Enclosure: L Agenda item: 16 Title of paper: Quality report GOVERNING BODY Date of meeting: 28 March 2018 Presented by: Yvonne Leese Prepared by: Anne Douse Title: Director of Quality and Integrated Governance & email contact: yvonne.leese@nhs.net Title: Associate Director of Quality & email contact: annedouse@nhs.net Corporate Objective addressed by this paper (please select one or more with an X): 1. To commission safe, sustainable, efficient and affordable services to meet the health and wellbeing needs of the population of Greenwich and reduce health inequalities with an additional focus on the urgent and emergency care system improvement along the pathway 2. To ensure the CCG s position recovers to meet its financial and governance duties and performance standards 3. To nurture and support primary care to be resilient and thrive 4. To strengthen productive relationships with partners and the public to work as a x health and care system 5. To actively engage with our communities to improve their experience of healthcare x 6. To play an active and influential role in shaping SE London and London wide commissioning. x x Purpose of the report: This report has been compiled to update the Governing Body and provide assurance regarding the quality of commissioned services and highlight areas of quality improvement. The report also provides an overview of the CCG position in relation to Continuing Healthcare (CHC) key performance indicators (KPIs) and the Quality Alert Management System (QAMS), including reverse reporting from commissioned services. Key Highlights: Lewisham and Greenwich NHS Trust (LGT) has established a Quality Assurance Working Group to oversee the implementation of their CQC inspection action plan. The CCG is represented at this group. A commissioner quality visit took place at Lewisham Hospital Emergency Department in January 2018 and a further visit to Queen Elizabeth Hospital (QEH) is planned. NHS Resolution has provided all trusts with details of a CNST incentive scheme for trust providing maternity services. The scheme requires trusts to discuss compliance with CCGs before submission on progress with the 10 actions by the end of June 2018. Oxleas has reviewed themes from homicide investigations. Oxleas are taking part in work being undertaken across London Mental Health trusts regarding treatment of clients with schizophrenia. The CCG performance in meeting the compliance requirements for NHSE targets for Continuing Healthcare (CHC) decisions being reached within 28 days for Q3 has fallen
below trajectory and an improvement plan has been submitted to NHSE. The CCG forecasts that it will achieve the required standard by the end of March 2018 as planned. Between 12 and 16 February 2018 there was a joint inspection of the multi-agency response to children who go missing, are at risk of child sexual exploitation and who are at risk of criminal and other forms of exploitation through gangs. The inspection included a deep dive focus on a number of cases in which these issues were known to be concerns where children were involved. The report is awaited by the end of April 2018 after which a partnership Improvement Plan will be developed. Summary of actions, if any, following this meeting: Actions will be followed up through Clinical Quality Review Groups (CQRGs) and Quality reviews with providers. Previous committee involvement: Quality Committee Recommendations to the Greenwich Executive Group The Governing Body is asked to note the content of this report (Please provide details below where Yes is indicated ) Impact on Governing Body Assurance Framework (x) Yes x No N/A Impact on Environment (x) Yes No N/A Legal Implications (x) Yes No N/A Resource and or financial implications (x) Yes No N/A Equality impact assessment (x) Yes No N/A Privacy impact assessment (x) Yes No N/A Impact on current NHS Outcomes Framework areas (x) Yes x No N/A Patient and Public Involvement (x) Yes x No N/A Communications and Engagement (x) Yes x No N/A Impact on CCG Constitution (x) Yes No N/A Attachments: i. Quality Report 2
QUALITY BRIEFING REPORT February 2018 Lewisham and Greenwich NHS Trust (LGT) CQC inspection: Following CQC inspections in 2017, the trust has produced an action plan with actions to deliver improvements in line with CQC recommendations. A key aspect of this is the quality assurance working group (QAWG) responsible for monitoring, tracking and reviewing progress of the overall improvement plan. The Associate Director of Quality at Lewisham CCG has been confirmed as the representative for Lewisham, Greenwich and Bexley CCGs and will attend this meeting in future. The Clinical Quality Review Group (CQRG) continues to review progress and seek assurance on the effective implementation of the plan. Emergency Care: The CQRG has requested evidence from the trust regarding the impact of emergency care performance