NHS TRAFFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY 19 DECEMBER 2017

Part 1 X Part 2 NHS TRAFFORD CLINICAL COMMISSIONING GROUP GOVERNING BODY 19 DECEMBER 2017 Title of report Purpose of the report and key highlights Directorate Update - Nursing The report updates the Governing Body on the progress of the CCG s Nursing Directorate in achieving key quality outcomes for patients including: Clinical oversight of pathway development driving improvements for Delayed Transfers Care. Achieving <15% of Continuing Healthcare Assessments in Hospital Being early adopters for future Children s and Adults Safeguarding Mobilisation to transform care and Nursing home quality Recognising the work on-going for public and patient engagement and experience, by listening and responding Actions requested Decision (Decision and discussion required) Discussion (No decision required. Discussion only which may lead to actions ) X Information (no discussion required) Strategic objectives supported by the report Recommendations Continually improve engagement with member practices, patients, the public, carers, providers, our staff and other partners to effectively contribute to and influence the work of Trafford CCG. Working with health and social care partners deliver the transformation plan for Trafford including an increasing proportion of services from primary care and community services in an integrated way. Through effective integrated commissioning improve the quality of services and reduce the gap in health outcomes between the most and least deprived communities in Trafford. To be a sustainable economy both in terms of clinical services and finances. The Governing Body is asked to: Review the contents of the report. X X X X

Continue to support the completion of the engagement calendar Note the requirement of NHSE to report on CHC performance in relation to DToC Trafford Coordination Centre implications Discussion history prior to the Governing Body Financial implications Risk implications Equality Impact Assessment Communications Issues Public engagement summary Prepared by Responsible Director Nothing contained in the report is directly applicable to the Coordination Centre. This is the first Chief Nurse Report to Governing Body and is produced with input and discussion from the team she manages Increasing complexity and demographic of patient groups and market forces in the independent nursing care sector may result in quality and performance issues, a reduction in the market and subsequent cost pressures. MH001, MH003, MH004 No EIA required. None. Trafford Talks Health Annual General Meeting Public Reference Advisory Panel Mary Moore, Director of Nursing/Chief Nurse Mary Moore, Director of Nursing/Chief Nurse Priorities 2017/18 1. To design, plan and begin implementation of the Transformation Plan including New Models of Primary Care, integration with Trafford MBC, Local Care Organisation and maximising the Trafford Co-ordination Centre. 2. To attain and further reduce delayed transfers of care targets (DTOCs). To meet waiting time standards in urgent care, cancer, mental health and planned care. 4. To achieve financial plans: a. Enhance CRES scheme delivery b. Prepare a medium term financial plan 5. To implement delegated primary care commissioning, including GP Forward View 6. To prepare a Trafford-wide integrated estate and service plan including Altrincham and Limelight. 7. To enhance engagement with communities, providers and primary care. 8. To progress organisational development throughout the health and social care sector. Director 9. To of progress Nursing/Chief commissioned Nurse Update service changes (e.g. end of life and diabetes).

DIRECTORATE UPDATE - NURSING 1. INTRODUCTION AND BACKGROUND 1.1 This paper is a narrative and provides an update the work of the teams under the Director of Nursing so the Governing Body will be sighted on activity not reported elsewhere. This report is supported by quality and performance metrics reported via sub committees to this Governing Body: Areas covered are: Care Quality Children and Adults Safeguarding Individualised Care Individual funded care Patient experience 1.2 The Chief Nurse has transitioned to full-time working at NHS Trafford CCG since the beginning of October and continues to develop her understanding of the teams and her direct reporters. Priorities for winter 2017/18 are now identified from a nursing perspective and include enhanced focus to outcomes and quality of care for patients whilst achieving service improvements for: Delayed transfers of care (DToC), unscheduled care pathways (including independent nursing home provision), and additional rigour and redesign of individualised funded care, namely continuing health care and personal health budgets. Also to support the whole of Trafford in the delivery of children s and adults safeguarding 2 CARE QUALITY The Chief Nurse and Dr Mark Jarvis jointly hold executive responsibility for care quality for Trafford with the support of a Central Manchester CCG s Quality Team. A recent change in role for Dr Jarvis to interim Medical Officer has meant a re-evaluation of responsibilities. The Chief Nurse will now attend GM Quality Board as the voice of Trafford and also support the Quality Team in respect of quality assurance for services delivered by Pennine Care NHS Foundation Trust (PCFT). The Chief Nurse will also now have quality oversight as a member of Trafford s Urgent Care Board and Transfers of Care Group. She has also commenced a series of quality visits across Trafford s

