Quality and Patient Safety Report Board Meeting 17 October 2011 Author(s)/Presenter and title Sponsor Director Purpose of Paper Patient Safety/Quality Leads South Yorkshire and Bassetlaw Margaret Kitching, Executive Nurse Director To provide assurance to the Board in relation to some key areas of the Patient Safety/Quality agenda Key Messages/Issues Recommendations Each PCT in the cluster has a role to assure themselves that services are safe and of high quality. There are mechanisms locally within each PCT which provide this assurance. This report presents the first monthly overview of some of the priority quality and patient safety work being monitored and reviewed across the whole of NHS South Yorkshire & Bassetlaw. Providers need to maintain and sustain their performance in relation to patient safety and quality This summary report identifies where issues have been identified and provides assurance that there are actions in place The Board is asked to: Note the report and the assurance that it provides in relation to some elements of the patient safety and quality agenda Note that reporting and assurance mechanisms across the cluster are in place locally Acknowledge that work is underway across the cluster to align reporting processes 1
Background (brief summary) Analysis of Risks Equality Impact: This report presents the first monthly overview of some of the priority quality and patient safety work being monitored and reviewed across NHS South Yorkshire & Bassetlaw. Failure to monitor patient safety and quality issues and ensuring appropriate action is taken could have serious implications for patients, staff and members of the public as well as reputational, financial and operational risks. No Implications 2
Quality and Patient Safety Report Board Meeting 17 October 2011 1. Introduction This report presents the first monthly overview of some of the priority quality and patient safety work being monitored and reviewed across NHS South Yorkshire & Bassetlaw. In addition to these areas detailed reports on these and other areas will be routinely submitted for review to the Patient Safety Committee 2.0 Significant Issues The report contains key information and assurance in relation to some areas of the patient safety/quality agenda. This compliments the reporting and assurance mechanisms that are in place locally. 3.0 Recommendations The Board is asked to: Note the report and the assurance that it provides in relation to some elements of the patient safety and quality agenda Note that reporting and assurance mechanisms across the cluster are in place locally Acknowledge that work is underway across the cluster to align reporting processes Margaret Kitching Executive Nurse Director October 2011 3
Overview This report presents the first monthly overview of the some of the priority quality and patient safety work being monitored and reviewed across NHS South Yorkshire & Bassetlaw. Detailed reports on these and other areas will be routinely submitted for review to the Patient Safety Committee. Work is underway across South Yorkshire & Bassetlaw to review and align reporting mechanisms and processes to ensure that providers maintain and sustain their performance in relation to patient safety and quality. Healthcare Associated Infection August 2011 Report PCO ONLY Indicator Barnsley Bassetlaw Doncaster Rotherham Sheffield Period MRSA (trajectory up to 31.8.2011) 3 3 4 3 5 Cumulative Value 0 5 6 3 5 30/08/2011 CDiff (trajectory up to 31.8.2011) 35 15 30 33 79 Cumulative Value 58 16 31 36 162 30/08/2011 Actions Taken Locally re Cdifficile and MRSA Bacteraemia trajectories NHS Barnsley C-Difficile Commissioner Target At the end of August there had been total of 58 cases of C-Difficile against a target of 35 The increase in C-Difficile is a result of an increase in the amount of Norovirus in the community and other organisations which in turn has led to an increase in the amount of testing in patients. This has in turn identified patients with C-Difficile. Each case of C- Difficile reported in Barnsley is reviewed on a monthly basis by the root cause analysis group and unavoidable and modifiable cases are identified. Unavoidable cases include patients that have required antibiotic treatment as a result of their severe illness. For those patients where it was deemed modifiable action plans are in place and are monitored e.g. deep clean MRSA Year to date Target = 3, Year to date Actual = 0 4
NHS Bassetlaw C-Difficile Commissioner Target Cumulative year to date16 cases against a target of 15. One case in August (out of area patient). All cases of infection have been subject to the root cause analysis process. Scrutiny of antibiotic prescribing of all cases is in place in order to feedback validated data to prescribers. 11 out of 12 GP practices in Bassetlaw have targets to reduce Cephalosporin & Quinolone prescribing as part of the QOF Quality and Productivity targets, the other practice already being a low prescriber of these. MRSA Cumulative 5 cases against target of 3 (end of year target 3) 3 Cases in August. (2 of these relate to the same patient at Pinderfields Burns Unit but have been confirmed as separate episodes and not treatment failure of the original episode.) All MRSA bacteraemia s are subject to the root cause analysis process to review all aspects of the occurrence and action plans are in place for addressing areas found to be contributing to each case Data for both of the above is being critically analysed jointly between NHS Bassetlaw and NHS Doncaster NHS Doncaster C-Difficile Commissioner Target At the end of August there had been total of 31 cases of