Agenda Item: 08 Pam Fenner NHS Norwich CCG Governing Body Tuesday 22 March 2016

Size: px
Start display at page:

Download "Agenda Item: 08 Pam Fenner NHS Norwich CCG Governing Body Tuesday 22 March 2016"

Transcription

1 Agenda Item: 08 Pam Fenner NHS Norwich CCG Governing Body Tuesday 22 March 2016 Subject Presented By Submitted To Purpose of Paper Quality and Patient Safety Committee Executive Harvest Summary Pam Fenner Quality and Safety Committee Chair and Lay Member (Registered Nurse) NHS Norwich CCG Governing Body Tuesday 22 nd March 2016 For Information Summary The purpose of this paper is to provide a summary of the key highlights of clinical quality and patient safety relating to our NHS provider services. Further information and performance data can be found within the accompanying dashboard. CT / March 2016 / Executive Harvest Summary / FINAL

2 NCH&C Serious Incidents (SI) There were 53 SI reported in February 2016 which is comparable with the 6 previous months. The majority, 48, relate to grade 3 pressure ulcers which were acquired within patient s own homes, including residential care, 11 of which relate to Norwich CCG patients. Other SI include two grade 4 pressure ulcers, two falls and on information governance breach, none of which relate to Norwich CCG patients. Pressure Ulcers (PU) The Trust PU policy has been reviewed, however the launch of the policy has been delayed until March 2016 to allow commissioners the opportunity to comment and make recommendations. Norwich CCG has provided feedback on the draft policy and made a number of recommendations. Following the launch of the updated policy, the Trust will commence reporting PU in line with the Serious Incidents Framework (2015), where RCA for avoidable PUs will be completed, with a monthly audit of unavoidable PUs to provide assurance that PU have been appropriately classified. The RCA reports will continue to be presented at the PU Validation Meeting to support and facilitate learning from avoidable PUs. CT / March 2016 / Executive Harvest Summary / FINAL Page 2

3 Falls The number of falls reported in January 2016 reduced to 46. This is the lowest number of falls reported over the last 12-month period. There was one severe harm fall reported in January 2016 categorised by the Trust as severe harm, relating to a Norwich CCG patient who had sustained a fracture following a fall. The number of falls per month remains comparable with previous months, with the exception of the spike in August Medications Incidents There were 42 medication incidents reported in January 2016, this is comparable with previous months, although all categories of harm have reduced this month. One moderate incident was reported in January 2016 which was due to a lack of availability of diamorphine (national shortage) delaying the replenishment of a syringe driver. There had been an increase in the number of Controlled Incidents (CDs), culminating in a peak (12) in September These figures have now reduced and plateaued with 6 incidents reported in January The Trust reported a 40% increase in CDs incidents over the last three years. Findings suggest this may be as a result of an increase in the number of patients requiring complex clinical care, for example End of Life care. This will be discussed at CQRM. Infection Prevention and Control (IP&C) There were no cases of C.Diff reported in January 2016 and to date the Trust have a total of 6 cases year to date against a trajectory of 7. There are 2 further cases currently awaiting appeal which may see the Trust breach their trajectory. The Trust IP&C team have been undertaking a series of commode audits. The audits demonstrated poor compliance with IP&C standards, with the percentage of clean commodes within inpatient settings ranging from 21% to 83%. Areas identified as noncompliant are being re-audited on a weekly or fortnightly basis until compliance with cleaning schedule is achieved. The audit identified a number of commodes that need replacing this should be achieved by the beginning of the financial year April The IP&C team will continue to undertake monthly audits for at least the next 3 months as a minimum until they are assured of consistent compliance with cleanliness standards. Safety Thermometer The number of patients receiving harm free care over the last 3 months has continued to improve: January % December % November % There were no new VTEs reported in January 2016, however an RCA is underway regarding the VTE reported in December The CAUTI project remains ongoing with an aim to reduce the number of CAUTI s reported across the organisation. Catheter passports have now been printed and are available within all clinical teams for completion and dissemination. There is a strategic piece of work being undertaken by a Public Health Consultant who will be liaising with local Directors of Nursing to encourage wider collaboration in the use of catheter passports. Mortality The Mortality Review Group convened in February 2016 and agreed the revisions to the mortality review process. As from the beginning of February 2016 Ward Managers and CT / March 2016 / Executive Harvest Summary / FINAL Page 3

4 Doctors will record all inpatient deaths on a dedicated form, highlighting any sub-optimal care and classifying all deaths according to a nationally recognised mortality scale. For patients where anything untoward has been recognised, those with a Learning Disability and a random sample of other patients will be subject to a more detailed review. These revisions are in line with the recommendations within the Mazars Report. The Mortality Review Group will meet in April 2016 to review stages one and two documentation to identify any subsequent trends and learning and consider the need for remedial action plans where appropriate. NCHC s mortality data has been reviewed for January 16 and there are no significant areas of concern noted. Complaints 21 complaints were received during January 2016, compared to 16 in November The numbers of complaints received over the past 6 months have remained comparable. There were three complaints received regarding specialist services, two of which specifically related to difficulties in contacting the Trust s podiatry department at Norwich Community Hospital and lack of communication when cancelling appointments. This will continue to be monitored to see if this becomes a reoccurring issue. There has been a further complaint regarding the poor quality of continence products being provided. As problems with continence products are identified by patients, a reassessment of their continence needs is undertaken. Patients with more complex needs may require more than one assessment to determine the most appropriate product to meet their needs. Some patients take 3 6 months to work through their new continence products and this may be why this issue appears to be a reoccurring theme. Friends and Family Test (FFT) The overall Trust FFT score for January 2016 is 99 with year-to-date at 98, demonstrating a slight improvement from November and December All categories received less than 10 negative comments during January 2015, with estates and facilities receiving the most negative comments. This is consistent with the previous month. A new category (survey/questions) is being collated and has recorded the second highest number of negative comments (8) during January Looked After Children (LAC) The LAC Project Steering Group met for the second time on 2 March 2016 and is currently completing the Project Initiation Document. Four work-streams have been established: Commissioning, Adoption, IM&T and Workforce. NCH&C is still exploring opportunities to work with secondary provider(s) to reduce the backlog. Fortnightly operational meetings continue to take place between the LAC Designated Nurse and Dr, Providers and NCC to ensure any process blockages are highlighted and resolved. Lymphoedema The current service model is in the process of being reviewed to ensure that this can be delivered within the cost envelope available. There are currently staffing shortfalls within the service which will impact on the Trust s ability to assess and follow up patients on the caseload. The Trust is actively trying to recruit to increase capacity within the service, despite any formal agreement regarding a new service model. IC24 Serious Incidents (SI) and Quality Issue Reporting (QIR). There were 2 new SI reported during February 2016, both of which relate to treatment CT / March 2016 / Executive Harvest Summary / FINAL Page 4

