Quality Report Quarter 1, 2013/14 v1.1
Contents Section 1: Quality Introduction... 3 Section 2: Summary Quality Issues... 1 Section 3: CQC Intervention... 3 Ofsted Report published: 10 th July 2012... 4 CQC report published 28 th August 2012... 4 Section 4: Quarterly Key Quality Issues and Action Plans (by Provider)... 5 4.1 King s College Hospital NHS Foundation Trust... 7 4.2 Guy s & St. Thomas s NHS Foundation Trust... 15 4.3 Guy s & St. Thomas s NHS Foundation Trust Community Health Services... 16 4.4 South London & Maudsley NHS Foundation Trust... 23 4.5 St George s Hospital NHS Trust... 24 4.6 Continuing Care Providers... 29 4.7 Primary Care (including WIC, community outpatients etc.)... 30 Section 5: Patient Experience... 31 5.1 King s College Hospital NHS Foundation Trust... 31 5.2 Guy s & St. Thomas s NHS Foundation Trust (including Community Health Services)... 33 5.3 South London & Maudsley NHS Foundation Trust... 35 5.4 St George s Hospital NHS Trust... 37 5.5 Primary Care (including WIC, community outpatients etc.)... 38 Section 6: Engagement Issues and Feedback... 39 Section 7: Quality Alerts... 41 7.1 Quality Alerts: Overall Themes & Actions Q1 2013-14... 41 7.1.1 King s College Hospital NHS Foundation Trust... 43 7.1.2 Guy s & St. Thomas s NHS Foundation Trust... 44
7.1.3 South London & Maudsley NHS Foundation Trust... 47 7.1.4 St George s Hospital NHS Trust... 48 Section 8: Clinical Visits and Clinical Audits... 49 8.1 Clinical Site Visits & Audit Schedule... 49 8.2 Clinical Site Visits & Audit Detail... 50 Section 9: Quality Surveillance Group (QSG) Update... 56
Section 1: Quality Introduction The NHS is the only healthcare system in the world with a definition of quality enshrined in legislation. An organisation delivering high quality care will be offering care that is clinically effective, safe and delivering as positive an experience as possible for patients. The following Quality Report provides information pertaining to our main healthcare providers, Guy s and St Thomas s NHS Foundation Trust, King s College Hospital NHS Foundation Trust, South London and Maudsley NHS Foundation and St Georges Healthcare NHS Trust. It covers information on key quality issues and action plans, patient experience, patient engagement issues specific to Lambeth CCG, quality alerts and clinical visits and audits. This is the first of regular quarterly quality reports and in light of the Francis, Keogh and Berwick reports and collaborative work with other regulators and our providers is likely to be amended over time to enable a comprehensive picture of quality within our provider services. Keogh Report Summary The recent report by Sir Bruce Keogh, National Medical Director NHS England, the Keogh report, was a review into the quality of care and treatment provided by 14 hospital trusts with persistently high mortality rates. The rationale was that high mortality rates at Mid Staffordshire NHS Foundation Trust were associated with failures in all three dimensions of quality clinical effectiveness, patient experience and safety as well as failures in professionalism, leadership and governance. Whilst pockets of excellent practice were found in all 14 of the trusts the review identified some common themes or barriers to delivering high quality care: Limited understanding of how important and simple it can be to genuinely listen to the views of patients and staff and engage them in how to improve services. The capability of hospital boards and leadership to use data to drive quality improvement compounded by difficulties in accessing data. The complexity of using and interpreting aggregate measures of mortality, including HSMR and SHMI. The fact that some hospital trusts are operating in geographical, professional or academic isolation leading to difficulties in recruiting enough high quality staff and an over-reliance on locums and agency staff The lack of value and support being given to frontline clinicians, particularly junior nurses and doctors. The imbalance that exists around the use of transparency for the purpose of accountability and blame rather than support and improvement. The findings of the review demonstrated the need to set out an achievable ambition for improving and raising standards in our hospitals. Sir Bruce was clear that whilst the review used mortality statistics to trigger the inclusion of particular hospitals in the review, a broader set of triggers spanning the three dimensions of quality should be used as poor standards do not necessarily show up in mortality rates. As a result of the review a study into the relationship between excess mortality rates and actual avoidable deaths will pave the way for the introduction of a new national indicator on avoidable deaths in hospital measured through the introduction of systematic and externally audited case note reviews. The sharing of soft intelligence, particularly between local CCGs and regulators, will be vital and the new Quality Surveillance Groups provides an important mechanism for supporting this and avoiding duplication of effort.
It is anticipated that the measures included in this report will develop over time. Berwick Report Summary The even more recent report on the safety of patients led by Professor Don Berwick published in August 2013, A promise to learn a commitment to act : Improving the Safety of Patients in England, makes recommendations for the NHS, its regulators and the Government. Given resource constraints it recommended the best way was through improvement introducing new models of care and new partnerships among clinicians, patients and carers that can produce better care at lower cost, in essence embracing a culture of learning. The headlines recommendations are: Hospitals should know the right level of staffing for every ward The National Institute for Health and Care Excellence should draw up guidance on the right nursing-topatient ratios Criminal sanctions in extreme cases of staff neglect A summary of the recommendations are as follows: Continual reduction in patient harm by embracing an ethic of learning All leaders concerned with NHS healthcare should place quality of care in general and patient safety in particular, at the top of their priorities Patient and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to boards of Trusts Govt., HEE and NHSE should assure sufficient staff available to meet NHS needs Mastery of quality and patient safety sciences and practices NHS should become a learning organisation Transparency should be complete, timely and unequivocal, All data on quality and safety.should be shared All organisations should seek out the patient and carer voice in monitoring safety and quality of care. Supervisory and regulatory systems should be simple and clear. Responsive regulation of organisations with a hierarchy of responses GSTT are currently reviewing the implications of these reports which will be covered at a Clinical Quality Review meeting.
Section 2: Summary Quality Issues 1 Provider Quality Issue Implementation of recommendations from CQC inspection of SLaM facility March 2013 (page 3 and page 53). Description of Quality Issue SLaM did not pass three CQC outcome indicators. These were associated with HCAIs; staff training; and patients care records. Commissioners should receive assurances that agreed action plans are being i9mplemented to plan. CCG commissioners should report on the CQC follow-up inspection. Outcomes/ Actions Action plan and regular updates received. Deep clean and redecoration undertaken Programme of mandatory training underway to be completed by end of Q4 2 3 Implementation of recommendations of Ofsted/CQC inspection of Implementation of multi-agency action plan agreed and monitored by Southwark Safeguarding Executive safeguarding and looked after and Southwark Safeguarding Children Board. children s services in Southwark (page 3). Implementation of recommendations from CQC inspection of Dulwich Care Centre (page 50) DCC were issued 2 warning notices relating to two CQC standards: record keeping & care and welfare of service users. Action plan to be completed by 31 August 2013. Monitored by LBL and fed back to CCG via SCMT. 4 King s adult safeguarding training (page 7). Current reported performance is below the required standard in terms of the proportion of staff trained. 5 King s Never Events (page 7). 3 reported retained swabs and concern over level of Never Events related to surgery. 6 7 8 KCH Phlebotomy waiting times (page 7). King s reported patient experience for cancer services and patients at the Betty Alexander unit (page 32). Never Events and near misses at Guy s & St. Thomas (page 15). CCG alerted to long waits at Dulwich Hospital. Issue not yet resolved by commissioners with KCH. King s performed comparatively poorly in the national cancer patient survey. Concerns have also been raised by patients and others about quality and patient experience of the King s Betty Alexander Unit. There was one Never Event in May 2013 involving a retained object in a maternity patient. Actions are being monitored by Lambeth CCG. 1
Provider Quality Issue 9 Safeguarding adult training for GSTT CHS staff (page 16). 10 GSTT Discharge Letters 11 Response to patient complaints at GSTT (page 33). 12 SLaM: IAPT capacity (page 23). 13 14 Trust policy on discharging patients after re-arranging appointment/dnas (page 41). Primary care access to district nursing services (page 30). Description of Quality Issue Current reported performance is below the required standard in terms of the proportion of staff trained. Quality of letters deemed unacceptable by GPs. Also, IT incident resulting in about 4,000 electronic discharge letters not being sent out found to be due to deterioration of a server. The response time for a number of complaints is in breach of trust policy. The newly established talking therapies service which has the IAPT component within its integrated service model will improve both capacity and delivery of treatment through more effective integration of recovery or move on options. CCG member practices have flagged concerns about inappropriate discharge from secondary care services at KCH and GSTT and also about the quality of discharge communications. Issues have been raised through Quality Alert system. This issue has yet to be resolved and fed back by the CCG. CCG member practices have flagged a risk posed by challenges contacting and communicating with GSTT CHS District Nursing teams. Discussed at locality leads and community nurses meeting late May 13 and immediate actions agreed Outcomes/ Actions Training has now met the target set of 85% GSTT CHS to provide report on impact of training for contract monitoring meeting in September 13 Corrective actions being implemented. Discussions led by LCCG and flagged to GSTT Medical Director GSTT reviewing and amending internal processes to improve compliance timeliness and tone. Revised referral guidance to be circulated Electronic referral and communications to be improved Community nursing improvement plan to be put in place and discussed at locality meetings in Autumn 2
Section 3: CQC Intervention Name of Provider(s) CQC Regulation Intervention Action Reported Date of CQC Intervention Description of Agreed Improvement Plan / Trajectory Description of CCG Assurance Process (Note: Responsible Clinician & Officer) South London and Maudsley NHS Foundation Trust Regulation: The registered person did not ensure that service users and staff were protected from the risk of exposure to health care associated infections by maintaining the premises at an appropriate standard of cleanliness. (Regulation 12 (2)(c)(i)). 21/03/2013 Action: Cleanliness of building to be monitored via contract meetings with service manager/monthly checks. Fittings, Furniture and exposed plaster being dealt with by facilities and monitored. Staff told to follow correct procedures and discussion with contractor. Progress against actions is being monitored via the core contract and individual service meetings with SLaM. Liz Clegg South London and Maudsley NHS Foundation Trust Regulation: The registered person did not have suitable arrangements in place to support people delivering care by not providing regular training, professional development, supervision or appraisal. (Regulation 23 (1)(a)). 21/03/2013 Action: Establishment of new supervision and appraisal structure & audits, all appraisals to be completed by June 2013. Development of a supervision tree progressing. Managers working with staff to encourage completion of on line training. Data is reviewed by CEO and log is reviewed monthly by CAG. Progress against actions is being monitored via the core contract and individual service meetings with SLaM. Liz Clegg South London and Maudsley NHS Foundation Trust Regulation: The registered person did not ensure that service users were protected from the risk of unsafe or inappropriate care and treatment by ensuring accurate records were kept in relation to the care and treatment provided to each service user. (Regulation 20 (1)(a)). 21/03/2013 Action: Electronic Patient Standards document & policy to be read by all staff also part of supervision. New care plans in place to meet individual patient requirements. Primary nurse to review all care plans. SLT will also devise patient care plans and not just EPS system. Staff will be reminded how to access interpreter services for patients. New scanners to be installed and staff instructed to use these where information cannot be entered onto EPJS. New business manager appointed to clear backlog of paperwork. Weekly audited Tissue Viability action plan in progress. New Wellbeing and Recovery plans in implementation across the Trust. Progress against actions is being monitored via the core contract and individual service meetings with SLaM. Liz Clegg 3
