Board meeting date: 15 December, 2011 Agenda Item number: 9.1 Enclosure: 6 Title Quality report Accountable Director: Authors(name & title): Maggie Bayley, Director of Nursing and Quality Maggie Bayley, Director of Nursing and Quality Paul Draycott, Associate Director of Nursing Peter Foord, Risk Manager Action required from the Board: Decision / Approval Gain assurance Discussion Information What other Trust Committee has considered this report? Committee Issues considered at Quality and Safety Committee Date reviewed 28 th October 25 th November Key points or recommendations Outlined in the report Purpose of the report To provide a briefing to the Board on Quality and Safety Issues within the Trust and actions implemented to mitigate any risks Summary of Key Issues What are the key issues that the board needs to consider in this report? There have been two Quality and Safety (Q&S) Committee meetings since the last board meeting. A number of key areas were discussed to provide assurance in relation to a systematic approach to review aspects of quality and safety. Detailed discussions and agreement took place in relation to the content of the quality indicators on the performance dashboard that would reflect outcome measures of performance rather than an input of indicators/incidences. Progress is being made by the teams to ensure the revised dashboard incorporates all elements required by the Primary Care Trusts (PCTs), at their monthly review with the Trust, and that future proofing has occurred to include metrics that Monitor have outlined as areas to include. The exception report on key quality indictors has now been split from the main performance report and key issues are highlighted in the report. Areas where monitoring is required are highlighted in the report, these include: pressure sores, falls, complaints and sickness levels. A key area of concern continues to be the number of serious incidents related to pressure ulcers in patients within the community setting in their own homes/ nursing homes. A review of the Serious Incidents reported has occurred in collaboration with the PCT to review actions taken. It is clear that as a Trust increased training has occurred with staff and proactive review of root cause analysis is taking place to ensure lessons learnt are highlighted and shared by all teams. Staff awareness of reporting appears to have Trust Board Quality Paper MB/PF/PD December, 2011 Page 1
increased which possibly accounts for the increased reporting, although this will be monitored to ensure every action is taken to prevent avoidable harm. This will be supported and monitored through the launch of the Harm Free work (previously Safe Care) being launched on 14 th December. No Never Events have been reported by the Trust. The number of patient incidents in October was the highest number in the last four months at 188, falling to 150 in November. This increase was due to a high number of pressure sores, both received in and developed under Trust care, and a higher number of falls in the community hospitals. Pressure sores have decreased to an average figure in November, and falls for November are the lowest level so far in 2011. Graph 1 shows the incident trends so far for 2011. Detailed reports in relation to the patient experience surveys have been discussed at Q&S committee. Members of the Q&S committee challenged the actions being taken to resolve concerns and assure themselves that lessons were being learnt. A specific concern was the response in relation to contact details for patients that have been discussed through the management teams. Two external reports have been received by the Trust- one related to Her Majesty s Prison, Shrewsbury which highlighted that all essential standards relating to health services are being met. The second report was the Dignity and Nutrition National findings from visiting 100 Hospitals. An overview was provided of key actions already in place within the Trust and those to be implemented to ensure lessons are learnt and systems strengthened. For example: The Trust is one of eight pilot sites to trial The Midlands and East Strategic Health Authority (SHA), Care Quality Commission (CQC) Outcomes Nursing Practice Assurance Framework. This will provide a methodology for self, peer and external peer assessment to support assurance and learning. Development of a new quality assurance process taking the best of the existing tools and consolidating these into one approach. This will include the West Midlands SHA Appreciative Enquiry methodology. There were no serious incidents related to safeguarding reported in October, however, one has been reported at the end of November. Intervention has occurred to mitigate all risk. Recommend ation(s) to Board The Board is asked to: Note the operational issues and actions being taken to maintain quality and safety Note the key incidents reported and actions taken to mitigate those risks Note the external reports and actions being taken to ensure lessons learnt are implemented. Discuss and question the report to ensure appropriate assurance is in place. Trust Board Quality Paper MB/PF/PD December, 2011 Page 2