on clinical effectiveness and patient outcomes. This is particularly important in the light of challenges faced in all aspects of urgent and emergency care due to increased demand over the winter period. The CQRG was informed the Trust now has in place 4 hourly quality and safety reviews for all patients to ensure any concerns are escalated utilising the agreed pathways. This action is in line with recommendations arising from the CQC inspections. Additional quality rounds are undertaken by the Head of Nursing, Matron and Clinical Director to monitor the effectiveness of the quality and safety reviews. Regular audits of delayed transfers of care are being carried out along with reviews of serious incidents, complaints and patient feedback. Key themes identified are the need to improve communication related to patient discharge, long waiting times for emergency department and specialist doctors. This is attributed to physical capacity in the department. CQRG has requested action plans to address the issues and regular updates. The trust reported three 12 hour trolley breaches in A&E on 17 January 2018 under the duty of candour. Commissioner visits to emergency departments: In response to the increased activity within the two A&E departments quality visits were arranged at both Lewisham and QEH during January 2018 by the three commissioning CCGs quality leads (Lewisham, Greenwich and Bexley). The first visit to Lewisham Hospital was carried out on 15 January 2018 with broadly positive feedback (the full report is awaited). The second visit to QEH was planned to take place the following week, but was delayed due to pressure within the emergency care system and across SEL on the day. Another visit was arranged for 12 March 2018, but once again was delayed due exceptionally high pressure within A&E; a further visit is being arranged as soon as possible. Maternity Services: NHS Resolution recently contacted all NHS Provider trusts with details of a CNST incentive scheme for those delivering maternity services to support the DH Maternity Safety Strategy. The process will require trusts to self-certify with board sign off progress on 10 actions by 29 June 2018. It is anticipated progress regarding the 10 actions will be part of regular quality monitoring discussions and review by CCGs and trusts have been asked to discuss their compliance before submission to NHS Resolution with commissioning CCGs. GB Quality Report March 2018 Page 1
Maternity deep dive: Pan London scorecard: The SEL maternity group is collecting GP views to review the current medical information process required for antenatal booking. Early access rates for women 12+3 booking at QEH is 83.3% (target= 85%). Antenatal booking rates at 10 weeks is 44.5% target = 85%. C- Sections: LGT have similar C section rates to others in SEL with the exception of PRUH. The trust is carrying out a number of audits based on the Robson criteria and has in place a number of iniatives to support women to have a natural birth. Audit results will be reported to CQRG alongside action plans. Saving babies lives: This is a national iniative with 4 work streams: Reducing the number of women who smoke during pregnancy, the trust has trained Obstetricians and Midwives to establish whether pregnant women are smoking and to refer them to quit smoking services. However, referral rates are low at 1%. This programme requires review by the trust with commissioners. Improving the management of women with reduced fetal movements, information is provided to all women regarding fetal movements including appropriate advice. Improving fetal monitoring, staff now undertake improved training and education, this includes a competency test. All fetal monitoring is monitored centrally on both the QEH and Lewisham sites. Improving detection of small for gestational age babies, this includes compliance with NICE requirements and additional scans to aid early detection. Episcissors: Commissioners noted the use of episcissors is nationally prescribed to reduce the incidence of 3 rd degree tears for women in labour. The trust is implementing the OASI (obstetric and anal sphincter injury) care bundle which includes the use of episcissors. Workforce report: The November workforce report highlights: Vacancies = 16.55% (16.27% in 16/17) trust target = 12% Agency pay as a percentage of total pay = 7.31 (7.6% in 16/17) trust target = 6%. Total trust pay to date = 13.6m (30% reduction on 2016 which was 17.2m) This was attributed to Pan London pay rates for Doctors, moving to permanent and bank staff reducing agency spend. Annual staff turnover = 14.45% (13.87% in 2016/17) trust target = 12% Sickness and absence = 4.7% (4.73% in 16/17) trust target = 3.5% The trust reported being able fill 90% junior doctor vacancies with agency staff to ensure appropriate staffing levels. Safer staffing: Commissioners noted the comprehensive safer staffing dashboard, but expressed concern regarding nursing establishment, recruitment and retention with high staff vacancies in accident and emergency medicine. The trust reported this is also an issue for other London trusts and they had used more agency staff to ensure safe staffing levels. They are mobilising a number of initiatives such as adopting learning from the St George s model of skills academies and workshops. CQRG has information at each meeting and will continue to monitor and review the position with the trust. GB Quality Report March 2018 Page 2