Name of Provider(s) CQC Regulation Intervention Action Reported Date of CQC Intervention Description of Agreed Improvement Plan / Trajectory Description of CCG Assurance Process (Note: Responsible Clinician & Officer) King s College Hospital NHS Foundation Trust / Guy s and St Thomas s NHS Foundation Trust / South London and Maudsley NHS Foundation Trust / LA Action Plan to address recommendations for Health Services in Southwark from Ofsted/CQC inspection of safeguarding and looked after children services 21 May 1 June 2012 Ofsted Report published: 10 th July 2012 CQC report published 28 th August 2012 Multi-organisational action plan focusing on improving Safeguarding and Looked After Children (LAC) systems, processes and services in Southwark Clinical Lead: Dr Sian Howell Director Lead: Gwen Kennedy Action plan monitored through CCG Safeguarding Executive and Southwark Safeguarding Children Board Dulwich Care Centre CQC have issued 2 warning notices on DCC relating to failing to comply with Regulation 9 (1) (a) (b)(i)(ii) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Relating to:- Record Keeping Care and Welfare of Service Users CQC are requiring DCC to be compliant with these regulations by the 31 st August 2013 24 thj june 2013 Dulwich Care Centre to provide action plan to address how they will ensure compliance. This is being overseen by LBL Adult and Community Services LBL have placed embargo on new placements to DCC. All commissioners are required to ensure patients they have placed at DCC are reviewed Action plan monitored by LBL and fed back to CCG via SCMT Lambeth CCG have instructed GSTT CHS Care Home Support Team to review patients placed at DCC who are fully NHS funded Director Lead: Helen Charlesworth-May 4
Section 4: Quarterly Key Quality Issues and Action Plans (by Provider) Quality Information Glossary SHMI - The Summary Hospital-level Mortality Indicator (SHMI) is a national mortality indicator. It is a statistical model which calculates the expected number of deaths at an individual provider and compares this to the actual number of deaths within the period. A value of less than 1 indicates that the mortality rate is lower than would be expected, and a figure greater than 1 would indicate that the mortality rate is higher than would be expected. CAS Alerts - The Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance. Should a trust have a CAS alert outstanding, it means that the Trust has not yet taken the actions required to step down the alert, and that the alert is overdue VTE Risk Assessments All patients who are admitted to hospital should have a venous thromboembolism (VTE) risk assessment completed to assess whether the preventative measures need to be taken to minimize the risk of the patient developing a blood clot It allows hospital trusts to gain real time feedback on their services down to individual ward level and increases the transparency of NHS data to drive up choice and quality Friends and Family Test From April 2013 all trusts had to implement the Friends and Family Test (FFT) and ask patients (initially inpatients and those attending A&E) whether they would recommend A&E and inpatient wards to their friends and family if they needed care or treatment. Trusts were set the target of achieving a 15% response rate for Q1 (rising to 20% in Q4), and improve their scores over the course of the year. The test allows hospital trusts to gain real time feedback on their services down to individual ward level with the intention to increase the transparency of NHS data and drive up choice and quality. Results of the surveys were published on 30 July 2013 covers the first three months of the survey. Specialist hospitals tended to have higher scores for inpatient services. The Friends and Family Test scores are available at Trust, hospital, speciality and ward level. The scores for inpatients ranged from 100 to 43. The England-wide response rate for both inpatient and A&E surveys was 13.1 per cent. GSTT combined response rate for quarter 1 was 12%, KCH was 11.4% and St Georges 17.6%. Data on trust scores can be found under individual trust reports that follow. In June 36 wards out of 4,500 across the country scored an overall negative figure, down from 66 in April. However, this was based on less than 5 responses. These low responding wards were supposed to be excluded from published data but were not. NHSE(L) expecting that this will be changed for future published data. The Care Quality Commission will use the data as part of its new surveillance system when assessing risks at hospitals, together with other data such as mortality rates and never events. 5
CCGs are expected to be able to demonstrate what they are doing through Quality meetings in response to FFT information what debates are taking place and how this is working to improve patient experience. It was acknowledged that the way the experience scores are calculated is creating some anomalies a small number of highly likely responses can make a big difference and where there are low response rates a small number of unlikely or very unlikely can tip into a negative score. The next phase is rollout to maternity we are asked to test rust readiness to roll out. It was acknowledged that trusts are struggling with ante and post natal data gathering. Mental health and community implementation starts March 2014. Guidance for primary care coming out February 2014 for implementation December 2014. Apparently CCGs will be asked to determine go live dates for optometrists, dentists and pharmacists. As a result of the quarter 1 results there has been a change to CQUIN for trusts that didn t achieve response rates for Q1 - they will get payment if they achieve higher score by Q4 and achieve 20% response rates obviously a significant challenge for local trusts. Quality Surveillance Group (QSG) QSGs were set up in response to the Francis Enquiry and the new commissioning landscape that was created post April 2013. There was recognition that because of the different structures that had been created it was possible that there was a danger that quality could suffer as there was a lack of clarity as to whose role it was to address quality issues from the commissioner side. By collectively considering and triangulating information and intelligence, QSGs will work to safeguard the quality of care that people receive. Local QSGs (in our case South London) are the backbone of the network. They engage in surveillance of quality at a local level by those closest to the detail and most aware of concerns. They will not only consider information and intelligence but also be able to work together to take coordinated action to mitigate quality failure. Regional QSGs (ie London) provide an escalation mechanism for Local QSGs. They assimilate risks and concerns from local QSGs, identifying common or recurring issues that would merit a regional or national response. The will also have a key role, particularly in 2013/14, in assuring the effective operation of local QSGs. The group s membership consists of Chief Officers of CCGs, Monitor, the TDA, CQC, HealthWatch and the CSU. See section 9.0 for further detail. 6
4.1 King s College Hospital NHS Foundation Trust 1 Quality Issue Identified Maternity Capacity within Denmark Hill labour ward to offer safe, high quality care in light of the numbers of women delivering at KCH. Maternity Unit Closure in Nov 12 indicates high level of pressure. Access to ante-natal care by 12 weeks and 6 days. KCH performance below target Commissioner Actions Taken and Planned Addressed via CQRG in Feb and April. KCH to share fuller action plan on capacity and developing MLBU capacity. Maternity dashboard reported at CQRG, to have focus on maternity quarterly from now on. New CCG maternity clinical lead identified. Site visit planned to KCH maternity unit June 2013. CSU and CCG discussing maternity quality commissioning structures. Further work to be undertaken in the light of TSA recommendations. CCG Group with Oversight CCG Integrated Governance & Performance Committee 2 Never Events (Retained Swabs) In 12/13 there have been 3 retained swab never events, in 13/14 1 prevented NE relating to wrong site surgery. In addition, 1 misplaced NG tube Never Event in Q 1 13/14, currently being reported. Concern over level of Never Events relating to surgery CCG wrote to Trust in February 2013 expressing concern at level of Never Events relating to surgery and asking for assurance on Trust actions to prevent NEs. Reviewed at CQRG in February and April, and at Trust Patient Safety Committee, where issues are investigated & actions agreed. KCH have selected WHO Safer Surgical Checklist as one of their 13/14 Quality priorities, and will embed this throughout all surgical sites. 3 Serious Incident Reporting and Assurance Processes KCH reporting Serious Incidents on STEIS since April 2013. Commissioners are reviewing the processes for reviewing KCH SIs. Currently commissioners attend the King s SI meeting, and sign off is done via that route. Lambeth CCG Governance Manager invited to attend the KCH SI meetings from August. There is a potential recommendation that SI sign off for KCH is done by commissioners. 4 Pressure Ulcers and Falls Increase in the number of falls through 2012/2013. Increase in the number of pressure ulcers, particularly grade 2. Deep Dive undertaken by Southwark CCG which established that rates or Pressure Ulcers and Falls had increased over 2013/2014, even after accounting for increased activity. Reasons for increase have been discussed with Trust, including suggestion that increased acuity is a contributing factor. CCG recommended range of actions including greater assurance of Trust response to increases in rates. KCH now reporting grade 3 pressure ulcers as SIs King s CQRG 5 Safeguarding Training Take up of adult safeguarding training below the 80% expected. KCH developed action plan to improve. KCH requested to develop action plan, which is reported at CQRG monthly. King s CQRG 6 Phlebotomy waiting times. Via patient engagement events and informal feedback, the CCG has also been alerted to the very long waits at Dulwich Hospital for phlebotomy and the negative impact on patient experience. Raised at the CQRG 08/12 and 10/12. Issue not conclude to be raised again in June 2013.CCG completed review of phlebotomy in July 2012, which recommended range of options for improving the commissioning of the service. Primary Care strategy to address options and workplan for improving access. King s CQRG PCCS/IGP 7
4.1 King s College Hospital NHS Foundation Trust 7 Quality Issue Identified Positive Quality Aspects: KCH Hospital standardised mortality rates Infection control: 0 MRSA bactaremias in 2013/2014 so far, and below trajectory on CDiff Venous Thrombo-Embolism (VTE) assessment and prevention KCH are leaders in good practice and have overachieved the 12/13 National CQUIN in this area. Commissioner Actions Taken and Planned Continue to monitor these areas via monthly quality meetings and reports CCG Group with Oversight KCH CQRG 8
Experie nce Safety Quality Dashboard King s College Hospital NHS Foundation Trust Category Indicator Reporting Period Target Apr May Jun Jul Aug Sept Data source Mortality: SHMI Quarterly <1 0.9255 0.9255 0.9255 HSCIC SIs: Number of SIs (TOTAL including NE, Falls that result in major harm or death and Grade 3 and 4 pressure ulcers only attributable) Monthly 6 10 11 STEIS Number of Never Events (NE) Monthly 0 1 1 0 STEIS CAS Alerts Outstanding Monthly 0 0 1 0 NPSA Adult Safeguarding: % of staff compliant with training Quarterly 80% Not yet available Not yet available Not yet available Trust Data Child Safeguarding: %of staff compliant with training Level 2 Quarterly 80% 74 Trust Data Child Safeguarding: %of staff compliant with training Level 3 Quarterly 80% 76 Trust Data Falls: Moderate Harm Monthly 3 0 1 NHS Thermometer Falls: Major Harm Monthly 1 1 0 STEIS Falls: Death Monthly 0 0 0 STEIS Pressure Ulcers, Grade 2* Monthly 32 31 30 NHS Thermometer Pressure Ulcers, Grade 3 (attributable) Monthly 0 1 0 STEIS Pressure Ulcers, Grade 4 (attributable) Monthly 0 0 0 STEIS VTE Risk Assessments Completed on Admission Quarterly 95% 97.26 98.71 97.39 Unify Complaints: Number of complaints Monthly 69 77 56 Trust data Complaints: % replied to within agreed timeframe Monthly 59.7 53.6 50.3 Trust data 9
