Agenda Item 0. 4 th September 05 WNCCG Quality Report September 05 Subject: Presented by: Submitted to: Purpose of the paper: Quality Report Provider Quality Assurance regarding QEH Kings Lynn, NCH&C, NSFT, OOH/, Care Homes and Independent Providers. Maggie Carter, Head of Clinical Quality and Patient Safety NHS West Norfolk CCG Governing Body Information and Assurance Summary: The Quality report contains exceptions to key indicators of the quality and safety of patient care of our providers. The Quality and patient safety Committee reviews a variety of information including; serious incidents, Quality Issue Reports, performance, CQC standards, complaints, litigation and soft intelligence to gain assurance of the quality of the services provided to our local population. The level of assurance is based on a framework through which organisations are accountable with the ambition of continuously improving the quality of services and mitigating risk through actions to safeguard standards of care. For providers for which NHS West Norfolk CCG are not the co-ordinating commissioner, the assurance is based on the services for the West Norfolk locality only. This level of assurance may vary between the coordinating CCG. The information in the report is based on the July 05 data available as of 8 th September 05 Recommendation: The Governing Body is asked to consider the content of the report and levels of assurance assessed for each provider by the Quality and Patient Safety Committee.
In summary, assurance ratings have been assessed by the NHS West Norfolk CCG Patient Safety and Quality Committee as defined in the indicators below. This is based on the July 05 data and information available as of 8 th September 05. QEHKL NCH&C NSFT EEAST/OOH / CARE HOMES
QUEEN ELIZABETH HOSPITAL KINGS LYNN QUALITY REPORT Are Services Safe and Effective? Patient Safety Org Oct4 Nov4 Dec4 Jan5 Feb5 Mar5 4/5 Apr5 May5 Jun5 Jul5 Serious incidents reported QEHFT 8 7 5 8 0 3 97 9 5 6 Never events reported QEHFT 0 0 0 0 0 7 0 0 0 Complaints - non-clinical QEHFT 0 4 0 0 0 3 3 3 Complaints - clinical QEHFT 59 4 36 36 9 3 53 3 6 3 30 Pressure ulcers - Grade QEHFT 4 5 3 6 4 59 4 3 3 9 Pressure ulcers - Grade 3 QEHFT 3 3 5 6 3 3 55 6 4 4 Pressure ulcers - Grade 4 QEHFT 0 0 0 0 0 0 0 0 0 Pressure ulcers - avoidable QEHFT 3 4 0 0 30 0 3 NA Pressure ulcers - unavoidable QEHFT 0 0 0 4 0 0 NA Catheter-associated UTIs reported QEHFT 5 5 8 4 5 4 3 0 0 6 Falls (serious incident level) resulting in QEHFT 0 0 0 7 0 0 severe injury MRSA bacteraemia QEHFT 0 0 0 0 0 0 0 0 Clostridium difficile infections QEHFT 3 4 4 0 3 39 6 5 Venous thromboembolism QEHFT NA NA NA NA NA Mixed sex accommodation breaches QEHFT 0 0 0 6 5 0 8 0 0 0 0 Quality incident records (QIRs) reported QEHFT 3 4 0 3 4 7 48 5 0 5 3.0 Serious Incidents, Pressure Ulcers and Never Events. There were serious incidents reported in July 05 which related to:- grade 3 pressure ulcers The RCAs for these incidents are not yet due. There were no never events reported in July. Further work has been undertaken regarding masks for Non-invasive ventilation (NIV). A new mask has been trialled and has now been implemented for use. The Trust will monitor the impact this change has on the number of pressure ulcer cases. A significant drop has occurred in the number of open SI s from 43 in June to the 7 open in July. This is due to the Trust providing additional support for RCA investigators and ensuring that the quality of the reports is high when submitted for review by the CCG. This is further supported by the joint RCA meetings with the CCG and the Trust which enables sign off of the majority of reports without further queries. The Trust pressure ulcer action plan is reviewed at CQRM and includes actions associated with:- A review of medical devices and pressure ulcer risks Review of the type of masks used for non-invasive ventilation 3
