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 Director of Quality, NHS Norwich CCG NHS Norwich CCG Governing Body Meeting Tuesday 23 rd January 2018 For Information and Discussion Summary: The purpose of this paper is to provide a summary of the key highlights around clinical quality and patient safety relating to the following local NHS Trusts and Provider Organisations: 1. Norfolk & Norwich University Hospitals NHS Foundation Trust (NNUH) 2. Norfolk and Suffolk NHS Foundation Trust (NSFT) 3. Integrated Care (IC24) NHS 111 / Out of Hours GP Service 4. Norfolk Community Health & Care NHS Trust (NCHC) 5. East of England Ambulance Service Trust (EEAST) 6. ERS Medical Non-Emergency Patient Transport Service 7. Norfolk Community Eating Disorder Service (NCEDS) 8. General Practices in Norwich 9. Care Homes and Domiciliary Care Providers 10. Influenza 11. Pressure Ulcers The Consolidated Quality and Patient Safety Report should be read in conjunction with the Chair s Report of the latest Quality & Patient Safety Committee Meeting. All data is provided by NHS North East London Commissioning Support Unit.
Exception Summary Norfolk and Norwich University Hospital NHS Foundation Trust (NNUH) Mortality: For the year to August 2017 HSMR was 98.27 and is within expected range. HSMR diagnostic group monitoring continues. A number of clinical governance forums have been undertaken to raise aware around key clinical areas. CQC Update: NHS England, NHS Improvement and Central CCGs are committed to supporting the Trust to make necessary improvements following the recent CQC inspection. A detailed review of the improvement plan is to be presented to commissioners at January 2018 CQRM. Performance: The Trust did not achieve national performance standards in relation to A&E, RTT and some stroke care standards. A quality assurance visit to A&E during December 2017 highlighted the challenges within the department as a result of the winter pressures and the system wide impact. Emergency demand and lack of theatre time are the key causes of cancelled operations within the Trust. 62 and 104 Day Cancer Breaches: There was an increase in 62 breaches during October 2017 as a result of delays within the prostate pathway; the Trust is actively focusing on improvements in this area. The number of 104 day breaches remain low although slightly increased from the previous months. This mainly due to issues within the lung pathway which is under review by the STP. Norfolk and Suffolk NHS Foundation Trust CQC Update: The Oversight and Assurance Group meeting took place on 12 th December 2017. Agreed deep dive subjects for the meeting were Well-led, Board Development, Divisional/Locality Leadership and Workforce Safety and Safe Staffing levels. Findings were presented and subsequent action plans to address deficits agreed. The action plan has been developed on a service line basis and will be subject to regular review. Out of Area placements (OOA): The number of working age adults placed OOA as at 28th December 2017 was 24 (NCCG 14). Older people placed OOA is 6 (NCCG 2). The Trust has appointed a designated staff member for a 12 month period to actively manage these placements. This will continue to be monitored via SPRG and CQRG. Workforce: Appraisal rates across the block and wellbeing contract remain below target in November 2017, but are showing a significant increase compared with previous months. Mandatory training rates for November 2017 for the central cluster remains below the 90% target for block and for PCMHS. This area is part of the CQC action plan. Integrated Care 24 (IC24) NHS 111 Service and Out of Hours GP Service Performance: The provider s overall performance during November 2017 was positive, although the service experienced sustained pressure during December 2017, particularly during the Christmas and New Year period. There were several call surges which resulted in Page 2 of 18
calls queuing and call volumes were higher than predicted. This is reflective of pressures across the healthcare system. Norfolk Community Health & Care NHS Trust (NCHC) Wheelchair Services: The Trust is currently not achieving the 92% RTT standard for this service, however, they achieving above the agreed trajectory. The service is back to full establishment and an increase in capacity has supported improved performance. Work remains ongoing to redesign the service to maximise efficiency. Paediatric Continence Service: A service review has been completed and a fortnightly Patient Treatment List meeting commenced on 22 nd December 2017 to review long waits for assessment to determine and monitor clinical risk. The Trust is actively engaging with another local service provider who may be able to provide some additional capacity Looked After Children: The Trust is looking to provide additional administrative support to release clinical capacity for review health assessments to be undertaken. Page 3 of 18