5 delays. Neither of these incidents relate to Norwich CCG patients. There were 8 QIR reported in February 2016, with 4 of these relating to a delay/difficulty in obtaining clinical assistance, this has almost halved when compared to the previous month. Performance The final copy of the CCG s report following unannounced visits have been shared with CQC and Monitor. An improvement plan was developed in October 2015 and this has now been superseded with a remedial action plan. This has been agreed with the provider, the coordinating commissioner and NHS England. Bi-monthly operational meetings between the provider and local CCGs continue to monitor and review the remedial action plan. 111 Service The main area of the CCG s focus is on the number of calls answered in 60 seconds and the percentage of abandoned calls. The workforce is not running at full capacity due to attrition and high levels of sickness which reflects on the current level of performance. Active recruitment of call handlers is taking place to achieve over establishment to support timely call taking. Recruitment via a specialist agency remains ongoing to ensure the most appropriate staff are appointed to these posts. Activity within the service remains consistently higher than anticipated and IC24 are remodelling their workforce to meet the current level of demand. Ratios of call handlers to clinicians are closely monitored to ensure patient safety. A graduation bay with a separate coach is in place to provide additional support for newly trained and trained staff. A Norwich-centric dispatch is in place to support local knowledge, although this will not be at full capacity until the recruitment process has been completed. A DOS review is ongoing to ensure providers are listed with work progressing regarding local amendment to include SWIFT service for falls. OOH Service There is a Contract Query Notice raised regarding performance against speak to a GP within 1, 2 and 6 hour, PPC and home visit standards. Recruitment to GP vacancies is improving with 10 GPs recruited over the last few months. The introduction of a remote GP service has been implemented to support the service at times of high activity. There is active recruitment to other roles including Urgent Care Practitioners and Advanced Practitioner Nurses remains in progress. IC24 have reviewed and adapted a number processes to make improvements following trends highlighted within QIR relating to treatment delays for palliative care patients. This has included the pilot of a rapid response vehicle to improve the response times and provision of a stock box supply for clinicians to access. IT systems and processes have been amended to improve the identification of Palliative patients that are End of Life to improve the timeliness of access to care and treatment. Improvements have been evidenced through a reduction in QIR submissions. We are more assured of progress made within the OOH service following implementation of the oversight GP, home triage and local dispatch, including the booking of urgent base visits to address performance. Workforce IC24 have now recruited a substantive Chief Executive Officer. There are a number of strategies in place to improve communication within the organisation. This includes the development of a monthly newsletter which is shared with operational staff. There are regular meetings between executive and operational teams with an open door approach being promoted. IC24 have developed an action plan to address current compliance with CT / March 2016 / Executive Harvest Summary / FINAL Page 5

6 safeguarding training and policy update. They are working closely with Adult Safeguarding Lead for Norfolk CCGs and NNCCG. Commissioners continue to work with the new provider to monitor and manage progress against the RAP to plan and mitigate the risks wherever possible to ensure safe provision of service. NSFT Serious Incidents (SI) and Quality Issue Reporting (QIR) There were 6 SI reported in February 2016, two of which occurred in January 2016 and refer to unexpected deaths. One incident following initial investigation appears to relate to a physical cause with an inpatient requiring resuscitation, there is no evidence to suggest that the patient received any sub-optimal treatment at this stage. RCA submission date Of the remaining four incidents, two relate to falls resulting in injury, one was an unexpected death of an ex service user and one was an expected death of a client under a Deprivation of Liberty Safeguards. The Trust completed an internal review of unexpected deaths to support this work a further external review of unexpected deaths has been commissioned. Quality Improvement Plan (QIP) There are currently 23 active QIPs and 5 new QIPs are currently being scoped in support of the 2016/17 Quality Plan: Two are Red Nine are Amber Twelve are Green The two red QIPs, Physical health Monitoring and Mandatory Training, are being monitored via CQRM. It is expected that once the results of the internal mock CQC audit have been reviewed further work will be required in redefining/revisiting existing QIPs and/or creation of new. This is to be orchestrated at the bi-weekly CQC Preparedness Meeting (CPM) led by their Director of Nursing. Performance Central Norfolk Contract A Remedial Action Plan (RAP) remains in place in relation to the non-achievement of the AAT 28-day target. A 95% target has been proposed by July The Trust is confident that restructuring their Central Norfolk Community Adult services will support the achievement of this. The Trust has highlighted a significant number of 4-hour referrals received within AAT service that are inappropriate. To address this from April 2016, Primary Care Liaison Workers within secondary care will be in place to provide greater support and education in referral management. The long term aim of the Trust is to eliminate the use of prone restraint. The Trust continues to make good progress in decreasing the use of prone restraint with only two breaches of the standard reported in July & October Seclusion numbers are also below the internal Trust target for December Waiting list analysis undertaken in February 2016 has raised some concerns. A detailed review has been requested of the number of patients waiting to be seen by patient group. CT / March 2016 / Executive Harvest Summary / FINAL Page 6

7 The Trust will present a report to March 2016, CQRM and SPRG. Out of Trust Placements Out of Trust placements remain a significant feature. Eleven patients were reported as out of placement 18 February Four patients were placed at Mundesley hospital with a joint visit agreed to be undertaken for assurance purposes within the next two months. Of the remaining seven patients two relate to older age service users. The co-ordinating commissioner is working on a repatriation template to be included within the 2016/17 contract. Workforce The Trust has an 11.35% vacancy rate. Recruitment continues to be an issue for Band 5 nurses (25% vacancy rate) and consultants (12.4%); however these positions have shown some improvement compared to Q2. benchmarking data that indicates in comparison other Trusts have higher vacancy rates than NSFT. Workforce analysis indicates an improvement across all localities within Norfolk. Voluntary Turnover rate within the Trust at end of Q3 was 8.80%; with work-life balance and relocation continue to be the highest voluntary reasons for leaving. National Benchmarking for turnover amongst all Mental Health Trusts and Learning Disability Trusts is 13.50% (September 2015). Central Norfolk = 7.13% (up) at end of Q3. Absence rate within the Trust at end of Q3 was 4.82%, the lowest rate in 2015 with an improving trend over the last 12 months. The Trust is assured that it is on target to reach 4.5% by March Current UK average for absence in mental health Trusts is 4.70% (September 2015). Central Norfolk Locality 4.91% at end of Q3. Incidents related to staffing concerns continue to reduce in number, after reaching a peak of 272 incidents in August Feedback suggests that where teams have been booking long term regular agency staff, the temporary staff have become part of the team and ward staff are no longer report staffing concerns. Appraisal rate within the Trust at end of November 2015 was 87.10%. System issues prevented appraisal reporting at end Dec There is an improving trend during Q1 and Q2, continuing into Q3 with an average increase of 1% per month. Central Norfolk Compliance is 83.90%. The number of reported assaults on staff with harm were at their lowest level in December NNUH HSMR (Hospital Standardised Mortality Rate) The Trust HSMR figure for September and October 2015 was 96.1 and 98.0 respectively. This remains below the annual target of 100, however HSMR has predominantly remained above this threshold for majority of 2015/16 financial year to date. Mortality rates are monitored through governance structures at the Trust for example mortality group, CQRM and benchmarks HSMR against national rates. NCCG gains assurance of this process through Quality and Patient Safety Committee. Maternity Services Serious Incidents (SI) A number of SI has been reported within Maternity Services the Directorate is undertaking Root Cause Analyses (RCA) to identify any learning outcomes and or recommendations that may be required. The Local Supervisory Authority (LSA) has undertaken an RCA of one of the incidents and has identified some recommendations that will be followed up through the CT / March 2016 / Executive Harvest Summary / FINAL Page 7