C-Difficile against a target of 30 NHS Doncaster infection prevention and control team continue to work closely with DBHFT, Bassetlaw PCT and other commissioned services. This includes jointly undertaking root cause analysis to identify and establish agreed actions against both MRSA bacteraemia and C-Difficile infection. The team also continue to monitor the agreed set trajectories across the health economy liaising closely with the performance team. NHS Rotherham C-Difficile Commissioner Target The provisional levels of C-Difficile (Hospital and Community acquired) to August 2011 amount to 36 cases against a target of 33. This is an improving trend but remains as a key issue for the whole Health community. NHS Rotherham s Infection Control lead is continuing to work closely with The Rotherham Foundation Trust (TRFT) Infection Prevention and Control Team. TRFT continue to report that they are on red alert with regard to C-diff. A C-Diff Infection Control Review meeting was held with TRFT in early July where a range of actions were agreed to help support the improvement in C-Diff rates. NHSR are monitoring this area very closely. 5
MRSA As at August 2011 NHS Rotherham have 3 cases of MRSA reported, against a target of 3. None of these are RFT acquired cases. NHS Sheffield At the end of August there had been total of 162 cases of C-Difficile against a target of 79 (end of August trajectory) This is a challenging national target. Contract target for STHT is 184 (last year s outturn). Trust Board level action plan in place since May. Significant financial investment has been made. CEO level leadership and a deep cleaning programme in place. RCA s are undertaken on every case. Expert review undertaken from former DH cleaner Hospital Team in August provided assurance that all correct action is being taken. Assurance visit undertaken in early September by SHA, PCT and HPA and full assurance provided. A gradual decline in weekly cases is now being reported. MRSA MRSA - as at the end of August there were 5 cases against target of 5 (end of August trajectory) RCA s were undertaken on 5 community cases (2 were contaminants and 1 was recurrence from previous case). 6
Serious Incidents Open Serious Incidents only including open Never Events NHS Barnsley NHS Bassetlaw NHS Doncaster NHS Rotherham Provider Open Sis of which Never Events BHNFT 19 1 Care Services Direct 5 SWYFT 11 NHS Barnsley not including Safeguarding 3 Independent Contractors 1 NHSB Safeguarding Children 4 NHS Bassetlaw (not safeguarding) 3 NHS Bassetlaw Safeguarding 1 (though not SCR) Bassetlaw Community Health 2 Nottinghamshire healthcare (relating to SY& Bassetlaw Patients) 3 Doncaster Community Healthcare 5 RDASH 44 DBHFT 23 Independent Contractors 0 Safeguarding Children 3 Prisons 6 Other Commissioned Services. 1 RFT 9 RDASH 12 Independent Contractors 0 Safeguarding Children 0 NHS Sheffield Sheffield Teaching Hospitals FT 13 Sheffield Health & Social Care FT 29 Sheffield Children's Hospital FT 2 Independent Contractors 2 NHSS (not including Safeguarding) 1 NHSS Safeguarding Children 3 NHSS Safeguarding Adults 0 NB for NHS Rotherham the figures for RDASH are performance managed by NHS Doncaster and will be included in their figures 7
Any Issues relating to out of area placements by exception only, NHS Barnsley No current concerns. NHS Bassetlaw No current concerns other than detailed in SCRs below Note: Child in the SCR action plan below was an out of area placement when he died NHS Doncaster No current concerns. NHS Rotherham No current concerns. NHS Sheffield There are two care homes where CHC patients are placed out of area causing concern, both in Rotherham. 1. Care Home 1 (Learning Disabilities) Safeguarding investigation Current suspension of placements. Three clients placed from Sheffield and plans are in place to move all three to other homes 2. Care Home 2 (Nursing) Safeguarding and Quality Investigation Current suspension of placements. Four clients placed from Sheffield who are currently being monitored and reviewed by CHC team. Castle beck Homes Embargos were immediately placed on all homes and now the regulator, the Care Quality Commission has now placed embargos on them. In Sheffield there are CHC or IFR funded patients in 12 Castle beck homes. All patients have been reviewed by Sheffield Continuing Healthcare team and appropriate action has been taken to ensure all these patient are safe. 8
Children's Safeguarding NHS Barnsley No new Serious Case Review s in September One open Serious Case Review Report with Ofsted. Feedback awaited. Completed within timescales One Serious Case Review has been recently commissioned. IMR reports currently being completed NHS Bassetlaw No new Serious Case Review s in September Open Serious Case Review Allegations of multiple abuse of children whilst looked after This is being led by NHS Nottinghamshire, but includes Bassetlaw children. Health overview report is under NSCB. Bassetlaw Community Health have submitted their report (short report, not IMR) DBH are submitting an IMR Serious Case Review Action Plans Separate Action plans for GP, DBH, Bassetlaw Community Health and Notts Healthcare are in place. Protected Learning Event organised. Awaiting Ofsted evaluation of the overview report and action plans. Note: though actions are progressing, some are behind original timescales NHS Doncaster Serious Case Reviews There are currently no Serious Case Reviews open within the health economy. Lessons Learnt Reviews There are currently five Lessons Learnt Reviews open within the health economy, two which have been reported to Doncaster Safeguarding Children s Board and a further three new cases. The Doncaster Safeguarding Children Board Serious Cases Panel met on 9 September 2011 to consider three new cases for Serious Case Review. At this meeting it was agreed that none of the cases met the criteria for a Serious Case Review however; it was agreed that a Lessons Learnt Review would be undertaken for all. One of the cases was historical and two cases were new. The terms of reference for these three Lessons Learnt Reviews are currently being developed by the DSCB Board Manager. All IMR s, Action Plans and Overview Reports have been completed and presented to the DSCB for the two current Lessons Learnt Reviews. The tables below provide an update on the action plans for these cases. 9