Quality and Patient Safety Report 1. Norfolk & Norwich University Hospitals NHS Foundation Trust (NNUH) 1.1. Serious Incidents (SI) and Quality Issue Reports (QIR) In the month of December 2017, the Trust reported 12 SI; this is comparable with the previous month. Of those raised, 3 occurred in November 2017 and were reported in December 2017. Two of the SI reported related to a delay in clinical review and treatment within the A&E department. A quality assurance visit of A&E department was undertaken on 15 th December 2017, the key findings included: Long ambulance waits seen on day of visit; High levels of vacancies; medical vacancies an area of specific concern, Trust reports ongoing recruitment drive for A&E; Difficulties in patient flow; Positive patient feedback despite long waits; Positive feedback regarding specialty support; Introduction of ROSIER assessment (Rule Out Stroke In the Emergency Room) to be implemented in A&E to support the identification of Stroke patients (the aim of this assessment tool is to enable medical and nursing staff to differentiate patients with stroke and those with stroke mimic symptoms); Potential positive impact of Older Peoples Emergency Department (OPED) seen.. The key findings from the visit will be discussed with the Trust at its January 2018 Clinical Quality Review Meeting (CQRM) with Commissioners. A long term strategy has been agreed for the department and recruitment to medical and nursing vacancies as part of this strategy remains ongoing. QIR In the month of December 2017, the Trust reported 49 QIR, compared with 63 in November 2017. There are two main themes being reported relating to discharge and referral related issues. QIR continue to be triaged and escalated as required due to the numbers reported and the capacity of the Trust team. 1.2. Pressure Ulcers A total of 19 patients developed a Grade 2 Healthcare Acquired Pressure Ulcer (HAPU) during November 2017, which is an increase on the previous month's total of 10. The Trust has reported more Grade 2 HAPU year to date, than the same period last year. Approximately 62% of those reported Grade 2 HAPU have been deemed as avoidable. The Trust has been asked to provide assurance audits that actions have been delivered and embedded into practice as most actions are repeated across wards. The position for Grade 3/4 HAPU is slightly lower than the same period last year. However, the numbers cannot be correlated with the numbers reported as SI. A review of reported cases is currently being undertaken. Page 4 of 18
1.3. Infection Prevention and Control Elective Methicillin-resistant Staphylococcus Aureus (MRSA) screening achieved 94.37% for the month of November 2017; this has remained static for the past 2 months and continues to sit slightly below the 95% target. Emergency MRSA screening remains above target. Following the Trust s monthly Post Infection Review Meeting, the 3 pending cases of hospital acquired Clostridium difficile (C. diff) from October 2017 were reviewed; 1 case was deemed trajectory and 2 cases were non-trajectory. There were 4 cases of C. diff identified as hospital acquired in November 2017, 2 cases deemed trajectory, 1 case was non-trajectory and 1 case was awaiting agreement at the next Post Infection Review Meeting. 1.4. Medicine Management There were a total of 103 medication incidents reported and reviewed in November 2017. Of this, 18 were deemed not to be true errors. Of the remaining 85, there was identification of patient harm in one case.. The number of medication incidents being reported has been increasing over recent months; however those resulting in actual or potential patient harm remain low. The open and positive reporting culture of the staff within the Trust has been acknowledged. There were 8 Insulin-related medication incidents reported in the month, all resulting in no patient harm. They related to factors such as: Missed dose Incorrect Insulin Variable rate infusion error Insulin out of date Management of diabetic patient There was one incident of potential or actual harm related to Insulin in the last 12 months (May 2017). This was raised at the Trust s December 2017 CQRM with the Trust Medical Director reporting that the Trust held an open Clinical Governance Forum where they addressed the patient safety issues around Insulin. 1.5. Patient Falls In November 2017 there were 155 patient falls reported to the Trust s Datix Incident Management System. This is a continued decrease on the previous 2 months (180 in September, 161 in October) and part of an overall reducing trend over the previous year. During November 2017 there was 1 fall that resulted in moderate patient harm. 1.6. Mortality For the year to August 2017, the Trust s Hospital Standardised Mortality Ration (HSMR) was 98.27, which is a decrease following the slight increase in July 2017 and sits within the expected range. The Trust continues to undertake a number of key actions around their HSMR, which includes monitoring specific diagnostic groups. A number of focused Clinical Governance Forums have been undertaken on: Page 5 of 18
Early Warning Score and response to Sepsis 6; Insulin, with a Patient Story; Electrolyte and Fluid Management with the introduction of a new Fluid Chart. 1.7. Electronic Discharge Letters (EDL) There is continued non-achievement of EDL completed within 24 hours. Performance was reported at 79.23% against a target of 95% for November 2017. This remains comparable with October 2017 achievement. Triangulation with QIR has demonstrated that non-compliance with this target has a negative impact on quality of patient care. Discussions between Commissioners and the Trust remain ongoing regarding the need for improvement and contractual action is being considered if this is not achieved. 