Under duty of candour the trust reported staffing shortages across different clinical areas and particularly in nursing. This is monitored daily and staff redeployed to ensure safe care is provided. Flu immunisation as a key CQUIN remains below the 75% target, currently 45%. The trust has in place 10 internal peer immunisers to support achieving the target. The trust also reported having access to 1,500 flu vaccines in case of a flu outbreak. Complaints: The Trust performance for response to complaints has deteriorated again and most delays relate to the surgery division. The Trust has put in place additional support and performance review and will continue to report progress. Safeguarding: Children s core safeguarding training compliance has further deteriorated. Medical staff compliance continues to be an issue of concern for staff is below compliance level, which is of concern. The Trust continues to take a number of actions and the issue will be reviewed at the next CQRG. Prevent WRAP training is at 66%, an improvement on the last report. VTE compliance: The trust is in the process of changing the VTE audit from 10 notes across the trust to 5 notes per ward to provide improved assurance on the trust performance with VTE requirements. Serious Incidents: The Trust has now added falls and fractures to the serious incident (SI) criteria. This will increase the number of SIs reported by the trust. This addition was supported by commissioners as a positive measure. National Early Warning Scores (NEWS): A further trust-wide NEWS audit was carried out in December 2017 utilising a revised audit tool focusing on patients referred to the critical care outreach team (CCOT). The trust has put place in measures to embed NEWS across the trust and the audit demonstrated an improvement in escalating deteriorating patients, finding 6% of patients were not appropriately escalated. Ward scorecards are utilised as part of the incentive to provide assurance on ongoing compliance. CQC regulation compliance: While the trust continues to work on improvements the breach of three CQC standards will remain in place until a follow up review is conducted with a revised report. Making Time in General Practice: The Making time in General Practice Group met in mid-january and DNA letters were part of the agenda, the group will report back to CQRG. Fit notes: The trust has confirmed fit notes can be sent to GPs electronically. Oxleas NHS Foundation Trust Bromley CCG recently chaired the first of the new style quarterly quality meeting for trust wide specialist and mental health services. Greenwich and Bexley CCGs CQRG met for the first time on a bi-borough basis, chaired by Greenwich CCG for community services, the next meeting agenda will be to examine local mental health services, chaired by Greenwich CCG. The annual work programme agreed by the three CCGs and the new format incorporates deep dives into commissioned services to facilitate greater detail and exploration of the quality of each service. GB Quality Report March 2018 Page 3
Mental Health CQRG (Bromley, Greenwich and Bexley CCGs) Mental Health Homicides: The trust has undertaken a review of the themes from the cases, these were similar to other mental health SIs including CPA, discharge planning and engagement. Additionally drug and alcohol issues were a contributing factor. Anti-psychotics & Optimising Treatments QI Project: The CQRG received an update and presentation on the work being undertaken across London Mental Health Trusts. In 2016/17 50% of acute bed occupancy related to patients with schizophrenia and these are often long and complex admissions. Challenges in the management of these patients are: Relapse Hospital admission (poor outcome for patients and NHS) Harm to self and others (1 in 10 take their own life and there is a lifetime risk of 16% harm to others) Clinical evidence based reviews confirm medications make a significant difference. Oral medications are particularly problematic where there is treatment reluctance/ resistance. One quarter of patients do not take oral medications 10 days after admission. SLP Prescribing Project Aims: Minimise poor/non-adherence by increasing use of depot/long-acting medication Maximise use of clozapine in suitable patients The current work streams within the project including information dissemination, benchmarking of prescribing rates and participation in the POMH national quality improvement programme. Survey of people who use mental health services: CQRG received a presentation on the annual CQC survey results for adults and older people. 