures are not truly comparable for benchmarking purposes. ** The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- continually developing and improving robust working processes for prescribing, cleanliness and patient flow guided by learning points developed in the root cause analysis programmes, inspection and assurance. 25 (i) Patient safety incidents and the % that resulted in severe harm or death. (i) Total Incident rate per 100 Admissions Apr 15 - Sep n/a The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The information includes incidents reported across Acute, Mental Health, Ambulance and Community services, so the figure will be higher compared to other Trusts and therefore the national average. This means the figures are not truly comparable for benchmarking purposes. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- ensuring root cause analysis is undertaken on incidents and that lessons are learnt and shared across the organisation. Data from Health & Social Care Information Centre - Indicator Portal Ref Indicator Description Period Latest Performance National Target National Worst National Best National Average Performance 20 Patient safety incidents and the % that resulted in severe harm or death. (ii) % Incidents that resulted in severe harm or death Apr 15 - Sep % n/a 2.9% 0.1% 0.4% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The information includes incidents reported across Acute, Mental Health, Ambulance and Community services, so the figure will be higher compared to other Trusts and therefore the national average. This means the figures are not truly comparable for benchmarking purposes. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- ensuring that the improvements in reducing incidents that have resulted in severe harm continues through the ongoing cluster Reviews/root cause analysis undertaken on incidents and that lessons are learnt and shared across the organisation Patient Friends & Family test, combined result for A&E Jan % n/a 45.5% 100.0% 86.7% Patient Friends & Family test, combined result for Inpatients Jan % n/a 79.5% 100.0% 95.7% The Isle of Wight NHS Trust considers that this data is as described for the following reasons:- The Trust is continue to review and improve the mechanisms to capture patient feedback. The Isle of Wight NHS Trust intends to take the following actions to improve this indicator, and so the quality of its services, by:- ensuring all patients are given the opportunity to provide feedback using a variety of methods, and that action is taken on the results to improve the patient experience

56 56 Quality Account 2016/17 Isle of Wight NHS Trust Key quality performance indicators were monitored during 2016 / 17 via the monthly Quality Report; which is reviewed by the SEE Committee and Quality Governance Committee each month and made available on the Trust s website. The tables below outline the annual performance against each indicator. Safety Effectiveness Experience Other Mar-17 Main Summary Trustwide Measure description Detail page included Local or national target Target 2016/17 Monthly target Date Latest data Performance trend in month YTD target Current YTD 2016/17 Year end forecast 2016/17 Previous year Projected performance if current trends continue 2015/ Trustwide MRSA bacteraemia (Healthcare acquired) 10 National 0 0 Mar Clostridium difficile cases (Healthcare acquired) 10 National 0 Mar MSSA bacteraemia (Healthcare acquired) - N / A N / A N / A Mar E.Coli bacteraemia (Healthcare acquired) - N / A N / A N / A Mar MRSA screening quarterly only New SIRIs reported Elective Mar-17 95% 100% 96% 1 - Non-elective Mar-17 89% 100% 89% 100% 1 Local 10% 4 Mar SIRIs in month Number of ongoing SIRIs 12 N / A N / A - Mar Number of SIRIs closed in month N / A N / A - Mar All reported Local 10% Mar Clinical incidents Resulting in any harm Local 10% 82 Mar Resulting in harm (major) Local 10% 1 Mar Resulting in harm (catastrophic confirmed after investigation) Local 10% 0 Mar All reported Local 10% Mar Slips, Trips & Falls Resulting in any injury 14 Local 10% 16 Mar Resulting in serious injury Local 10% 0 Mar Pressure ulcers Hospital setting (newly developed) Local 17 Mar Community setting (newly developed) 16, 17, N / A Local 12 Mar Deteriorated (grades 2 4) Trustwide Local 50% 1 Mar Venous-Thromboembolism (VTE) Acute contract service users only 3 National 0% 95% Mar % 95% 99% 99.1% Mortality Number of inpatient deaths 9, 10 N / A N / A N / A Mar SHMI update (quarterly) 11 N / A N / A N / A Mar Number of healthcare cases going to inquest (inquests held) 26 N / A N / A N / A Mar Mixed sex accommodation breaches (sleeping accommodation) 28 National 0 0 Mar Pharmacy avoidable missed doses (includes stock not available) 25 N / A - - Mar % % 1.10% / 17 only DoLS (Deprivation of Liberty safeguards 19 N / A Mar Complaints Local 10% 19 Mar Patient satisfaction Concerns 30, 31, Local 71 Mar Compliments 32, 33 N / A - - Mar Contacts (neither complaints nor concerns) N / A - - Mar Duty of candour (actual incidents reported) 29 N / A N / A - Mar Chaplaincy visits 35 N / A - - Mar Emergency readmissions (Trustwide all areas, all diagnoses, all ages) 27 1% Mar % 8.20% - - Patient moves (numbers of patients involved) without clinical justification 39 Local 0 0 Mar Cancelled appointments Consultant lead outpatient appts Local 10% 1871 Mar Service group outpatient appts 36, N / A, 37, 38 Local 10% 481 Mar Inpatient elective operations Local 5% 81 Mar Delayed Transfers of Care (DToCs) 1 month retrospectively reported 3 Feb Patient discharges recorded as after 23:00 and before 06:00 40 N / A 0 0 Feb Patient discharges recorded as after 06:00 and before 12 (noon) 40 Local 50% 294 Mar

