Item E1 - Bart s Health Quality Indicators 1.0 Purpose 1.1 The purpose of this report is to provide the CCG Board with an update on quality matters across pertaining to our main local Provider organisations. 1.2 This report will cover an update on the following areas: Serious incidents Mixed Sex Accommodation MRSA Friends and Family Test C.Difficile Amber Alerts Venous thromboembolism (VTE) 2.0 Serious Incidents 2.1 Number of incidents reported Barts Health has reported 259 incidents since April to August 2013. For the same period last year the Trust reported 176. The increase in the number of reported incidents should be seen in good light, as the increase in reporting suggests a better safety culture within the Trust. The Trust reported 4 never events since April to August 2013. All never events related to retained swabs with one incidents occurring at Newham site. 2.2 Current reporting period The Trust reported 50 incidents in August 2013, which is an increase in the number of incidents reported in the same period last year (43). Of the 50 reported incidents, 10 incidents were reported at the Newham site. 1
No never events reported in August 2013. M a j o r i t y ( 4 6 % ) o f the incidents are reported as Grade 3 Pressure Ulcer, with a slightly higher number of Pressure Ulcers present on admission, and the remainder acquired at the Trust. The Trust has a large number of Serious Incident investigation reports overdue, as of the 31 st July 2013 the Trust had 88 cases overdue. 2.3 Action by the Trust Following the development of a Serious Incident management improvement plan the Trust has reduced the number of overdue cases, and as at the 31 st August, the Trust now has 39 overdue cases. As a result of the improvement plan the ECAM CAG has seen a significant decrease in the number of overdue cases. In early July the CAG had over 70 cases overdue, and currently (as at week ending 30 th August) now have 9 overdue cases. 2.4 Action by the CCG/CSU Monthly reports of over overdue cases are provided to the Quality Team by the CSU. The CCG continue to monitor the implementation of the plan at monthly Clinical Quality Review Meetings (CQRM). 2.5 Incident reporting by exception There has been an outbreak of Klebsiella at the Neonatal Intensive Care Unit (NICU) at the Newham site, which resulted in the ward being closed. The Trust stated that any babies born at Newham requiring admission are being accepted, but any referred in from outside the Trust are not. The unit is currently closed to external admissions. The decision to admit internal babies was made in conjunction with Public Health England, who is involved in the weekly outbreak meetings. 2
The NICU falls under specialised commissioning, therefore NHS England is taking the lead commissioner role regarding this incident. The CCG and the CSU would be kept informed and updated. The case is still under investigation. 3.0 Mixed Sex Accommodation 3.1 Number of breaches reported Barts Health has reported 217 breaches from April to August 2013. Royal London site owning majority (64%) of the breaches. 3.2 Current reporting period In August the Trust reported 40 breaches. Of the 40 breaches, 3 of which occurred at the Newham site. 3.3 Action by the Trust Implementation and embedding of the mixed sex accommodation plan. Key areas of focus include: Embedding the escalation process to monitor compliance with the policy and ensure all breaches are accurately reported. Reduction of out of hours transfers from ACCU when nurse specials are not available. Trust internal bi weekly meetings/conference calls to review progress Audit of MSA breaches to increase awareness of issues Establish Trust wide critical care board Increase nursing staff with ability to care for patients with tracheotomy Review single sex bay arrangements in High Dependency Unit. Regular feedback to staff re breaches and required actions 3.4 Actions by CSU/CCG 3
The CCG and CSU continue to monitor implementation of action plan through the CQRM meetings. The impact of the change in the guidance for elimination of mixed sex accommodation will be monitored. 4.0 Venous thromboembolism (VTE) 4.1 VTE Compliance Barts Health has been achieving the national CQUIN target of 95% since April 2013. 4.2 Current reporting month The most recent reporting month (July) the Trust has achieved with 96.5% of patients risk assessed for VTE. The Newham site achieved 98.9% compliance with patients risk assessed. 4