1.8. Patient Experience and Complaints During November 2017 to date, 2478 Family and Friends Test responses were received by the Trust. October 2017 responses totaled 3095 once all final submissions were included. The overall Trust score remains high in November 2017 at 97%. Individually, Cromer Minor Injuries Unit (96.8%), In-patient Wards (98%), Maternity Services (99.9%) and Day Patients (98.2%) continued to be amongst those receiving strong positive scores. In relation to the #hellomynameis campaign, 98.5% of the 970 patients asked responded that staff members had introduced themselves. In relation to Dignity and Respect, of the 607 patients who responded when asked if they had been treated with dignity and respect, 99% of patients were either very satisfied (91%) or satisfied (8%). In November 2017, 78 complaints were received by the Trust, compared with 68 complaints received in November 2016. This is only the second time in the last 10 months where the number of complaints has exceeded the total from the previous year. The cumulative number of complaints received remains the lowest at this point in the year of any in the last 4 years. An analysis of Clinical Treatment General Medicine related complaints have been undertaken for in-patient & outpatient areas. High patient volume areas such as Admissions Medical Unit (Male), General Medical Out Patient Department and Gastroenterology Unit have generated the largest number of complaints; with an even spread across other areas. The two leading themes relate to incorrect/delay in making diagnosis, followed by delay in receiving treatment/results. Learning from complaints this month includes IT adaption of printers to print only on one side for discharge letters to mitigate the risk of a patient receiving another patient s details on the reverse side. 1.9. Quality Assurance Audits In total, there were 15 audits scheduled to be undertaken in October 2017. Feedback has been received for 4; (3 supported by External Auditors). Twenty-four fundamental standards were reviewed during in-month audits; 11 more from the previous month s reports. More staff members have been inducted into the Audit Programme and training is being provided in order to improve the number of audits undertaken. Overall the Page 6 of 18
percentage of Good or Outstanding standards remains high across the Trust at 90.4%. All findings were reported promptly to department leads for action. 1.10. CQC Report The regional NHS England Quality Surveillance Group has requested that a meeting is held between the Norfolk Clinical Commissioning Groups, CQC and NHS Improvement Team to discuss progress with the Trust following their inspection. A detailed review of their Improvement Plan is scheduled to take place at the Trust s January 2018 CQRM. 1.11. Performance Cancer 62 Day Standard The Trust s 62 Day performance for Referral to Treatment was achieved in November 2017 following a dip in performance the previous month due to backlog clearance. The deterioration in performance reported in October 2017 was due to backlog clearance within the Lung Pathway. Late Tertiary referrals and capacity constraints for CT Guided Lung Biopsies have impacted on the Lung Pathway and this is currently under review by the Norfolk and Waveney Sustainability and Transformation Partnership (STP). Capacity constraints around MRI and Template Biopsies continue to impact on the Urology Pathway. Prostate pathway remains an area of focus to reduce the number of patient breaches. Cancer 62 and 104 Day Breaches During October 2017 there were 30 breaches of the 62 day standard, compared to 17.5 the previous month. This increase was mainly as a result of delays within the Prostate Pathway. This continues to be an area of focus for the Trust. During October 2017 there were 5 patients breaching 104 days, compared to 3 the previous month. This slight increase is mainly due to issues within the Lung Pathway. This is currently under review by the STP. NHS Norwich CCG continues to attend the Trust s monthly CQRM, where clinical harm reviews of 104 day breaches are discussed. A&E The A&E 4 Hour Standard was not achieved in November 2017 (79.8% against 90% standard). Contributing factors were due to disruption to Ambulatory Care Pathways due to major construction work and increased admissions and complexity of patients. The Trust continues to prioritise their estate redesign. RTT Performance for November 2017 was 83.7% against a 92% standard. Achievement has remained broadly the same over the last 6 months. Capacity concerns remain across most surgical specialities and Cardiology. Demand Management schemes are in place and an increased awareness and use of advice and guidance by primary care clinicians has been seen in-month. Some Cardiology patients were admitted to mitigate risk whilst waiting for treatment. Assurance was provided at the trust s December 2017 CQRM regarding Cardiology waits due to pressure on the specialty. Weekly Review Meetings continue to take place to review priority grading. Additional operating lists are being established where possible and the trust is exploring conversion of estates to mitigate demand. Systemwide Page 7 of 18