Friends and Family Test: Net promoter score Monthly 53 51 48 Unify Fig 1. Quality Dashboard Footnote : CQUINs will be reported on quarterly in a separate report. * Data has not been validated. NHS Thermometer Data source to be changed for more complete data. 10
Quality Commentary King s College Hospital NHS Foundation Trust Changes have been made to the monitoring and management of quality standards for 2013/14 with a move to monthly Clinical Quality Review (CQRG) meetings to support a more in depth focus on quality. A wealth of supplementary monitoring information is available through these contractual processes, with the Integrated Report focusing on performance at provider level for a number of key quality metrics only. Some data fields are missing for month 2 as performance is reported and assessed on a quarterly basis. A summary of the key issues discussed at the most recent CQRGs is also included in this section of the Integrated Report. Mortality KCH continues to achieve a better than expected mortality rate. Their SHMI of 0.92 puts the trust into the top quartile nationally. Serious Incidents and Never Events Safeguarding Falls and pressure ulcers KCH experienced two Never Events during April and May. The first was on a patient who had to be transferred to ITU with respiratory failure due to a misplaced nasogastric tube (NGT). The NGT passed through vocal cords at intubation and was visible in left lung on the chest x-ray post intubation. The second Never Event was a retained femoral guide post-surgery which was later discovered when conducting follow up scans. Both incidents are being fully investigated and will report to the SI group. Neither were Lambeth residents. Both have been to the KCH Serious Incident Committee and action plans are due for review in September and October. 11 serious incidents were reported in June but no Never Events. Due to reporting issues adult safeguarding figures are not available. KCH narrowly missed the target for child safeguarding training in May, but there had been a significant improvement in the percentage of staff undertaking training in recent months. Due to the volume of new starters and a number of staff s training expiring, reaching the target has proved difficult. In order to improve their level of compliance, KCH is investing in additional external training to increase the number of sessions available for staff to receive training. Grade 2 pressure ulcer information and falls are currently derived from the national safety thermometer submissions. These are a single point of data collection in a month. The data source for future reports will be obtained from the Trust for the full month. These include attributable and non attributable incidents. Grade 3 and Grade 4 pressure ulcers and Falls resulting in Major harm or Death are reported as serious incidents with data obtained from the national STEIS system. The quantity and level of patient falls is in line with the same period last year, and remains low for a trust of the size of KCH. 3 Grade 3 and Grade 4 pressure ulcers were reported in June but were unattributable to KCH and de-escalated. For reference, KCH had no attributable Grade 4 pressure ulcers throughout 12/13. 11
VTE Assessments Complaints Friends and Family Test (FFT) As part of a national CQUIN, Trusts are tasked with completing VTE risk assessments for a minimum of 95% of patients. KCH met this target consistently throughout 12/13 and have continued to conduct VTE risk assessments on over 97% of patients in 13/14, comfortably avoe the threshold. The number of complaints received at KCH decreased in June to 56 from a 12 month high of 77 in May. Timeliness of responses remains an issue, with 49.9% of complaints not being responded to within agreed timeframes. Complaints will be discussed as a key substantive item at the next CQRG meeting, and a fuller briefing will be available in next months report. KCH has not been able to consistently meet the Q1 15% response rate target set by NHS England, particularly for A&E. However, commissioners are assured that every effort has been made to increase response rates, and KCH has been asked by NHS England to give a presentation to other trusts on some of the initiatives they have introduced. The breakdown of net promoter scores was 36 for A&E and 60 for inpatients. NHS Choices have reported that these figures place KCH in the lowest performing quartile in the country, though it should be noted that of 714 inpatients surveyed, only 20 reported that they were unlikely or very unlikely to recommend KCH. Further work is ongoing to analyse the data and understand why scores would be below expectations. 12
Clinical Quality Review Group Update King s College Hospital NHS Foundation Trust Each of the SE London Trusts has now increased the frequency of their Clinical Quality Review Group (CQRG) meetings to monthly in order to allow for issues relating to the quality of services to be discussed in more depth. The below summaries give an overview of the areas of discussion at the last CQRG meetings and an indication of topics due to be discussed at upcoming meetings. Cost Improvement Plans Francis Report Phlebotomy clinic waits From 2013/14 CCGs are required to assure themselves that any cost improvement plans (CIPs) that their providers initiate have been assessed for quality, with any project that it is deemed to be high risk or high value to be assessed by the CQRG. Although details of individual CIPS were unavailable for the last CQRG meeting, KCH were able to describe the arrangements for designing, implementing and monitoring schemes. CIPs were developed at department level and managers completed Quality Impact Assessments for each CIP. Any scheme that scored a risk score of 8 or above out of a possible 25 against risk to patient safety, impact on patient experience, or risk to patient outcomes must include additional information and have mitigating actions. All schemes must be reviewed by the clinical lead for the area to ensure that they are satisfied that the scheme (including its mitigating actions) will not have a negative impact on quality. Should this be approved, schemes are then subsequently reviewed by divisional managers and the Medical and Nursing Directors. Schemes can be rejected at any stage, or sent back to departments to further review the mitigating actions. The CQRG agreed that the development process and governance arrangements appeared robust but asked KCH for more detail on individual schemes. The impact of CIPs will be monitored by the group throughout the course of the year. KCH have started a series of flash mob style pop-up conversations to try and continue to engage staff. Although attendance at some of the post Francis engagement events was good, the pop up events take sessions to locations such as canteens to broaden staff participation. Pop-up events are also being run in the evenings so that staff that generally work at night can also be involved. Similar sessions will also be run on the Princess Royal site. The governance team were keen to stress to staff that the Francis report, and its recommendations were about more than Mid-Staffs, but about the wider issue of culture within NHS organisations, and as a result are keen to make sure that engagement exercises continue. KCH gave an update on phlebotomy clinic waits which had previously been noted as being higher than expected. The average wait decreased from 50 minutes to 33 minutes in May, and is expected to be down to 20 minutes in June. Key to the improvement was increased staffing levels in the team, and moves to automated systems. A Project Manager has also been appointed to drive waits down further. The building work that needs to be completed for the clinic should also be complete in August which should allow for further improvement 13
Future Agenda Planning The Trust were able to report that there had been some improvement in the response rate to complaints, with 50% now being responded to within the 25 day period, as opposed to 40% at the end of the last financial year. The Chief Operating Officer has raised the issue with divisional managers to try and drive further improvement. The Francis working groups are also looking at complaints so it is likely there will be a bigger push on complaints once that group has made recommendations on how complaints should be handled in future. It was likely that the Department of Health/NHS England would also be issuing new guidance on how to handle complaints and this would be factored in to future planning. The August meeting is due to have maternity and complaints as the main items, and will also discuss Quality Alerts, the Friends and Family Test and the most recent performance report. Planning is currently underway to redesign the agenda of the CQRG in order that topic items can be set well in advance to allow adequate time for preparation for the Trust and commissioners and in order to stimulate a full and well-informed discussion. 14
4.2 Guy s & St. Thomas s NHS Foundation Trust Quality Issue Identified Commissioner Actions Taken and Planned CCG Group with Oversight 1 Reporting of SIs The numbers of reported Serious Incidents remains consistent for GSTFT. Concerns have been raised around the process of timely reporting of Maternity SIs and the CCG is working with the Trust to confirm that robust processes are in place. Completed investigation report submission times are an area of concern and the Trust and CCG are working together to address the backlog of overdue reports. GSTFT Serious Incident Review Meetings have been held every two months and from September 2013 these will be moving to monthly to allow all incidents to be reviewed appropriately and actions / themes identified and discussed in a timely manner. These meetings will be chaired by the newly appointed GP clinical Quality Lead. GSTT CQRG and SI Group 2 Never Events There was one never event reported in May 2013 involving a retained object in a maternity patient. The investigation report has been completed and received by the CCG. It is currently being evaluated. Discussion on the use of the WHO checklist is planned for an upcoming CQRG meeting to ensure that lessons are learnt and actions implemented by the Trust. Actions are led and monitored by Lambeth CCG as Lead Commissioner. WHO Safer Surgery checklist was re-launched in November 2012 with a clinical champion identified per area. Re-audit of WHO safer checklist undertaken May 2013. This was included in discussions with the Lambeth Governing Body in their July 2013 Seminar. The Maternity Never Event is currently being evaluated for further discussion at the GSTFT Serious Incident Review Group and CQRG. GSTT CQRG and SI Review Group 3 Pressure Ulcers Pressure ulcers continue to be reported by GSTFT and are the highest category of SI reported by the Trust up to 90% of all SIs. There are still concerns about the length of time taken to submit completed investigations to the CCG. GSTFT now have an integrated outreach team including tissue viability nurses working across acute and community. This fits with NHS England s expectation that major providers take a system lead on areas such as PUs GSTT CQRG 4 Infection Control: Routine update by DiPC at GSTT CQRG meeting led to discussion on early warning systems for other resistant bugs, especially e Coli, pseudomonas etc. rather than focus being solely on MRSA and C Diff. Current programme running to replace all taps due to pseudomonas threat. Will focus on high vulnerability areas first e.g. HDU, paediatrics. GSTT CQRG The Datix system used by Lambeth CCG has been reviewed and relaunched in July 2013 as QUIC and there is now one easier reporting system for inputting Quality Alerts as well as Incidents and Commendations. 5 Quality Alert Reporting Lambeth CCG are working with GSTFT and GPs to encourage and enable two-way Quality Alert reporting. The updated system details will be made available to Southwark CCG to introduce the same model of working. GSTT CQRG Specific areas or themes will be identified as focus areas for reports going forward, e.g. Talking Therapies in August 2013. Reports are being developed for GPs and other providers. 15