57 Isle of Wight NHS Trust Quality Account 2016/ Healthcare Associated Infections (HCAI) The Isle of Wight NHS Trust has continued to focus work on better managing and reducing the incidence of HCAI this year. The overall trends in HCAI have been monitored through the Infection Prevention and Control Group and reported in the monthly Quality Report. The Infection Prevention and Control Annual Report 2016 / 2017 to be published shortly will contain more detailed information. Clostridium Difficile Infections (CDI) Achieving the low trajectory (target) of only seven cases for 2016 / 2017 was always going to be a challenge and unfortunately this year the Trust has reported 13 hospital attributed cases. However this is a significantly improved figure on the 23 reported hospital attributed cases for the period 2015 / Number of Cases HCAI CDiff April March 2017 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total Clostridium Difficile Infections (CDI) A root cause analysis (RCA) was taken for all hospital acquired CDI cases and the following issues were identified as the key service and care delivery factors that may have contributed to the infection or risks for further infections: Delays in the reporting and sampling of specimens from patients with loose stools. Problems with isolating patients with loose stools in a timely manner with evidence of escalation when no side room was available. The 2015 / 2016 action plan developed by the CDI Action Group has not been implemented in its entirety however despite this we have seen a significant reduction in the number of hospital attributable healthcare associated infections for the period 2016 / The Trust continues to employ the Hydrogen Peroxide Vapour (Bioquell) system for the terminal cleaning of any area from which a patient with a CDI has been discharged or transferred.

58 58 Quality Account 2016/17 Isle of Wight NHS Trust Methicillin-Resistant Staphyococcus Aureus (MRSA) and Methicillin Sensitive Staphyococcus Aureus (MSSA) 4 HCAI MRSA & MSSA April March 2017 There is a national zero tolerance for MRSA Bacteraemia cases. Unfortunately there was one case reported as hospital attributable in December There was a total of one MRSA case attributable to the Trust for 2016 / Number of Cases MRSA MSSA A post infection review was undertaken for this case from which it was identified the patient had a long term indwelling urinary catheter (by this we mean it was fixed in their body for a sustained period of time). As a result of the review an action plan was produced actions form which were: Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total MSSA MRSA Methicillin-Sensitive Staphylococcus Aureus MSSA Bacteraemia 2016 / 2017 The need to improve documentation and auditing practices around catheter insertion and ongoing care. The need to increase compliance with staff being trained in Aseptic Non Touch Technique (ANTT). There was a total of ten MSSA case attributable to the Trust for 2016 / This figure has increased by 100% on the 2015 / 2016 figure of 5. Root cause analysis investigations are undertaken for all hospital attributable cases. Themes identified as a result of these investigations mimic the findings of a need for improved documentation and auditing processes in relation to any indwelling devices e.g. peripheral cannulae and catheters.

59 Isle of Wight NHS Trust Quality Account 2016/17 59 E. coli bacteraemia surveillance There were a total of 18 cases of E. Coli bacteraemia during 2016 / 2017 attributable to the Trust. This figure has remained the same for 2014 / 2015 and 2015 / Root cause analysis investigation is undertaken for all hospital attributable cases. The common theme arising from these investigations remains the need to improve our care and management of indwelling urinary catheters. A new catheter insertion and management care plan has been developed which is currently being piloted within the Trust. Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar Total Number of cases HCAI EColi April March cases of E. Coli bacteraemia during 2016 / 2017

60 60 Quality Account 2016/17 Isle of Wight NHS Trust Complaints & Compliments During 2016 / 17 reporting of complaints data has continued to be part of the performance report to Trust Board and the monthly quality report which is reviewed at the Patient Safety, Experience and Clinical Effectiveness Committee, and Quality Governance Sub Committee. The complaints data is also shared at various other committees as part of performance reports. The Trust welcomes complaints as a valuable part of patient experience feedback, and allows the Trust to learn lessons to improve and refine services for current and future users of our services. Whilst this year the Trust did not set a target to reduce complaints received, it has seen a decrease of 24% on last years complaints. Outlined below is the month on month performance in relation to complaints and concerns. Individual months are RAG rated against the individual monthly target with the YTD rated against the comparative YTD position Measure Target Period Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar YTD total Total Trustwide Complaints logged within NHS formal procedure Complaints process 0 20 days 2015 / / Compliance days N / A 2016 / (closed within month) >45 days Percentage of complaints managed within timescale negotiated with complainant (retrospectively updated at closure, figures in italics will change) Number of concerns received within month % concerns resolved within 3 working days Number of cases referred to PHSO* in month Number of cases reported upheld / partially upheld * Parliamentary & Health Service Ombudsman N / A In time Out of time Number / in time 59% 33% 35% 46% 31% 13% 14% 21% 36% 33% 53% 9% 32% 2015 / / Number / in time 89% 83% 81% 94% 78% 86% 91% 85% 93% 92% 88% 85% 87% The top 10 main subject areas across all complaints and concerns is shown below: Complaints by Subject (primary) - Top ( 10 )

61 Isle of Wight NHS Trust Quality Account 2016/17 61 During the year the PHSO opened 11 new cases, these are cases were the complainant was not happy with the final outcome they received from the Trust. At the time of writing the PHSO closed 14 cases. From 16 cases where a decision has been made in 2016 / 17, 14 have been closed, and 2 are awaiting completion of the recommendations. The decision of the PHSO for all 16 cases was 2 upheld, 6 not upheld, 7 partly upheld and 1 not investigated. All complaints received by the Isle of Wight NHS Trust are investigated and reviewed directly with the staff involved, to ensure lessons are learnt, developed and shared with the wider clinical area. The following positive outcomes and actions have been identified from a sample of complaints received in order to prevent similar situations occurring. The number of compliments about the Isle of Wight NHS Trust services continues to exceed complaints with 17 compliments for every one formal complaint received; this is an increase on 2015 / 16 where there were 15 compliments for every one formal complaint. The table right highlights the month on month performance. The top 10 areas receiving the highest number of complaints and concerns are shown below: April May June July Aug Sept Oct Nov Dec Jan Feb Mar Yearly Total The Trust has continued to review and refine its complaints handling process during 2016 / 17, and has increased the number of local resolution meetings that have been held with complaints to effectively manage their concerns at an early stage. Further analyses, including trends have been undertaken by the Trust and this is available in the Trust s Annual Complaints report.