QEHKL Improving the process for shared learning to include organisation wide learning (OWL) Adapted Waterlow score and ASKINS tool in use Linking the infection control and tissue viability nurses together Updated medical photography policy and updated training in medical photography for staff WNCCG actions WNCCG continues to review all Serious Incident RCAs as part of the RCA review meeting held weekly with QEHKL. Action plans resulting from never events are reviewed at CQRM and the monthly serious incident information is reviewed at CQRM. The Trust will also provide a quarterly detailed report at the October CQRM and ongoing on the pressure ulcers not declared as a serious incident against the criteria as agreed with WNCCG.. Quality Issue Reports (QIRs) The Trust received 3 QIRs in July. These related to:- Quality Issue Reporting 05/6 All Categories - QEHKL Apr 5 May 5 Jun 5 Jul 5 Treatment TransferTransport InformationGovernance Voided Appointments MedicationDispensing Referral Communication 3 Equipment MedicationPrescribing 3 3 ClinicalAssessmentTreatment 4 3 6 Discharge 5 7 0 4 6 8 0 4 6 8 One theme noted within the July submitted QIR s was a delay in receipt of electronic test results from QEH to general practice. This was identified in 3 separate QIR s. The issue was associated with receipt of results via the ICE system. All three QIRs were reviewed 4
by QEH an audit is currently being undertaken in conjunction with one practice to identify any issues. WNCCG actions. Following discussions at CQRM with regard to the quality of the responses to QIRs received from QEHKL, the Trust has implemented a standard format for responses which will identify the outcome of the QIR investigation and associated actions taken as a result of this. QIR themes are reviewed on a monthly basis at CQRM.. Infection Control There were 5 Clostridium Difficile (C.Diff) cases reported for July 05. These were on Tilney, Windsor, Stanhoe and Shouldham ward also had its first case of C.Diff. The data for C.Diff for July is comparable for June data and demonstrates a significant increase from the April and May data. It should be noted that an increase in cases in June and July was seen in other Trusts as well. There were 3 cases in August and none as of the 0 th September. An Infection Control Quality Visit is to be undertaken in September. The Trust has a plan in place to implement improved storage on the wards following infection control review. The Trust has also undertaken an inspection audit of mattresses which has resulted in a number being replaced. The infection, prevention and control nurse team have been working alongside ward staff to review practice and raise staff awareness. The Trust has also implemented further education for staff on the management of MRSA to include swabbing relevant patients over the weekend period as well as during the week and guidelines on the use of topical applications for the management of MRSA. WNCCG actions Infection control data is reviewed on a monthly basis at CQRM. The WNCCG consultant in Public Health Medicine has raised concerns at CQRM with regard to the Trusts infection control performance in June. WNCCG has undertaken joint infection control visits with the infection prevention and control team to Windsor and Tilney wards. The outcomes from these visits have been fed back to the Trust. Infection control plans are reviewed at CQRM and the WNCCG Consultant in Public Health Medicine and CCG Chair have met with the Director for Infection Prevention and Control at QEHKL to undertake a review of infection prevention and control management within the Trust. 5
Are Services Caring and Responsive? Services Safe and Effective?.3 Friends and Family Test (FFT) Scores and Response Rates Patient Experience Org Stnd Oct4 Nov4 Dec4 Jan5 Feb5 Mar5 4/5 Apr5 May5 Jun5 Jul5 5/6 Friends & Family A&E QEHFT None 88 90 93 9 88 9 NA 9 9 88 86 NA England None 87 87 86 88 88 87 NA 88 88 88 88 NA Friends & Family A&E response rate QEHFT 5%.6% 4.8% 8.%.% 38.7% 5.0% NA 6.3% 0.8% 9.9% 9.% NA England None 9.6% 8.7% 8.% 0.%.%.9% NA 4.8% 4.% 5.% 5.% NA Friends & Family Inpatients QEHFT None 90 89 94 9 9 9 NA 95 9 95 95 NA England None 94 95 95 94 95 95 NA 95 95 96 96 NA Friends & Family Inpatients response rate QEHFT 5% 3.% 5.8% 3.3% 36.5% 49.3% 49.0% NA.9%.4%.7% 4.8% NA England None 37.0% 36.8% 33.6% 36.% 40.% 44.9% NA 5.6% 5.9% 6.7% 6.7% NA Friends & Family Maternity - Q Antenatal Care QEHFT None 86 96 93 98 97 97 NA 95 97 95 94 NA England None 95 96 96 95 95 95 NA 95 96 96 95 NA Friends & Family Maternity - Q response rate QEHFT 5% NA NA NA NA NA NA NA NA NA NA NA NA England None NA NA NA NA NA NA NA NA NA NA NA NA Friends & Family Maternity - Q Birth QEHFT None 90 00 98 98 98 96 NA 98 00 98 97 NA England None 95 97 97 97 97 NA 97 97 97 97 NA Friends & Family Maternity - Q response rate QEHFT 5% 0.