4.3 Guy s & St. Thomas s NHS Foundation Trust Community Health Services 1 2 Quality Issue Identified District Nursing Service District nurse productivity and perceived relationship with GP practices Health visiting productivity, numbers and perceived relationship with relating GP practices Commissioner Actions Taken and Planned Monitor KPIs closely: o Monthly meetings with GP practices o Increase patient facing time o DN referral to patient contact in 24 hours and activity reporting requirements o Monitoring of service improvement plan o Closer working between localities and district nursing service and identification of locality leads to monitor progress on improvement plan Ensure NHS England, now responsible commissioner, to invest in Health Visiting Trajectory for final 3 years of 5 year trajectory Monitor KPIs closely: o monthly meetings with GP practices o Increase patient facing time o CCG Group with Oversight GSTTCHS Contract meeting GSTTCHS Contract meeting 3 Safeguard training for all relevant staff in Community services Monitor progress through monthly performance reports Monitor exception reporting on Adult Safeguarding training GSTTCHS Contract meeting 4 Consistency of care for patients with long term conditions Implement Joint Care Planning CQUIN with District Nurses focused on patients with long term conditions GSTTCHS Contract meeting 16
Safety Quality Dashboard Guy s and St Thomas s NHS Foundation Trust Category Indicator Target Apr May Jun Jul Aug Sept Data source Reporting Period Mortality: SHMI Quarterly <1 0.8264 0.8264 0.8264 HSCIC SIs: Number of SIs (TOTAL including NE, Falls that result in major harm or death and Grade 3 and 4 pressure ulcers only attributable) Monthly 13 19 19 STEIS Number of Never Events (NE) Monthly 0 0 1 0 STEIS CAS Alerts Outstanding Monthly 0 0 0 0 NPSA Adult Safeguarding: % of staff compliant with training Quarterly 80% 84* 87 Trust Data Child Safeguarding: %of staff compliant with training Level 2 Quarterly 80% 83* 83 Trust Data Child Safeguarding: %of staff compliant with training Level 3 Quarterly 80% 85* 85 Trust Data Falls: Moderate Harm* Monthly 1 0 2 NHS Thermometer Falls: Major Harm Monthly 0 3 1 STEIS Falls: Death Monthly 0 0 0 STEIS Pressure Ulcers, Grade 2* Monthly 26 44 45 NHS Thermometer Pressure Ulcers, Grade 3 (attributable) Monthly 10 14 14 STEIS Pressure Ulcers, Grade 4 (attributable) Monthly 2 3 3 STEIS VTE Risk Assessments Completed on Admission Quarterly 95% 96.1 96.3 96.92 Unify 17
Experience Category Indicator Target Apr May Jun Jul Aug Sept Data source Reporting Period Complaints: Number of complaints Monthly 110 93 69 TBC Complaints: % replied to within agreed timeframe Monthly Trust data Not available Not available 96 STEIS Friends and Family Test: Net promoter score Monthly FFT national data 66 69 68 Unify Fig 2 - Quality Dashboard Footnote : CQUINs will be reported on quarterly in a separate report. * Data has not been validated. NHS Thermometer Data source to be changed for more complete data. 18
Quality Commentary Guy s and St Thomas s NHS Foundation Trust Changes have been made to the monitoring and management of quality standards for 2013/14 with a move to monthly Clinical Quality Review (CQRG) meetings to support a more in depth focus on quality. A wealth of supplementary monitoring information is available through these contractual processes, with the Integrated Report focusing on performance at provider level for a number of key quality metrics only. Some data fields are missing for month 2 as performance is reported and assessed on a quarterly basis. A summary of the key issues discussed at the most recent CQRGs is also included in this section of the Integrated Report. Mortality GSTT continue to achieve a better than expected mortality rate. Their score of 0.82 means that the trust has one of the 10 lowest SHMIs in the country. Serious Incidents and Never Events Safeguarding Falls and pressure ulcers VTE Assessments 19 Serious Incidents were reported in June, but no never events. The never event reported in May involved a retained object in a maternity patient. Investigations are ongoing and a full discussion on the WHO checklist is planned for an upcoming CQRG meeting to ensure that lessons are learnt and actions implemented by the Trust. GSTT consistently met staff safeguarding training targets for both adults and children throughout 12/13 and have continued this good performance into Q1 of 13/14. Their performance of 87% staff trained on adult safeguarding and 85% staff trained on level 3 child safeguarding is the Trust s highest compliance level in over a year. Grade 2 pressure ulcer information and Falls are currently derived from the national safety thermometer submissions. These are a single point of data collection in a month. The data source for future reports will be obtained from the Trust for the full month. These include attributable and non attributable incidents. Grade 3 and Grade 4 pressure ulcers and Falls resulting in Major harm or Death are reported as serious incidents with data obtained from the national STEIS system. The number of major falls in June (1) is slightly higher than the same point last year (3 vs 1) but the number of moderate falls has decreased substantially, with only 1 reported compared with 7 in the same period last year. 3 Grade 3 and 4 pressure ulcers in April and 19 in May. Both figures however show raw data it is expected that the majority will be de-escalated as they will either be non-attributable to the trust or unavoidable. For reference, GSTT had no attributable Grade 4 pressure ulcers throughout 12/13. As part of a national CQUIN, Trusts are targeted with completing VTE risk assessments for a minimum of 95% of patients. These figures will be reported quarterly and as such are not 19
currently available for this financial year. However, in Q4 of last year, GSTT completed risk assessments for 95.09% of patients, indicating that the target should be achievable. Complaints Friends and Family Test (FFT) The level of complaints received by GSTT has been on an upward trajectory over the last year, with April s figure of 110 being the highest recorded for over 2 years. Complaints will be discussed as a substantive item at the next CQRG meeting, and a fuller briefing will be available in next months report. Response rates to complaints were unavailable at the time of publication. As with most trusts, GSTT has struggled to consistently meet the 15% response rate target set by NHS England, particularly for A&E. The breakdown of net promoter scores for quarter 1 was 48 for A&E and 78 for inpatients. As national data has yet to be published, it is not possible to assess how these scores compare with other trusts. 20
Clinical Quality Review Group Update - Guy s and St Thomas s NHS Foundation Trust Each of the SE London Trusts has now increased the frequency of their Clinical Quality Review Group (CQRG) meetings to monthly in order to allow for issues relating to the quality of services to be discussed in more depth. The below summaries give an overview of the areas of discussion at the last CQRG meetings and an indication of topics due to be discussed at upcoming meetings. Cost Improvement Plans From 2013/14 CCGs are required to assure themselves that any cost improvement plans (CIPs) that their providers initiate have been assessed for quality, with any project that it is deemed to be high risk or high value to be assessed by the CQRG. At the June CQRG, GSTT presented an overview of the CIPs that they intended to introduce in 2013/14. CIPs have been developed following extensive staff engagement, and as part of GSTT s Fit for the Future programme, which is an overarching change programme designed to improve safety, quality and efficiency. The total value of GSTT s CIP plans for this year is 70m, or 10% of controllable expenditure. In order to ensure that any of the CIP schemes did nor negatively impact on quality, the programme had an in built assurance process involving sign off from executive directors including Medical Director and Chief Nurse which is replicated at directorate level with clinical and nursing leads and a senior responsible officer who represented the work stream at the Programme Board. The CQRG were assured that whilst GSTT had planned for a CIP saving of 16m against pay, this should not lead to job significant losses and should instead be made by savings accrued from the reduction in bank and agency spend due to higher levels of substantive staff in post. The CQRG agreed that the development process and governance arrangements appeared robust but asked GSTT for more detail on individual schemes. The impact of CIPs will be monitored by the group throughout the course of the year. KCL Governance Arrangements Quality Alerts In recent months there have been a number of Serious Incidents (and Never Events) relating to dental surgery conducted on GSTT premises by King s College London (KCL) dentists. The CQRG had asked for assurance that KCL staff were sufficiently aware of GSTT clinical protocols and governance procedures. It was confirmed that the Trust had met with KCL representatives and that it had been reaffirmed that all KCL staff operating on GSTT premises would be subject to GSTT clinical governance arrangements. GSTT has clinical representation on KCL committees and all incidents were (and would continue to be) recorded on DATIX and sent to commissioners as part of SI reporting. Investigations and, where appropriate, disciplinary procedures are ongoing in relation to recent incidents. It was noted that improvements have been made to the Quality Alert process. Quality Alerts allow GPs to report any issues which impact on the quality of services that patients receive. Previously 21
Future Agenda Planning Quality Alerts have been a one-way process from GPs to providers, but improvements have now been made to make it possible for providers to report quality issues relating to primary care. The process has also been made simpler. The system has been re-launched for GPs and work is underway to also enable reporting by hospital staff. Key themes that have been identified following recent Quality Alerts have included issues relating to Choose and Book, communication with patients and GP practices, and concerns regarding discharge and referral processes. Work is ongoing with GSTT to address these issues. The main focus of the July CQRG was on complaints and patient experience. GSTT presented on real time patient feedback, how the complaints process works, and case studies on how complaints and feedback were handled, what lessons were learnt, and how feedback has affected changes to the quality of patient care. This month s meeting also discussed Quality Alerts, the Friends and Family Test, and the recent publication of consultant level mortality data. Planning is currently underway to redesign the agenda of the CQRG in order that topic items can be set well in advance to allow adequate time for preparation for the Trust and commissioners and in order to stimulate a full and well-informed discussion. 22
4.4 South London & Maudsley NHS Foundation Trust A quality dashboard for SLaM will be developed for the Q2 report. 1 2 Quality Issue Identified Numbers of patient s receiving physical health checks Quality of patients assessment and triage, Primary Care access to Assessment Service and demand for in-patient beds Commissioner Actions Taken and Planned SLaM required to perform physical health checks on all new admissions and additional tests on patients receiving antipsychotic medication as part of 2013/14 CQUIN.. Baseline at Q1 for new admission is 22% and for those who receive antipsychotic medication is 56% has been established. Quarterly targets to be established in near future. In response to the mixed quality of provision and fragmented assessment process Lambeth s Living Well Collaborative has developed a service offer which seeks to develop a front end assessment function that intends to integrate primary care, social care, and voluntary sector into a coordinated hub that acts as a gateway to secondary mental health services. A coordinated hub that integrates key assessment functions will potentially better manage demand into Lambeth s inpatient services which are presently struggling to meet local demand as well as provide a coordinated and transparent approach to bed management, delivery of treatment interventions, and discharge into the community. CCG Group with Oversight LSLC Lambeth CCG 3 The IAPT service is now part of the new talking therapies service so I would delete Number 3. 4 Dementia assessment s needed to be carried out in 2013/14 to achieve national target. Liz to check. Patients over the age of 65 on anti-psychotic medication without a dementia assessment identified as key group to target and will be raised with individual practices. Increased capacity in Memory Service to carry out more assessments and review dementia register with GPs to ensure it is accurately reflecting demand. The Easy In / Easy Out CQUIN aims to increase the number of users who when discharged who have a Discharge Summary comprising of discharge and crisis support elements from the over-arching Recovery and Support Plan sent to their GP within 7 working days. Lambeth and Southwark CCG 5 Numbers of patients receiving copies of their care plans and GPs experience of referral process SLaM will also work to improve response rate to GP questionnaires and develop action plan to identify how they will improve GP satisfaction LSLC This CQUIN is linked to the 2013/14 Lambeth Living Well Collaborative initiative which established the community options service which aims to provide effective support to patients discharged from secondary to primary care identifying the necessary support provision that will enable them to be effectively managed within primary care.. 6 Improve quality of talking therapies service inadequate review of first six months of Integrated Talking Therapy Service to be undertaken in September 2013 by Community Sense and agree action plan December 2013 Lambeth CCG 23