62 62 Quality Account 2016/17 Isle of Wight NHS Trust Patient Feedback (inc FFT) Since the initial implementation of the NHS Friends and Family Test in October 2012; the Trust has continued to offer the question across all services in the Trust at either the point of discharge, or during their pathway of care. The question asked is: How likely are you to recommend our <ward / A&E Department / Service> to friends and family if they needed similar care or treatment? In July 2016 the Trust commenced work with iwantgreatcare (iwgc) to improve our collection of real time patient experience feedback. iwgc works with healthcare providers to enable patients to leave meaningful feedback on their care. The service is independent and captures and publishes feedback on a trusted website for healthcare reviews. The Trust has a total of 117 services currently registered and using the system to capture real-time patient feedback. Since the introduction of iwgc the Trust has received a total of 12,713 reviews of its services and has a 5 star rating at the time of reporting. Other mechanisms to enable patients to feedback to the Trust are via the NHS choices and patient opinion website, via Healthwatch Isle of Wight or the Care Quality Commission. The Trust and Healthwatch Isle of Wight regularly share information including themes of complaints, concerns and issues raised to ensure wider lessons are learnt and key themes identified. The Trust continues to capture patient and carer experience via the patient story video programme, which is shared with Board. All videos are shared with clinical staff to ensure that lessons are learnt, and the Trust is reviewing the process to ensure that these are used in appropriate forums to further widen and improve the sharing of this valuable patient experience feedback. All of these mechanism are monitored and reviewed by the Board as well as being shared with the appropriate clinical services to ensure learning occurs. Below is the 2016 / 17 Friends and Family Test recommend scores and response rate by submission areas: Individual months are RAG rated against the individual monthly target with the YTD target rated against the comparative YTD position Measure Target Period Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD total Inpatient areas (acute hospital wards) Outpatient areas Accident & Emergency Maternity (birth point) Community services Mental health services Ambulance Response rate N / A 40% 52% 23% 10% 37% 23% 23% 38% 44% 41% 38% 32% 34% % 2016 / 17 Recommended 90% 97% 95% 97% 90% 94% 93% 100% 96% 94% 96% 99% 97% 96% Response rate N / A % 2016 / 17 Recommended 90% 96% 95% 96% 96% 95% 96% 96% 94% 97% 96% 96% 96% 96% Response rate N / A 6% 3% 3.8% 2.5% 9% 3% 4% 6% 6% 5% 4% 8% 5% % 2016 / 17 Recommended 90% 95% 93% 97% 87% 85% 91% 87% 85% 81% 92% 89% 92% 89% Response rate N / A 18% 19% 13% 0% 0% 0% 6% 100% 12% 12% 6% 13% 17% % 2016 / 17 Recommended 90% 100% 95% 92% 100% 100% 100% 100% 100% 100% 99% Response rate N / A 1.4% 1.5% 1.1% 0.8% 5% 3% 3% 4% 1% 4% 4% 3% 3% % 2016 / 17 Recommended 90% 99% 97% 95% 93% 96% 97% 95% 96% 94% 95% 99% 97% 96% Response rate N / A 1.2% 1.4% 1.4% 1.0% 0.36% 2% 2% 2% 3% 1% 1.1% 1.9% 1% % 2016 / 17 Recommended 90% 98% 94% 91% 94% 91% 89% 98% 94% 98% 94% 97% 100% 95% Response rate N / A 0.4% 0.5% 0.5% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% % 2016 / 17 Recommended 90% 100% 100% 100% No returns available since change over 100% The Isle of Wight NHS Trust values feedback from patients, carers and relatives and will continue to build on work undertaken during 2016 / For NHS Choices there were only 2 ratings given in Better use of this site by patients / service users would offer the Trust a valuable insight into their services. Informal Methods In addition to acquiring specific feedback through asking patients / service users about their experience it is important the Trust recognises the impact of its care on people. Whilst it should be acknowledged that the CQC found staff to be caring and compassionate, the report highlighted a number of issues that would have led to a very poor patients experience including moves of patients at night, mixed sex breaches, inappropriate environments for people in the last days of their life and for those with dementia as examples. The Quality Improvement Plan addresses the formal and informal issues raised through the examination of the experience of patients and service users and ensure that there are sound systems going forward to capture and utilise this information and provide continuous improvement. Furthermore, the Trust will ensure that it undertakes thorough quality impact assessments when making decisions that affect the care of those they serve.