8 Trust internal Directorate and Corporate clinical governance processes. The scanning for small for gestational age (SFGA) has been identified as a 16+ risk by the Trust as they are non-compliant with Royal College of Obstetricians and Gynaecology guidance. This relates to a skills gap within the workforce, the Trust has trained a midwife to undertake the scanning process with a further midwife due to commence their training in March Harm Free Care CAUTIs Catheter care The Trust has confirmed that their ambition is to treat the insertion of catheters as if they were a prescribing and administering a drug with the same rigor of reviewing a drug chart. The appropriateness of catheter use, regularity of review and possible removal before discharge has been discussed at CQRM. It is recommended that revisiting this topic at CQRM is considered based on the data provided in the NNUH Integrated Report. Medication Incidents Three medication incidents resulting in possible harm or death were reported in Jan 2016, outcome of RCA waited. Falls Seven inpatient falls were reported in January A further three falls was reported as falls relating to moderate/severe harm in February It is not possible to comment at the time of this report RCAs are awaited. Boarders 18 per cent of Patient Advisory Liaison Services contacts for January 2016 relate to patients boarded into the Day Procedure Unit (DPU) overnight at times of internal escalation. Norwich CCG is seeking assurance regarding the process for patients boarded to DPU and other areas that their needs can be met by staff caring for them out of specialty. Performance The Trust continues to breach the Emergency Department (ED) 4 hour standard reporting 12 hour trolley waits RCA awaited. The predominate reasons for non-compliance relates to: Bed Availability DTOC & complex discharge issues severely impacting upon the flow out of ED, Acute Medical Unit Actions by Trust Internal and external focus on delayed discharges. Twice weekly exec review of patients requiring complex discharge with escalation to system partners including Clinical Commissioning Groups. Rapid Action Plan. Cancer Targets Cancer 62-day GP referral performance remains a priority for recovery. Failure to meet the agreed backlog reduction in December 2015 related to delays in accessing CT CT / March 2016 / Executive Harvest Summary / FINAL Page 8

9 Colonography driven by unprecedented levels of demand. This has been resolved and good progress is being made. It is anticipated that a sustainable backlog (20 patients) will be achieved by February 2016 with the associated delivery of this critical performance target in March Performance data provided by the Trust indicates that overall backlog for Cancer 62 day remains above trajectory of 20 for actual backlog and below trajectory for rollovers. A remedial action plan has been agreed with commissioners. RTT admitted backlog trajectory is not being met and has led to increasing number of cancellations due to bed pressures impacting on elective activity. Care Homes Gryphon Place A routine announced quality visit was carried out on 8 February The provider is a small care home providing specialist care. There was evidence of good person centred care. The manager was advised to address the staff s training compliance rate and the Clinical Quality and Patient Safety (CQPS) manager will follow up with the care home on any recommendations made at the time of the visit. The Hawthorns A routine announced quality visit was carried out on 11 February There were no issues or concerns noted at this visit and some good practice was noted. The Infection Prevention and Control (IPAC) officer Norfolk County Council (NCC) had previously carried out an audit and identified areas for improvement. The provider has developed an action plan that has been updated following an inspection by the IPAC to reflect improvements made. Ivy Court The provider was visited by a Safeguarding practitioner and Quality officer NCC in December The visit identified concerns with poor documentation and recommendations not being acted upon. Although improvements were observed the assessors do not have full confidence that the changes are sustainable a further CQPS visit is planned. Any requests for placing of CHC patients must firstly be discussed with the CQPS team or Safeguarding. Cavell Court Requirements required relating to documentation; care plans, audit of plans and medicines management. A Safeguarding Practitioner and Quality Assurance Officer, Norfolk County Council visited on 29 January 2016 to undertake a joint visit to gain assurance of progress with required improvements. The assessors identified there still remained some significant gaps in documentation and the provider needed to demonstrate the auditing of the care plans. Medicines management team visit identified some improvements on previous findings of medications omissions and errors. GP surgeries will contact medicines management team if they have any concerns. Current restrictions on CHC placements are to continue and will be reviewed following the next CQPS manager. Larchwood CT / March 2016 / Executive Harvest Summary / FINAL Page 9

10 Unannounced visit by the CQPS was undertaken on 14 January 2016, a slight improvement was noted with leadership becoming more visible. A more comprehensive shift handover has been implemented with work ongoing to improve documentation. Funding has been agreed for a refurbishment programme and a schedule being developed to address actions from the previous Infection Prevention and Control (IPAC) audit. The CQPS team plan a further visit. Current restrictions, no CHC admissions until the improvements can be embedded. CT / March 2016 / Executive Harvest Summary / FINAL Page 10

11 Norfolk Community Health & Care NHS Trust (RY3) Patient Safety Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar-16 Trend line Serious incidents reported NCHC Serious incidents reported NCHC (N) Never events reported NCHC Pressure ulcers - Grade 2 NCHC Pressure ulcers - Grade 3 NCHC Pressure ulcers - Grade 3 NCHC (N) Pressure ulcers - Grade 4 NCHC Pressure ulcers - Grade 4 NCHC (N) Quality issue reporting (QIR) NCHC Quality issue reporting (QIR) NCHC (N) Injurious falls by occupied bed days NCHC Total falls NCHC No harm falls NCHC Low harm falls NCHC Moderate harm falls NCHC Severe harm falls NCHC Total Medication incidents NCHC Medication Incidents - no harm NCHC Medication Incidents - low harm NCHC Medication Incidents - moderate harm NCHC Medication Incidents - severe harm NCHC Clostridium difficile cases NCHC MRSA bacteraemia NCHC Mortality - Discharges (exc. PBC & Pall) NCHC N/A N/A 183 N/A N/A Mortality - Deaths (exc. PBC & Pall) NCHC 8 1 N/A 3 4 N/A 1 N/A N/A 0 17 Mortality -% Deaths (exc. PBC & Pall) NCHC N/A N/A 0.5 N/A N/A Workforce Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar-16 Trend line Sickness absence rate NCHC Staff turnover rate NCHC Vacancy rate NCHC info Appraisal rate NCHC Mandatory training compliance NCHC Patient Experience Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar-16 Trend line Friends and family score NCHC Compliments NCHC Compliments NCHC (N) Complaints NCHC Complaints NCHC (N) CT / March 2016 / Executive Harvest Summary / FINAL Page 11

12 Integrated Care 24 (IC24) Patient Safety Org Stnd Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Serious incidents IC Quality Issue Reporting (QIR) IC Quality Issue Reporting (QIR) IC24 (N) Performance Org Stnd Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line % calls answered within 60 seconds at the end of the introductory message IC % calls referred to ambulance service with 3 minutes which are life threatening IC % answered calls triaged IC24 60 % abandoned calls IC % answered calls passed for call back IC % call backs within 10 minutes IC % calls warm transferred as percentage of calls eligible to go to a clinician IC Patient Experience Org Stnd Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Friends & Family IC Complaints IC Compliments IC Workforce Org Stnd Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Sickness IC Turnover IC CT / March 2016 / Executive Harvest Summary / FINAL Page 12