85% of mental health trusts across the country participate; however, the sample size is a very small subset of the total caseload with less than 1% response. Improved Results: Continuity of care and knowing who was in charge Knowing who to contact in crisis Declining Results: Knowing who co-ordinates care Formal annual meetings Received crisis help after making contact Explanation of care and treatment Advice/support on physical health needs and finance/benefits The results have been presented to Oxleas Patient Experience Group and to Borough Directorates who were asked to consider the outcomes. CQUINs: The trust outlined the following challenges with CQUIN requirements: Flu despite numerous efforts it was unlikely Oxleas would meet this target Frequent Attenders: Oxleas confirmed actions were underway in Bromley, but there were challenges in Greenwich Staff Survey whilst the final survey was not due until the end of Q4 Oxleas felt it unlikely they would meet the target. GB Quality Report March 2018 Page 4
The CCGs agreed confirmation of agreement and sign-off decisions would be shared by the CCGs at the CQRG meeting. Quality Report: Patient Experience: Patient feedback for the internal survey had a larger response rate than in the CQC national survey (not comparable questions). It was noted that the response figures for Bromley are lower as this relates to MH services only; Bexley and Greenwich include community services. The trust had rated response from adults with Learning Disability Services red due to the low response rate which was flagged to service managers to support improvement. Safeguarding: Oxleas remain on target with PREVENT and WRAP training and have put in place a VIP protocol as part of safeguarding procedures. The trust is recruiting an Adult Safeguarding lead. Safeguarding Children: A joint review visit had taken place and the key issues identified were supervision training for CAMHs (this is continuing to be followed-up) and a drop in supervision in Greenwich, both issues are in the process of being resolved. The trust aims to ensure all Health Visitors have received level 3 training by the end of the financial year. A historic risk regarding the A&E liaison protocol related to Greenwich (QEH) and this is being audited by the trust. Mortality & Learning from Deaths Oxleas has begun to upload information onto their public website. A new template is now being used and a record of structured judgement reviews is being progressed. Workforce report: Oxleas has a programme to reduce vacancy rates and agency staff usage. The trust approach to retention has mainly focused on nursing and AHPs and this is being rolled out to other staff groups. WRES: Oxleas is working on improving career opportunities, recruitment, protecting staff from harassment and bullying and leadership opportunities. The trust has also set a WRES target to increase staff at band 8a and above. CQRG requested an update on progress at the next CQRG. Community CQRG (Greenwich and Bexley CCGs): The Bexley and Greenwich borough CQRG meeting focussed upon the community Rapid Response Service (Greenwich) and JET (Bexley). Rapid response: This service commissioned by Greenwich CCG has noted the increasing acuity of patients being referred to the service over recent months, there has also been an increase in referrals from London Ambulance Service. The team has constant access to a Consultant Geriatrician to ensure patients receive appropriate care and there is a daily handover with daily multidisciplinary (MDT) input. The service presentation highlighted staff shortages for senior physiotherapists, social workers and social work assistants which mirrors the position across London. The service presented information on clinical effectiveness and commissioners requested this should have a greater emphasis on quality assurance in future. The service has recently undertaken a study on falls and will focus on the patient journey in the next study. GB Quality Report March 2018 Page 5