% 3.4% 43.5% 56.7% 5.7% 9.4% NA 8.3% 9.%.6% 5.4% NA England None.3%.% 0.0%.9% 4.4% 4.5% NA 3.6% 3.% 3.6%.4% NA Friends & Family Maternity - Q3 Postnatal ward QEHFT None 87 98 95 9 95 98 NA 96 94 93 94 NA England None 9 93 93 93 93 93 NA 94 93 93 94 NA Friends & Family Maternity - Q3 response rate QEHFT 5% NA NA NA NA NA NA NA NA NA NA NA NA England None NA NA NA NA NA NA NA NA NA NA NA NA Friends & Family Maternity - Q4 Postnatal Community Provision QEHFT None 00 00 00 00 00 98 NA 00 98 98 00 NA England None 96 97 98 97 00 93 NA 98 98 98 98 NA Friends & Family Maternity - Q4 response rate QEHFT 5% NA NA NA NA NA NA NA NA NA NA NA NA England None NA NA NA NA NA NA NA NA NA NA NA NA The Friends and Family Test response rates for both Inpatients and Day Cases are reported as a combined rate of 4.78% against a target response rate of 30%. There was a small improvement in the response rate in July, but day procedure and day case areas need further input to ensure they have similar response rates to the inpatient wards. Several measures have been taken to support an increased response rate, which include provision of colour coded cards for the Observation Bay in the Emergency Department and other outpatient areas where day procedures occur. Patients recommending the service saw an increase of % up to 95.%, whilst marginally over % of patients do not recommend the service. Patient comments such as delays, communication problems, noise and call bells are being looked in to as a reason as to why certain ward areas such as West Newton and Gayton Ward have recommended rates below 90%. A Maternity Patient Survey has been completed and will be presented to CQRM, whilst an Inpatient Survey is awaiting completion of the report and will also be presented to CQRM. A National Cancer Patient Survey will commence shortly..4 Patient Experience - Complaints During July 05 there were 3 complaints, a slight decrease of 4 from the previous month. 30 of the complaints were clinical and non clinical. In comparison to the past two financial years (3/4 &4/5) there has been a clear decrease in the number of complaints. As shown in the table below the Emergency Department received the largest number of complaints in July with other areas remaining relatively consistent in comparison. 6
Lessons identified within the complaints process include improving communication to patients regarding the discharge process and ensuring staff are aware of their environment and sensitivities of the environment when discussing patients. The table below details the 5 Speciality/Department with the highest number of complaints received:- A & E 6 Cardiology General Surgery Midwifery Paediatrics + Short Stay WNCCG actions. A patient experience report is reviewed monthly at CQRM and the Patient Opinion website is reviewed by the CCG as reports are submitted online. These are also reviewed at the WNCCG Clinical Quality and Patient Safety Committee..5 Care Quality Commission The Trust has been removed from special measures by Monitor. The Trust has established an internal quality improvement group chaired by the Trust chief executive to ensure action plans associated with quality improvement are implemented and progressed and issues are escalated for resolution..6 Workforce Are Services Well Led? Workforce Org Stnd Oct4 Nov4 Dec4 Jan5 Feb5 Mar5 4/5 Apr5 May5 Jun5 Jul5 Sickness Absence Rate QEHFT 4.7% 5.3% 5.% 5.6% 5.3% 4.7% 4.5% NA 4.3% 4.58% 4.3% 4.4% Staff turnover rate Complete Trust QEHFT 0.0%.0%.%.5%.0%.5%.8% NA.%.37%.66%.69% Staff turnover rate Medical & Dental QEHFT 0.0% 9.9% 9.9% 0.7% 0.7% 0.%.4% NA 0.% 0.83%.08%.0% Staff turnover rate Registered Nursing & Midwifery QEHFT 0.0%.9%.7%.7%.6% 3.% 3.7% NA 3.9% 3.6% 3.95% 4.6% Staff turnover rate Allied Health Professionals QEHFT 0.0%.% 8.3% 8.% 0.3% 8.6% 8.5% NA 7.% 8.36% 8.60% 6.45% Medical & Dental Vacancies (as % of Medical Posts) QEHFT 5.0% 9.5% 9.6%.6% 0.8%.3%.4% NA 4.0%.53%.47% 6.3% Nurse & Midwives Vacancies (as % of Nurse Posts) QEHFT 6.0% 5.8% 9.3% 9.3% 9.6% 9.7% 7.9% NA 9.5% 8.34% 9.0% 9.3% Contracted staff in post (WTE) QEHFT Trend,55,589,585,63,60,68 NA,636,65,656 677 Temporary staff in post (WTE) QEHFT Trend 9 99 3 57 44 NA 6 38 37 9 The vacancy rate for registered nurses and midwives increased in July to 9.3%. The Trust anticipates that the number of vacant posts will reduce in the coming months with the arrival of nurses from Spain. The Trust has also recently undertaken a further recruitment drive in Spain however, issues remain in staff recruited obtaining the relevant certificates of sponsorship. This has been escalated regionally. 7