Strategic Objective(s) to which this paper relates: / To increase quality, safety and productivity of the services we provide To explore every opportunity to innovate and improve To build financial strength and resilience To develop strong community links and a reputation for responsiveness Which key standards or State specific standard / outcome or BAF risk assurances does this report relate to? CQC Outcomes 1, 4, 5, 6, 8, 10, 13, 14, 16, 17 NHSLA Board Assurance Framework 956,958,991 IMPACTS & IMPLICATIONS Patient safety & experience Financial (revenue & capital) Equality & Diversity OD/Workforce What patient & public involvement has there been in this issue? The information contained in the report provides an overview of areas that may impact on experience and any safety issues that have occurred Nil No direct implications Action plans implemented through teams to ensure learning from incidents. The quality report is designed to provide assurance of quality and safety of services provided to patients/public Trust Board Quality Paper MB/PF/PD December, 2011 Page 3
QUALITY AND SAFETY REPORT 1. INTRODUCTION This report focuses on operational issues affecting quality / safety and patient experience and builds upon the information provided to the Quality and Safety (Q&S) Committee at its meeting in October, 2011. The paper also provides a high level summary of areas discussed at the Quality and Safety Committee in its October and November meetings. The information contained is current data for the Trust since 1 st July and retrospective to the previous individual provider organisations. 2. CURRENT OPERATIONAL ISSUES 2.1 MINOR INJURIES UNITS ( MIU) The Care Quality Commission (CQC) visited the MIU at Oswestry Primary Care Centre on 3 rd November to inspect the new facilities. Following the visit the Trust has received approval to re-locate MIU to the new facilities as soon as the installation of radiological equipment has occurred. Minor requests were made for clarification of a call bell system and drinking facilities for patients to meet CQC outcome measure 5 nutrition and hydration. The issues are being actioned by the service delivery manager. 2.2 Sub Groups of Q&S Committee Progress is being made in establishing and structuring the sub-groups of the committee. The Organisational Development and Workforce group has met. Key highlights from that meeting include; approving the Terms of Reference for the Library Sub Group; reviewing the new Mandatory Training Policy; agreeing the mandatory training requirements for all staff groups to replace the previous two matrices; receiving and approving the Mental Capacity Act Competencies Framework which is now to be delivered across the Trust; receiving a report on the Workforce Planning process including key milestones; agreeing the next set of policies to be updated with timeframes; and agreeing an outline framework for the Leadership, Organisational Development and Workforce Strategy for the Trust. 3. INCIDENTS & RISK 3.1 Serious Incidents(SIs) As previously detailed in Board papers, a number of SIs transferred to the community Trust on 1 st July. In addition there have been reported incidents as detailed below. 3.1.3 Current SIs 13 SIs have been reported by the Trust in October and 7 in November. Of these 17 are pressure sores, one is a fall, one relates to potential child protection issues and one refers to lost data. Investigations have been completed in 10 cases A number of recommended actions are being implemented, as a result of the root cause analysis investigations. These include: Fall - Refinements in the organisation and layout of falls prevention classes Lost data - New methods of transporting patient lists Pressure Sores - Sharing of findings with team members; Improving grading consistency within team; Discussions with Acute Trust relating to pressure relief when receiving dialysis; Trust Board Quality Paper MB/PF/PD December, 2011 Page 4
Investigation into methods of photographic recording of pressure sores; Improvements in documentation fed back to teams and individual members of staff As detailed in previous Board reports, a number of SIs have been carried over from the provider arms of the PCTs to the Community Trust as they are related to Trust services. An update is provided in Table 1 in relation to the current status of the SIs. Table 1: Incident Position Update November 2011 1 unexpected death, care given by Community Hospital 3 deaths in custody, 1 natural causes, 2 selfinflicted Investigation completed and recommendations being implemented, including introduction of an early warning score system. All awaiting coroner s inquest 1 pressure sore Investigation Completed. Actions implemented relating to training, identification of key workers and assessment recording 1 unexpected death Investigation and actions complete. Follow up review by Care Quality Commission completed. Commissioners have been asked for closure Inquest has been held for cancer death, verdict natural causes, no issues relating to prison healthcare or prison. Several witnesses praised the care given. For the 2 self inflicted deaths inquests are likely to be held in February and March 2012 Commissioners have been asked for closure Inquest held on 22 nd November. A narrative verdict was given. The coroner accepted that actions have been implemented to improve the risks associated with food service and communication and reporting of Do Not Attempt Resuscitation (DNAR) orders. No Rule 43* recommendations were made *Rule 43: Coroner can issue a recommendation to a Trust which becomes a legal obligation 3.1.5 Never Event Category No Never Events have been reported in October or November or since Trust Authorisation. 