Agenda Item: 10.2 Subject: Presented by: Patient Safety & Clinical Quality Committee Chair s Report Sue Hayter, Governing Body Registered Nurse Member Submitted to: NHS West Norfolk CCG Governing Body, 24 September 2015 Purpose of Paper: For noting Executive Summary: The key areas discussed at the meeting held on Tuesday 18 August 2015 were: 1. Executive Summary for June 2015 and Clinical Quality Review Meeting (CQRM) minutes for July 2015 Maggie Carter (MC) MC circulated a revised style quality report which reflects RAG assurance from the providers using the CQC 5 domains Safe, Effective, Responsive, Caring and Well-Led. The Queen Elizabeth Hospital King s Lynn NHS Foundation Trust (QEHKL) Both CQC and Monitor have agreed that special measures can be lifted, there are still some areas requiring further improvement which includes sustainability, it will be monitored by the CQRM. C. Difficile rates had improved in April and May; an increased had been noted in June with no ward trend identified. Maternity there was a discussion at the August CQRM on the number of post-partum haemorrhages reported. Root Cause Analysis (RCAs) are being completed to be discussed at the September CQRM. A Maternity Improvement Board, supported by several work streams which includes workforce and the development of the Midwife-led Birthing Unit. A contract query notice is in place concerning delays with the 62 day Cancer waits. The Never Event earlier this year relating to Methotrexate has been downgraded to a Serious Incident. Norfolk Community Health and Care NHS Trust (NCH&C) Hub visits and Hub Quality Issue Reports (QIRs) the work allocation system is being reviewed to ensure a clear auditing system is in place; Dr Tony Burgess (TB) has visited, Yodah Galloway (YG) to arrange a visit for September and Jayne Lunn (JL) to re-visit. International Normalised Ratio (INR) QIRs - A Band 3 administrator is now in place to map the QIRs through the pathway. Adult Speech and Language Therapy (SALT) concerns were noted that only 39% of patients were seen within the 12 weeks. MC and Sue Hayter (SH) to have regular meeting with NCH&C Director of Nursing. Norfolk & Suffolk NHS Foundation Trust (NSFT) The Trust is in special measures, with Trust-wide monthly stakeholder meetings; it was agreed that the RAG would remain unchanged. Workforce at the Fermoy Unit was identified as a concern; there are different models being considered to support the recruitment process, monitored by CQRM. Five unexpected deaths have been reported in West Norfolk CCG between April and July 2015; all RCAs are pending. PSCQ committee was made aware that x 2 dementia patients had been placed out of county; both had severe and complex behavioural issues. An algorithm in terms of sign-off and agreement to ensure that there is challenge made within NSFT is being developed. Referrals in to the new Health and Wellbeing service have increased; positive feedback has been received with patients being seen in GP surgeries. 1
2. Care Homes Pressure Ulcer Prevention training Sarah Taylor (ST) is working with the NCH&C tissue viability nurse who is working with residential homes. There are also plans to have the Continence Team to deliver training. Public Health there is an infection control champions initiative which has good take up in the West with a champion identified in each care home, who will require support as many do not have previous care home management experience. 3. Winterbourne Derek Holesworth A quarterly update was provided identifying the key current issues: Funding invoices from Norfolk County Council (NCC) to Clinical Commissioning Groups (CCGs) for patients who have been stepped down community care; Care and Treatment annual reviews - in future to be the responsibility of CCGs with less support from NHS England, a bank of suitable professionals will need to be identified; Fast Track Process the Committee agreed that placement s must be appropriate and will take the time they require to have a safe and effective placement. Individual placements process is managed by North and East London Commissioning Support Unit (NELCSU) with the social care package overseen by the Learning Disability (LD) locality lead and NCC. 4. Maternity Services Maggie Carter The Committee reviewed the June 2015 Child Health and Maternity Quarterly report, the report was collated with combined information from all the Norfolk acute trusts; it is mainly dashboards, supported by little narrative. Following the publication of the Kirkup Report (Morecombe Bay Investigation) maternity services are being scrutinised nationally. The Head of Midwifery at QEHKL has been asked via CQRM to update the report; the RAG rating has been discussed by MC with the QEHKL Director of Nursing. 