4.5 St George s Hospital NHS Trust 1 2 Quality Issue Identified SI management responsibilities previously carried out by the PCT and NHS London transferred to NHS Wandsworth Clinical Commissioning Group (WCCG) from the 1 st April 2013. SGH undertook an internal deep dive review of C.Diff. Subsequently SGH suggested that they would adopt an approach involving the review of all cases clinically at a Review Committee meeting post a microbiological diagnosis of C.Diff. By using the Review Committee meeting post a microbiological diagnosis approach the number of cases would be reduced. The Clinical Support Unit Infection Control Specialists raised concerns regarding this approach, asserting it was not in line with the Trust Development Authority (TDA) and Department of Health (DH) guidance. Commissioner Actions Taken and Planned A policy was developed by WCCG Clinical Governance Team to explain the responsibilities and actions for dealing with Serious Incidents (SIs) and the tools available to help within the new English NHS structure from April 2013. The Wandsworth CCG Serious Incident Management Policy and Procedure has been approved for use within WCCG and by its commissioned provider organisations. Infection control team took extensive advice from the TDA and DH WCCG IGC meeting discussion. Outcome/conclusion: The SGH microbiology team should consider developing a system whereby all C.Diff stool requests are assessed to ensure the patients have clinical symptoms PRIOR to testing Once treated and positive the result has to be uploaded The retrospective analysis should continue as a means to inform local commissioners and would be used as a means of assessing against a local target CCG Group with Oversight WCCG Integrated Governance Committee (IGC) WCCG Integrated Governance Committee (IGC) 24
Safety Quality Dashboard St George s Hospital NHS Trust Category Indicator Target Apr May Jun Jul Aug Sept Data source Reporting Period Mortality: SHMI* Quarterly <1 0.8174 0.8174 0.8174 HSCIC SIs: Number of SIs reported (TOTAL including Never Events, falls that result in major harm or death and Grade 3 and 4 pressure ulcers attributable and unattributable) Monthly 47 35 12 STEIS Number of Never Events Monthly 0 0 0 1 STEIS CAS Alerts Outstanding Monthly 0 0 1 1 NPSA Adult Safeguarding: % of staff compliant with training Quarterly 80% Not available Not available Not available TBC Child Safeguarding: %of staff compliant with training Level 2 Quarterly 80% Not available Not available Not available TBC Child Safeguarding: %of staff compliant with training Level 3 Quarterly 80% Not available Not available Not available TBC Falls: Moderate Harm* Monthly 4 5 Not available NHS Thermometer Falls: Major Harm Monthly 0 0 0 STEIS Falls: Death Monthly 0 0 1 STEIS Pressure Ulcers, Grade 2* Monthly 67 53 Not available NHS Thermometer Pressure Ulcers, Grade 3 (attributable) Monthly 31 16 6 STEIS Pressure Ulcers, Grade 4 (attributable) Monthly 3 0 1 STEIS VTE Risk Assessments Completed on Admission Quarterly 95% 95.2 94.4 95.0 Unify 25
Experience Complaints: Number of complaints TBC Monthly Not available Not available Not available Complaints: % replied to within 25 days 85% Monthly 78 670 76 Trust Data Friends and Family Test: Net promoter score FFT national data Monthly 48 60 59 Unify Fig 3. Quality Dashboard *Data has not yet been validated. CQUINS will be reported on a quarterly basis in a separate report. 26
Quality Commentary St Georges Hospital NHS Trust NPSA CAS Alert Pressure Sores The overdue alert reference is NPSA/2009/PSA004B Safer Spinal (intrathecal), epidural and regional devices Part B. The issue is not particular to SGH. The Trust is keen not to act in isolation and a decision has been taken to wait for more robust evidence before making a change to one system. Pressure ulcer data is from Unify2. Serious Incidents and Never Events Complaints There was one never event which occurred in June but was reported in July involving a retained object in a maternity patient. Investigations are ongoing and a full discussion on the WHO checklist is planned for an upcoming CQRG meeting to ensure that lessons are learnt and actions implemented by the Trust. 76% of complaints received in June were responded to within 25 working days. This is an improvement on May s results. 88% of complaints with an agreed extension were resolved within that agreed deadline. In June, 7% of complaints were re-opened. Healthcare Acquired Infections MRSA C-Diff CQC Inspection- January 2013 The number of MRSA infections had reached 2 by the end of May. There is a zero tolerance for incidences of MRSA in 2013/14, with a financial penalty of non-payment of the inpatient episode. All MRSA cases are subject to review at the Clinical Quality Review Meeting. The accumulative number of C-diff infections by the end of May was 12. A multi stakeholder meeting took place with the Trust on.to review the Trust s performance including review of all root cause analyses since January 2013. Commissioners were assured of the Trust s actions and no trends were identified. In January 2013 St George's Hospital (Tooting) was subject to a routine inspection by the Care Quality commission of compliance against eight of the 28 essential standards for quality & safety. The CQC found much to commend in their report, including many positive comments direct from patients and their families. Most of the people the inspectors spoke to said they d had a good experience and praised the hard work of the Trust s staff. 27
Friends and Family Test (FFT) However, the report also highlighted a number of individual instances where the inspectors observed that the care provided or the environment for patients fell short of expectations. The report identifies six areas of non-compliance in which action is required. Of these six areas, three were considered by the CQC to have a minor impact on patients and services and three were considered to have a moderate impact. There were no observations which had a major impact on patients. All actions highlighted as a result of the inspection have been completed as at the 1 st July 2013. As with most trusts, St Georges has struggled to consistently meet the 15% response rate target set by NHS England, particularly for A&E. The breakdown of net promoter scores for quarter 1 was 46 for A&E and 64 for inpatients. 28
4.6 Continuing Care Providers 1 Quality Issue Identified Monitoring the quality of care in nursing homes in Lambeth Commissioner Actions Taken and Planned Awarding of contracts via AQP process Re-opening AQP window for other providers to apply Encouraging non AQP providers in Lambeth to join the AQP Framework to support improvement in quality and contract monitoring. Develop joint contract monitoring mechanism with Lambeth ACS Scope out collaborative commissioning approach to health offer for care homes CCG Group with Oversight SCMT 2 Monitoring the quality of care in out of borough nursing homes Use of the AQP Framework to monitor quality in homes outside the borough Implementation of the Winterbourne action plan SCMT 3 Maintaining improvements in end of life care Supporting the implementation of the CMC Register, including GP outcome targets for CMC and preferred place of death Supporting the continued roll out of the Care Home GSF Review use of Liverpool Care Pathway (LCP) and resuscitation guidance following local coroners ruling and National Review of the LCP Analysis of acute admissions at end of life (Lambeth and Southwark) to identify opportunities to support admission avoidance Analysis of place of death information Unplanned care programme board 4 Quality improvements in children s continuing care providers 4 borough tender process for a children s continuing care provider framework with a focus on quality of care provision 29
4.7 Primary Care (including WIC, community outpatients etc.) 1 Quality Issue Identified Reducing Variation in quality and outcomes in primary care Commissioner Actions Taken and Planned Support for practices - virtual clinics, training, clinical facilitators, referral checklists Practice visits for specific issues Practice Development Plans Primary and Community Care Strategy Development CCG Group with Oversight PCCSG (Primary & Community Care Strategy Group) 2 Improving access to GP services Primary and Community Care Strategy Development PCCSG 3 Delivering better Integrated Care Primary and Community Care Strategy development and implementation SLIC development Risk Profiling Enhanced Service development and implementation PCCSG 4 Walk In Centre inappropriate service use (substitution of regular GP appointments) Commencement of Quarterly Contract Monitoring Meetings Broader Review in light of King s Urgent Care Service CCG Commissionin g Strategy Committee 30
Section 5: Patient Experience 5.1 King s College Hospital NHS Foundation Trust Patient Experience Themes Summary of Patient Experience Data & Information Actions agreed with provider 1 Response to Francis Report Working group set up, with workstreams including Listening to patients. CCG has been invited onto Francis group. Actions include inviting patients to staff listening events, including patient stories in KCH comms, reviewing complaints procedures etc. CCG to sit on Patient Experience Committee. Group Responsible for Oversight CCG IGP SMT Quality Working Group 2 Cancer Patient Experience National Cancer Patient Experience result place KCH in bottom quartile. Cancer patient experience not agreed as a CQUIN. Cancer PE not included in Quality Accounts as priority for 13/14. Trust actions focussing on internal improvements. CCG to raise request for update via CQRG. KCH CQRG 3 Inpatient Survey KCH was the most improved of all London Trusts and were in the upper quartile in several areas. The vast majority of Trusts who performed best in the survey were specialist units, and that if those are removed, KCH is one of the top performers. None. KCH CQRG 4 Friends and Family Overall performance for the new Friends and Family Test for the Q4 12/13 was positive with scores of 61.4 and 63.8 for January and February. The average response rate for inpatients for January and February was just over 32%. F&F implemented in A&E in April after piloting in Feb and March. Low response rate, meaning total response rate below 15% national target on a Trust aggregate basis. Issue being tracked via CQRG. Local CQUIN agreed, including A&E uptake rate. Trust exploring use of IT and other innovations to increase A&E uptake. KCH CQRG EPEC 31
5.1 King s College Hospital NHS Foundation Trust Patient Experience Themes Summary of Patient Experience Data & Information Actions agreed with provider 5 Betty Alexander Unit As part of the Dulwich engagement process, issues were raised by a Southwark carer about the quality and patient experience of the Betty Alexander Suite since its move to Denmark Hill. In particular, physical space, patient transport and discharge arrangements were highlighted as being of concern. The CCG supported investigation into the issue, including visit to the unit by GP lead along with the complainant. Issue discussed at CQRG in February, with Trust report on actions taken in response to user complaints. CCG and KCH have agreed that issues to be taken forward under umbrella of overall Frail Elderly integration workstream in future The Trust have shared detailed PE figures for the unit which overall are very positive, and shared improvement plans for transport, which was acknowledged to be an issue. Group Responsible for Oversight KCH CQRG Increase in the number of complaints 651 against a target of 540, up 10% compared to 2011/12. Reduction in number of complaints in Q4. 6 Summary of Complaints (Key themes) Complaints Response times continue to be an issue, with only 47% of complainants receiving a response within the target time compared with the 70% local target. In addition there has been a slight increase in the number of cases referred to the Ombudsman. Complaints handling is a key area of focus with the Trust, with commissioners seeking assurance around actions to improve performance. CCG to continue to monitor trend in number of complaints and areas they are coming from and to raise concern over response times via the CQRG and other for ums. GSTT CQRG 32