13 Norfolk & Suffolk NHS Foundation Trust (RMY) Patient Safety Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Serious incidents reported NSFT Serious incidents reported NSFT(N) Never events reported NSFT Pressure ulcers - Grade 2 NSFT Pressure ulcers - Grade 3 NSFT Pressure ulcers - Grade 3 NSFT(N) Pressure ulcers - Grade 4 NSFT Pressure ulcers - Grade 4 NSFT(N) Catheter-associated UTIs reported NSFT Falls NSFT Falls NSFT (N) Unexpected Deaths NSFT Unexpected Deaths NSFT (N) Quality issue Reporting (QIR) NSFT(N) Patient Experience Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Friends & Family (% recommended) NSFT Complaints NSFT Complaints (Central) NSFT Compliments NSFT Performance (Central) Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Patient safety thermometer NSFT Number of inpatients reported to have self-harmed NSFT Medication incidents with harm reported for inpatients NSFT Number of occasions where restraint was used (target) NSFT Number of occasions where restraint was used (actual) NSFT Number of occasions when prone restraint was used (target) NSFT Number of occasions when prone restraint was used (actual) NSFT Number of seclusion incidents in month (target) NSFT Number of seclusion incidents in month (actual) NSFT Number of people secluded in month NSFT Number of episodes of long term segregation (June 2015 onwards) NSFT Number of physical assaults on service users with harm NSFT Number of physical assaults on staff with harm NSFT Number of working age adults placed in out of area bed in month NSFT Number of older people placed in out of area bed in month NSFT % Bed Occupancy monthly NSFT Number of people under 18 admitted to adult wards NSFT % long term inpatients (>12m) with an annual health check NSFT x x x x x % of qualifying patients with a MHCT cluster NSFT x x x x x % Care Plans assessed as being complete (Trustwide only) NSFT x x 95 x x x x x x x CPA patients having formal reviews within 12m NSFT x x x x x % inpatient finished episodes during the periods with an ICD10 code NSFT x x x x x x x x x x Service users followed up in 7 days post discharge NSFT x x x x x IAPT patients who complete treatment and move to recovery in month NSFT Control Panel (Central) Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line % of patients on CPA who were followed up within 7 days after discharge from psychiatric inpatient care NSFT % of admissions to adult care acute wards gate-kept by CRHT teams (denominator the total number of admissions to the trust's acute wards) NSFT % of patients whose transfer of care was delayed NSFT % of long-term (over 12 months) inpatients that have received an annual health check NSFT % of CAMHS patients have been seen within 8 weeks of referral received date (completed pathways) NSFT % of patients having at least two face to face attended contacts with a valid MHCT assessment and a care cluster NSFT AAT/CRHT Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Patients seen within 4 hours (Lorenzo) NSFT x x x x x x x x Patients seen within 4 hours (Service reported data) NSFT x x x x x Patients seen within 120 hours (Lorenzo) NSFT x x x x x x Patients seen within 120 hours (Service reported data) NSFT x x x x x Patients seen within 28 days (Lorenzo) NSFT x x x x x x Patients seen within 28 days (Service reported data) NSFT x x x x x MH Liasion Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Patients seen within 4 hours NSFT Patients seen within 24 hours NSFT Patients seen within 3 days NSFT Section 136 Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line % NSFT S136 dedicated staff available in S136 suite within maximum one hour of police arrival in the S136 suite NSFT Adult ADHD Service Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line % patients treated in month who have waited less than 18 weeks NSFT Workforce Org Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend Line Vacancies (Central) NSFT Appraisals (Central) NSFT N/A Turnover (Central) NSFT Sickness (Central) NSFT Mandatory Training (Central) NSFT CT / March 2016 / Executive Harvest Summary / FINAL Page 13

14 Norfolk & Norwich University Hospital NHS Foundation Trust (RM1) Patient Safety Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Serious incidents reported NNUH Serious incidents reported NNUH (N) Never events reported NNUH Pressure ulcers - Grade 2 NNUH Pressure ulcers - Grade 3 NNUH Pressure ulcers - Grade 3 NNUH (N) Pressure ulcers - Grade 4 NNUH Pressure ulcers - Grade 4 NNUH (N) Quality issue reporting (QIR) NNUH info Quality issue reporting (QIR) NNUH (N) info Catheter-associated UTIs reported NNUH Mortality HSMR NNUH MRSA bacteraemia NNUH Clostridium difficile cases NNUH Early Warning Score (EWS) NNUH Workforce Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Sickness absence rate NNUH N/A Staff turnover rate NNUH Vacancy rate NNUH 10 N/A N/A 3.84 N/A N/A N/A 4.9 N/A Appraisal rate NNUH N/A N/A Mandatory training compliance NNUH Patient Experience Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Complaints NNUH Friends & Family A&E NNUH Friends & Family A&E response rate NNUH ` Friends & Family Inpatients NNUH Friends & Family Inpatients response rate NNUH Friends & Family Maternity - Q1 Antenatal Care NNUH 100 N/A N/A N/A Friends & Family Maternity - Q2 Birth NNUH Friends & Family Maternity - Q3 Postnatal ward NNUH Friends & Family Maternity - Q4 Postnatal Community Provision NNUH N/A Cancer Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Percentage of patients seen within two weeks of an urgent GP referral NNUH Percentage of patients receiving subsequent treatment for cancer within 31-d NNUH Stroke Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line % length of stay on the stroke unit NNUH % of patients with a primary diagnosis of stroke admitted to a HASU within 4 NNUH % of urgent scans performed on eligible patients within 60 minutes of arrival annuh A&E Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Percentage of patients who spent 4 hours or less in A&E NNUH Maternity Org Stnd Apr15 May15 Jun15 Jul15 Aug15 Sep15 Oct15 Nov15 Dec15 Jan16 Feb16 Mar16 Trend line Born Before Arrival (BBA) NNUH Closure to admission NNUH CT / March 2016 / Executive Harvest Summary / FINAL Page 14

WNCCG Quality Report

WNCCG Quality Report Agenda Item 0. 4 th September 05 WNCCG Quality Report September 05 Subject: Presented by: Submitted to: Purpose of the paper: Quality Report Provider Quality Assurance regarding QEH Kings Lynn, NCH&C,

More information

Integrated Performance Report

Integrated Performance Report Integrated Performance Report M06 September 2014 Presented by: Paul Bostock (Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer) An

More information

COVENTRY AND RUGBY CLINICAL COMMISSIONING GROUP

COVENTRY AND RUGBY CLINICAL COMMISSIONING GROUP COVENTRY AND RUGBY CLINICAL COMMISSIONING GROUP Report To: Governing Body 11 September 2013 Report From: Title of Report: Purpose of the Report: Jacqueline Barnes, Executive Nurse The Nursing and Quality

More information

Patient Safety & Clinical Quality Committee Chair s Report. Sue Hayter, Governing Body Registered Nurse Member

Patient Safety & Clinical Quality Committee Chair s Report. Sue Hayter, Governing Body Registered Nurse Member Agenda Item: 10.2 Subject: Presented by: Patient Safety & Clinical Quality Committee Chair s Report Sue Hayter, Governing Body Registered Nurse Member Submitted to: NHS West Norfolk CCG Governing Body,

More information

Norfolk and Suffolk NHS Foundation Trust mental health services in Norfolk

Norfolk and Suffolk NHS Foundation Trust mental health services in Norfolk Norfolk Health Overview and Scrutiny Committee 7 December 2017 Item no 6 Norfolk and Suffolk NHS Foundation Trust mental health services in Norfolk Suggested approach by Maureen Orr, Democratic Support

More information

Item E1 - Bart s Health Quality Indicators

Item E1 - Bart s Health Quality Indicators Item E1 - Bart s Health Quality Indicators 1.0 Purpose 1.1 The purpose of this report is to provide the CCG Board with an update on quality matters across pertaining to our main local Provider organisations.

More information

Nottingham University Hospitals Emergency Department Quality Issues Related to Performance

Nottingham University Hospitals Emergency Department Quality Issues Related to Performance RCCG/GB/14/123 Nottingham University Hospitals Emergency Department Quality Issues Related to Performance Introduction NUH have failed to meet the 95% 4 hour wait standard for a number of consecutive months.