5. Adult Safeguarding Quarter 1 Report Howard Stanley (HS) Safeguarding Adults Reviews (SAR) there are two in place relating to LD patients, learning will be shared, and HS is representing Great Yarmouth & Waveney CCG on the panel. A 10% increase in referrals is being reported. Communication issues have been noted between NSFT with social care and primary care, legal advice is being taken as NCC identified some cases for a SAR which has a financial impact on CCGs. All providers have been asked for their PREVENT training delivery plan. QEHKL is supporting HS with trainer the trainer sessions. Mental Capacity Act (MCA)/ Deprivation of Liberty Safeguards (DoLS) for patients in their own homes who are funded by NHS Continuing Health Care (CHC), around 37 cases, an options paper is being produced relating to patients who may require an application to Court, to ensure a consistent process across the county which includes the cost implications. The first quarter s Dashboard was reviewed by the Committee; members were reminded that the data is very raw at the moment. 6. Medicines Management Update for Information Debbie Craven (DC) The Adult Safeguarding Lead asked if there was support in place for a cohort of patients who are struggling with self-medication in their own home; DC is aware and is working with NCC and other CCGs to review the service. 7. NHS Continuing Health Care Dashboard Jayne Lunn There is to be a discussion with the CCG s Senior Management Team on Personal Health Budgets (PHB) The CHC team to monitor the number of 3 month and annual planned reviews which are cancelled by families who request a new date. Delays with Social Services engaging with the CHC eligibility decisions. Capacity to complete out of area reviews was identified. The CHC Quality, Innovation, Productivity & Prevention (QIPP) is progressing to plan with a reduction in some packages being seen. 2
8. Patient Opinion stories and responses Jayne Lunn The PSCQC members found it very useful to review the stories and responses submitted; it was confirmed that NCH&C and QEHKL monitor them closely. 9. Risk Registers The Senior Management Team has agreed to restructure both the risk registers. The key risks on the Corporate Register relate to Tier 3 Bariatric Services, Infection Control issues, DoLS relating to NHS CHC funded patients in their own home, and Safeguarding in relation to Looked After Children. 10 July Healthwatch Norfolk Newsletter attached for information. 11. Any other business NCC Detox Beds two beds have been commissioned by NCC in the Fermoy Unit to allow more choice of providers; NCC has requested that admissions are discussed by a panel rather than by direct placements. 12. Future meeting dates 2015 dates 15 September, 20 October, 17 November and 22 December 22. The key areas were discussed at the meeting held on Tuesday 15 September 2015 were: 1. Executive Summary for July and CQRM minutes for August Maggie Carter MC circulated the first draft of the revised style quality report which reflects RAG assurance from the providers using the CQC 5 domains Safe, Effective, Responsive, Caring and Well Led. The Committee agreed the assurance rating on page 2 of the report for July 2015 data. QEHKL There were x 2 Serious Incidents (SIs) reported in July 2015, both Grade 3 pressure ulcers. There has been further work regarding masks used for non-invasive ventilation, a new mask is currently being trialled. WNCCG Quality Team continues to review all SI RCAs at the meeting held every 2 weeks to review RCAs for SIs and Never Events. The Trust received 13 QIRs in July, one theme noted in x 3 QIRs was a delay in the receipt of electronic test results from QEHKL to GPs, QIR themes to be reviewed at the monthly CQRM. Five C.diff cases were reported in July 2105 on four different wards. It was reported that a similar increase in C.diff was reported by other acute trusts in Norfolk. The Trust has also undertaken an inspection audit of mattresses which has resulted in a number being replaced. Friends and Family Test a small improvement noted in July, but day procedures and day cases need further work to ensure similar responses as the inpatient areas. Staffing the vacancy rate for nurses and midwives has increased in July to 9.3%, the new nurses from Spain arrive in the next few months. The turnover rate for allied health professionals has reduced to the lowest level since October 2014. NCH&C 7 SIs were reported in July, all Grade 3 pressure ulcers, and the Trust is piloting an alternative assessment tool from Waterlow, known as Purpose T which has been developed by the Tissue Viability Network. Actions implemented as a result of QIRs have included changes to the pathway and audit processes. There was an increase in injurious falls per 1000 bed days from 0% to 4.5% which related to one patient. One case of C.diff was reported at Swaffham Community Hospital in July. NCH&C West Locality staff turnover has reduced, staff sickness. Absence rates have also improved. 3