63 Isle of Wight NHS Trust Quality Account 2016/ Learning from Serious Incidents / Never Events Our quality improvement framework outlines how the Trust wishes to make services better and therefore improve the overall patient experience. For 2016 / 17 the IW NHS Trust set itself five quality priorities for action, one of which was reducing incidence of patient harm (patient safety). Serious Incidents requiring investigation are investigations instigated where significant harm has occurred to an individual or individuals where there is clear evidence or reason to believe that lapses of care or service delivery occurred. The SIRI framework enshrines the key actions needed to investigate, draw out lessons learned and provide assurance and mitigation that the issues will not repeat themselves. Significant improvement in the process of local review by clinical business units, prior to the declaration of a SIRI, means that only those incidents in which the harm was truly avoidable are declared as SIRIs and investigated using this robust process. This has lead to a drop over the last two years, although 2016 / 17 has seen a slight increase on 2015 / 16. The following SIRI numbers were reported: 2014 / 15 = / 16 = / 17 = 58 (to-date) Attention has moved to the identification and implementation of improvements (lessons learnt) that will prevent recurrence of serious incidents, rather than simply the completion of a series of tasks. Clustering similar incidents such as falls and pressure ulcers (as described above) allow for learning across clinical business units. Lessons learnt continue to be shared across the Trust via a Learning Lessons Newsletter, and outcomes of SIRIs and their learning are added to the Trust s intranet page. In addition, as and a serious event is identified, a Patient Safety Alert is publicised across the Trust. KPI (key performance indicators) This has largely been monitored from Q3 onwards. KPI information for Care Quality Commission Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 New SIRIS reported in month Table top review within 48 hours Managers comments completed within 48 hours SIRIs submitted to CCG in month Number submitted within 60 days Number accepted at first submission Number returned for further work Number awaiting acknowledgement from CCG 58 number of 2016 / 2017 SIRIs to date NB: February 2017: the 19 reported are made of 17 cases of 12-hour breaches, which are managed in line with the National Operational Pressures Escalation Levels Framework; as all these cases were reviewed and escalated at Bed Managers meetings, this would be the equivalent to a table top review and so has been reflected as such.

64 64 Quality Account 2016/17 Isle of Wight NHS Trust Never Events The Trust declared 4 Never Events this year: Retained Foreign Object post procedure x 2 Wrong Site Surgery x1 Wrong route administration of Medication x 1 Training The Trust previously commissioned four, 2-day training courses, in investigation skills, with approximately 20 people attending each session. The purpose of this was to ensure that the Trust had a good selection of staff that were up to date in investigative training, and could therefore be called upon to undertake an investigation as required across the Trust. Skills learnt continued to be used, with other staffing learning by becoming a buddy to a trained member of staff. For 2017 / 18, further funding has been identified externally via Health Education Wessex to enable further training in investigative methodology and also duty of candour principles. A number of staff have already expressed an interest in this training. This should ensure the continuation and recruitment of potential investigating officers, especially as some of the original staff trained in 2015 are now no longer available to undertake the investigating officer role. Latest initiatives The Quality Governance team is continually reviewing the SIRI process to ensure it remains user-friendly and complies with national guidance. To help influence the completion and checking of final SIRI reports prior to them being formally sent to the Commissioners for closure, we have recently introduced an aide memoire for use by the Executive Chair at the IPR meeting. This lists and prompts all the information that should be contained within the report, as a minimum, and gives guidance on who is responsible for further work and by what date it should be returned for formal submission. End of year stats Below is a table showing the number of SIRI cases reported over the last 3 years. The surge in the numbers in February can be attributed to the directive from NHS Improvement to report validated 12-hour breaches as SIRIs. NEW SIRIs April May June July Aug Sept Oct Nov Dec Jan Feb March TOTAL 2014 / / /

65 Isle of Wight NHS Trust Quality Account 2016/17 65 The next set of figures shows the SIRI type against each Clinical Business Unit for the year. SIRI Subjects Surgical Medicine Clinical Community Mental Health Corporate Pressure ulcers IG breaches Unexpected deaths Clinical issues Delay in treatment Medication issues Suboptimal care Allegation against staff Patient fall IG issue hour breach Never Event Below is a Quarterly count of SIRI cases against each Clinical Business Unit. Clinical Business Unit Q1 Q2 Q3 Q4 Surgical Medicine Clinical Community Mental Health Corporate

66 66 Quality Account 2016/17 Isle of Wight NHS Trust Learning / Improvements As a result of undertaking SIRI investigations, below are some examples of outcomes and improvements made to prevent recurrences of incidents. Clinical event it was identified that compliance with catheter care and specific supra pubic catheter training was low across the wider service. ACTION All Nurses undertaking catheterisation in the community will have completed the latest catheter management training in line with RCN College Clinical Guidance. In addition, training also put in place for identifying sepsis, including subsequent responsibilities with regards to escalation of care. Training arrangements made. Screening issue Outcome revealed that staff were unclear who was responsible, at each stage of the clinical course, for coordinating decisions and ensuring that treatment occurred in a timely manner ACTION Consultant now in post and second substantive Consultant commenced Jan Monitoring issue review identified human factors, a delay in contacting a doctor for review together with observational, documentation and procedural issues. ACTION Feedback provided to all staff regarding maternal observations and timings for taking maternal pulse now added to the labour ward board. Auscultation and Modified Early Obstetric Warning Score (MEOWS) local guidelines updated. All staff involved undertook further training and the relevant NICE guidance was promoted to staff. Unexpected Death outcome concluded that teams treating patient did not have access to all relevant information from previous Trust or GP and that internal process for information sharing was not robust. ACTION expected standards of communication with other Trusts / agencies have been discussed at Leadership meeting; a standard operating procedure is being implemented. Service has since met with mainland Trust to discuss communication and discuss solutions. Initial discussions have taken place with relevant stakeholders to review possibility of scanning all documents in medical notes onto service s electronic system. Patient fall Investigation identified differing opinions regarding patient s level of cognitive impairment; decisions to remove bed and chair sensors were not clearly documented. Patient had extended stay in hospital even though medically fit for discharge. ACTION staff reminded that mental capacity and level of cognition should be documented and considered in relation to use of falls prevention equipment e.g. bed & chair sensors / bed rails. The falls care plan is being updated so that staff can reflect changes in patient need due to changes in their physical and mental status, without having to commence a new document Sister to undertake documentation checks to ensure that, as patients condition changes, regular reviews take place, including documenting the rationale for removal of bed sensors. Summary 2016 / 17 has continued to see a real focus on the SIRI process, from refreshing the Trust s own SIRI processes, tools and documentation, to the engagement of helpful and knowledgeable staff by acting as investigating officers; it is further appreciated and noted that some staff have undertaken multiple cases. The Long Term Quality Strategy, underpinned by a key Quality Improvement Framework, outlines how the IW NHS Trust wishes to make services better and therefore improve the overall patient experience we look forward to continuing the progress we have made.