4.3 Action by the Trust The Trust is monitoring the monthly performance against the CQUIN target, which also includes completion of root cause analysis of all cases of VTE. 4.4 Actions by CSU/CCG The CCG and CSU continue to monitor this at the CQRM and through CQUIN compliance. 5 MRSA 5.2 Number of MRSA reported Barts Health has reported 3 MRSA cases since April 2013, 1 in May and 2 in June. Newham site had no MRSA cases, with the 3 cases occurring at Royal London (2) and Whipps Cross (1). For the same period last year (April to July 2012-13), 7 MRSA cases were reported. There is zero tolerance around MRSA. 5.3 Current reporting month No MRSA cases reported in July 2013. 5.4 Action by Trust Barts health have developed an infection control strategy and associated action plan, which incorporates all the key areas of learning identified through the post infection review process undertaken for all cases. The plan has been approved at the Trust infection control committee and is being embedded within each CAG to operationalise. 5.5 Action by CSU/CCG MRSA cases are monitored via daily health care associated (HCAI) reports from Barts Health. 5
The CQRM will continue to monitor implementation of learning identified through oversight of the infection control strategy and annual work plan. 6 C.Difficile 6.2 Number of C.Difficile reported Barts Health reported 21 C.Difficile cases since April to July 2013. For the same period last year the Trust reported 30 C.Difficile cases. The Trust is currently below their trajectory for period April to July 2013. 6.3 Current reporting month Barts Health reported 5 C.Difficile cases in July 2013. 6.4 Action by Trust C.Difficile cases are monitored via daily health care associated (HCAI) reports from Barts Health. The CQRM will continue to monitor implementation of learning identified through oversight of the infection control strategy and annual work plan. 6.5 Action by CSU/CCG The CQRM will continue to monitor implementation of learning identified through oversight of the infection control strategy and annual work plan. 6
7 Friends and Family Test (FFT) 7.2 Number of responses (August) Barts Health overall achieved a low response rate of 11.57%, which is below the CQUIN target of 15%. 7
In Inpatient Wards the Trust achieved 23.40%. However in A&E, the Trust achieved a low rate of 6.64% which is contributing to the overall low score. Newham site overall achieved a low response rate of 8.6%, with only 4.42% in A&E contributing to the overall low response rate. However achieved a 21.2% response rate in Inpatient Wards. 7.3 Action by Trust An action plan is in place that aims to improve A&E compliance; this is beginning to see results. 7.4 Action by CSU/CCG FFT is monitored at the CQRM, including implementation of the action plan for improvement. Regular participation in the FFT teleconference with NHS England is undertaken to ensure shared learning. 8 Safeguarding 8.2 Safeguarding targets Children s safeguarding training is not being met across the entire Trust. The Trust has a compliance to meet 85% by October 2013. August has shown some improvements, however the Trust continues to not achieve the target. 8.3 Current reporting Month Children s For Children the Trust achieved 83% (Level 1), 66% (Level 2) and 75% (Level 3). Improvement in training compared to last month (August 2013), however still under target. Adults For Adults the Trust achieved 76% (Level 1) and 62% (Level 2). Improvement in training compared to last month (July 2013), however still under target. 8.4 Action by Trust The Trust presented a refreshed action plan at the CQRM in July 2013; this incorporates safeguard training within the mandatory training booklet. 8.5 Action by CSU/CCG Implementation of the action plan will be monitored at CQRM. 9 Amber Alerts 9.2 Number of Amber Alerts raised 8
A total of 46 Amber Alerts were raised from July (go live date) to August 2013. 61% of the alerts related to the Newham site, and 39% related to Whipps Cross, Royal London and other Barts Health sites. Majority (12%) of the alerts related to Pathology Lab, followed by A&E (8%). The themes related to the alerts were; delay in obtaining results (18%), followed by incomplete discharge summary (10%) and patient incorrectly being informed that they need to be re-referred (10%). 9.3 Action by Trust Of the alerts actioned, majority (24%) related to patient being offered appointment without re-referral required, and 18% related to no error by provider. 9.4 Action by CCG 9