Commissioners requested at least six months of data in future, instead of the one month provided to aid comparison. In addition information on both formal and informal complaints was requested as well as more detailed information on actual patient numbers within the report. Greenwich Intermediate Care: Commissioners requested admission and readmission rates to be audited on at least a twice yearly basis Greenbrook Healthcare (Urgent Care Centre (UCC) at QEH) Patient Safety: Quarter 3 information indicates there have been no Serious Incidents (SIs) over the reporting period, a total of 34 incidents have been reported. Safeguarding: Children: 57 referrals were made to Social Services up to the end of Quarter 2 of 2017-18. 191 children subject to a Child Protection Plan and 68 Looked After Children were seen in the department. Two child protection referrals and 14 new referrals were made to social services. Six children and young people with bullying and assault concerns were seen in the UCC. Adults: Within UCC there was one adult safeguarding alert and 5 adult safeguarding referrals were made to Social Services. 2 adults were identified as having domestic violence concerns. 4 adults at risk with mental health issues, 1 with adults at risk with drug or alcohol issues and 2 adult carers at risk. Audits: The UCC has a programme of monthly audits, all audits have improvement plans and feedback to staff incorporated; the reported audits were: Child and Adult Safeguarding, indicating a number of learning points, but also two aspects of exemplary practice. A consultation notes audit showing an improvement on the previous audit. Streaming referral audit Emergency Department referral, the results indicate overall improvement in the quality of referrals and an increase of referrals to the ED. Patient Experience: Complaints and Compliments A total of 15 complaints and two compliments were received in Quarter 3. All complaints were acknowledged within three working days and 13 received a response within 4 weeks. The complaints related to staff behaviour and attitude, the environment, waiting times, x-ray, diagnosis, medication, and the out of hours service. Friends and family 75.46% of patients attending UCC were likely or extremely likely to recommend the UCC to friends and family. UCC attendance 148 unregistered patients attended the UCC and 60 patients were supported to register with a GP 72 patients attended for dressings and 62 could potentially have been seen in Primary Care. GB Quality Report March 2018 Page 6
Circle (Musculo-Skeletal Service) VTE assessment: Circle reported a reduction in VTE assessment compliance to 95% at BMI Shirley Oaks. However, compliance remains within tolerance levels. LGT performance: PROMS (Patient reported outcome measures) continue to improve month on month for the contract, now at 56% (target =80%) 18 RTT at 87.6% in the last report, Circle is monitoring and reviewing the 18 week RTT trajectory with LGT in the light of the national directive. LGT has provided exception reports for routine physiotherapy assessments and orthopaedic assessments. These issues are reviewed at each meeting with Circle alongside action plans and plans for improvement. Continuing Healthcare Quality Premium 17-18 Table 1 Monthly NHS CHC assessments <15% DST to take place in an acute hospital setting Month July Aug Sept Oct Nov Dec Jan Trajectory <15% <15% <15% <15% <15% <15% <15% Performance 9% 5% 5% 7% 5% 8% 14% Less than 15% of DST Completed in Acute Setting 16% 14% 12% 10% 8% 6% 4% 2% 0% July Aug Sept Oct Nov Dec Jan Performance 9% 5% 5% 7% 5% 8% 14% <15% DST Completed in Acute 15% 15% 15% 15% 15% 15% 15% Table 2 Quarterly GB Quality Report March 2018 Page 7
NHS CHC assessments <15% take place in an acute hospital setting Quarter Q2 Q3 Q4 Trajectory <15% <15% <15% Actual 9% 10% Variance >6% >5% Quarterly Performance <15% DST Completed in Acute 16% 14% 12% 10% 8% 6% 4% 2% 0% Q2 Q3 Q4 <15% DST in Acute 15% 15% 15% Actual 9% 10% Table 3- Monthly NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the Checklist (or other notification) >80% Month July Aug Sept Oct Nov Dec Jan Feb March Trajectory 50% 50% 50% 51% 55% 60% 65% 75% 82% Performance 50% 63% 50% 44% 64% 77% 36% 79 Variance >0% >13% >0% <7% >9% >17% <29% >4% GB Quality Report March 2018 Page 8
Monthly Performance >80% Completed within 28 Days 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% July Aug Sept Oct Nov Dec Jan Feb Marc h Trajectory 50% 50% 50% 51% 55% 60% 65% 75% 82% Performance 50% 63% 50% 44% 64% 77% 36% 79% >80% Completed within 28 Days 80% 80% 80% 80% 80% 80% 80% 80% 80% Table 4- Quarterly NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the Checklist (or other notification) >80% Quarter Q2 Q3 Q4 Trajectory 50% 55% 74% Actual 54% 62% TBC Variance >4% >7 Quarterly Performance >80% Completed within 28 Days 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Q2 Q3 Q4 Trajectory 50% 55% 74% Actual 54% 62% >80% Completed within 28 Days 80% 80% 80% GB Quality Report March 2018 Page 9