Demand Management schemes are being tracked and implemented. Clinical Meetings in key specialities continue. Cancelled Operations There were a total of 123 patients not re-booked within 28 days for first seven months of 2017/18 according to the Trust Integrated Performance Report. It is felt that emergency demand is impacting on surgical bed flow, causing cancellation due to bed capacity pressures and lack of theatre time. Additional CCC capacity is coming on-line from 11 th December 2017, which will reduce days due to lack of recovery space. Stroke The Trust achieved the Door to Needle Time and 90% Length of Stay standards during November 2017. Access to Hyper-acute Stroke Unit (HASU) Within 4 Hours was not achieved and was impacted by congestion and reduced flow of patients through the hospital. Standards requiring access to Radiology were not met due to demand on services. Doppler availability, timeliness of referrals to Stroke Team and availability of specialist beds were all contributing factors in non-achievement. The Trust s Stroke Pathway work is to be refreshed and the first meeting is scheduled for 15 th January 2018. The Trust is to ensure ring-fenced beds on Heydon Stroke Ward and Heydon Neuro Ward are protected to maintain the Stroke admission pathway. 1.12. Workforce and Capacity Benchmarking data indicates that NNUH performs similarly to other local NHS Acute Hospital Trusts (latest available data). Significant improvement has been observed in November 2017 with Registered Nurse fill rates. Voluntary Turnover The 12-month turnover rate at the end of November 2017 was 10.34%. This upturn reflects 2 months of lower turnover in Autumn 2016 that has fallen out of the 12 month rolling calculation. As a local comparator, the turnover rate for NNUH compares very favourably with other Trusts e.g. Cambridge University Hospitals (13.7%) and Queen Elizabeth Hospital Kings Lynn (11.3%). Mandatory Training The overall compliance rate for Mandatory Training for November 2017 is 83.5% and is demonstrating gradual improvement. Interventions have progressed to enhance compliance, including training days/events where support is available to maximise uptake of Mandatory Training. All divisions are focused on improving their compliance rates through enabling staff to attend training sessions, undertake e-learning and participate in flexible learning programmes. Divisional level Mandatory Training rates are discussed at the trust s Divisional Performance Committee. Sickness The most reliable measure of sickness absence is the 12-month rolling average and this is currently 3.93% for October 2017. This is broadly similar to the previous month. Appraisal Page 8 of 18
The Trust achieved 65.6% compliance for staff appraisal during November 2017, compared to 64.6% the previous month; appraisal rates are slowly rising. Further detail is to be requested from the Trust as to how they intend to improve current achievement. 2. Norfolk and Suffolk NHS Foundation Trust 2.1. Serious Incidents (SI) and Quality Issue Reports (QIR) In the month of December 2017, the Trust s SI reports decreased from 7 to 6. Of the 6 cases, a small proportion were attributable to Norwich CCG patients. These cases related to an unexpected death and an incident of disruptive/aggressive/violent patient behaviour. Overall there was no change in themes. The most commonly reported category of SI continues to be unexpected deaths. In the month of December 2017, the Trust s QIR total has decreased to 7, compared with 9 in November 2017. The emerging theme in December 2017 relates to admission related issues, which is a change from the previous month which saw referral as the leading theme. 1 QIR reported in December 2017 related to a Norwich CCG patient. 2.2. CQC Status Following the most recent CQC inspection, the Trust has been placed into special measures. The trust held an Oversight and Assurance Group Meeting on 12 th December 2017. The agreed deep dive subjects for the meeting where; Well-led, Board Development, Divisional/Locality Leadership and Workforce Safety and Safe Staffing levels. Findings were presented and, subsequently, Action Plans to address deficits were agreed. A Quality Improvement Dashboard is being developed to track improvements in line with Service User Focus and Staff Focus. These are broken down into 10 further measures, with time frames for action identified. Delivery risks were discussed and agreed with corresponding actions for addressing mitigation. These also highlight the need for external and wider system support for the Trust, including that of Local Authority and Commissioners. All aspects of the Trust s Action Plan have been developed on a Service Line basis to match the approach taken by the CQC inspection. The improvement plan is being monitored by the Quality Programme Board on a weekly basis, with the agenda planned so that each service line is reviewed every two weeks. CQC Service Line Reports must and should do s have been cross-referenced into individual actions. Peer reviews have been established and staff members have received training. These reviews check that the actions are taking place and outcomes being delivered. The Trust s PMO has identified that there is a significant challenge around the scale of change activity being planned. There are 25 generic CQC must / should dos which translate to approximately 400 internal actions. Any projects that do not support the CQC Action Plan, or are non-essential, will be paused or put in a slow stream until April 2018 to release capacity to support the CQC must-dos Action Plan. 2.3. Out of Area (OOA) Placements Page 9 of 18