The CCG continues to receive and coordinate the alerts received from practices ensuring the alerts are acknowledged and actioned. 10 Update from CQC 10.1 CQC Information Newham The CQC report highlighted that action was needed in the following areas: Staffing (1 compliance action) Supporting workers (2 compliance actions) Royal London Antenatal Care/ Clinic and Maternity inpatient wards were reviewed and the following actions taken: Respecting and involving people (1 compliance action) Care and welfare of people who use services (1 compliance action) Staffing (1 compliance action) Supporting workers (2 compliance actions) Whipps Cross The full CQC inspection report was released in August. This report highlighted the following actions within maternity services: Cleanliness and infection control (1 enforcement action) Safety, availability and suitability of equipment (1 enforcement action) Respecting and involving people who use services (1 compliance action) Care and welfare of people who use services (1 compliance action) Safety and suitability of premises (2 compliance actions) Staffing (2 compliance actions) Assessing and monitoring quality (1 compliance action) Records (2 compliance actions) Within care of the elderly (and A&E) the following issues were raised: Supporting workers (1 enforcement action) Care and welfare of people who use services (2 compliance actions) Meeting nutritional needs (2 compliance actions) Safety, availability and suitability of equipment (1 compliance action) Staffing (1 compliance action) 10.2 Action by Trust 10
Full action plans have been provided by the Trust to the CQC and CCG/CSU which highlight how the compliance actions and enforcement actions will be met. This also looks at the monitoring of implementation. Clinical Fridays (senior team visits to the clinical areas) at the Trust are being focussed on the key elements of the warning notices received. CCG representation will also be participating in these days. 10.3 Action by CSU/CCG The CSU/CCGs have met with the CQC to review outcomes and agree next steps. There has been attendance at the Clinical Fridays by a CCG Quality Lead. A quality assurance visit has been carried out to the affected services at Whipps Cross and a further quality assurance visit is to be carried out. Action plans will be reviewed and monitored at CQRM. The CQC has identified 18 NHS Trusts representing the variation of care in hospitals in England. These will be the first hospitals to test the new CQC inspection regime. Barts Health will be part of this first wave of inspections as they are considered a high risk rated Trust by the CQC. Barts are carrying out internal inspections prior to these visits, CCG representation will be part of the inspections. 11 Update from Barts Health CQRM The quality leads from CCG s have maintained a focus and prioritised on the CQRM agenda, the large number of complaints and incidents that were overdue. 11
11.1 Barts Health ECAM CAG As at week ending 7 th July ECAM had 46 overdue incidents. As at week ending 7 th July ECAM had 62 overdue complaints. 11.2 Current update As a result of the quality leads focus on the issue, ECAM CAG at Bart Health has made a significant improvement in their number of overdue incidents and complaints. As at the 30th August 2013, ECAM has only 9 overdue incidents. As at the 30 th August 2013, ECAM has 0 overdue complaints. 11.3 Action by Trust The Trust has put several actions in place around management, process, ownership and education. The actions by Barts Health have seen a significant improvement in ECAM. 11.4 Action by CSU/CCG The CCG with the CSU will continue to maintain the focus on overdue cases. 12
ELFT - Mental Health 1.0 Purpose 1.1 The purpose of this report is to provide the CCG Board with an update on quality matters across pertaining to our main local Provider organisations. Areas of priority: Serious Incidents Service User Led Audit Areas where the Trust has no significant concern: Safeguarding Adults CQC Update 2.0 Serious Incidents 2.1 Number of incidents reported East London Foundation Trust (ELFT) has reported 24 incidents from April to August 2013. For the same period last year the Trust reported 21. There has been a small increase this year compared to last year. The Trust has reported no never events from April to August 2013. 2.2 Current reporting month The Trust reported 1 incident in August 2013. Which is a slight decrease compared to last year with 2 incidents. The 1 incident reported related to sub-optimal care of deteriorating patient. The Trust as at 31 st July 2013 has 9 cases overdue. 2.3 Action by the Trust 13