The turnover rate for allied health professionals has reduced to its lowest level since October 04. WNCCG actions Workforce data and safer staffing levels are reviewed monthly at CQRM..7 Nurse revalidation The Trust has identified the current position for all nurses in the Trust requiring revalidation. A series of workshops are taking place to support staff with the process. 8
Norfolk Community Health and Care Are Services Safe and Effective? Patient Safety Org Stnd Sep4 Oct4 Nov4 Dec4 Jan5 Feb5 Mar5 4/5 Apr5 May5 Jun5 Jul5 Serious incidents reported NCHC 0 35 5 8 4 47 4 56 38 49 3 49 4 Serious incidents reported NCHC (W) 0 6 3 4 4 6 7 4 7 4 7 Never events reported NCHC 0 0 0 0 0 0 0 0 0 0 0 0 0 Complaints NCHC 0 30 36 8 0 8 5 9 7 0 0 5 Complaints NCHC (W) 0 3 9 5 Pressure ulcers - Grade NCHC 0 7 0 8 7 8 6 6 7 0 8 0 Pressure ulcers - Grade NCHC (W) 0 NA NA NA NA NA NA NA NA NA NA NA NA Pressure ulcers - Grade 3 NCHC 0 3 8 40 37 5 336 40 5 44 38 Pressure ulcers - Grade 3 NCHC (W) 0 6 3 4 3 4 5 35 6 4 7 Pressure ulcers - Grade 4 NCHC 0 3 0 3 4 3 4 4 6 5 3 Pressure ulcers - Grade 4 NCHC (W) 0 3 0 3 4 3 4 4 0 0 Pressure ulcers - Avoidable Grade 3+ NCHC (W) 0 0 0 0 0 0 0 3 4 Falls (serious incident level) NCHC 0 0 0 3 0 4 3 0 0 Falls (serious incident level)/000 OBD (Swaffham Hospital) NCHC (W) 4 6..9 0 NA NA NA NA NA 4. 0 0 4.6 Catheter-associated UTIs reported NCHC 0 30 7 7 4 4 9 307 5 0 9 MRSA bacteraemia NCHC 0 0 0 0 0 0 0 0 0 0 0 0 0 VTE assessment undertaken in or after admission(inpatient Unit) NCHC (W) 95 NA NA NA NA NA NA NA NA 89.3 96. 97. 95.5 Referrals for diagnostic doppler (quarterly) NCHC NA NA NA NA NA NA NA NA NA NA NA NA Quality issue reporting (QIR) NCHC (W) Info 8 9 7 4 67 7 8 8 3 CN&T Access Category A(Immediate needs.4hour response) NCHC (W) 95 98.0 96.0 99.0 96.0 95.0 97.0 95.0 NA 97.5 96.8 95. 99. CN&T Access Category B(Urgent needs. 4Hour response) NCHC (W) 93 89.0 90.0 87.0 00.0 96.0 00.0 00.0 NA 95.9 93.3 94. 94. CN&T Access Category C(Routine needs.4hour response) NCHC (W) 90 97.0 9.0 94.0 96.0 96.0 00.0 00.0 NA NA NA NA NA.0 Serious Incidents, Pressure Ulcers and Never Events. There were 7 serious incidents reported for the West Norfolk locality in July 05. These all related to grade 3 pressure ulcers. The RCA s for 4 of these have been received and the rest are not yet due. There were no never events reported for July by NCH&C There was an increase in injurious falls per 000 bed days from zero in June to 4.6% in July. This related to one patient who fell while mobilising when waiting for transport home. The patient was still able to be discharged. NCH&C review the learning from pressure ulcer RCAs at the pressure ulcer steering group and have identified a consistent theme within the RCAs as the way in which the Waterlow pressure ulcer risk screening tool is applied and the variation in scoring between clinicians. The Trust are piloting the use of an alternative tool called the Purpose T tool which has been sourced from the tissue viability network. WNCCG actions WNCCG hold RCA validation meetings with NCH&C to review all RCAs submitted. Review of serious incidents takes place at CQRM. Falls data is reviewed at CQRM on a monthly basis and analysis is undertaken to identify any trends and themes. 9
ClinicalAssessme nttreatment Referr al NCH&C Communi cation Informati onadmini stration Transf ertran sport Voi de d Sta ffin gis sue s Inf or ma tio ng ov ern an ce. Quality Issue Reports (QIRs) The Trust received 3 QIRs in July. These related to:- Quality Issue Reporting 05/6 NCH&C Categories and Sub-Categories NHS West Norfolk Patients Apr 5 May 5 Jun 5 Jul 5 Disclosure / breach of confidentiality from another Inadequate levels Withdrawn Inadequate handover Refusal patient Appointment recording error No access to medical documentation Healthcare record missing/inadequate/illegible Other Failure to provide death notification Failure to communicate treatment