NSFT There was one SI in July relating to an unexpected death, there have now been 6 unexpected deaths in the West locality since April 2105. RCA validation meetings to take place with SIs reviewed at CQRM. Data is not expected from Lorenzo now until October 2015; it was agreed at the last CQRM that the Trust would start to collate the data manually. The majority of QIRs to NSFT relate to referrals which includes delays and failure to act. 2. Care Homes The QIR template has been shared with the care homes to use along with their own incident/ accident reporting procedures. A letter has been sent to all care homes identifying which medicines should be sent with the resident when they are admitted to hospital to ensure wastage is minimised. The Public Health scheme for an infection prevention and control champion in all care homes, the aim is to provide half day training days about 3 months apart then regular quarterly meetings of 2 hours with a training element. 3. Norfolk Healthwatch Quarterly Report Peter Brown (PB) Two additional reports have been included on the Norfolk Healthwatch website: 5 August 2015 Looked After and Adopted Children, Young People and Families. 5 August 2015 Health and Wellbeing needs of Children and Young People in Norfolk. PB has produced very useful summaries of these complex reports which identify the key conclusions on each paper and its recommendations. The reports are timely as the NCC Children s Services review by Ofsted is due this week. 4. Nurse Revalidation Maggie Carter There is now a link on the West Norfolk CCG website which identifies information from NHS England and the Nursing & Midwifery Council (NMC) on nurses revalidation. There will be a raising awareness session at the next Practice Managers meeting. CG has agreed to produce some sample documentation on portfolios and evidence of practice which will be posted on the Nurse Revalidation link on the website. 5. Safeguarding Children Quarter 1 Report Mark Gower CQC inspection of Health Services for Safeguarding and Looked After Children (LAC) which was carried out in October 2104 was published on the CQC website on the 4 June 2105; an action plan addressing the recommendations has been developed. PREVENT the Adult Safeguarding Team is the lead, they are working closely with the Designated Safeguarding Children team. Domestic Abuse health provider teams have agreed to undertake a pilot to contribute to the Multi-Agency Risk Assessment Conferences (MARAC) across Norfolk. Child Protection Information Sharing (CPIS) project all relevant organisations have submitted a letter to agree to progress the CPIS in relevant work places, regular contact calls are to be scheduled between Health and NCC to track progress from all organisations. There are a number of current Serious Care Reviews (SCRs) in Norfolk, the reviews are multiagency with the family, with an opportunity to reflect and learn, and GPs have a duty to cooperate with reviews, supported by the designated team. The new full time Designated Nurse post holder commenced on the 3 August 2015, a Designated Doctor for Safeguarding and LAC has been appointed. MG informed the Committee that he is leaving the Health Safeguarding and LAC team to join NCC as the Health SEND lead. His post is to be advertised as a 3 day LAC lead. Negotiations with commissioners and providers on the delivery and performance of a health provider for LAC have been escalated to the Chief Officers of the 4 CCGs. Health assessments are currently completed by Health Visitors for under 5 year olds and by an NCH&C team of 3 part time nurses for children over 5 years. 4
6. Risk Registers The Committee reviewed each entry under quality in the CCG Assurance Framework. An amendment was made to section 1.8 relating to NCH&C, to include that there is a CQUIN in place for 2015/2016 concerning the Hub. 7. Complaints The July /August report was provided for information. It was noted that there were 4 complaints for this period x 1 CHC, x 2 Home Birth requests and x 1 on breach of confidentiality (anonymous). Five complaints were closed with a summary of the outcome of the complaint. 8. August Healthwatch Norfolk newsletter attached for information. 9. Any Other Business Discussion on the potential CQUINs for 20916/2017 and whether a system-wide CQUIN could be considered. The notes of the Team Away day on the 5 August were shared with the Committee. The day included QIPP, a review of the team s workload and planning for the next 3 months. 10. Future Meeting Dates 2015 dates 20 October, 17 November and 22 December. KEY RISKS Clinical: The Committee reviews mitigation with clinical quality risks as part of provider performance discussions. Finance and Performance: The Committee s role is to review the effectiveness of mitigation strategies for all clinical quality performance risks. Impact Assessment (environmental and equalities): N/a Reputation: The Committee reviews the impact of risks on CCG s reputation as part of its role. Legal: The Committee reviews the CCG s ability to meet statutory obligations in relation to patient safety and clinical quality Patient focus (if appropriate): The Committee reviews mitigation with clinical quality risks as part of provider performance discussions Reference to relevant Governing Body Assurance Framework (GBAF): All quality risks on GBAF. RECOMMENDATION: The Governing Body is asked to note the Chair s Report. 5