More information

WEST HAMPSHIRE PERFORMANCE REPORT. Based on performance data available as at 11 th January 2018

WEST HAMPSHIRE PERFORMANCE REPORT. Based on performance data available as at 11 th January 2018 WEST HAMPSHIRE PERFORMANCE REPORT Based on performance data available as at 11 th January 2018 1 CCG Quality and Performance Executive Summary Introduction: The purpose of this report is to provide an

More information

NHS performance statistics

NHS performance statistics NHS performance statistics Published: 8 th February 218 Geography: England Official Statistics This monthly release aims to provide users with an overview of NHS performance statistics in key areas. Official

More information

The Royal Wolverhampton NHS Trust

The Royal Wolverhampton NHS Trust The Royal Wolverhampton NHS Trust Meeting Date: 3 th June 214 Trust Board Report Title: Executive Summary: Action Requested: Report of: Author: Contact Details: Resource Implications: Public or Private:

More information

Agenda Item: 09 NHS Norwich CCG Governing Body Tuesday 23 rd January 2018

Agenda Item: 09 NHS Norwich CCG Governing Body Tuesday 23 rd January 2018 Agenda Item: 09 NHS Norwich CCG Governing Body Tuesday 23 rd January 2018 Subject: Presented By: Submitted To: Purpose of Paper: NHS Norwich CCG Consolidated Quality and Patient Safety Report Karen Watts

More information

NHS Performance Statistics

NHS Performance Statistics NHS Performance Statistics Published: 8 th March 218 Geography: England Official Statistics This monthly release aims to provide users with an overview of NHS performance statistics in key areas. Official

More information

NHS performance statistics

NHS performance statistics NHS performance statistics Published: 14 th December 217 Geography: England Official Statistics This monthly release aims to provide users with an overview of NHS performance statistics in key areas. Official

More information

BSUH INTEGRATED PERFORMANCE REPORT. 1) Responsive Domain 2) Safe Domain 3) Effective Domain 4) Caring Domain 5) Well Led Domain

BSUH INTEGRATED PERFORMANCE REPORT. 1) Responsive Domain 2) Safe Domain 3) Effective Domain 4) Caring Domain 5) Well Led Domain BSUH INTEGRATED PERFORMANCE REPORT 1) Responsive Domain 2) Safe Domain 3) Effective Domain 4) Caring Domain 5) Well ed Domain RESPONSIVE DOMAIN RESPONSIVE DOMAIN Metric Defined by Standard Apr-16 May-16

More information

Board of Director s Meeting

Board of Director s Meeting Board of Director s Meeting Meeting Date: 15 November 212 Agenda item: 6.1 Title: Purpose: Summary: Recommendation: Author: Presented by: QUALITY AND PATIENT SAFETY ASSURANCE COMMITTEE To provide an exception

More information

Integrated Quality Report

Integrated Quality Report Integrated Quality Report Data provided by Patient Services and the Clinical Governance and Risk Department June 2018 Included this month: Health-care Associated Infections Patient Falls Pressure Ulcers

More information

Integrated Performance Report

Integrated Performance Report Integrated Performance Report M12 March 2015 Presented by: Paul Bostock (Chief Operating Officer) Des Holden (Medical Director) Fiona Alsop (Chief Nurse) Paul Simpson (Chief Financial Officer) An Associated

More information

Newham Borough Summary report

Newham Borough Summary report Newham Borough Summary report March 2013 Prepared on 18/03/13 by Commissioning Support team Finance and Activity Millions Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Newham Headlines March 2013 Feb-12 Apr-12 Jun-12

More information

Newham Borough Summary report

Newham Borough Summary report Newham Borough Summary report Item K1 September 2013 Prepared on 30/09/2013 by Support team GREEN Finance and Activity Millions AMBER RED Headlines M5 Financial position M4 activity data The QIPP net savings

More information

Newham Borough Summary report

Newham Borough Summary report Newham Borough Summary report April 2013 Prepared on 17/04/13 by Commissioning Support team Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 GREE N Finance and Activity

More information

Quality Framework Healthier, Happier, Longer

Quality Framework Healthier, Happier, Longer Quality Framework 2015-2016 Healthier, Happier, Longer Telford & Wrekin Clinical Commissioning Group (CCG) makes quality everyone s business. Our working processes are designed to ensure we all have the

More information

Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care.

Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Learning from Deaths Policy A Framework for Identifying, Reporting, Investigating and Learning from Deaths in Care. Associated Policies Being Open and Duty of Candour policy CG10 Clinical incident / near-miss

More information

November NHS Rushcliffe CCG Assurance Framework

November NHS Rushcliffe CCG Assurance Framework November 2015 NHS Rushcliffe CCG Assurance Framework ASSURANCE FRAMEWORK SUMMARY No. Lead & Sub Committee Date placed on Assurance Framework narrative Residual rating score L I rating in 19 March 2015

More information

SUMMARY OF INDICATOR CHANGES FOR VERSION 3 INTELLIGENT MONITORING REPORTS Acute and Specialist NHS Trusts 23 June Final Draft, Subject to Change

SUMMARY OF INDICATOR CHANGES FOR VERSION 3 INTELLIGENT MONITORING REPORTS Acute and Specialist NHS Trusts 23 June Final Draft, Subject to Change Never Event incidence Yes: 01 May 2013-30 Apr 2014 Incidence of Clostridium difficile (C.difficile) Incidence of Meticillin-resistant Staphylococcus aureus (MRSA) Dr Foster Intelligence: Mortality rates

More information

Integrated Performance Report August 2017

Integrated Performance Report August 2017 Integrated Performance Report Contents Section Page High Level Dashboard Balanced scorecard 3 Domain Scorecards and Director Commentaries Operational Performance 4 Quality and Patient Safety 9 Workforce

More information

Waiting Times Report Strategic. Thematic Goals

Waiting Times Report Strategic. Thematic Goals Strategic Improved Quality of Care Transformation - Prevention & Wellbeing Thematic Goals Waiting Times Report 2016-17 Transformation through Integration Improved Access to Services Improved Value This

More information

Performance and Delivery/ Chief Nurse

Performance and Delivery/ Chief Nurse Governing Body 26th May 2017 Quality and Performance Report 22nd May 2017 Author: Other contributors: Executive Lead Audience Eileen Clark - Acting Director of Clinical Performance and Delivery/ Chief

More information

Strategic KPI Report Performance to December 2017

Strategic KPI Report Performance to December 2017 Strategic KPI Report Performance to December 2017 Trust Board 25 th January 2018 Strategic KPI summary SROs: All Directors Objective KPI SRO Target Apr May Jun Jul Aug Sep Oct Nov Success Is Deliver A

More information

Appendix A: University Hospitals Birmingham NHS Foundation Trust Draft Action Plan in Response to CQC Recommendations

Appendix A: University Hospitals Birmingham NHS Foundation Trust Draft Action Plan in Response to CQC Recommendations No. Domain CQC Recommendation Lead Operational Lead Current Status 1 Appendix A: University Hospitals Birmingham NHS Foundation Trust Draft Action Plan in Response to CQC Recommendations Wording in long

More information

Improving Care, Delivering Quality Reducing mortality & harm in Welsh Ambulance Services NHS Trust

Improving Care, Delivering Quality Reducing mortality & harm in Welsh Ambulance Services NHS Trust National Learning Session - 10 th June 2011 Improving Care, Delivering Quality Reducing mortality & harm in Insert name of presentation on Master Slide Reducing Mortality & Harm in the Welsh Ambulance

More information

WOLVERHAMPTON CLINICAL COMMISSIONING GROUP QUALITY & SAFETY COMMITTEE

WOLVERHAMPTON CLINICAL COMMISSIONING GROUP QUALITY & SAFETY COMMITTEE Wolverhampton Clinical Commissioning Group WOLVERHAMPTON CLINICAL COMMISSIONING GROUP QUALITY & SAFETY COMMITTEE Minutes of the Quality and Safety Committee Meeting held on Tuesday 12 th May 2015 Commencing

More information

Report to Patients. A summary of NHS Norwich Clinical Commissioning Group s Annual Report for 2014/15. Healthy Norwich. Patient

Report to Patients. A summary of NHS Norwich Clinical Commissioning Group s Annual Report for 2014/15. Healthy Norwich. Patient Report to Patients A summary of NHS Norwich Clinical Commissioning Group s Annual Report for 2014/15 Healthy Norwich GP Care Patient Quality YourNorwich The work of the CCG, what it has achieved for patients,

More information

Integrated Performance Report Executive Summary (for NHS Fife Board Meeting) Produced in February 2018

Integrated Performance Report Executive Summary (for NHS Fife Board Meeting) Produced in February 2018 6b Integrated Performance Report Executive Summary (for NHS Fife Board Meeting) Produced in February 2018 2 Contents Integrated Performance Report: Executive Summary 5 Clinical Governance: Chair and Committee

More information

Standardising Acute and Specialised Care Theme 3 Governance and Approach to Hospital Based Services Strategy Overview 28 th July 2017

Standardising Acute and Specialised Care Theme 3 Governance and Approach to Hospital Based Services Strategy Overview 28 th July 2017 Standardising Acute and Specialised Care Theme 3 Governance and Approach to Hospital Based Services Strategy Overview 28 th July 2017 Background Theme 3 builds upon previous key strategic commissioning

More information

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 10. Date of Meeting:.24 th March 2017.