67 Isle of Wight NHS Trust Quality Account 2016/ Dashboards & Scorecards The Isle of Wight Trust continues to focus on new and innovative ways of presenting data both in dashboards and scorecards. Building on previous success new developments are taking place to enable the collection and analysis of real time data at Clinical Business Unit and individual service level. There is a continued focus on the triangulation of different aspects of quality and overall service performance, as presented in the Trust Clinical Business Unit scorecards which have been extended during 2016 / 17. Dashboards continue to be used during Performance Reviews as part of the overall performance management process, to highlight positive trends and to enable root cause analysis on service performance issues and reviews of data quality. The Trust will continue to drive towards richer sources of information with the development of direct access to system data and with the additional benefit of improved processing times and closer to real time analysis Patient Safety Walkrounds The Trust Board reviewed the process of undertaking ward visits, and the decision was taken to move to a different approach to this programme of activity. The approach currently being used is known as In your shoes and is a concept widely embraced in hospitals throughout the Country. It typically involves meeting patients and spending times with them to understand what it is like to be in their shoes and see the NHS from a patient s perspective. The Isle of Wight NHS Trust chose to embrace this concept but wanted to go beyond the familiar boundaries; and not only wants to walk in the shoes of patients but also of our staff. There is no central monitoring of actions in relation to the visits, and Trust Board members are aligned to either a Clinical Business Unit or corporate area and are responsible for ensuring that feedback is provided directly to the service visited Quality Action Plans Duty of Candour The Isle of Wight NHS Trust has been embedding Duty of Candour within its existing processes since its publication; this includes incorporating the requirements of the duty within serious incidents requiring investigation and complaints. During the year the Trust has been providing dedicated training to staff; having recognised that there remained a lack of knowledge in relation to complying with the regulation. This training has been well attended, and further sessions are booked for 2017 / 18. In relation to ensuring that Duty of Candour is embedded the Trust has used the internal incident reporting system Datix, to capture decisions and actions taken and an audit has been undertaken on a random sample of incidents where the duty applied. To further improve our compliance, the Trust has updated its Being Open Policy to incorporate Duty of Candour, provided template letters to support staff with taking appropriate action, and has set up an internal website page to enable staff to easily access materials to support them with these sometimes difficult conversations. The numbers of duty of candour incidents are regularly reported as part of the Quality Report, and audit reports shared through our internal governance processes.

68 68 Quality Account 2016/17 Isle of Wight NHS Trust The Trust recognises that further work needs to be undertaken to ensure we have a clear mechanism in place to clearly capture and monitor action taken in relation to the duty, and continue to work to revise current systems and processes to improve this further. Sign up to Safety Sign up To Safety is a national campaign aimed at reducing harm to patients by 50% over the next 3 years. During 2016 / 17 the Trust continued with its Safety Improvement Plan in Accident and Emergency. Accident and Emergency, in conjunction with the Claims Department, identified a significant issue related to claims around missed fractures. The project aimed to improve the interpretation of X-rays, the identification of Achilles tendon injuries, and the detection of blood clots and DVTS. Other significant areas of support were around the prompt recognition of cauda equine, including appropriate diagnostic testing and effective transfer. Training has been and continues to be delivered to the ED staff in relation to these main aims. The Trust continue to monitor the delivery of this training, and any clinical incidents that arise as a result of concerns regarding the treatment of these conditions. Since the original purpose of the project was the raising of awareness, the impact in terms of actual reduction in claims cannot be quantified at this time as this is a more long term monitoring task, and claims take longer to come to light than the original delivery timescale of this project. The monitoring of educational uptake and the clinical outcomes in relation to the conditions identified continues through the Trust s Medical Education Committee, and the Quality and Patient Safety meetings conducted by the Ambulance, Urgent Care and Community Clinical Business Unit, in which the Accident and Emergency department operate. During 2017 / 18, the Sign up to Safety Campaign for the Isle of Wight NHS Trust will focus on avoidable moisture lesions. Moisture lesions, or incontinence associated dermatitis, is a skin condition where the skin reacts to being contact with urine and faeces. As there are a number of steps that clinical teams can take to avoid patients experiencing this form of skin damage, these lesions can in many circumstances be prevented. Isle of Wight NHS Trust is one of a number of Trusts nationally which report moisture lesions as a category of skin damage against the National Association of Tissue Viability Nurses Skin Excoriation tool. The categories go from Category 0 which is normal healthy skin, to Category 3 which represents widespread painful and infected skin lesions associated with skin that has been in prolonged contact with urine and or faeces.

69 Isle of Wight NHS Trust Quality Account 2016/17 69 During 2016 / 17 the Trust reported 230 incidents of moisture damage. The month by month report is below. Moisture lesions reported month by month Moisture Lesion deteriorated to Category 3 Moisture Lesion deteriorated to Category 2 Moisture Lesion deteriorated to Category 1 Moisture Lesion Category 3 Moisture Lesion Category 2 By quarter / 18 the Trust will aim to reduce moisture lesions by 25% against baseline for 2015 / 16. A number of actions will be undertaken to support this: Implementation of skin care pathways to support frontline staff in the management of patients continence. Review and dissemination of updates to the barrier cream formulary to support clinical teams in selection of products to prevention moisture lesion damage. A clinical project with the Procurement services to ensure that best practice is being undertaken with regard to the continence products that are being used in clinical areas. Reporting will be undertaken weekly at the Patient Safety Working Group, and monthly via the Quality Report. Staff survey results for indicators KF26 and KF21 The Isle of Wight NHS Trust is an integrated Trust which means that our Acute services, Community services, Mental Health and Ambulance service are all within the umbrella of the Isle of Wight NHS Trust. These are traditionally individual organisations and therefore the reporting for the staff survey is broken down in accordance with national guidance under the separate headings. For the first time in 2016 the whole staff group has been surveyed, previously only 32% (n=800) of those in the acute Trust sector survey were given the opportunity, all in mental health and all in ambulance. This means that while ambulance and mental health can be directly compared, the acute sector is perhaps more of an accurate picture than previous years. The response rates this year were 45% (n=169) mental health; 28% (n=48) ambulance; 46% (n=1151) acute. Nationally the response rate for Acute was 43% Mental Health 49% and Ambulance 38%.