The number of working age adults placed OOA as of 28th December 2017 was 24 (14 Norwich patients). Older people placed OOA is 6 (2 Norwich patients). The Trust has appointed a designated staff member for a 12 month period to actively manage these placements. This will continue to be monitored via the Trust s monthly System Performance and Resilience Group (SPRG) and CQRM. 2.4. Safety Thermometer There were 95 new cases that met the Harm Free Care standard in November 2017. However, fewer patients were surveyed in November 2017 than in any other month during the past 12 months and the Trust has been requested to investigate this. One new Grade 2 HAPU was reported in the month, with no reports of higher Grade incidences; no Grade 3 or 4 HAPU have been reported since April 2017. The Trust reported 3 patient falls in November 2017; all falls resulted in no patient harm. There have been no new cases of Venous thromboembolism (VTE) reported in the month of November 2017. This is the fifth consecutive month of no cases reported. 2.5. Delayed Transfers of Care (DToC s) The Trust s DToCs have risen in November 2017 by 2.2%, running at 8.6%. This rise is mainly attributable to the Central cluster, which has seen a 5.3% increase in the month. The majority of these are later life cases. The weekly Norfolk County Council and NSFT interface meetings continue and will be attended by CCG representation from South Norfolk, who are the Coordinating Health Commissioner for the Trust. 2.6. Workforce and Capacity Sickness overall has risen slightly in the month of November 2017, with the increase attributable across all localities. This has been attributed to seasonal illness, but will continue to be monitored closely. Staff reports of anxiety/depression and mental ill health has dropped in two localities (Central and Children Families and Young People), but West Norfolk rates have risen again for the fifth consecutive month. This will continue to be monitored closely via the Trust s monthly CQRM. Vacancy rates remain below the target and have dropped by a further 0.3% in the month. Staff Appraisal rates across the block and Wellbeing Service contracts remain below target in November 2017, but are showing a significant increase across both service areas. Mandatory training rates for the central cluster remains below the 90% target for block and Wellbeing Service contracts. This area is part of the Trust s CQC Action Plan. Vacancy rates for the Trust as a whole decreased to 7.2% against a benchmark of 13.7% during November 2017. This is the fourth consecutive month of decreased rates. The rate for the central cluster is following this trend and has decreased further to 7% Page 10 of 18
from 7.2% against the same target. Whilst this is an improvement for the Trust overall, the West and Children Families and Young People remain of concern. 2.7. Wellbeing Service During November 2017, staff sickness rates decreased further to 3.23% against a benchmark of 4.63%. Mandatory Training rates increased to 90.7% from 89.8% in the month which is above the target figure. Vacancy rates have risen to 7.5% from 5.8% against a benchmark of 13.7%. Voluntary staff turnover has decreased to 10.3% from 11.7% against a benchmark of 10%. Management supervision has improved in the month for non-clinical staff. It has increased to 76% from 73.6% against a benchmark of 89%. Clinical staff supervision was not reported for November 2017. October reported a static position at 50% for the fourth consecutive month. The lack of staff supervision remains a concern and is on the Trust s CQRM agenda for further exploration. The number of patients who waited less than 6 weeks for their first treatment contact decreased significantly in November 2017 to 59.6% against a target of 75%. This is the first month that this target has not been achieved in the previous twelve. 2.8. Complaints Wellbeing Service There have been eight complaints received by the Service. Of these, six have been generated by the North Norfolk locality. The Service is reviewing these in line with any significant staffing changes, as North Norfolk is currently reported as having a high number of counseling professionals within the Service. 3 Integrated Care (IC24) NHS 111 / Out of Hours GP Service 3.1. Serious Incidents (SI) and Quality Issue Reports (QIR) Any SI reported during December 2017 will be reviewed to determine if there was an adverse outcome. All SI and QIR continue to be reviewed via the call audit meeting. In December 2017, IC24 received zero QIR compared to 6 in November 2017. 3.2. NHS 111 Service Overall performance during November 2017 was good with an abandoned call rate of 0.19% against a target <5%. The performance started to decline during weekends in December 2017 for calls answered within 60 seconds and did not meet the 95% target from 20th 31st December 2017. This is broadly in line with increased pressures experienced across the entire urgent care system. Exception reports provided to commissioners outlining the reasons for the low performance included: Significant call surges throughout the day which resulted in calls queuing; Page 11 of 18
Actual call volumes being higher than predicted; Staff sickness; Average handle time being higher than predicted; Peak staffing requirements; Immediate mitigating actions taken included: Enhanced call handling capacity by using coaches and managers to take calls; Not ready times monitored; monitoring of call handling times and call volumes with support given to staff with long calls; Attempts to bring in additional staff via requests for overtime cover; Management of break times to avoid main surges of calls. 