plan(s) Other Referral - Delay / failure to act on Treatment delay/failure in recognising complications Patient incorrectly identified Test results/report missing Test failure/delay to undertake Issues relating to INR results / tests 3 3 3 0 3 4 5 6 7 8 9 0 There are no specific overarching themes within the QIRs submitted for NCH&C for July. WNCCG actions. Following receipt of QIRs relating to the CN&T transformation project and the outcomes of quality visits to the community team and the West CN&T hub WNCCG were not fully assured that the quality of the service had been maintained. Concerns were raised with NCH&C at CQRM and as a result NCH&C have developed an action plan to address the concerns raised which is reviewed at CQRM. Actions already undertaken to address the concerns include changes to the pathway and audit process for undertaking INR tests in the community and changes within the systems and processes within the West Norfolk CN&T hub. The Trust have also changed the allocation of work between registered and unregistered staff in response to concerns raised..3 Medication Incidents There were 3 medication incidents submitted in July. These related to omission of medication due to poor communication at staff handover, missed administration of medication as had not been dispensed and medication left unattended in a care home. 0
The number of medication incidents reported month on month continues to vary with no recurrent themes identified. WNCCG actions Analysis of medication incidents is undertaken on a monthly basis at CQRM and any areas of concern are discussed at CQRM. The Trust Medicines Management lead attended CQRM on July 4 th to provide an update and review on NCH&C medication incidents to WNCCG..4 Infection Prevention and Control Clostridium Difficile (C.Diff) There was case of C. Diff reported for Swaffham Hospital in July. This case is currently being investigated and will be reported to CQRM once the investigation is complete. Early indications reported by the Trust are that the case may be suitable for appeal. The ceiling for C.Diff cases for NCH&C as a whole has been set at 7. WNCCG actions. NCH&C infection prevention and control reports are reviewed on a monthly basis at CQRM. Infection control is reviewed as part of quality visits to the Provider. Are Services Caring and Responsive? Are Services Safe and Effective?.5 Friends and Family Test (FFT) Scores and Response Rates In July, the West locality for NCH&C continues to report a high percentage (99%) of those who had responded to the Friends and Family Test reporting that they would recommend the service. The 5/6 year to date average recommended for the West is also reported at 99%
NCH&C report Friends and Family Test scores at team level at CQRM with the majority of services scoring at 00% recommended with two services reporting at 97% recommended..6 Patient experience Complaints and Compliments NCH&C received complaint for July which was coded as care and treatment and related to the availability of a specific blood test bottle to enable a community patient to undergo a blood test. NCH&C now stock a small supply of these items. WNCCG actions The Friends and family Test scores and feedback comments are reviewed monthly at CQRM together with complaint trends and themes and compliments. The Patient Opinion website is reviewed by the CCG as reports are submitted online. These are also reviewed at the WNCCG Clinical Quality and Patient Safety Committee. Are Services Well Led?.7 Workforce NCH&C West locality staff turnover has reduced in July and however, staff sickness absence rates have also improved but remain outside of the Trust threshold. In July 05 the West locality reported 7. wte vacancies across community teams and a breakdown of this is detailed below:- Total planned Community and Nursing and Therapy establishment 97.8 % Vacancy 7.36% Coastal 0% Swaffham & Downham 8.00% Kings Lynn 0.50% An update provided at August CQRM identified that the majority of these vacancies had been recruited to and staff would have commenced in post by mid September 05..8 Nurse revalidation NCH&C have a planned programme of workshops for staff to support nurse revalidation and a project plan is in place to ensure that systems and processes are in place to support the implementation of nurse revalidation.