70 70 Quality Account 2016/17 Isle of Wight NHS Trust Improvements made in 2016 as a result of the 2015 staff survey results Appraisal coverage. Continued proactive compliance reporting. Documentation for 2017 / 18 streamlined with behaviours sign off. Thank You Cards (commended by CQC). New designs and online format. Health & Wellbeing (HWB) activity Headline areas for improvement. Actions that we will undertake for continuing improvement Harassment, Bullying and Abuse (HBA) which has been raised as a concern Behaviour Focus Group set up (evidence based plan of action in place). Behaviour Buddies network to be implemented. address set up as first point of contact. Review of policy and processes. Interactive forum training scheduled to cascade from Exec / Senior leaders onwards. Corporate induction new format (April) values & behaviours golden thread. Appraisal documentation reviewed to incorporate HBA discussion. Intranet area and e-learning module to be developed. Communications and raising awareness through posters, events etc. Communications with staff Review of internal communication methods. 10 Minute Team Brief introduced 3 corporate, 2 business unit and 5 local items delivered face to face in 10 minutes. Introduction of Staff News weekly hard copy, copies sent to every area. Changes made to monthly Senior staff meeting Executive Briefing becomes Leadership Briefing with more focused CEO weekly message made shorter and more informal in response to readers comments. Forthcoming changes to Trust wide weekly e-bulletin more focused on Trust rather than system and new delivery system (GovDelivery) being implemented. Health and wellbeing of staff who have high levels of stress Recruit an additional (CQUiN funded) Occupational Health Nurse to develop and support actions to improve HWB initiatives. Stress audits & improved recording & monitoring of causes. Employee Assistance Programme (EAP) promotion. Deep dive pilot for causes of work related stress to be implemented during Focus on formal management referrals for MSk problems. Healthy Eating initiatives. Exercise classes & health checks. Leadership development Business case to increase capacity within leadership development team. Competency profiles in development. Leadership development schedule to meet the needs of the competency profiles. Bespoke plan for CBU leads and teams. Increased coaching provision.

71 Isle of Wight NHS Trust Quality Account 2016/17 71 Indicator KF26: Percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months: Acute and Community: 25% Ambulance: 33% Mental Health: 21% National Key finding comparisons Acute and Community: 25% 24% Ambulance: 30% 29% Mental Health: 23% 22% Indicator KF21: Percentage believing that the organisation provides equal opportunities for career progression or promotion Acute and Community: 87% Ambulance: 68% Mental Health: 86% National Key finding comparisons Acute and Community: 86% 85% Ambulance: 70% 70% Mental Health: 84% 85% Workforce Equality & Diversity In November 2011 the NHS Equality and Diversity Council launched the Equality Delivery System (EDS); a framework developed to assist NHS organisations to ensure they comply with equality legislation and embed equality matters across the National Health Service (NHS). The EDS has proven to be most successful in organisations where they have made it work for them. Even so, the Equality and Diversity Council published a revised version of the EDS in November The EDS requires the Trust to evidence that different groups of people (e.g. people over the age of 35) have the same, or better, outcome / experience as those under the age of 35. The groups of the community and our staff are required to consider are: people of different ages; people who are married or in a civil partnership; people who may be pregnant; people with varying religions and beliefs; sexual orientation as well as Transgender individuals and those who have undergone a gender reassignment; people from different ethnic backgrounds; people who have a disability, and men and women. These are referred to as Protected Group. The EDS assessment involves gathering evidence such as reports, surveys and complaints, along with working with patients and service users to help us arrive at an initial assessment. For most outcomes the key question is: how well do people from protected groups fare compared with people overall? A significant challenge for the Trust moving forward is to establish a robust process for gathering evidence so a fair and informed EDS assessment can be undertaken. This can be achieved through greater engagement with the Clinical Business Units. The table opposite illustrates the outcome of our self-assessment when it was last undertaken in 2015.