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 10. Date of Meeting:.24 th March 2017. NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 10 Date of Meeting:.24 th March 2017. TITLE OF REPORT: CCG Corporate Performance Report AUTHOR: Melissa Laskey Director of Service

More information

NHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011)

NHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011) NHS LANARKSHIRE QUALITY DASHBOARD Board Report October 2011 (Data available as at end August 2011) INTRODUCTION This paper provides a monthly quality dashboard for NHS Lanarkshire. This is in line with

More information

Report to: Trust Board 25 th April Enclosure 4. Title Integrated Performance Report March Sponsoring Executive Director

Report to: Trust Board 25 th April Enclosure 4. Title Integrated Performance Report March Sponsoring Executive Director Report to: Trust Board 25 th April 2013 Title Integrated Performance Report March 2013 Enclosure 4 Sponsoring Executive Director Author(s) Purpose Previously considered by Peter Herring Chief Executive

More information

SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Trust Key Performance Indicators May Regular report to Trust Board

SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Trust Key Performance Indicators May Regular report to Trust Board SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST Trust Key Performance Indicators May 20 Report to: Trust Board July 20 Report from: Sponsoring Executive: Aim of Report/Principle Topic: Review History to date:

More information

OPERATIONAL PERFORMANCE REPORT: March Swindon Community Health Services Overview

OPERATIONAL PERFORMANCE REPORT: March Swindon Community Health Services Overview OPERATIONAL PERFORMANCE REPORT: March 2018 Swindon Community Health Services Overview 1.0 Introduction This overview brings to the attention of committee members the key areas of Community Health Service

More information

Performance and Quality Report Sean Morgan Director of Performance and Delivery Mary Hopper Director of Quality Dino Pardhanani, Clinical Director

Performance and Quality Report Sean Morgan Director of Performance and Delivery Mary Hopper Director of Quality Dino Pardhanani, Clinical Director Sutton CCG Clinical Commissioning Group Governing Body Date Thursday, 06 September 2018 Document Title Lead Director (Name and Role) Clinical Sponsor (Name and Role) Performance and Quality Report Sean

More information

Section 1 - Key Performance Indicators

Section 1 - Key Performance Indicators Clinical Quality Report Month 6 2016/17 period ending 30th September 2016 Section 1 - Key Performance Indicators 1.1 NHS Improvement; Risk Assessment Framework Clostridium difficile Indicator M6 2 YTD

More information

Governing Body. TITLE OF REPORT: Performance Report for period ending 31st December 2012

Governing Body. TITLE OF REPORT: Performance Report for period ending 31st December 2012 - Governing Body DATE OF MEETING: TITLE OF REPORT: Performance Report for period ending 31st December 2012 KEY MESSAGES: We are responsible for securing improvements in the quality of care and health outcomes.

More information

Report of the Care Quality Commission. May 2017

Report of the Care Quality Commission. May 2017 Report of the Care Quality Commission May 2017 1. Purpose 1.1 The purpose of this report is to formally confirm the findings of the Care Quality Commission (CQC) following its inspection in October 2016;

More information

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST Agenda item A5(iii) PROVIDING CLINICAL ASSURANCE: CLINICAL ASSURANCE TOOLKIT (CAT), NURSE STAFFING, FRIENDS & FAMILY TEST (FFT) A SUMMARY REPORT EXECUTIVE

More information

TRUST BOARD. Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director. Jo Hunter, Deputy Chief Nurse. Mary Heritage, Assistant Director of Quality

TRUST BOARD. Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director. Jo Hunter, Deputy Chief Nurse. Mary Heritage, Assistant Director of Quality TRUST BOARD Document Title: Presenter: Quality Report Jo Hunter, Deputy Chief Nurse Authors: Contact details for further information: Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director Jo Hunter,

More information

Status: Information Discussion Assurance Approval. Claire Gorzanski, Head of Clinical Effectiveness

Status: Information Discussion Assurance Approval. Claire Gorzanski, Head of Clinical Effectiveness Report to: Trust Board Agenda item: Date of Meeting: 2 October 2017 SFT3934 Report Title: Annual quality governance report 2016-2017 Status: Information Discussion Assurance Approval X Prepared by: Executive

More information

Quality Accounts: Corroborative Statements from Commissioning Groups. Nottingham NHS Treatment Centre - Corroborative Statement

Quality Accounts: Corroborative Statements from Commissioning Groups. Nottingham NHS Treatment Centre - Corroborative Statement Quality Accounts: Corroborative Statements from Commissioning Groups Quality Accounts are annual reports to the public from providers of NHS healthcare about the quality of services they deliver. The primary

More information

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST CHIEF EXECUTIVE S REPORT. BOARD OF DIRECTORS 21 st March 2012

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST CHIEF EXECUTIVE S REPORT. BOARD OF DIRECTORS 21 st March 2012 SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST I CHIEF EXECUTIVE S REPORT BOARD OF DIRECTORS 21 st 212 1. PERFORMANCE In overall terms, the Trust continues to perform well against both regulatory and

More information

Quality Improvement Scorecard March 2018

Quality Improvement Scorecard March 2018 Mortality: HSMR Nat NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the monthly average of Apr-15 to Mar-16. Performance further improved in October. November data not yet available. Mortality:

More information

2017/18 Trust Balanced Scorecard

2017/18 Trust Balanced Scorecard ITEM 8b ENC 9 2017/18 Trust Balanced Scorecard Author: Performance Management Team March 2017 The purpose of this paper is to provide an update on the development of the 2017/18 Balanced Scorecard for

More information

Worcestershire Acute Hospitals NHS Trust

Worcestershire Acute Hospitals NHS Trust Worcestershire Acute Hospitals NHS Trust Worcestershire Royal Hospital Quality Report Charles Hastings Way Worcester WR5 1DD Tel: 01905 763333 Website: www.worcsacute.nhs.uk Date of inspection visit: 12,

More information

Integrated Performance Report

Integrated Performance Report Integrated Performance Report M04 July 2016 Presented by: Angela Stevenson (Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer) An Associated

More information

Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group Governing Body Meeting In-Common

Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group Governing Body Meeting In-Common Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group Governing Body Meeting In-Common Date: Tuesday 7 th November Time: 13.30 Location: Cleve Rugby Club, The Hayfields, Mangotsfield,

More information

Learning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 2018

Learning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 2018 Learning from Patient Deaths: Update on Implementation and Reporting of Data: 5 th January 218 Purpose The purpose of this paper is to update the Trust Board on progress with implementing the mandatory

More information

Integrated Performance Committee Assurance Reports, January 2016 and December 2015 Crishni Waring, Chair, IPC Committee

Integrated Performance Committee Assurance Reports, January 2016 and December 2015 Crishni Waring, Chair, IPC Committee EPB53/825 Title of Report: Prepared By: Sponsor: Action Required: Integrated Performance Committee Assurance Reports, January 2016 and December 2015 Crishni Waring, Chair, IPC Committee Gale Hart, Director

More information

Special Measures Action Plan. Norfolk and Suffolk NHS Foundation Trust

Special Measures Action Plan. Norfolk and Suffolk NHS Foundation Trust Special Measures Action Plan Norfolk and Suffolk NHS Foundation Trust June 2015 KEY Delivered On Track to deliver Some issues narrative disclosure Not on track to deliver 1 Norfolk and Suffolk NHS Foundation