3.3. Out of Hours GP Service Overall performance for November 2017 was good. The total of OOH calls and number of callers referred to the GP OOH service increased during weekends in December 2017 and continued to rise through the Christmas period. The total number of calls taken from non-commissioned areas (Out of Area) also remained high. The Provider reported that they believe that they are not always being alerted to when National Contingency has been actioned. Urgent and Routine Home Visits A Remedial Action Plan was agreed by commissioners on 21st August 2017. A revised trajectory has now been agreed, to ensure compliance is on track to achieve by February 2018. Performance in November 2017 was not compliant. This continues to be monitored via the Trust s monthly SPRG. 3.4. Safeguarding Safeguarding Training compliance for sessional GPs has been placed on IC24 risk register. Further Norfolk training sessions are due to take place at the beginning of March 2018. Compliance will continue to be monitored via CQRM. 4. Norfolk Community Health & Care NHS Trust (NCHC) 4.1. Serious Incidents (SI) and Quality Issue Reports (QIR) In the month of December 2017, the Trust reported 8 SI; this is equal to that reported the previous month. The number of SI reported over the last two months has reduced when compared to previous months. The leading reporting theme continues to be Pressure Ulcers. None of the SI reported in December 2017 relate to Norwich CCG patients. In December 2017, 12 QIR were received by the Trust, compared with 15 in November 2017. In contrast to the trend seen with SI, the QIR received over the past two months have increased when compared to the previous six months, with the exception of the spike in August 2017. There are no specific trends or themes noted for December 2017 4.2. Safeguarding and PREVENT Page 12 of 18
The Trust reported PREVENT training compliance at 74% for December 2017 and provided assurance that they are on track to achieve 80% compliance by the end of March 2018. The Trust s Safeguarding Lead is carrying out monthly reviews to monitor progress and this remains a standing item for the Trust s CQRM. 4.3. Wheelchair Service (Adults and Children) A Contract Performance Notice has been served for the Adult and Children s Wheelchair Service due to non-compliance with the 92% standard for delivering treatment to patients within timescale. Improvements have been made as a result of increased capacity and the service returning to full establishment. For the week ending 10 th December 2017, the Trust exceeded their trajectory in respect of 18 week wheelchair service compliance at 90% for children and 89.2% for adults. Whilst this remains just short of the 92% standard, both services are achieving above trajectory and are track to become compliant before the end of March 2018. The Trust has commenced a Service Transformation Project to improve and sustain performance going forward. A team workshop is being held in January 2018 to redesign the non-complex clinics and reduce the new to follow up ratio by providing definitive treatment at the first appointment where possible. A key priority is also ensuring IT systems are re- configured. 4.4. Paediatric Continence A service review has been completed and the trajectory for 18 week compliance has been deemed unachievable due to limited service capacity. A fortnightly Patient Treatment List meeting commenced on 22 nd December 2017 to review those waiting for assessment to determine and monitor clinical risk. A clinical assurance framework has been developed and shared with the Trust as a tool for monitoring and reviewing long waits. It has been identified that the James Paget University Hospital may have some capacity to support with paediatric enuresis patients. The Trust is currently in discussions about this. A business case is for additional human resource is currently being scoped. 4.5. Neuro-Developmental Services Pathway Recruitment into the Neuro Developmental Services Pathway continues, with a focus on filling nursing and psychologist vacancies. A joint evaluation of the pathway has been completed by commissioners and the provider. An action plan has been developed and is being progressed. This is being monitored through the trust s monthly CQRM. 4.6. Looked After Children Review Health Assessments remain slightly below the 95% standard. An action plan is in place and the Trust is looking to recruit additional administrative resource in order to release clinical nursing time to complete assessments. 5 East of England Ambulance Service Trust Page 13 of 18
EEAST continues to face winter pressures and are receiving a high volume of calls. Currently performance cannot be compared month on month until further data has been collected for the new categories. 5.1. Ambulance Response Programme (ARP) The new ARP changes to the computer systems have now been running for 10 weeks. The Emergency Operations Centre functions appear to be working well, however performance would suggest that the urban areas are meeting the new targets better that the rural areas of Norfolk. This continues to be monitored. A new roving Patient Safety Team (one per STP area) has been set up and is deployed where required to assist with reducing patient handover delays, which remain lengthy. Performance reports were not yet available for December 2017 at time of writing. The early drafts will continue to evolve. Feedback has been provided. The changes to resources continue after appropriate risk assessments and analysis of the potential impact has been completed. Some Rapid Response Vehicles will remain in rural areas due to the time factors for getting Double Staffed Ambulances on scene. The expectation is that this process will take in excess of 9 months to complete which will include the consultation with staff. Clinical review of the call stack by senior clinical staff continues throughout every shift, and the policies and protocols to support this have been requested to provide assurance of this process. Performance of outcomes for Return of Spontaneous circulation (ROSC) have reduced in October 2017 (50% down to 25%) and reduced for Survival to discharge (16.7% down to 14.3%). 