72 72 Quality Account 2016/17 Isle of Wight NHS Trust Goal 1. Better health outcomes 2. Improved patient access and experience 3. A representative and supported workforce 4. Inclusive leadership Workplace Race Equality Standard Since the Workplace Race Equality Standard was introduced to the NHS by the Equality and Diversity Council in July 2015, it has been reported on annually. The move followed a number of reports which have highlighted disparities in the number of BME people in senior leadership positions across the NHS, as well as lower levels of wellbeing amongst the BME population. There standard is a matrix of nine indicators. Five of the indicators are specifically on workforce data including BME representation at Board level. The remaining four indicators use data from the national NHS Staff Survey and compare the experience and treatment of White staff and BME staff in the NHS, with a view to closing the gaps highlighted by those metrics. The standard now forms part of the Care Quality Commission s assessment against the Well Led domain. Grading The majority of patients in up to five of the protected groups fare as well as people overall. The majority of staff in up to eight of the protected groups fare as well as people overall. The majority of staff in up to eight of the protected groups fare as well as people overall. The majority of staff in up to eight of the protected groups fare as well as people overall. In comparison with our first report the 2016 report showed: BME staff had reduced by 1.34% of our total workforce. There had been a reduction in the number of BME staff entering formal disciplinary proceedings compared to white employees. The number of BME staff accessing non-mandatory training had increased by 40% compared with % of BME staff, an increase of 2%, believes the Trust provides equal opportunities for career development and promotion, compared with 82% of white employees. As a result of this data and concerns about inherent bullying and harassment within the Trust, Unconscious Bias training has been incorporated into the Trust s High Performing Leaders and Managers Programme. The Trust s Race Equality Reports and Action Plans can be found at Accessible Information Standard From the 1 st August 2016 onwards, all organisations that provide NHS care or adult social care are legally required to follow the Accessible Information Standard. The standard aims to make sure that people who have a disability, impairment or sensory loss are provided with information that they can easily read or understand and with support so they can communicate effectively with health and social care services. The Trust has undertaken a self assessment against the standard which showed that the Trust uses a variety of systems to record a person s information needs; consequently this information is not easily shared. Responding to a person s information needs also varied across the organisation. An action plan is now being developed through the Quality Governance Directorate. On the horizon is the Equality Act 2010 (Gender Pay Gap Information) Regulations 2017 which will require the Trust to publish pay gap information by from the 5 th April 2017 the Trust will be required to publish its gender pay gap annually.

73 Isle of Wight NHS Trust Quality Account 2016/17 73 Part Statements provided by Commissioning PCT, LINks or OSCs Statement from Patient s Council The Patient Council has welcomed the opportunity to support and contribute to initiatives from the Isle of Wight NHS Trust. Council members have again been busy this year visiting all areas of the hospital and other services, assessing the service from the patient s perspective and providing feedback to the services. Members attend numerous sub-committee meetings and help suggest ways to improve the patient experience. Many members undertook training in how to be a Dementia Friend and gained a greater understanding of the requirements of patients with dementia and its impact on services. The Patient Council heavily supports the need for integrated care records and continues to support the need for WiFi to be installed for patients. Patient Council members have been involved with the Acute Service Redesign project which will set out what the Island s acute services could look like in the near future. We are aware that it has been a particularly challenging year for the Trust, being placed on Black Alert on numerous occasions. A key priority, as stated in this report, is to improve the discharge planning process and reduce the length of stay for some patients. After being informed of the work taking place to reduce pressure ulcers it is surprising to see that no improvement in the data is apparent. The outcome of the CQC inspection is very disappointing and the staff survey indicator KF26: Percentage of staff experiencing harassment, bullying or abuse from staff is very poor but having read the Quality Account the Council is pleased to see that so many changes, initiatives and training taking place to address this issue. We would like to congratulate the teams on the timely identification & treatment of sepsis and the work of the Pre-Pip programme. Overall the hospital is improving in a lot of ways and we look forward to the improvements that are expected over the next months. Statement from Healthwatch Healthwatch Isle of Wight has reviewed and considered the Quality Account of the Isle of Wight NHS Trust, and acknowledged the recognition of the quality improvements required for 2016 / 17 relating to the reduction of falls, pressure ulcers and infections. We welcome the goals of the Trust for 2017 / 18 which include improving experience for people who use their services, a commitment to provide excellent patient care; effective partnership working to improve Trust services and an emphasis on ensuring that they are cost effective and sustainable; and we acknowledge the input of the Trust staff who strive to provide excellent care and support to patients, patient`s families and carers. We support the ongoing focus of the Trust to ensuring proactive and safe discharge; improving services for people of all ages with mental health

74 74 Quality Account 2016/17 Isle of Wight NHS Trust needs; personalised care and support planning; and actions to improve staff health and wellbeing. However, we are concerned that poor communication and information sharing (both internally and externally); shortcomings in leadership, risk management and safeguarding vulnerable individuals; low morale, staff shortages and sickness have had a negative impact on the quality of services provided by the Trust and the level of risk of harm to patients. All these issues were reflected in the recent inspection report of the Care Quality Commission CQC, and led to the recommendation that the Trust should be placed in special measures. As part of our work plan in 2016 / 17, Healthwatch Isle of Wight has undertaken a number of visits of Trust services, including a visit of the Emergency Department to talk to patients about their experience of the service and also a number of follow up visits to identify whether the improvements that the Trust implemented to their complaints process following a Healthwatch Isle of Wight report, have led to an improvement in patient experience. We hope these will assist the Trust in implementing the required improvements to its services. We believe that sharing the feedback we receive relating to patient experience is the most important way of helping the Trust in meeting its priorities, as well as addressing the recommendations of the Care Quality Commission, by ensuring that patients remain at the centre of the delivery of care. We look forward to developing our relationship with the Trust as a critical friend, and supporting its journey towards improved, safe services that are cost effective and truly delivered in partnership with patients. Statement from Overview Scrutiny Committee In its statement last year the Council s Health and Adult Social Care Scrutiny Sub Committee indicated that it hoped that service delivery was of the standard expected for each individual and that it was vital that the safety of patients remained paramount. It is with great disappointment that a number of serious issues were identified by the Care Quality Commission following an inspection of the Trust in November Members were recently concerned that the Trust was unable to satisfactorily demonstrate progress on the 2016 / 17 priorities when asked to do so. The Trust will be robustly challenged to clearly demonstrate that, from the vast array of data that it appears to collect, all patients are actually getting the desired outcomes required in a safe and timely manner. In making this challenge the sub-committee will ensure that the Trust and its staff are fully supported in moving out of special measures and delivering a level of service that is independently assessed as being safe, effective and well led. Whilst it is appreciated that the process for the Quality Account is imposed on the Trust by the Department of Health it seems to have little benefit to patients and stakeholders in its style and content The release of an easy to read version of this, and other key documents, is suggested. Little progress has also been made to ensure the use of plain English by the Trust in its strategies and policies. To enhance public engagement and involvement it must take steps to make the content more meaningful and relevant. There should also be a more transparent and open engagement process with the whole Island community on the delivery of priorities which reflect the views of those it serves. Councillor Gordon Kendall Chairman, Health and Adult Social Care Scrutiny Sub Committee, Isle of Wight Council Statement from Isle of Wight Clinical Commissioning Group The Isle of Wight Clinical Commissioning Group (CCG) welcomes the opportunity to provide a statement in response to the presented Quality Account from the Isle of Wight NHS Trust. However at the time of comment the draft report made available for comment preceded the publication of the findings of the CQC inspection in November The CCG is extremely disappointed with the findings of the CQC inspection and is sorry that local people are not currently receiving the quality of care that they expect and deserve from the Trust.