5.2 Guy s & St. Thomas s NHS Foundation Trust (including Community Health Services) Patient Experience Themes Summary of Patient Experience Data & Information Actions agreed with provider 1 2 Complaints Difficult defining the CCG s role and hence what information would best serve that Francis Report GSTT Response GSTT have delays in responding to complainants (and closing issue) against their own deadline of 25 working days Themes within complaints are predominately - Standard of clinical care, esp negative impact of procedure - Poor communication - Attitude and behaviour However many of these could be interchangeable so difficult to pinpoint Significant engagement has occurred throughout Trust to hear staff views through focus groups, surveys. Questions asked were - How to put patient first? - How do we encourage speaking out? - How do we make sure we listen to staff and patients? Dementia awareness training has been delivered to over 8,000 Trust staff using the Barbara s story video GSTT NED had sampled 9 complaints to understand blockages in system. Recommended 1. amendment to tracking made where complainant agrees to extension. 2. language used does not offer enough compassion 3. complaints with multiple organisations involved are complex however GSTT should be prepared to lead and prompt others for responses To be a regular agenda item for CQRG. Having started with staff views GSTT were encouraged by HealthWatch to widen their feedback loop to patients. Group Responsible for Oversight GSTT CQRG GSTT CQRG One-stop feedback: target is 85%+ for each of 6 feedback areas covering patient experience. Highest area was listening/respect/dignity = c93%. Lowest was giving the patient clear information = c78% 3 Patient feedback, Inpatient survey, friends/family Patient feedback is collected via handheld devices and goes to Ward Sisters on a very regularly basis (daily??) and is discussed at weekly staffing meetings. F&F: DH expects minimum response rate of 15%. GSTT have set wards minimum target 20% based on an average of discharges for their ward over a 9 month period. CQRG requested sight of the patient feedback. GSTT CQRG 33
5.2 Guy s & St. Thomas s NHS Foundation Trust (including Community Health Services) Patient Experience Themes Summary of Patient Experience Data & Information Actions agreed with provider 4 Discharge letters Quality of letters (content, use of acronyms) deemed unacceptable by GPs. Also, issue had occurred whereby IT failure resulted in about 4k electronic discharge letters not being sent out. Investigation showed this was due to deterioration of a server which was not corrected. Recommendations for corrective action are being implemented. Discussions led by LCCG (John Balazs). Flagged to Medical Director for assurance of corrective action. GSTT responses have been slow Group Responsible for Oversight GSTT CQRG 34
5.3 South London & Maudsley NHS Foundation Trust Patient Experience Themes Summary of Patient Experience Data & Information Actions agreed with provider 1 Complaints There were 555 complaints recorded by SLaM from 1 st April to 31 st March. This was an increase of 1% from the previous year 2010/11 in which the Trust received 551 complaints. SLaM complaints and compliments are monitored on a monthly basis via core contract monitoring meetings. Group Responsible for Oversight CCG 1. Involvement with BME groups to work with young people in care on improving ambition and life chances. 2 SLaMs Single Equality Scheme 1. Targeted mental health promotion working with groups at greatest risk. 2. Improving engagement with BME communities. 2. Mental Health Promotion team and Spiritual and Pastoral Care service deliver training to local faith leaders and groups on mental health, wellbeing and spirituality SLaM 3. Improving employment opportunities for service users 3. SLaM supports service users to participate in peer support, volunteering and time bank schemes with some of these opportunities being financially reimbursed. 3 Eliminating mixed sex accommodation The Trust remains complaint with EMSA requirements and there were no breaches in FY 2012/13. Mixed Sex Accommodation included as a Quality Indicator in the 2013/14 contract where it s reported monthly with a sanction of 250 per patient per day. CCG 4 2013/14 CQUIN - SLaM The SLaM Patient and Public Involvement (PPI) team will run focus groups with ward link workers to identify the top 5 issues which they feel need to be improved. The patient experience CQUIN will establish a baseline in Q1 of areas that need to be improved with SLaM producing an action plan in Q2 and progress against this action plan evaluated by focus groups in Q3. a CCG 5 Patient Experience SLaMs PPI team undertake regular, anonymous surveys of patient experience which is fed back to CAGs to make improvements. This initiative very much links to the 2013/14 patient experience CQUIN described above. SLaM 35
5.3 South London & Maudsley NHS Foundation Trust Patient Experience Themes Summary of Patient Experience Data & Information Actions agreed with provider 6 7 Recovery and Support Plan CQUIN Summary of Complaints (Key themes) The CQUIN incentivises the implementation of the new recovery and support plan that places the service user at the centre of the care/support planning process where they are supported to define their own goals based on their personal needs and aspirations. 145 complaints received in Q4 2012/13. 65 for treatment and care, 31 for attitude and behaviour and 9 for communication. A baseline for this CQUIN will be established at Q1. A target for Q4 will be agreed which seeks to significantly improve on the number of support and recovery plans completed within Adult Mental Health. In addition, the CQUIN requires SLaM to produce an implementation plan that identifies the specific initiatives introduced to increase the number and quality of support and recovery plans completed. The evidence that this plan has been successfully implemented will be evaluated. SLaM has a panel which meets at the end of the year to look at trends and analyse complaints across all CAGs. They agree actions and feedback to SCCG which will influence Mental Health commissioning intentions for 2014/15. Group Responsible for Oversight CCG SLaM 36
5.4 St George s Hospital NHS Trust Patient Experience Themes Summary of Patient Experience Data & Information Actions agreed with provider 1 Appointment waiting times 2 Francis report 3 Complaints In 2012/13 various patient groups and service users looked at the culture of outpatients, outputs of the business and improving the patient journey. A service improvement plan has been produced to improve key areas identified. Improvement plan has 5 aspects. As at June 2013the following have been implemented Improving case note availability at clinics 97% now prepared and provided 3 days in advance of clinic Improved appointment booking process centralisation of call booking system urgent care pathway team designed cross division working to enable sickness/leave cover Two approaches to the Francis Report agreed To complete a response to the 290 recommendations in the report applicable to the trust To consider the high level corporate commitments that the Trust Board will make in response to the key findings of the report to improve quality for patients. 7 high level corporate commitments agreed. Action plan to be developed. In 2012/13 the Trust saw a decrease in the number of complaints received. There were 828 formal complaints, a decrease of 20% on 2011/12 (1031 complaints). The top themes were Clinical Treatment Communication/ information to patients Appointments delay/ cancellation Attitude of staff The PALS department was contacted on 6753 occasions for help and assistance during 2012/13 an increase in contacts from the previous year. The top themes were Request for information Appointments Communication Care. Monitor outpatient service improvement programme Review success criteria as improvements in processes may not reflect and match the patient experience Action plan to be monitored by SGH Quality and Risk Committee and reviewed by SGH Trust Board and by Wandsworth CCG Nursing to focus on the 30 recommendations in the report focused on Nursing in conjunction with the CQC report and national strategy for compassionate care Review complaints procedure and policy PALS re-launch Group Responsible for Oversight WCCG CQRG WCCG CQRG WCCG CQRG 37
5.5 Primary Care (including WIC, community outpatients etc.) Patient Experience Themes Summary of Patient Experience Data & Information Actions agreed with provider Group Responsible for Oversight 1 Improve access Annual Patient Survey 46 providers with various access issues Practice Development Plans Summer 2013 Primary & Community Care Strategy Group 2 Reducing Variation in quality and outcomes in primary care QoF data 46 providers with various issues Practice Development Plans Summer 2013 Primary & Community Care Strategy Group 3 Access to diagnostic services at each practice Out of Hospital Event 46 providers with various services Phlebotomy Service Review to be completed Summer 2013 PCCS Primary & Community Care Strategy Group Commissioning Strategy Group 38
Section 6: Engagement Issues and Feedback Patient engagement themes and quality issues that arise through our engagement work are documented below by provider with a note of how it was captured. CareConnect a new system currently being piloted via NHS Choices was launched on 1 August 2013. GSTT are taking part as a pilot site. Patient engagement themes and quality issues identified by patients, carers and local people will be categorised and listed below according to provider along with actions taken to address the issues. Data is currently unavailable but will be included in future reports. 1 2 Name of Provider(s)/ Service Guy s and St Thomas NHS Foundation Trust SLaM Patient Engagement Themes As part of the current review into the Urgent Care Centre at Guy s hospital, we have posted on the SE1 Forum and the website to ask for feedback on experience of using the service. We have only had a few responses but the majority are from people who have used the service with children all responses have indicated a positive experience with the service but one person indicated they had been made to feel that they shouldn t have been there but at the GP. A previous thread on the same forum about the Minor Injuries Unit indicated that most people who posted were concerned about the shorter opening hours of MIU. Joint engagement programme with Lambeth CCG and SLaM as part of the QIPP continuing care re-design programme. Monthly meetings are being held during the engagement process both at Woodlands and Greenvale Family member representation on the joint SLaM and CCG Governing Group overseeing the work Family member representation on the subgroup specifically tasked to carry out environmental assessments BIG Lambeth Health Debate discussion 11 July 2013 Information presented to Older People s Partnership Board on 17 th July 13 Actions Identified Feedback from local people via the website, SE1 forum and the engagement event due to take place on 29 May will be incorporated into the review paper which will be presented and discussed at Commissioning Strategy Group in June and the Governing Body in July 2013. Feedback from families has been included in the tool used for the environment assessment Need to support families during this process and if their relatives are moved to another home. Details of engagement process to be included in recommendations paper going to CCG board for decision at board meeting on 4 th September 13 39