ELFT continues to report low numbers of SIs each month, reporting only one in August this is not out of line with reporting levels in August 2012. The only incident reported in August is that of a suboptimal care of the deteriorating patient, the incident was declared in response to an inpatient on a mental health ward, who was admitted to Newham General ITU following a diagnosis of diabetic ketosis; hence an investigation in to the physical health care of the inpatient will take place. ELFT has done much work to improve the physical health care provided to its mental health patients, and this is the first incident of this type reported by the Trust this year (2013/14). 2.4 Action by the CCG/CSU The number of overdue reports has not changed significantly over the course of the past four months. The CSU will meet with the Trust to discuss incident management processes. A new serious incident review and feedback process is being developed, whereby boroughbased CQRMs will receive incident feedback, depending on the borough where the incident occurred. The process is currently being finalised following a meeting between the CSU and CCGs on 19th September. At that meeting, the CCGs agreed to close 26 legacy incidents following a thematic workshop and subsequent receipt of evidence from the Trust. 3 Service User Led Audit 3.1 Issue The Trust was rated red on standards relating to the Trusts welcome pack and the provision of practical information. 3.2 Action by the Trust The Trust reported that this was largely related to the Welcome pack and they were about to undertake some qualitative work to understand why. 3.3 Action by CCG/CSU The CSU and CCG will receive feedback from the qualitative work through the CQRM and performance meetings. 4 Safeguarding Adults 4.1 Safeguarding Audit A safeguarding adults audit is currently underway by London Borough of Newham which will investigate the procedural pathway surrounding ELFT response to safeguarding adult queries. 14
4.2 Action by the Trust An action plan will follow, which will include awareness raising over and above statutory training for each team/service, this will commence in the autumn which will be a joint initiative by London Borough of Newham and Trust Senior Staff. 4.3 Action by the CCG/CSU The CCG will ensure at CQRMs and performance meetings that the Trust ensures that staff have a fundamental understanding of the safeguarding process and procedure. 5 CQC Update 5.1 CQC Information There was an unannounced visit at the Trust Mental Healthcare for Older Persons Directorate on the 15 th and 16 th July 2013. The CQC measured the following standards: Respecting and involving people who use services Care and welfare of people who use services Cooperating with other providers Staffing Assessing and monitoring the quality of service provision Records 5.2 Result of the inspection The CQC report shows that the Trust has met all 6 standards. The results of the CQC are as follows: Respecting and involving people who use services People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Care and welfare of people who use services People experienced care, treatment and support that met their needs and protected their rights. Cooperating with other providers People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. Staffing There was enough qualified, skilled and experienced staff to meet people's needs. Assessing and monitoring the quality of service provision 15
The provider had an effective system to regularly assess and monitor the quality of service that people receive. Records People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. 5.3 Action by CCG/CSU The CCG and CSU will ensure that Trust continues and maintains the positive results following the CQC inspection. 16
ELFT - Community Health Newham 1.0 Purpose 1.1 The purpose of this report is to provide the CCG Board with an update on quality matters across pertaining to our main local Provider organisations. Areas of priority: Serious Incidents Areas where the trust has no significant concern: Audit CQUIN Amber Alerts CQC 2.0 Serious Incident 2.1 Number of incidents reported Community Health Newham (CHN) has reported 16 incidents from April to August 2013. For the same period last year the Trust reported 11. There has been a small increase this year compared to last year. Community Health Newham has reported no never events. 2.2 Current reporting month CHN reported 3 incidents in August 2013. For the same period last year the Trust reported none. All 3 incidents related to Unexpected Death of Community patients. All 3 cases are homicides. 17