75 Isle of Wight NHS Trust Quality Account 2016/17 75 This is obviously a very demanding time for the Trust and the scale of the challenge can t be underestimated. However, the CCG remain dedicated and committed to working closely with the Trust to ensure they develop and implement a robust and effective improvement plan that quickly delivers significant change. The CCG will also be working in close partnership with regulators and our local and mainland system leaders. The Sustainability and Transformation Plan offers opportunities to ensure we provide excellent commissioning of high quality, safe and sustainable services. The Isle of Wight NHS Trust 2016 / 17 Quality Account, as a public facing document, presents as quite formal and uses a level of abbreviations. Whilst some terms commonly used in the NHS are explained in the glossary, taking into consideration reasonable adjustments, an easy read version or executive summary may be helpful. The Quality Account has been shared with representatives of the CCG, including Clinical Executives and Heads of Commissioning for their comments. The CCG acknowledges that, as an integrated Trust, it is not always possible to establish priorities in all services; however, it is the opinion of the CCG that the account disproportionately focuses on acute services. A brief and balanced overview of key quality issues, achievements and or quality improvements in community, mental health and learning disability and ambulance services should be included to inform and assure readers with regard to all services provided. Whilst the CCG recognises the importance of the priorities identified by the Trust going forward, with the exception of a reduction in non clinically justified bed moves, it is not felt to be reflective of the priorities identified within the Trust by the CQC; the priorities are also considered to be acute focused. In addition, whilst the priorities identified within the Quality Account reflect the national drive to reduce patient harm, there appears to be limited linking with local initiatives such as My Life a Full Life, and the Sustainability and Transformation Plan. Whilst the Quality Account notes commencement of the Acute Redesign project, other areas are also noteworthy. For example, the work underway to redesign Mental Health services via the Mental Health Redesign Board, and the redesign work regarding the Urgent Care service which commenced in The CCG is aware that there is both national and local challenge to recruiting healthcare staff. A more detailed section on workforce planning and development, including Trust links with academic institutions, would offer a level of assurance about the Trust s future recruitment and retention plans. This could include information in relation to a HR / recruitment strategy. Overall, the Isle of Wight CCG would agree that the detail which has been included within the Quality Account is accurate; however, the account does not contain the necessary breadth across the range of services provided by the Trust. With that in mind the CCG cannot comment on achievement across the quality agenda throughout 2016 / 17 for the Trust as a whole. The CCG do consider there to be significant gaps in the report, particularly in relation to Community, Mental Health and Learning Disability, and Ambulance services.

76 76 Quality Account 2016/17 Isle of Wight NHS Trust Part Statement of Directors Responsibilities The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the above legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010(as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011). In preparing the Quality Account, directors are required to take steps to satisfy themselves that: the Quality Account presents a balanced picture of the Trust s performance over the period covered; the performance information reported in the Quality Account is reliable and accurate; there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice; the data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health Guidance. The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account. By order of the Board Eve Richardson Chair, Isle of Wight NHS Trust Date: 27 June 2017 Maggie Oldham Interim Chief Executive Officer, Isle of Wight NHS Trust Date: 27 June 2017

77 Isle of Wight NHS Trust Quality Account 2016/17 77 Part Changes made to the final version of the Quality Account The table below provides a summary of changes that were made to the final version of the Quality Account following feedback from stakeholders. Location Across the quality account Contents page Part One Chairman & CEO statement on Quality Changes made Formatting and spelling corrections Added Specific issues added to Priority 3 Clinical Effectiveness KPIs updated for Mental Health Participation in clinical research Figures updated to include end of year What others say about the provider statement from the CQC Outcome from CQC reports included Data quality iv) clinical coding error rate updated Improve discharge planning process Narrative added around discharge summaries Quality indicators Additional supporting narrative added Complaints and compliments Figures updated to include end of year Patient feedback Updated to include end of year Staff survey results Now includes national information 3.2 Statements provided by others Statements added

78 78 Quality Account 2016/17 Isle of Wight NHS Trust Part How to Provide Feedback on the Account This important document sets out how we continue to improve the quality of the services we provide. Your Views on Quality We welcome your views and suggestions on our Quality Priorities for 2017 / 18 set out in Part 2 of this Quality Account. We welcome feedback at any time on our Quality Account. This can be sent to the Quality Team Isle of Wight NHS Trust, St. Mary s Hospital, Parkhurst Road, Newport, Isle of Wight, PO30 5TG or ed to quality@iow.nhs.uk. You can read more about the national requirements for Quality Accounts on the NHS Choices or Department of Health websites. You can download a copy of this Quality Account from (Publications section) or (listed as NHS Isle of Wight Provider Services ).

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