Norfolk and Suffolk NHS Foundation Trust Are Services Safe and Effective? Patient Safety Org Stnd Sep4 Oct4 Nov4 Dec4 Jan5 Feb5 Mar5 4/5 Apr5 May5 Jun5 Jul5 Serious incidents reported NSFT 0 5 3 3 7 7 6 7 80 8 4 7 Serious incidents reported NSFT (W) 0 0 0 Never events NSFT 0 0 0 0 0 0 0 0 0 0 0 0 0 Complaints NSFT 0 50 63 39 55 49 NA NA NA NA NA NA NA Pressure ulcers - Grade NSFT 0 3 0 0 0 0 0 6 0 0 Pressure ulcers - Grade 3 NSFT 0 0 0 0 0 0 0 0 0 0 0 Pressure ulcers - Grade 4 NSFT 0 0 0 0 0 0 0 0 0 0 0 0 0 Catheter-associated UTIs NSFT 0 0 0 0 0 0 0 0 0 0 0 Falls resulting in severe injury (serious incident level) NSFT 0 0 0 0 0 0 0 0 5 0 0 Unexpected Deaths NSFT 0 5 3 6 4 3 45 6 3 6 4 Unexpected Deaths NSFT (W) 0 0 0 0 0 7 Quality issue reporting (QIR) NSFT (W) Info 7 3 4 4 0 8 5 3.0 Serious Incidents, Pressure Ulcers and Never Events. NSFT reported serious incident in July. This related to an unexpected death and the RCA has not yet been received as the Trust are awaiting confirmation of cause of death. There have been a total of 6 unexpected deaths in the West locality since April 05. There were no grade 3 or 4 pressure ulcers reported for the NSFT West locality in July and no never events reported. There has been an increase in the number of unexpected deaths in the West since April 05. The total number of serious incidents associated with unexpected death was 7 in total for 04/5. The total from April to July 05 is 6 which is a significant increase. The Trust is moving towards reporting deaths per 000 patients to enable benchmarking with other Trusts. The Trust has also introduced a monthly lessons learned report that identifies key learning topics to inform locality managers and lead clinicians who cascade this information via local governance team meetings. WNCCG actions WNCCG are planning to hold regular RCA validation meetings with NSFT to review all RCAs submitted. Review of serious incidents takes place at CQRM including assessment 3
Referral NSFT Admiss ion Transfe rtransp ort Appoin tments Medica tionpre scribing against the recommendations following the independent review in to unexpected deaths undertaken in the West. 3. Quality Issue Reports (QIRs) The Trust received 5 QIRs in July. These related to:- Quality Issue Reporting 05/6 NSFT Categories and Sub-Categories NHS West Norfolk Patients May 5 Jun 5 Jul 5 Wrong strength / dose / frequency Extensive delay in appointment wait Other Lack of / delayed availability of beds Referral lost Referral - Re-graded Other Referral - Delay / failure to act on 3 0 3 4 5 6 7 There are no specific overarching themes within the QIRs submitted for NSFT. WNCCG actions. QIRS are reviewed and discussed at CQRM Are Services Caring and Responsive? Are Services Safe and Effective? 3. Friends and Family Test (FFT) Scores and Response Rates The NSFT Friends and Family Test data is only available on a Trustwide basis currently. The percentage of positive responses recorded Trustwide for July is 93%. 4
Are Services Well Led? 3.3 Care Quality Commission The Trust remains in special measures. NSFT are undertaking internal quality review visits as part of the quality improvement plan. Quality themes of concern identified during the visits include:- Medication storage especially in community teams MHA section papers Appraisals and supervision Lessons learned and team meetings The Director of Nursing is writing to all staff with regard to the roles and responsibilities within the NMC Code of Conduct for medicines administration and storage. 3.3 Workforce and Caseloads NSFT are currently not reporting on caseloads within services due to the implementation of the Lorenzo system. The Trust have identified that reporting will commence in September 05 at the earliest. Sickness absence in the West locality is below the Trust threshold at 4.73%. The West vacancy rate is highest across the Norfolk system at 9.8% and the voluntary turnover rate is also the highest across Norfolk. NSFT acute services in the West (Churchill Ward and the Crisis Resolution Team) have had 9 registered nursing staff leave the Trust since April 05. The Trust has a rolling advert in place to support recruitment to the posts. The Trust also reports high demand for community services. The volume of referrals is greater than the discharges from the service causing increased demand on the team. The Trust also report that the implementation of Lorenzo continues to impact on capacity within services in particular delaying the clinician s ability to process referrals in an efficient manner. WNCCG actions Due to the lack of validated data and information provided by NSFT it is not possible to provide full assurance as to the quality of the services provided by NSFT. Subsequently the lack of robust data is to be escalated via the contract meeting held with NSFT. Workforce and the level of vacancies remain of concern and progress with this is reviewed at monthly CQRM and at the monthly assurance meetings with NSFT and Monitor. 3.4 Nurse Revalidation NSFT advised that posters have gone up with regard to the new validation processes and staff are aware of the requirements. 5