All three were known to community health services because they either had children or were receiving child services. Two of the deaths are being investigated as Domestic Homicide Reviews, and ELFT are participating in the reviews. The third case involves a child, who was also referred to CAMHS, and was allegedly stabbed to death by an unknown person initially the case was thought not to require a Serious Incident review, but the Local Safeguarding Children s Board has subsequently decided to undertake a Cross Borough Learning Review. 2.3 Action by the Trust Community Health Services continue to report low numbers of SIs each month, reporting only three in August, however, this is an increase over August 2012, when none were reported. No Pressure Ulcer incidents were reported in August, but that does not mean none occurred. There tends to be a delay between when Pressure Ulcers are identified and reported at the Trust. ELFT does not report pressure ulcers identified on first contact, i.e. already present when the patient first came into contact with ELFT services. 2.4 Action by CSU/CCG The number of overdue reports has not changed significantly over the course of the past four months. The CSU safety manager will meet with the Trust to discuss the incident management processes. 3.0 Audit 3.1 Clinical Audit The Trust reported 100% compliance with VTE assessments The Trust audited their Phlebotomy service for waiting times, the national guidance is 6 minutes patient facing time per blood test. The Trust audit data showed that all centres perform consistently above the level. The Phlebotomy service received 3 complaints from August 12 to March 2013. All complaints have been investigated and none of which are upheld. The audit also consisted of Patient Satisfaction Survey, of the responses received 88% were positive responses, 3% were negative responses, and 9% where not applicable. 3.2 Action by Trust To report on audits and provide more detailed outcome reporting. 3.3 Action by CCG/CSU The CCG with the CSU are to review the detailed outcome reporting once report is submitted. 18
4.0 CQUIN 4.1 CQUIN status The Community Health Newham CQUINs have been signed off in September. The CQUINs are as follows: - Improving the Experience of Patients - Promoting effective Cardiac Rehabilitation - Promoting effective Self Care and Management of Long Term Conditions - Enhancing GP Communication - Improving End of Life Care 4.2 Action by Trust The Trust will report on this from quarter 2. 4.3 Action by CCG/CSU To monitor CQUINs as of quarter 2. 5 Amber Alerts 5.1 Number of Amber Alerts reported Since July (go live date), a total of 7 amber alerts were reported relating to Community Health. Majority of the alerts were categorised as District Nursing not arriving timely, followed by Attitude of staff, Patient inappropriately asked to call the GP for home visit, Patient not offered an urgent appointment and poor response and communication. Majority of the alerts belonged to District Nursing Service, followed by Diabetic Education, Community Matron and Foot Health Services. 19
5.2 Action by the Trust Of the alerts actioned, the outcomes of the actions were; appropriately actioned by provider, no error from provider and education and training of staff. 5.3 Action by CCG The CCG continues to receive and coordinate the alerts received from practices ensuring the alerts are acknowledged and actioned. 6 CQC 6.1 CQC Information There was an unannounced visit at the Trust Community Health Services on the 15 th and 16 th July 2013. The CQC measured the following standards: Respecting and involving people who use services Care and welfare of people who use services Cooperating with other providers Staffing Assessing and monitoring the quality of service provision Records 6.2 Result of the inspection The CQC report shows that the Trust has met all 6 standards. The results of the CQC are as follows: Respecting and involving people who use services People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Care and welfare of people who use services People experienced care, treatment and support that met their needs and protected their rights. Cooperating with other providers People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others. Staffing There was enough qualified, skilled and experienced staff to meet people's needs. Assessing and monitoring the quality of service provision The provider had an effective system to regularly assess and monitor the quality of service that people receive. Records People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. 6.3 Action by CCG/CSU 20
The CCG and CSU will ensure that Trust continues and maintains the positive results following the CQC inspection. 7 Recommendation The Board are asked to note this report. 21