3.2 Incident Trends Graph 1 details the incidents from the two provider arms and current position of the Trust from October 2010 to November 2011. The chart provides a breakdown of the detail provided in the dashboard in the performance report. It gives a high level overview of trends and shows a breakdown of all risks by incident type. There were 188 reported patient incidents in October and 150 in November. The number of incidents in October was high due to an increase for the month of both pressure sores (104) and falls (40) both of these decreased in November to 82 and 21 respectively. The number of falls recorded in November was the lowest so far in 2011. Other types of incidents remain low numbers. Trust Board Quality Paper MB/PF/PD December, 2011 Page 5
Graph 1: Incident Trends 3.2 RISK MANAGEMENT A workshop was held as part of the senior leaders forum to update existing directorate risks, and to identify any new risks associated with directorate activities. This will be reported to the Audit Committee at its January meeting. 4. INFECTION PREVENTION AND CONTROL In October and November no cases of MRSA bacteraemia involving Shropshire Community Health Trust were recorded and no cases of Clostridium difficile were diagnosed in Community Hospitals or Prisons. 5. PATIENT EXPERIENCE 5.1 Eliminating Mixed Sex Accommodation No breaches have been reported since 1 st July. 5.2 Patient Experience Commissioning for Quality and Innovation (CQUIN) - Outpatients Further to the high level summary reported to the Board in October, a detailed analysis of the findings of the survey was presented and discussed at the Q&S committee in November. The survey results in continence, wound care, respiratory and diabetes were very positive in 4 questions with scores of 80-90%. However, in relation to contact details available to patients out of hours, there is a clear gap in that 20-30% of patients felt they did not know how to do this. Members of the Q&S committee challenged the actions being taken to resolve concerns and assure themselves that lessons were being learnt. 5.3 CQUIN - Community Hospital In-Patient Survey Further to the high level summary presented in the October Board paper, a detailed analysis of the results of the community hospitals survey was discussed. The percentage of positive responses was Trust Board Quality Paper MB/PF/PD December, 2011 Page 6
comparable for most questions across all 4 hospitals. The question that stood out as being a lower performer was in relation to understanding of medications. It is worth noting that this result does not differ greatly from national surveys and is a key area for further work. Again, members of the Q&S committee challenged the actions being taken to resolve concerns and assure themselves that lessons were being learnt. 5.4 Complaints Complaints are reported as red on the dashboard and a total of eight were received in September. To date there is no single individual service area giving rise to or resulting in a high level of complaints, therefore it is difficult to predict when or if the current rate of complaints received by the Trust will reduce to the monthly target figure of five. However, both the Complaints Manager and the PALS/FOI Manager work closely together to ensure that concerns raised by patients are responded to under the appropriate processes. Trends in complaints are also analysed by the Complaints Manager to ensure that any recurrent issues are addressed in order to prevent recurrence of problems. Detailed combined Complaints & PALS reports have been provided to both the Quality & Safety Committee and Service Delivery Managers' meetings detailing any trends and action taken in responding to complaints/concerns. As an outcome of discussions held, the dashboard will be changed to provide more detail in relation to outcome monitoring of complaints and timescales for responses to improve the experience of the complainants. This is in addition to the regular contact that is maintained through the investigation process. 6. COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) 2011/12 The teams continue to work towards the CQUINs. A meeting is being held with commissioners on 8 th December to agree the expected outturn for all CQUINs as these were not set at the start of the year. In part, this was due to baseline data being required which was not available until the first part of CQUIN data has been collected. 