3 Name of Provider(s)/ Service SLaM NHS Foundation Trust Patient Engagement Themes The on-going work programme of Lambeth s Living Well Collaborative has engaged systematically with service users accessing mental health services across the primary and secondary care spectrum. They have consistently fed back a fragmented and mixed experience from services where they are not always listened to with their own goals and aspirations not at the centre of the support planning process. Overall service users have expressed a dis-satisfaction with mental health services in the current manner in which they are delivered, The over focus on clinical and risk needs has led to the patient being viewed as an individual person being lost. Actions Identified In response to this feed the Collaborative has sought to introduce service initiatives which improve the experience of users accessing mental health services and also plan to implement a service offer which aims to radically improve the quality and experience of the assessment process with a more coordinated approach to delivery of treatment options. 4 BIG Lambeth Health Debate (BLHD) BIG Lambeth Health Debate discussion 8 August 2013 Public Launch 12 July 2013 HealthWatch Lambeth 17 July 2013 Lambeth Country Show 20-21 July 2013 DMI Patient Forum Committee 31 July 2013 40
Section 7: Quality Alerts 7.1 Quality Alerts: Overall Themes & Actions Q1 2013-14 Quality Alerts Theme CCG and Provider Actions 1 2 3 Accuracy of hospital held information This includes letters being addressed to the wrong practice (within the same building) Trust policy on discharging patients after re-arranging appointment/dnas. Discharging patient due to re-arranging appointment more than once Discharging patient after single DNA due to miscommunication Appointment booking, including Choose and Book Unavailability of some clinics through choose and book. Delays in 2 week referrals due to vetting Delays caused by referrals being missed Issue highlighted to KCH, GSTT, and SLaM by Southwark CCG Individual patient records have been updated by KCH and GSTT KCH continuing to investigate reasons for letters being sent to incorrect GP GSTT have requested PIMs update re:gp details CCG have recommended to GP practice implementation of internal protocol for instances where correspondence is received incorrectly KCH confirmed that this is current policy Appointments made for individual patients Paper highlighting this theme to be made substantive item for September planned care board Southwark CCG Alerts triaged to following provider departments: KCH Paediatrics; Cardiology; MCATS GSTT Obstetrics; Paediatric Plastic Surgery; Gastroenterology; Cardiology; Endocrinology Individual appointment bookings resolved Alerts highlighted to trust C&B project managers and individual issues resolved with GPs Theme being picked up via the choose and book steering group Practice representatives have been invited to attend the national user group meetings GSTT addressing choose and book issues identified with individual clinics KCH working to increase proportion of directly bookable C&B services from 30% to 50% by end of year KCH developing link between C&B and DOCMAN so that referrals booked in C&B can be easily vetted by clinicians Communication to go out via GP bulletin (14 th August) highlighting where to find referral information for individual clinics and how to escalate if information is incorrect. 41
Quality Alerts Theme CCG and Provider Actions 4 Trust approach to onward/internal referral Discharging patient back to GP for re-referral Requesting GP to make diagnostic tests Querying internal referral to further specialism KCH undertaking audit of onward referral from ED Alerts triaged to following provider departments: GSTT Pain clinic; Gynaecology; A&E; Physiotherapy KCH A&E; Allergy SLaM 5 Quality and timeliness of discharge communications Inaccurate/missing clinical information Lack of information regarding onward care Missing patient details Missing clinician details Discharge summaries unsent or delayed Alerts triaged to the following departments: GSTT A&E; Ophthalmology; Acute services KCH A&E; Cardiothoracic Surgery SLaM 42
7.1.1 King s College Hospital NHS Foundation Trust Quality Alerts Theme CCG Actions Outcomes The Datix system used by Lambeth CCG has been reviewed and relaunched in July 2013 as QUIC and there is now one easier reporting system for inputting Quality Alerts as well as Incidents and Commendations. Lambeth CCG are working with GSTTFT and GPs to encourage and enable two-way Quality Alert reporting. 1 Quality Alert Reporting The updated system details will be made available to Southwark CCG as Lead Commissioner for King s to introduce the same model of working if required. Specific areas or themes will be identified as focus areas for reports going forward, e.g. Community Nursing Services / Discharges. Reports are being developed for GPs and other providers. In order for organisations who do not have direct access to the Lambeth CCG to access the Datix QUIC system for reporting and/or responses, a Citrix link is required. This needs to be followed up with IT departments at the provider and the CCG/CSU. 43
7.1.2 Guy s & St. Thomas s NHS Foundation Trust Quality Alerts Theme CCG Actions Outcomes 1 Accuracy of hospital held information This includes letters being addressed to the wrong practice (within the same building) Alerts triaged to appropriate department: KCH Nephrology GSTTT Plastic Surgery Where identified, individual records have been updated 2 Trust approach to onward/internal referral Discharging patient back to GP for re-referral Requesting GP to make diagnostic tests Querying internal referral to further specialism Alerts triaged by clinical governance team (or equivalent) at each provider to the appropriate department: GSTTT Clinical haematology GSTTT Paediatrics GSTTT Gynaecology GSTTT Cardiac Surgery Responses sent from provider departments clarifying reason for referral decision (either back to GP or for internal referral), or acknowledging that incorrect decision and relaying to team to improve future decision making. 3 Access to services Inability to refer directly for diagnostics Change in inclusion/exclusion criteria without notice Unavailability of service to start drugs at weekend Specimens not being collected from practice Alerts triaged by the quality assurance team (or equivalent) at each provider to the appropriate department: KCH diagnostic imaging GSTTT clinical haematology GSTTT Gynaecology Change in T-Quest form to reflect changes in inclusion/exclusion criteria for guy s phlebotomy. Plan for communication to be sent out to all practices regarding change in inclusion criteria Trust have organised for a courier to pick up specimens 4 Appointment booking Unavailability of some clinics through choose and book. Need for vetting of 2 week wait referrals leading to breaking of referral guidelines Unacceptable delays for urgent referrals Alerts triaged by the quality assurance team (or equivalent) at each provider to the appropriate department Individual issues with choose and book followed up with choose and book project management teams Choose and book issues have been brought to the attention of the Choose and book steering group GSTTT aiming to address choose and book issues identified with individual clinics Department management and staff made aware of issue with urgent referrals. 44
7.1.2 Guy s & St. Thomas s NHS Foundation Trust 5 Quality Alerts Theme CCG Actions Outcomes Quality of discharge communications Includes: Inaccurate/missing clinical information Lack of information on onward care Missing patient details Missing clinician details Discharge summaries unsent Alerts triaged by the quality assurance team (or equivalent) at each provider to the appropriate department: GSTTT A&E KCH General medicine KCH A&E GSTTT A&E identified internal issue with generation of GP letters A&E staff reminded to include basic information in discharge letter 6 7 Trust policy on discharging patients after rearranging appointment/dnas. This includes: Discharging patient due to re-arranging appointment more than once Discharging patient after single DNA due to miscommunication Communication and access to district nursing service. Includes: Lack of attendance at practice meetings Difficulties contacting district nursing team Lack of communication with patients and practice Alerts triaged by the quality assurance team (or equivalent) at each provider. SCCG to open discussions with provider regarding this discharge policy All alerts sent through to head of community nursing to investigate All individual alerts have been forwarded to Head of Adult Community Nursing Alerts to inform re-negotiation of contract for 2014/15 and targets set within this Proposal from JH to request figures on number of practice meetings attended by DN management 45
7.1.2 Guy s & St. Thomas s NHS Foundation Trust Quality Alerts Theme CCG Actions Outcomes The Datix system used by Lambeth CCG has been reviewed and relaunched in July 2013 as QUIC and there is now one easier reporting system for inputting Quality Alerts as well as Incidents and Commendations. Lambeth CCG are working with GSTTFT and GPs to encourage and enable two-way Quality Alert reporting. 8 Quality Alert Reporting The updated system details will be made available to Southwark and Lewisham CCGs to introduce the same model of working if required. Specific areas or themes will be identified as focus areas for reports going forward, e.g. Community Nursing Services / Discharges. Reports are being developed for GPs and other providers. In order for organisations who do not have direct access to the Lambeth CCG to access the Datix QUIC system for reporting and/or responses, a Citrix link is required. This needs to be followed up with IT departments at the provider and the CCG/CSU. 46
7.1.3 South London & Maudsley NHS Foundation Trust Quality Alerts Theme CCG Actions Outcomes The Datix system used by Lambeth CCG has been reviewed and relaunched in July 2013 as QUIC and there is now one easier reporting system for inputting Quality Alerts as well as Incidents and Commendations. Lambeth CCG are working with GSTTFT and GPs to encourage and enable two-way Quality Alert reporting. 1 Quality Alert Reporting The updated system details can be made available to Lewisham CCG as Lead Commissioner to introduce the same model of working. Specific areas or themes will be identified as focus areas for reports going forward, e.g. Talking Therapies in August 2013. Reports are being developed for GPs and other providers. In order for organisations who do not have direct access to the Lambeth CCG to access the Datix QUIC system for reporting and/or responses, a Citrix link is required. This needs to be followed up with IT departments at the provider and the CCG/CSU. 47
7.1.4 St George s Hospital NHS Trust 1 2 Quality Alerts Theme CCG Actions Outcomes Requirement to ensure that patients and carers receive excellent care delivered in a respectful and courteous way. Requirement for a process for alerts (positive and negative) to be made and coordinated by the CCG. Concerns re onward/internal referral/ 2 week rule referrals Discharging patient back to GP for re-referral Not making referral and no follow up A portal has been added onto the WCCG website named the Making A Difference (MAD) button. The MAD button allows GP practices to flag any concerns, issues, or feedback good practice about services for patients from our service providers. These issues may arise from patients referred, discharged or undergoing care, for example, concerns such as access, treatment, discharge, correspondence. The MAD button should not be used for serious incidents, complaints or issues requiring urgent resolution. It is in addition to and separate from the process for managing serious incidents and complaints. Alerts referred by clinical governance team to provider and requested to declare SI and investigate accordingly. MAD button available on WCCG website. Issues declared as SI by SGH. Investigation underway. Delayed treatment 48
Section 8: Clinical Visits and Clinical Audits 8.1 Clinical Site Visits & Audit Schedule Provider Audited / Visited Organisation undertaking the Audit /Visit Audit date St Thomas s Hospital - Routine inspection Guys Hospital Routine inspection GSTTS Pathology King s College Hospital Routine inspection GSTTT: Tunbridge Wells Kidney Treatment Centre SLaM CQC Routine Inspection Care Quality Commission Care Quality Commission Care Quality Commission Care Quality Commission Care Quality Commission 12 February 2013 14 February 2013 25 February 2013 12 March 2013 21 st March 2013 St Thomas s Hospital - CQC Routine inspection St George s Hospital Tooting site CQC Routine inspection Jessie Place (for those with mental health history) CQC Routine inspection Care Quality Commission Care Quality Commission Care Quality Commission 17 June 2013 31 st January 2013 29 th April 2013 49