5.2. Planned Observational Visits Further to the 12 hour shift on a Double Staffed Ambulance and a shift on a Rapid Response Vehicle, a further Commissioner visit to the Emergency Operations Centre (EOC) is planned, to review the dispatch element of the service and call stack monitoring and management. 5.3. CQC Status The most recent CQC report for the Trust is dated 9 th August 2016 and resulted in a requires improvement status. EEAST has received its Provider Information Return (PIR) notification from the CQC on 17 th November 2017 and responded by 6 th December 2017 as required. It is anticipated that there will be a CQC inspection in the New Year. The CQC Action Plan continues to be monitored at the Quarterly Regional Quality Meetings and the local action plan at the Monthly Locality Meetings. An update to the action plan was presented at the most recent Quarterly Quality Meeting, however dates still required updating and this remains the case on the EEAST website. Assurance was provided that the local CQC Action Plan is reviewed regularly and Norfolk has just 2 amber actions remaining. Assurance has been requested Page 14 of 18
regarding the corporate elements of the action plan, as the governance and risk processes have still not been seen by Commissioners. As a result, this has been added to the risk register due to currently having no evidence of what is in place. Confirmation has been requested concerning how EEAST monitor and quality assure the sub-contracted charities who provide emergency services on behalf of EEAST (Norfolk Air Ambulance and NARS Norfolk Accident Rescue Service). Currently, evidence has not been provided of robust processes, therefore this has also been added to the risk register. 5.4. Training, Infection Prevention & Control and Complaints Current levels of professional updates undertaken for Central Norfolk is 94%, with Waveney being the same and West Norfolk sitting at 92%. The appraisal rates are, however, much lower for Central Norfolk and Waveney and are currently 42% and 55% respectively. West Norfolk sits at 90%. Infection Prevention and Control audits are all within expected levels in Central Norfolk, however compliance in Waveney and West Norfolk sits at 86% for November 2017. 5.5. Stroke 60 No report has been received yet for November and December 2017 data. Performance of Face Arms and Speech Test-positive Stroke Patients admitted to HASU in under 60 minutes has improved in October 2017 from 52.6% to 60% for Norwich patients. The meeting has taken place with NNUH to review the ability to gather outcome data for EEAST from NNUH; this work is on-going. 5.6. Serious Incidents In the year to date, there have been 74 SIs reported by EEAST for the whole of the eastern region (14 more than for the same period last year). A breakdown of the SI s was provided in the quality report. 38 SIs remain open currently. There were no SIs for NHS Norwich CCG patients in November 2017. A deep dive into SIs for the whole of Norfolk has commenced with the permission of the other CCGs and in collaboration with EEAST and the Ambulance SI Lead CCG; Cambridge and Peterborough CCG. 5.7. Mental Health Conveyance A Commissioners meeting was held concerning the Mental Health specification and specific feedback was provided to EEAST. An updated version has been received and this will be reviewed ahead of any final agreement. 5.8. CQUIN Development The draft CQUIN proposals for 2018/19 across the region have been worked up and are awaiting final agreement. The Early Intervention Vehicle (EIV) for Mental Health to undertake street triage is still the preference in terms of a local CQUIN scheme for next year. Currently a pilot is being developed to run until the end of 2017/18. 5.9. Independent Service Review Page 15 of 18
A teleconference was undertaken to further clarify the responses to the queries raised from the first presentation of the Deloittes service review. The queries were regarding the testing of the models used and whether adequate time had been allocated to the training required by frontline staff (to include skills training). The information required is to be circulated as part of a pack of information including the assumptions and models used. 6 ERS Medical Non-Emergency Patient Transport The most recent review meeting with ERS took place on 20 th December 2017 and covered all aspects of performance and quality. All items on the agenda were discussed; however, two of the operational managers were not present. The transition to the new phone and IT systems went well on 2 nd and 3 rd December 2017 and there were no issues reported. The new Quality Dashboard was fully completed for the meeting and further enhancements will be made as an ongoing process. The complaints element had not yet been broken down to include trends, timescales for response and those overdue, however this will be produced for the next meeting in January 2018. The report demonstrated achievement in terms of training, with sickness reducing from 7% to 1.29% in November 2017 and the 1.40% vacancy rate remaining static as recruitment has not been completed. The service continues to meet most of the KPIs, although aborted journeys remain a concern with levels higher than target. Joint meetings between NNUH and ERS take place monthly to review aborted journeys and agree actions to reduce the number. The KPIs continue to be monitored monthly and patients experience of using the service is included within this monitoring. The Patient Information Leaflet produced and amended subsequent to feedback is now in use. The audit of the call centre which took place on 5th