EEAST/OOH/ Are Services Safe and Effective? 4.0 Out of Hours/ call back response times Out of Hours GP Service Org Stnd Dec4 Jan5 Feb5 Mar5 4/5 Apr5 May5 Jun5 Jul5 % urgent calls returned by a clinician within 0 mins EEAST 95 94. 96.3 95. 96. NA 96.4 94.0 93.0 95. % urgent calls returned by a clinician within 60 mins EEAST 95 8.9 90. 95.0 9.8 NA 96. 9. 9.3 96.3 Performance against urgent calls returned by a clinician has improved in July. The current provision of the OOH/ services by EEAST ceases on the st September 05. The new provider is IC4. 4. Workforce Workforce, vacancies and sickness absence are being monitored closely by the lead commissioner to ensure continuity and resilience of the service. The new provider is actively over recruiting staff to compensate for those members of EEAST who may not wish to TUPE into the new service. There needs to be clear mobilisation of the new service and demobilisation of the current service to ensure continuity and safety of care for our local population. Current vacancy levels and sickness absence are scrutinised by NCCG with shift fill for the old and new provider monitored closely to ensure provision of the service during transition. Training for new and existing staff commenced mid July 05. WNCCG actions The mobilisation of the new provider and demobilisation of the current service is being led and managed by NCCG as coordinating commissioner, with engagement from all relevant CCGs. The Provider CQRM is in the process of being re-established with NCCG and the first full meeting is planned for October. Are Are Services Services Caring Safe and and Responsive? Effective? 4. Friends and Family Test (FFT) Scores and Response Rates Friends and Family Test response rates have not yet been reported for July for the above services. 6
Care Homes Are Services Safe and Effective? 5. Quality Issue Reports (QIRs) One Care Home submitted QIR was received into WNCCG for the month of July. This was raised by a care provider in reference to an end of life patient received into their care. This incident was raised by the home manager with the Care Home Quality Lead and NCH&C who referred the patient have provided a response which shows learning from the incident. Care homes are asked to ensure they forward a QIR in reference to any incident meeting this criteria. The QIR template and associated information sheet has been shared with providers to complete and embed along with their own organisational incident/accident forms. This is robustly enforced through every care home visit to ensure issues raised by providers are taken forward and that there is value in this work. WNCCG actions. Any QIR received into the Patient Safety and Quality Team in reference to a care home is acted upon immediately by the Care Home Quality lead and discussed at the WNCCG Clinical Quality and Patient Safety meeting. 5. Medicines management A letter has sent to all care homes in the locality on behalf of the GP Prescribing Lead for WNCCG and the Assistant Chief Pharmacist at QEH to highlight the requirements of all providers on what medicines should be sent with a resident when they are admitted to hospital from a care home. This is to standardise the process and to ensure wastage of medications is minimised. The procedure for the provision of medicines for care home patients admitted to the acute Trust was not fully understood and it was identified in care home forums and visits that this pathway needed to be clarified. Care home managers were concerned that the process caused considerable spend for the Trust and a delay in discharge of their residents back to their Home due to the number of medications that needed to be prescribed prior to them leaving their ward. WNCCG actions Working with the QEH, the Medicines Management team developed correspondence to be shared with the care homes to streamline the process. There is ongoing evaluation by the pharmacy within the QEH who are highlighting care homes where this process is not being followed. This is then shared with the Care Home Quality Lead and Medicines Management team to take forward as appropriate. 7
5.3 Healthwatch Report Are Services Caring and Responsive? Are Services Safe and Effective? A recent report by Healthwatch Norfolk has reviewed practice within dementia settings in residential homes. The work was undertaken in-house by Healthwatch staff and volunteers and involved a qualitative study to gather the views and experiences of residents and their families through a series of visits to 9 residential homes across Norfolk. The findings of this project together with a list of recommendations on the observed good practice were responded to by WNCCG. 5.4 Nurse revalidation The Nursing and Midwifery Council (NMC) are undertaking a full review of all nurses currently in practice through a process of revalidation which is due to be implemented in April 06. Revalidation will give greater confidence to the public, employers and fellow professionals that nurses and midwives are up to date with their practice. The NMC have stated that The purpose of revalidation is to improve public protection by making sure that nurses and midwives continue to practice safely and effectively throughout their career. During visits to care homes the matter of revalidation is discussed and information has already been shared with nursing homes as to how they need to ensure their employees are supported through this process through the sharing of NMC guidance. 5.5 Norfolk Infection Control and Prevention and control champion A Public Health scheme has been implemented to develop an infection control champion role within care homes and a network group for these staff members to attend. The group will enable the infection control champions across Norfolk to receive some additional training and support on a regular basis from specialist infection prevention and control staff within the teams at Public Health Norfolk County Council and Anglia Health Protection Team. A similar programme has been running in the Great Yarmouth and Waveney area and Suffolk for some time and is well supported by care homes in these areas. This arrangement will assist care homes during CQC inspections as it will help in providing evidence of a strong infection prevention and control commitment within the home. The aim is to provide half day training days approximately 3 months apart and then a regular quarterly meeting of approximately two hours with a training element and networking element where ideas and best practice can be discussed. The first sessions 8