The table below provides an update on the first case. Provider Actions Completed Not Completed but Not Completed and within Timescale outside of Timescale DBHFT 13 9 0 4 NHSD 5 4 1 0 RDASH 6 3 3 0 The actions which have not been completed within timescale for DBHFT are as follows: Develop and agree a record for midwifery input with RDASH. Ensure this is distributed to relevant professionals within DBHFT and RDASH for consultation. Ensure use of the record within DBHFT and RDASH. Provide training to midwives attached to the Doncaster Drugs Service regarding use of the new assessment documentation. The new assessment documentation has been developed and is currently awaiting approval from DBHFT management. Once approved the documentation will be circulated to staff for consultation. The table below provides an update on the second case. Provider Actions Completed Not Completed but Not Completed and within Timescale outside of Timescale DBHFT 11 6 5 0 NHSD 1 0 1 0 DCIS 4 3 1 0 NHS Rotherham No new Serious Case Review s in September One open Serious Case Review, the report has been to Ofsted and was evaluated as Outstanding overall. IMR Evaluation Recommendatio ns Within Timescal e RCHS Good 5 Slight delay TRFT Outstanding 3 On target 10
GP Outstanding 3 On target Health Overview Outstanding 2 On target Rotherham Local Safeguarding Children s Board are not planning to publish the Serious Case Review until after Court Case, which is likely to be Spring 2012. Serious Case Review Composite Action Plan which is RAG rated available if required. NHS Sheffield No New Serious Case Review s in September One Serious Case Review s open with Ofsted evaluation completed. Two IMR action plans remain open one for GP s (2 actions outstanding) and one for NHS Sheffield (4 actions outstanding) which are on track Lesson Learned Review One lesson learned review open. 11
Adult Safeguarding NHS Barnsley No new Serious Case Review s in September There are currently no Serious Case Reviews open within the Safeguarding Adults process IMR Action Plan. One Action is outstanding re evaluation of partnership training being led by Local Authority. Compliance with the action plan is being monitored through existing processes NHS Bassetlaw No new Serious Case Review s in September There are currently no Serious Case Reviews open within the Safeguarding Adults process IMR Action Plans One action plan which relates to pressure ulcers within care homes. All actions taken except for one outstanding This relates to adult safeguarding supervision systematically to be put in place (currently happening as requested by staff but not automatically scheduled as it would be for safeguarding children), policy in place, staff supervision sessions are scheduled NSAB combined action plan Bassetlaw Community Health benchmarked against this action plan. The same action is outstanding as above. NHS Doncaster Serious Case Reviews There are currently no Serious Case Reviews open within the Safeguarding Adults process. Lessons Learnt Reviews There are currently no Lesson Learnt Reviews open within the Safeguarding Adults process. Domestic Homicide Review There is one new case which was identified on 3 October 2011. This will be considered for a Domestic Homicide Review. 12
NHS Rotherham No New Serious Case Review s in September One open Serious Case Review due to report to the Rotherham Safeguarding Adults Board NHS Sheffield No new Serious Case Review s One Serious Case Review open IMR action plan completed for NHS Sheffield actions Domestic Homicide Review There is one Domestic Homicide Review identified in April 2011 currently being undertaken 13
Any issues related to Southern Cross by exception only NHS Barnsley None noted No Southern Cross Homes in Barnsley, but several close to borders NHS Bassetlaw None noted - all the takeovers are going smoothly. Care homes Quality Monitoring Officer to re-check NHS Doncaster There are 5 homes in Doncaster affected by the Southern Cross situation. All homes now have transfer dates to new operators as approved by the landlords. Two homes, Eastfield hall and Swallow Wood transferred on 30 th September. Three further homes;- Warneford Amethyst and the Beeches will now transfer on either the 14 th October or the 31 st October. Out of Authority (OOA) There are a Total of 13 Homes with placements. The transfer dates will be either last week or one of the two subsequent dates. NHS Rotherham 6 Southern Cross homes are used by NHSR. A total of 105 Rotherham clients reside in these, which equates to 17.5% of the total client base. NHS Rotherham is aware of who is proposing to take these premises over. Work is currently in progress to assess the financial sustainability of the proposed landlords. NHS Sheffield 17 Homes owned by Southern Cross and transfers are in place to new owners, with a plan to complete by 31 st October. All staff are being transferred across. 14