7. ADULT AND CHILDREN S SAFEGUARDING 7.1 Children s safeguarding There were no new serious case reviews (SCR) in October or November. The action plan being implemented by the team from previous issues was reviewed at the Q&S committee in October. In addition, the Safeguarding Policy has been revised and was approved by the Q&S committee. As reported in the serious incident section, an incident has been reported that has potential child protection issues. This incident is being managed through application of appropriate policies and the PCT and the SHA are assured by the actions that have occurred. 7.2 Adult Safeguarding As reported in the sub-group section, competencies have been developed for level 1-4 safeguarding training for the Trust and will now be incorporated into mandatory training. A self-assessment against Department of Health Guidance for Adult Safeguarding is being undertaken and will be completed by the end of December to highlight compliance with best practice and any gaps. The results will be taken to the Clinical Quality Review meeting with the PCT and, if required, a bid will be developed to fund a specific adult safeguarding lead post. 8. QUALITY MONITORING The Trust continues to meet regularly to monitor quality issues with the Primary Care Trusts (PCTs) to provide assurance in relation to delivery of key targets including, complaints, incidents, serious incidents and CQUINs for example. The principle content of the dashboard has been agreed in line with PCT requirements. A specific meeting was requested by the PCT to review pressure ulcers, due Trust Board Quality Paper MB/PF/PD December, 2011 Page 7
to the rise reported in October. The meeting was positive with open and transparent dialogue regarding the current issues that have occurred and actions being taken by the Trust; recognising that the collaborative harm free care work should contribute to a structured health economy approach to develop and ensure sustained improvements. There are a number of key areas of quality performance that require noting by the Board related to the September dashboard. These include: The number of grade two pressure ulcers developed under the care of the Trust reduced in September to 13 which is within target but the number of grade 3/4 pressure ulcers reported exceeded the target at three. Both indicators continue to be reported as red within the dashboard for the six month period to the end of September. As detailed earlier in the paper, action is being taken to address this concerning issue. The falls indicator is reported as green within the dashboard at the end of September despite the numbers of reported falls having increased from 23 in August to 33 in September. This is considered to be related to an increased number of higher risk patients being admitted to community hospitals. In order to address the issue, all falls are recorded and investigated and all patients are risk assessed in relation to potential falls with individual action plans being devised. Staff are checking patients 1-2 hourly and there is more falls prevention equipment available such as hi - low beds and alarms. As previously reported, there is a new falls policy in place and training has been provided for staff in its implementation. In addition, the Bed Rails Policy has been rewritten and is awaiting ratification. The end of year projection for this indicator continues to be green. Sickness absence is 4.7% for September and is reported as amber within the dashboard for the six month period. Efforts are being made to foster employee engagement across the organisation through management training and staff newsletters and it is anticipated that the forecast position for this indicator will be green. 9. EXTERNAL REPORTS 9.1 CARE QUALITY COMMISSION DIGNITY REPORT In October 2011 the CQC produced a report that summarises findings and learning from their national inspection programme scrutinising dignity and nutrition within 100 NHS acute care providers between March and June 2011. This was discussed in detail at the Q&S committee in November, with key findings noted as being: 9.1.1 Outcome 1 respecting and involving people who use our services Of the 100 hospitals inspected findings were collated for the 20 hospitals that were not compliant. The following outline the main findings: Patients privacy and dignity were not respected for example curtains were not properly closed when personal care was given to people in bed. Call bells were put out of patients reach, or they were not responded to in a reasonable time. Staff spoke to patients in a condescending or dismissive way Both staff and patients told us that there were not always enough staff with the right training on duty to spend enough time giving care. Staffing levels were cited as a concern in hospitals that were meeting the standard, but no improvements were recommended. 9.1.2 Outcome 5 meeting nutritional needs The CQC found that 17 of the 100 hospitals were failing to deliver care that met this essential standard. The key themes in hospitals that did not meet the standard were: Trust Board Quality Paper MB/PF/PD December, 2011 Page 8