8.2 Clinical Site Visits & Audit Detail Dulwich Care Centre 17 December 2012 Reported 24 January 2013 Provider Audited/Visited: Name and Purpose of Audit/ Visit: A subsequent visit on 9 August 2013 Reported 17 August 2013 found that the Staffing Standard was compliant. Routine Inspection - CQC The Dulwich Care Centre provides care for up to 92 people. The service is delivered across four floors; the lower ground delivers a residential service, the ground and first floors are for general nursing and the second floor supports people with dementia. The service had taken action to address some of the shortcomings identified in earlier inspections, but the CQC found that further improvements were needed. Description of Audit / Visit Improvements had been made to the storage, administration and recording of medication. New medicines trolleys had been purchased and checks were in place to monitor the safety of medicine administration. Steps had been taken to ensure there were sufficient numbers of staff on duty to care for the people using the service. The provider had improved the way in which the quality of the services was monitored. Care plans were found to be in place to address health care needs and there were appropriate referrals to health services. However, evidence was that the changing needs of one of the people using the service had not been adequately reviewed. People could not be sure their records contained appropriate information about their care and treatment. The CQC observed staff sitting with people and supporting them to eat at a pace that was appropriate for them. However, the majority of interaction between staff and people using the service observed was task-based, and the CQC found that evidence of individual needs were not always met. Key Actions Agreed By Whom By When The following standards were inspected and found to have been met: 1 Management of medicine Staffing Assessing and monitoring the quality of service provision The following standards were inspected and found to require action: Records Care and welfare of people who use services 50
Provider Audited/Visited: St Thomas s Hospital 12 February 2013 Reported 16 March 2013 Name and Purpose of Audit/ Visit: Description of Audit / Visit Routine Inspection - CQC Six surgery wards and an outpatient clinic in the older person's assessment unit were inspected. Particular attention was paid to the treatment and care of older people in these areas. Key Actions Agreed By Whom By When 1 The following standards were inspected and found to have been met. No actions were required. Consent to care and treatment Care and welfare of people who use services Staffing Complaints Provider Audited/Visited: Guys Hospital 14 February 2013 Reported 16 March 2013 Name and Purpose of Audit/ Visit: Routine Inspection - CQC Description of Audit / Visit The hospital s Elderly Care Unit and all three wards on the unit were visited Key Actions Agreed By Whom By When 1 The following standards were inspected and found to have been met. No actions were required. Respecting and involving people who use services Cleanliness and infection control Staffing Complaints 51
Provider Audited/Visited: GSTTS Pathology King s College Hospital 25 February 2013 Reported March 2013 Name and Purpose of Audit/ Visit: Description of Audit / Visit Routine Inspection - CQC The CQC looked at the personal care or treatment records of people who used the pathology service, observed how people were being cared for and talked with people who had come to the phlebotomy department for blood tests, staff and commissioners of services. Key Actions Agreed By Whom By When 1 The following standards were inspected and found to have been met. No actions were required. Respecting and involving people who use services Care and welfare of people who use services Cleanliness and infection control Supporting workers Complaints Provider Audited/Visited: GSTTT: Tunbridge Wells Kidney Treatment Centre 12 March 2013 Reported 25 May 2013 Name and Purpose of Audit/ Visit: Routine Inspection - CQC Tunbridge Wells Kidney Treatment Centre provides dialysis services, haemodialysis patient training, support for peritoneal dialysis patients and outpatient clinics. It is part of Guy's and St Thomas' NHS Foundation Trust. There are five four bedded bays and four private rooms on two floors. Description of Audit / Visit The CQC looked at the personal care or treatment records of people who use the service, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. The visit included discussions with people who use the service, carers and / or family members and staff and a review of provider information. Key Actions Agreed By Whom By When 1 The following standards were inspected and found to have been met. No actions were required. Respecting and involving people who use services Care and welfare of people who use services Safeguarding people who use services from abuse Supporting workers Assessing and monitoring the quality of service provision 52
` Provider Audited/Visited: Maudsley Hospital 21st March 2013 - Reported 12th April 2013 Name and Purpose of Audit/ Visit: Routine Inspection - CQC Three wards at Woodlands Nursing Home; Cedar, Yorkdale and Hillcrest. At the time of the CQC inspection Cedar was a mixed sex ward and had six people using the service. Yorkdale was an all female ward with nine people using the service, and Hillcrest was an all male ward with eight people using the service. The following standards were inspected and found to have been met: Consent to care and treatment Care and welfare of people who use services Assessing and monitoring the quality of service provision Description of Audit / Visit The following standards were inspected and found to require action: Cleanliness and infection control Supporting workers Records 11 of 14 CQC standards met. The following standards were not met: 1. People should be cared for in a clean environment and protected from the risk of infection 2. Staff should be properly trained and supervised, and have the chance to develop and improve their skills 3. People's personal records, including medical records, should be accurate and kept safe and confidential Key Actions Agreed By Whom By When 1 Domestic staff members spoken to were clear about their responsibilities and there was a cleaning schedule in place. SLaM April 2013 2 The manager of the service informed CQC that there were new plans in place to overhaul the supervision and appraisal processes introducing standardised and personalised objectives for each staff member. SLaM April 2013 3 Records were stored securely. However the service was not able to evidence effective record keeping in relation to the care and treatment provided to people using the service. CQC staff discussed areas of improvement with staff. SLaM March 2013 53
Provider Audited/Visited: St Thomas s Hospital 17 th June 2013 Reported awaited Name and Purpose of Audit/ Visit: Description of Audit / Visit Routine Inspection - CQC This was a routine visit to monitor compliance with the Mental Health Act and its associated code of practice, for which the Trust was given two months notice. Inspectors visited Accident and Emergency, spoke to staff from our services and partner agencies, and reviewed partnership arrangements with South London and Maudsley. A full report is expected shortly. Provider Audited/Visited: St Georges Healthcare NHS Trust 30/31st January 2013 Reported 2 nd May 2013 Name and Purpose of Audit/ Visit: Routine Inspection - CQC The CQC visited the Accident and Emergency department, paediatrics, maternity, stroke and rehabilitation, care of the elderly and the renal units. 2 of 8 CQC standards met The following standards were met: Safeguarding people who use services from abuse - People should be protected from abuse and staff should respect their human rights Supporting workers - Staff should be properly trained and supervised, and have the chance to develop and improve their skills Description of Audit / Visit The following standards were not met and action is needed: Respecting and involving people who use services - People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run Care and welfare of people who use services - People should get safe and appropriate care that meets their needs and supports their rights Meeting nutritional needs - Food and drink should meet people's individual dietary needs Cleanliness and infection control - People should be cared for in a clean environment and protected from the risk of infection Staffing - There should be enough members of staff to keep people safe and meet their health and welfare needs Records - People's personal records, including medical records, should be accurate and kept safe and confidential Key Actions Agreed By Whom By When 1 SGH have produced an action plan to address the issues raised by the CQC. This consists of 55 actions and learning points which will be monitored internally by SGH and WCCG informed via the via the WCCG CQRM (SGH) SGH 54
Provider Audited/Visited: Jessie Place: 39 Stanthorpe Road, Streatham 29 th April 2013 - Reported 30 May 2013 Name and Purpose of Audit/ Visit: Routine Inspection - CQC Jessie Place has accommodation for 6 people with a mental health history. Currently there is one Lambeth resident placed in this facility. Description of Audit / Visit The CQC found the following standards were met: Standards of caring for people safely and protecting them from harm Standards of staffing Standards of quality and suitability of management The following standards were not met and action is needed: Standards of treating people with respect and involving them in their care: consent to care and treatment Support that meets peoples needs: care and welfare of people who use services. Key Actions Agreed By Whom By When 1 LBL Adult Social Care Lead was advised of the report and is seeking a review of the facility. LBL 55
Section 9: Quality Surveillance Group (QSG) Update QSGs were set up in response to the Francis Enquiry and the new commissioning landscape that was created post April. There was recognition that because of the different structures that had been created there was a danger that quality could suffer through lack of clarity as to whose role it was to address quality issues. By collectively considering and triangulating information and intelligence, QSGs will work to safeguard the quality of care that people receive. The group s membership consists of Chief Officers of CCGs, Monitor, the TDA, CQC, HealthWatch and the CSU. Pressure Ulcers Friends and Family Test CQC Inspections Lewisham and Greenwich are undertaking a strategy review on pressure ulcers, to establish what more work can be done to reduce their incidents. The general consensus amongst other commissioners was that providers of both acute and community services had done a lot to reduce the rates of pressure ulcers, but there was a concern on how those home alone were being monitored and informed of the risks of pressure ulcers. It was also queried about how Care Homes can be required to report pressure ulcers, and how the CQC will monitor these issues going forward. It was agreed that a full discussion on pressure ulcers, what best practice looks like, and the role the CQC will play should be discussed more fully at a future meeting. A presentation was given on the first published results for the Friends and Family Test. Results were very mixed across South London, with some hospitals performing well on inpatient scores but poorly on A&E scores. In addition, there were several individual wards across London that had received negative scores, but these were based on very low response rates in some cases just 1 or 2 total responses over the period. There were also examples where Trusts with high numbers of patients responding that they were unlikely or very unlikely to recommend services had achieved a higher net promoter score than Trusts with lower overtly negative responses, but lower levels of patients who said that they were very likely to recommend services. It was agreed that although FFT could be a very useful tool, it may be some time before a consistent patterns start to emerge. Starting in October, the CQC will start to undertake a revised form of inspections for all NHS Trusts, Under the new inspections 8 different service areas will be inspected during one visit, and inspections will also occur during evenings and at weekends. The model of the inspection is based on the work that Bruce Keogh s team undertook on their recent inspections of Trusts with higher than expected mortality rates. All hospitals will be inspected by the end of 2015 and will be assessed against 5 key criteria: safety, efficiency, leadership, responsiveness to peoples needs and whether they are caring and compassionate. SLHT and Croydon will be amongst the first wave of hospitals inspected. 56
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