have been concluded with a large number of homes attending. Care homes were positively encouraged to participate in this opportunity. 5.6 Green Envelope Scheme What is the Green Envelope Scheme? The Green Envelope Scheme provides a safe and secure process whereby GP surgeries can place a printed copy of a resident s summary care record in a sealed green emergency use only envelope that is retained securely by the care home. Until online access to an integrated digital care record becomes available over the next couple of years, the Green Envelope allows clinical information to be made available to emergency health care professionals, whilst remaining compliant with information governance requirements. The care home is provided with Green Envelopes, by their participating GP Practice of which 6 WNCCG practices are involved. The Green Envelopes are stored securely within the care home setting, where they can be easily accessed by staff and given to emergency health care professionals as required. The aim of this pilot is to enable improved, more informed clinical decision making which may lead to reduced emergency admissions from care homes, faster release of ambulance and out of hours/ resources and improved patient experience. 9
Safeguarding Adults and Children Quarterly Report Safeguarding Adults Prevent Training New guidance on the staff groups requiring differing levels of Prevent training states that all staff require a basic level of training and there is a significant increase in the number of staff who require the more detailed Workshops to Raise Awareness of Prevent (WRAP) training. An additional change is that NHS England have passed responsibility for monitoring compliance with prevent training within CCG commissioned services to the CCG Prevent lead. The compliance target is 85% of staff trained by 08. Care and Support Act/NHSE Assurance and Accountability Framework The Care Act has been in place since April 05 and NHSE have produced a new Accountability and Assurance Framework. Safeguarding adult policies will now be reviewed to reflect legislative changes. It is anticipated this will not require substantial changes to current practice and processes. Safeguarding Adults Board The Safeguarding Adults Board has now completed its re-structure with North Norfolk CCG providing representation for all CCGs in Norfolk. The Board has been successful in appointing a new Board Manager who is due to take up post in September. Deprivation of Liberties (DoLs) applications Following the Supreme Court ruling in March 04, the Continuing Heath Care (CHC) teams from NEL CSU have developed systems to assess packages of care for individual patients to ascertain if they meet the thresholds for a deprivation of Liberty and to notify CCGs of the patients for whom an application will be required. This will be reported to CCG Chief Officers in September 05. Safeguarding Adults Dashboard Providers are submitting quarterly safeguarding adults dashboards which are reviewed at CQRMs. Quarterly meetings have been established with the safeguarding lead and the WNCCG quality leads. Safeguarding Children Designated Doctor for Safeguarding Children and Designated Doctor for Looked After Children The Designated Doctor post has now been recruited to and the postholder will commence in post in August. 0
Designated Nurse for Safeguarding Children The designated nurse for safeguarding commences in post on the 3 rd August. Named GPs for Safeguarding Children The named GPs are facilitating a group for GP practice safeguarding children leads in each of the localities. These are aimed at helping the leads to understand the role and provide support to the leads in undertaking the role. The service plans to include GP information in the safeguarding children dashboard as part of monitoring of Section Children Act 004 compliance. Practices will receive a self-assessment audit and the team will assist practices in the provision of this information. CQC Review of Services for Looked After Children and Safeguarding in Norfolk The CQC inspection report following this inspection in October 04 was published in June 05. In response to the report an action plan addressing the recommendations has been developed and is managed by the Designated safeguarding children team on behalf of the CCGs. Child Protection Information sharing project (CP-ISP) Work is ongoing to ensure that providers are aware of the process of safeguarding children alerts and the systems associated with this. Progress is being reviewed by Norfolk County Council with support from the national team. Child Sexual Exploitation (CSE) The governance structure for this group has changed and transferred to the vulnerable children subgroup within Norfolk County Council. A strategic CSE group has been established which includes representation from the designated children safeguarding team. The national CSE working group have recently launched a national service for young people to report sexual exploitation. This is entitled Say Something and went live on the st July 05.
Infection and Prevention Control Quarterly Report Clostridium Difficile The trend across Norfolk and Waveney in Q 05-6 shows CCG s ranging from marginally to significantly higher than trajectory year to date, with the exception of WNCCG. The QEHKL are below trajectory at the end of Q. WNCCG Clostridium difficile cases 05/6 The chart below DOES NOT reflect successful Clostridium difficile appeals. Infection Prevention and Control Audits in Care Homes IP&C audits have been carried out in the following Care Homes during quarter : Millbridge Residential Care Home Gorselands Residential Care Home