More information

Members Position Voting Rights Alison Lewis-Smith Chair, Lay member, Quality and Safety

Members Position Voting Rights Alison Lewis-Smith Chair, Lay member, Quality and Safety Minutes (confirmed) Subject Quality Committee Date 4 April 2017 Time 10.00am 12.30pm Venue Goodwood Room Chair Alison Lewis-Smith Members Position Voting Rights Alison Lewis-Smith Chair, Lay member, Quality

More information

Agenda Item number: 9.1. Maggie Bayley, Director of Nursing and Quality

Agenda Item number: 9.1. Maggie Bayley, Director of Nursing and Quality Board meeting date: 15 December, 2011 Agenda Item number: 9.1 Enclosure: 6 Title Quality report Accountable Director: Authors(name & title): Maggie Bayley, Director of Nursing and Quality Maggie Bayley,

More information

Hard Truths Public Board 29th September, 2016

Hard Truths Public Board 29th September, 2016 Hard Truths Public Board 29th September, 2016 Presented for: Presented by: Author Previous Committees Governance Professor Suzanne Hinchliffe CBE, Chief Nurse/Deputy Chief Executive Heather McClelland

More information

Quality & Performance Report Author: John Adler Sponsor: Chief Executive Date: FIC, PPP + QAC 28 th September Executive Summary from CEO

Quality & Performance Report Author: John Adler Sponsor: Chief Executive Date: FIC, PPP + QAC 28 th September Executive Summary from CEO UNIVERSITY HOSPITALS OF LEICESTER NHS TRUST PAGE 1 OF 2 Quality & Performance Report Author: John Adler Sponsor: Chief Executive Date: FIC, PPP + QAC 28 th September 2017 Executive Summary from CEO Paper

More information

Quality Assurance Accreditation Scheme Assignment Report 2016/17. University Hospitals of Morecambe Bay NHS Foundation Trust

Quality Assurance Accreditation Scheme Assignment Report 2016/17. University Hospitals of Morecambe Bay NHS Foundation Trust Quality Assurance Accreditation Scheme Assignment Report 2016/17 Contents 1. Introduction 2. Executive Summary 3. Findings, Recommendations and Action Plan Appendix A: Terms of Reference Appendix B: Assurance

More information

Quality & Performance Report. Public Board

Quality & Performance Report. Public Board Agenda Item 12.1 Quality & Performance Report Public Board 27 th November 2014 Presented for: Presented by: Author: Previous Committees: Governance Professor Suzanne Hinchliffe CBE Chief Nurse / Interim

More information

Urgent & Emergency Care Strategy Update

Urgent & Emergency Care Strategy Update RCCG/GB/17/144 Urgent & Emergency Care Strategy Update 1. Introduction The purpose of this paper is to provide assurance on the effective delivery to date of our urgent and emergency care strategy within

More information

Ayrshire and Arran NHS Board

Ayrshire and Arran NHS Board Paper 12 Ayrshire and Arran NHS Board Monday 9 October 2017 Planned Care Performance Report Author: Fraser Doris, Performance Information Analyst Sponsoring Director: Liz Moore, Director for Acute Services

More information

Dartford and Gravesham NHS Trust. Susan Acott Chief Executive

Dartford and Gravesham NHS Trust. Susan Acott Chief Executive Dartford and Gravesham NHS Trust Susan Acott Chief Executive A First in Kent Retired policeman Richard Oliver aged 59 was the first patient to be fitted with the EMBLEM, Subcutaneous Implantable Cardiac

More information

EDS 2. Making sure that everyone counts Initial Self-Assessment

EDS 2. Making sure that everyone counts Initial Self-Assessment EDS 2 Making sure that everyone counts Initial Self-Assessment Equality Delivery System for the NHS EDS2 Summary Report Implementation of the Equality Delivery System EDS2 is a requirement on both NHS

More information

Influence of Patient Flow on Quality Care

Influence of Patient Flow on Quality Care Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District

More information

Improve, Inspire, Innovate Quality Improvement Plan

Improve, Inspire, Innovate Quality Improvement Plan Improve, Inspire, Innovate Quality Improvement Plan 1 QIP Final version 20170706 Contents Background & Summary Page 3 Who is Responsible? Page 4 How will we communicate our progress to you? Page 4 Chair

More information

ENCLOSURE: J. Date of Trust Board 29 February Pressure Ulcer Clinical Improvement Programme. Purpose of Report

ENCLOSURE: J. Date of Trust Board 29 February Pressure Ulcer Clinical Improvement Programme. Purpose of Report ENCLOSURE: J Date of Trust Board 29 February 2012 Title of Report Purpose of Report Abstract Pressure Ulcer Clinical Improvement Programme This paper provides a progress report on our work in support of

More information

QUALITY REPORT. Part A Patient Experience

QUALITY REPORT. Part A Patient Experience QUALITY REPORT Part A Patient Experience 1 Number of complaints Complaints and Patient Advice and Liaison Report 40 Total number of complaints received 30 20 10 Number of complaints received Trendline

More information

BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013

BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Borders NHS Board BOARD CLINICAL GOVERNANCE & QUALITY UPDATE MARCH 2013 Aim The aim of this report is to provide the Board with an overview of progress in the areas of: Patient Safety Person Centred Health

More information

Influence of Patient Flow on Quality Care

Influence of Patient Flow on Quality Care Influence of Patient Flow on Quality Care Patients Waiting on Trolleys for an Inpatient Bed Patients who are Medically Fit to be discharged and cared for at Home with Support or in a Nursing Home or District

More information

Open and Honest Care in your Local Hospital

Open and Honest Care in your Local Hospital Open and Honest Care in your Local Hospital Report for: Royal Wolverhampton NHS Trust January 2016 The Open and Honest Care: Driving Improvement Programme aims to support organisations to become more transparent

More information

Ayrshire and Arran NHS Board

Ayrshire and Arran NHS Board Paper 6 Ayrshire and Arran NHS Board Monday 11 December 2017 SPSP Update: Acute Adult Programme Author: Laura Harvey, QI Lead for Acute Services, Person Centred & Customer Care Sponsoring Director: Liz

More information

TRUST BOARD MEETING 24 JULY 2013 PERFORMANCE REPORT MONTH 3 DIRECTOR OF OPERATIONS DIRECTOR OF OPERATIONS DIRECTOR OF OPERATIONS

TRUST BOARD MEETING 24 JULY 2013 PERFORMANCE REPORT MONTH 3 DIRECTOR OF OPERATIONS DIRECTOR OF OPERATIONS DIRECTOR OF OPERATIONS TRUST BOARD MEETING 24 JULY 2013 PERFORMANCE REPORT MONTH 3 def Agenda Item: 10c PURPOSE PREVIOUSLY CONSIDERED BY Objective(s) to which issue relates * Risk Issues (Quality, safety, financial, HR, legal

More information

Report to the Board of Directors 2016/17

Report to the Board of Directors 2016/17 Attachment 8 Report to the Board of Directors 2016/17 Date of meeting 30 September 2016 Subject Report of Prepared by Purpose of report Previously considered by (Committee/Date) Local A&E Delivery Board

More information

The Royal Wolverhampton NHS Trust

The Royal Wolverhampton NHS Trust The Royal Wolverhampton NHS Trust Trust Board Report Meeting Date: 24 June 2013 Title: Executive Summary: Action Requested: Report of: Author: Contact Details: Resource Implications: Public or Private:

More information

Performance, Quality and Outcomes Report: Position Statement

Performance, Quality and Outcomes Report: Position Statement Performance, Quality and Outcomes Report: Position Statement Update to Governing Body 5 April 2018 Item 1 Author(s) Sponsor Directors Purpose of Paper Jane Howcroft Programme and Performance Assurance

More information

21 March NHS Providers ON THE DAY BRIEFING Page 1

21 March NHS Providers ON THE DAY BRIEFING Page 1 21 March 2018 NHS Providers ON THE DAY BRIEFING Page 1 2016-17 (Revised) 2017-18 (Revised) 2018-19 2019-20 (Indicative budget) 2020-21 (Indicative budget) Total revenue budget ( m) 106,528 110,002 114,269

More information

Agenda Item: 10.1 (3) HR & OD Monthly Trust Report (September 2016)

Agenda Item: 10.1 (3) HR & OD Monthly Trust Report (September 2016) Agenda Item: 10.1 (3) HR & OD Monthly Trust Report (September 2016) Prepared by: Karen Taylor, Assistant Director of HR & Kyriacos Kyriacou, Interim Deputy Director of HR & OD Presented by: Louise Ludgrove,

More information

The safety of every patient we care for is our number one priority

The safety of every patient we care for is our number one priority HUMBER NHS FOUNDATION TRUST INFECTION PREVENTION AND CONTROL STRATEGY 2015-2017 1. Introduction Healthcare associated infections (HCAI) continue to be a major cause of patient harm and although nationally

More information

Quality Improvement Scorecard November 2017

Quality Improvement Scorecard November 2017 Mortality: HSMR Performance remained below target in July Nat NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the monthly average of Apr-15 to Mar-16. Mortality: HSMR (weekday) vs. HSMR

More information

TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST

TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 25 th May 2017 Agenda Item 7b Title Sponsoring Executive Director Author (s) Purpose Previously considered

More information

Strategic Risk Report 12 September 2016

Strategic Risk Report 12 September 2016 Strategic Report September 20 Haringey CCG Register Introduction The Strategic Report (historically known as the Board Assurance Framework) evidences Haringey Clinical Commissioning Group s control over

More information

NHS Electronic Referrals Service. Paper Switch Off an update Digital Health Webinar 4 May 2018

NHS Electronic Referrals Service. Paper Switch Off an update Digital Health Webinar 4 May 2018 NHS Electronic Referrals Service Paper Switch Off an update Digital Health Webinar 4 May 2018 Aims of Session Introductions and refresh of Paper Switch Off Sharon Wilson Implementation manager NHS Digital

More information

A new integrated model for Care Homes from Walsall CCG/Healthcare NHS Trust

A new integrated model for Care Homes from Walsall CCG/Healthcare NHS Trust A new integrated model for Care Homes from Walsall CCG/Healthcare NHS Trust Sally Roberts - Director of Governance, Quality & Safety. Walsall CCG Katie Welborn Advanced Nurse Practitioner- Walsall Healthcare

More information

Our Achievements. CQC Inspection 2016

Our Achievements. CQC Inspection 2016 Our Achievements CQC Inspection 2016 Issued February 2017 HOW FAR WE VE COME SAFE Last year, we set out our achievements in a document for staff and patients. It was extremely well received, and as a result,

More information

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE TRUST BOARD HELD ON 18 NOVEMBER 2015

SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE TRUST BOARD HELD ON 18 NOVEMBER 2015 SHEFFIELD TEACHING HOSPITALS NHS FOUNDATION TRUST EXECUTIVE SUMMARY REPORT TO THE TRUST BOARD HELD ON 18 NOVEMBER 2015 Subject: Supporting TEG Member: Authors: Status 1 Data Quality Baseline Assessment

More information

NHS Fylde and Wyre CCG Performance Dashboard

NHS Fylde and Wyre CCG Performance Dashboard Governing Body January 2016 NHS Fylde and Wyre CCG Performance Dashboard October 2015 (Month 7) Governing Body This report provides a high level summary of performance and activity and across Fylde and

More information

TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST

TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST TAMESIDE & GLOSSOP INTEGRATED CARE NHS FOUNDATION TRUST Report to Public Trust Board meeting of the 29 th June 2017 Agenda Item 7b Title Sponsoring Executive Director Author (s) Purpose Previously considered

More information

Quality Improvement Scorecard December 2017

Quality Improvement Scorecard December 2017 Mortality: HSMR Performance improved in August Nat NB: Each month is a 12 month rolling value. I.e. Mar-16 reports the monthly average of Apr-15 to Mar-16. Mortality: HSMR (weekday) vs. HSMR (weekend)

More information

Overall rating for this trust Good. Inspection report. Ratings. Are services safe? Requires improvement. Are services effective?

Overall rating for this trust Good. Inspection report. Ratings. Are services safe? Requires improvement. Are services effective? Barnsley Hospital NHS Foundation Trust Inspection report Gawber Road Barnsley South Yorkshire S75 2EP Tel: 01226 730000 www.barnsleyhospital.nhs.uk Date of inspection visit: 17 to 19 October, 15 to 17

More information

RTT Assurance Paper. 1. Introduction. 2. Background. 3. Waiting List Management for Elective Care. a. Planning

RTT Assurance Paper. 1. Introduction. 2. Background. 3. Waiting List Management for Elective Care. a. Planning RTT Assurance Paper 1. Introduction The purpose of this paper is to provide assurance to Trust Board in relation to the robust management of waiting lists and timely delivery of elective patient care within

More information

RBCH Actions to meet CQC Essential Standards

RBCH Actions to meet CQC Essential Standards RBCH Actions to meet CQC Essential Standards REGULATION 17 How the regulation was not being met Patients, their relatives, and staff told us about incidents where people had not been treated with dignity

More information

Improvement and Assessment Framework Q1 performance and six clinical priority areas

Improvement and Assessment Framework Q1 performance and six clinical priority areas Governing Body 30 th September 2016 Improvement and Assessment Framework Q1 performance and six clinical priority areas Agenda item 16 Paper 10 Summariser: Authors and contributors: Executive Lead(s):

More information

UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST TRUST BOARD

UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST TRUST BOARD UNIVERSITY HOSPITALS OF MORECAMBE BAY NHS FOUNDATION TRUST TRUST BOARD Date of meeting: 25 July 2012 Title / Subject: Status Internal Purpose: The attached paper provides an update of progess made in UHMB

More information

Monthly and Quarterly Activity Returns Statistics Consultation

Monthly and Quarterly Activity Returns Statistics Consultation Monthly and Quarterly Activity Returns Statistics Consultation Monthly and Quarterly Activity Returns Statistics Consultation Version number: 1 First published: 08/02/2018 Prepared by: Classification:

More information

St Mary s Birth Centre

St Mary s Birth Centre University Hospitals of Leicester NHS Trust St Mary s Birth Centre Quality report Thorpe Road Melton Mowbray Leicestershire LE13 1SJ Tel: 0300 303 1573 www.uhl-tr.nhs.uk Date of inspection visit: 13-16

More information

Safer Nursing and Midwifery Staffing Recommendation The Board is asked to: NOTE the report

Safer Nursing and Midwifery Staffing Recommendation The Board is asked to: NOTE the report To: Board of Directors Date of Meeting: 26 th July 20 Title Safer Nursing and Midwifery Staffing Responsible Executive Director Nicola Ranger, Chief Nurse Prepared by Helen O Dell, Deputy Chief Nurse Workforce

More information

Royal College of Paediatrics and Child Health Service Review Action Plan and Progress Report 26 th May 2016

Royal College of Paediatrics and Child Health Service Review Action Plan and Progress Report 26 th May 2016 Royal College of Paediatrics and Child Health Service Review Action Plan and Progress Report 26 th May RAG Dark green Light green Amber Red White Definition Action complete and assurance gained Action

More information