Patients were not given the help they needed to eat, meaning they struggled to eat or were physically unable to eat meals Patients were interrupted during meals and had to leave their food unfinished The needs of patients were not always assessed properly, which meant they didn t always get the care they needed for example, specialist diets Records of food and drink were not kept accurately, so progress was not monitored Many patients were not able to clean their hands before meals In some cases, staff talked across patients rather than to them A lack of time to deliver care (due to short staffing, persistent high demand or excessive bureaucracy) was also cited as a reason why staff were unable to make sure that people s needs were assessed and that the right support to eat was given. 9.1.3 Current Assurance within Shropshire Community Health NHS Trust Within the four Community Hospitals within Shropshire Community Health NHS Trust there are already a number of existing assurance processes in place. These include: Weekly Quality Reviews o This process is carried out on a weekly basis and patients and staff are asked questions which include aspects of dignity and nutrition o Results of these are used by teams to understand and improve their service/performance Six monthly Patient Satisfaction audits these are collated and action plans implemented as a result Essence of Care benchmarking (a tool to help healthcare practitioners take a patient-focused and structured approach to sharing and comparing practice in areas such as Communication, Respect and Dignity, Food and Drink) this is a well-established process within the Community Hospitals High Impact Actions for Nursing and Midwifery (eight areas that have been identified by receiving feedback from nurses across the country as having significant impact on quality of care and efficiency. These include preventing falls, keeping patients nourished and protection from infection) a project has been running for over 18 months to support embedding these into practice Complaints and Patient Advice and Liaison Service (PALS) issues - these are monitored by the Service Managers and used to improve performance th CQC visit to Bridgnorth Hospital following an unannounced visit on 8 February 2011 which demonstrated compliance with standards for outcomes 2, 4 and 14. (Consent to care and treatment; care and welfare of people who use services; supporting workers) 9.1.4 Proposed and agreed actions to be delivered to increase robustness of processes One of 8 pilot sites to trial The Midlands and East SHA CQC Outcomes Nursing Practice Assurance Framework. This will provides a methodology for self, peer and external peer assessment to support assurance and learning. Development of a new quality assurance process taking the best of the existing tools and consolidating these into one approach. This will include the West Midlands SHA appreciative enquiry methodology. Implementation of a programme of visits by the Corporate Nursing and Quality team. This will make clear the assurance process, expectations of staff, frequency and feedback loops to ensure learning across the organisation. Feedback through the Performance Dashboard that supports the assurance process for the Trust. Participating in the Harm Free Care programme this national scheme consolidates and reframes existing good practice (e.g. High Impact Actions, Energising for Excellence) and Trust Board Quality Paper MB/PF/PD December, 2011 Page 9
works with partners across the health and social care economy to ensure minimal harm is done to patients. It will also ensure a focus on quality of services. Formation of an operational Quality and Safety/Clinical Group for the Service Delivery Directorate to engage and support delivery of robust service improvement in relation to quality and patient safety. Strengthening patient feedback mechanisms in the community hospitals to provide real or near time patient experience feedback. Work has already commenced in relation to this and also use of Patient Opinion [an e-feedback system] which can also be paper based as required. 9.2 Care Quality Commission review of compliance at Her Majesty s Prison- Shrewsbury A final report of a review undertaken in September was discussed at the Quality and Safety Committee. The findings demonstrate healthcare provision is meeting all essential standards of quality and safety and is considered compliant, meaning that people who use the services are experiencing the outcomes relating to the essential standards. A letter has been written to the team on behalf of the Q&S committee commending the excellent results. 10. RECOMMENDATIONS The Board is asked to: Note the operational issues and actions being taken to maintain quality and safety Note the key incidents reported and actions taken to mitigate those risks Note the external reports and actions being taken to ensure lessons learnt are implemented. Discuss and question the report to ensure appropriate assurance is in place. Maggie Bayley Director of Nursing and Quality Trust Board Quality Paper MB/PF/PD December, 2011 Page 10