December 2017 was fed back to ERS at a separate meeting to review all the findings in detail. Suggestions regarding improvements to the current service and proposed changes to the questions being asked were made. An action plan is being developed and the amended questions will be reviewed and agreed at a later date. 7 Norfolk Community Eating Disorder Service (NCEDS) Norwich CCG Quality Team continue to attend the quarterly NCEDS Performance Review Group and monitors the service at that forum and the newly created Quality Meeting that has been set up to take place monthly between the quarterly SPRGs. The Terms of Reference and Agenda have been agreed for the new Quality Forum. NCEDS explained that they have had a number of changes to their Team and now have a new Team that are starting to embed. A Task and Finish Group is being set up to ensure the contract captures the new NICE Guidance and DSM 5 for the Eating Disorders Services. Page 16 of 18
This Group will also ensure that the recommendations within the Parliamentary and Health Service Ombudsman Report are embedded within services and the wider remit of ensuring all Health organisations reflect on the report and ensure improvements identified are embedded. 8 Primary Care Care Quality Commission (CQC) NHS Norwich CCG is continuing to offer support to any practice that receives a CQC inspection outcome that requires actions to be taken to make improvements. NHS Norwich CCG is working with the local CQC Inspection Team to plan a Practice Seminar covering the new style CQC Annual Assessment and revised KLOEs that come into effect from 1 st April 2018. Workforce NHS Norwich CCG contributed to a third wave funding application for International GP Recruitment, which has been agreed by the NHS England moderation panel in principle. NHS Great Yarmouth & Waveney CCG will be coordinating the immediate next steps to mobilise recruitment activities locally. This scheme will support the achievement of our STP GP trajectories and offers a resource to increase capacity within our Practices. A meeting of the Joint Central Norfolk, West Norfolk and Great Yarmouth & Waveney CEPN Meeting is scheduled for 25 th January 2018. Clinical Variation Visits No visits were undertaken during December 2017. Executive Committee continues to maintain an oversight of visit outcomes and learning. CCG Variation Leads will be meeting during January 2018 to review variation data across Norwich and plan further visits. NHS Norwich CCG GP Education Sessions A session on Dementia has been planned for 17 th January 2018; this has been planned for Practice Nurses and Health Care Assistants and will be delivered by a Senior Consultant Admiral Nurse. Medi-Bites GP Education Session dates have been set for the year ahead. The first evening will be held on 7 th February 2018 and will have a Mental Health focus. Local Quality Improvement Incentive Scheme (LQIIS) An LQIIS has been agreed and launched in January 2018, to run over the last quarter of 2017-18. This LQIIS will be a modified replication of the previous year s scheme; embedding quality improvements around the identification, prevention and management of Chronic Obstructive Pulmonary Disease (COPD) and management of Asthma in children and young people. The repetition of quality improvement activities focused around these elements of respiratory care fulfils a recommendation made by NHS Norwich CCG Clinical Reference Group following review of the previous scheme s evaluation. 9 Care Homes and Domiciliary Care Providers Page 17 of 18
The CCG is currently working with three Nursing Care Homes in the Norwich area around addressing CQC Inspection outcomes. These are: Larchwood Nursing and Residential Home overall rating is inadequate Two Acres Care Home overall rating is requires improvement Ivy Court Care Home - overall rating is requires improvement Cavell Court, which is located in South Norfolk area, also requires improvement and NHS Norwich CCG will monitor and offer support in relation to seeking assurance on behalf of Norwich patients placed with the Provider. Commissioners are taking a collaborative approach to supporting improvements being made by Care Home Providers in respect of their CQC ratings. This includes input from: Norfolk County Council Quality Managers; CCG Quality Managers; Commissioning Support Unit Quality Managers; Medicine Management Advisors; Infection prevention & Control Specialist Nurses; Safeguarding Professionals, as required. 10 Influenza Central and West Norfolk CCGs have commissioned a service through NCH&C to respond to flu outbreaks in care homes. There have been two notified outbreaks so far, both affecting care homes in the Norwich CCG area. In one case the results of the viral swabs were positive. Norwich CCG is leading discussions with NCH&C to explore a longer term model that will become business as usual. 11 Pressure Ulcers The System-wide Strategic Pressure Ulcer Group has met for the second time in December 2017 and will continue to meet on a quarterly basis. A review of all local HAPU Root Cause Analysis templates will be undertaken to ensure the information being captured is consistent across the patch. Recommendations following this review will be shared with providers at the next Systemwide Strategic Pressure Ulcer Group meeting. Norwich CCG is working closely with NCH&C on the development of a business case proposal to increase community Tissue Viability Resource. A visit has been arranged for the January 2018 to visit another local community Provider to discuss their service model. Page 18 of 18