Exception reporting for 80% of DST being completed within 28 days The CCG s performance dipped from 69% in December 2017 to 36% in January 2018 which was 29% below the internal trajectory. This was due to challenges in capacity with Nurse Assessors and the Social Worker. The following actions have been implemented to manage the issues going forward and ensure planned consistency with meeting the monthly performance trajectory. The CHC nurse assessors will provide a weekly highlight report, to ensure that any delays can be anticipated and managed pro-actively in month A meeting had been scheduled with RBG to agree medium/long term plans for Social Work capacity CHC nurse assessors to gain access to provider clinical information systems to ensure timely completion of assessments The CHC nurse assessors are where possible, utilising the Multi-Disciplinary Team (MDT) capacity in the community, and where discharge-to-assess patients have been sent to Duncan House, to use both the Social Worker and MDT team to support DST assessments thereby reducing demand on the one and half days allocated social work capacity. Data is being collected weekly by the CHC Administrator to enable the Commissioning Manager to track and monitor the position and anticipate delays taking remedial action where necessary. The CCG has recently submitted its Q3 improvement plan to NHSE for non-compliance of the 80% target of decisions made within 28 days. Although the CCG exceeded its internal performance trajectory of 55% by 7%, it was still 18% below the expected national performance target. The CCG is forecasting achievement of the key performance indicators by March 2018 as planned. Quality Improvement Highlight Summary LGT: A&E 4 hourly quality and safety reviews for all patients to ensure any concerns are escalated utilising the agreed pathways, supports the improvements required in the CQC report Use of episcissors, following concerns raised by commissioners regarding the non-use of episcissors by the trust, the trust is now putting in place nationally prescribed practice to reduce the incidence of 3rd degree tears for women in labour. The trust is implementing the OASI (obstetric and anal sphincter injury) care bundle which includes the use of episcissors A multiagency discharge event (MADE) took place at QEH in February 2018 involving Greenwich CCG and Local Authority, Bexley CCG and Local Authority, NHSI, South East London surge hub and LGT senior medical and nursing staff. This followed a one day review by ward and clinical staff of all patients with a length of stay greater than 7 days. The review examined the patient journey, learning and actions that needed to be taken by all agencies to improve this in the future. Oxleas: Recruitment a Safeguarding Adult lead following recommendation by the CCG Mortality and learning form deaths process continues to be embedded and improved by the trust. Infection control: Post infection reviews are in place with acute trusts and general practice to ensure effective action plans are in place and learning from reported cases GB Quality Report March 2018 Page 10
Quality Alert Report April December 2017 The Quality Alert System is the process by which Greenwich GP practices are able to feed concerns derived from their interactions with patients and providers of services commissioned by NHS Greenwich CCG. Between 1 April and 31 December 2017 the CCG received and processed 72 Quality Alerts and Reverse Quality Alerts. Below is a breakdown of the member practices and service providers who raised alerts through the QAMS system. Providers GB Quality Report March 2018 Page 11
Themes Trend The highest number of concerns related to poor communication on discharge summaries being received by practices. This has been fed back to LGT via the CQRG and as a result the clinical divisions are all working towards the Trust standard to improve this. This will be reviewed regularly at CQRG until an improvement is seen and sustained. GB Quality Report March 2018 Page 12
Outcomes of Quality Alerts Reverse Reporting from Providers The CCG received 16 reverse quality alerts from NHS Lewisham and Greenwich Trust : Themes GB Quality Report March 2018 Page 13
Outcomes Learning Communication to all GPs to confirm with the patient at point of referral that they have they most upto-date patient information and contact details. GP to emphasise at point of referral the importance of the patient being available for the 2 week wait appointment. Referral forms to be checked to ensure all relevant information has been included. Status Update QAMS App will also be available soon to GPs using Vision GB Quality Report March 2018 Page 14
Joint Targeted Area Inspection Between 12-16 February 2018 Ofsted, CQC, HMI Constabulary and Fire & Rescue Services and HMI Probation undertook a joint inspection of the multi-agency response to children who go missing, are at risk of child sexual exploitation and who are at risk of criminal and other forms ofexploitation through gangs. The inspection included a deep dive focus on a number of cases in which these issues were known to be concerns where children were involved. The report from this inspection is awaited by the end of April 2018 after which a partnership Improvement Plan will be developed. GB Quality Report March 2018 Page 15