services, including care homes, intermediate care and acute and mental health services. There is active relationship building with partners at Trafford Council (TBC) ahead of integration in 2018. 3 CHILDREN AND ADULTS SAFEGUARDING - CHILDREN 3.1 The statutory function of both the Adults and Children s Local Safeguarding Boards was merged to form one Board and Trafford held its first integrated Safeguarding Children and Adult Board (TSCAB) on 2 nd October 2017. 3.2 The statutory guidance for safeguarding is outlined in the document Working Together to Safeguard Children; this is currently out to national consultation and proposes all Safeguarding Boards redesign to merge adults and children s. Trafford therefore is seen as an early adopter of the recommendations ahead of the revised publication of Working Together next spring. Core business for Trafford s Safeguarding Team continues with: The safeguarding team contribute to serious case reviews (SCR) and disseminate learning, as appropriate, throughout Trafford CCG s commissioned services. Recently published SCRs in Greater Manchester were discussed at the aforementioned TSCAB. In a recent Manchester SCR and domestic homicide review (DHR), it was found that the victim and perpetrator had different GPs and information sharing was insufficient. Following this insight, processes have been amended to ensure that both GPs are now informed of serious domestic abuse incidents. The Designated Nurse for Safeguarding Children/Children in Care (DNSC) agreed to share the DHRs with Trafford GPs to ensure the learning is taken into consideration in Trafford. Child N SCR has been published and is available on the TSCAB website. As the Review was completed some time ago; with publication delayed due to criminal proceedings most of the actions have been completed. Seminars have been delivered to the Trafford workforce in December to share the learning and support practitioners to work with families who are difficult to work with. Prepare for Serious Case Reviews (There are no new Serious Case Reviews and no ongoing SCRs at this time. In an attempt to have a standard approach to commissioning and service delivery for Looked after Children (LAC) the GM Designated Nurses have developed a strategy. We will focus on:- o o o o Quality and performance Emotional and mental health and wellbeing Voice of young people and engagement Commissioning of services

4 CHILDREN AND ADULTS SAFEGUARDING - ADULTS 4.1 The Designated Nurse for Safeguarding Adults chairs the Safeguarding Adult Review sub-group. Since April there have been 7 referrals into this group and two Safeguarding Adults Reviews (SARS) have been commissioned as a result. The SARs are now in progress with panel reviews in progress. There are 3 further referrals to screening panel pending. 4.2 The process for reviewing referrals has been refined over the course of the last ten months and has progressed onto a model whereby referrals are screened by a panel made up of senior representation from the three statutory agencies. Following screening where all information from agencies involved in the individuals care has been completed, the screening panel will make a decision as to whether the referral needs to be reviewed by a multi-agency SAR panel. 4.3 Safeguarding training is being provided to GPs, practice nurses, homecare agencies and a new initiative called Safeguarding Champions has been launched for care home staff. This includes bi-annual safeguarding training for identified nurses and carers within the homes who will act as a point of expertise for their colleagues to promote safeguarding referrals where required. In addition to the bi-annual training the team will also offer safeguarding supervision sessions for the Champions to attend. 4.4 The Designated lead has, together with TBC, refreshed the Terms of Reference for the Trafford Adults at Risk Group (TARGet) led by Greater Manchester Police. This group looks to have sight of and offer support to agencies who are managing high risk individuals. The aspiration of this group is that an at risk register will be created, either virtual or in hard copy to offer the Safeguarding Board oversight of the individuals who present the greatest risk to themselves within the borough. 5 PREVENT UPDATE DECEMBER 2018 5.1 NHS England (NHSE) has challenged NHS services to deliver Workshops to Raise Awareness of Prevent (WRAP) training to 85% of relevant staff and volunteers currently in the organisation by 31 March 2018. PCFT has consistently exceeded this target and basic training remains above 90%. Manchester University NHS Foundation Trust (MFT) Central and South have action in place to increase WRAP training to meet the end of year target. 5.2 MFT Central have given the individual divisions responsibility for WRAP training to allow for greater flexibility and oversight of training staff. Additional facilitators have been trained within each division to assist with the increased number of sessions required to increase compliance. WRAP sessions will be part of the nursing and midwifery induction and is provided on Foundation Doctor inductions. Refresher training is now provided via e-learning rather than face to face presentations offering more availability for face to face sessions for new staff. MFT South has trained additional WRAP facilitators and has added additional training sessions in December 2017 and January 2018. The additional training

spaces in each of the WRAP session has been increased and staff take up of the session is high. This has the effect of increasing uptake which has been part of their action plan to support achievement of the 85% target. 5.3 MFT Central and South WRAP reporting will remain separate for quarter 2 2017/18 as agreed with NHS England and single hospital reporting will be reviewed in quarter 3. 5.4 The Department of Health has released new online training and guidance. The guidance is aimed at providers of NHS mental health to support providers and staff to exercise their statutory and professional duties to safeguard vulnerable adults, children and young people at risk of radicalisation. A CCG review of training is underway to support staff training sessions scheduled for January and March 2018 5.5 The Strategic Prevent Forum, hosted by TBC, scheduled for 7 December 2017 has been postponed. An update on the number of referrals to the Trafford Channel Panel is unavailable at this time. 6 INDIVIDUALISED CARE 6.1 Individualised Care focuses on strategic commissioning of individual care. This may relate to the 24 hour private care market, homecare market or personal budgets. It also incorporates the development of the 24 hour nursing care market (new builds/extensions), and quality of provision. 7 PERSONAL HEALTH BUDGET (PHB) 7.1 The PHB programme team has been working hard throughout 2017/18 to engage the services who lie within the local offer. This has involved co-production meetings, on-hand support, individual meetings with service managers and awareness training available for all staff. 7.2 In November 2017, commissioners of these local offer services met with the programme team and shared concerns about the services in the offer. Since then, each commissioner has agreed to complete a template delivering feedback to the Project Support Officer. Upon receipt of this, the information will be collated and presented in a paper to the CCG s CMT. 7.4 For Quarter 4, more awareness training is booked and additional person centred planning coaching is scheduled which will be guided towards referencing how PHBs can work for all patients. 7.5 An approved provider list is being developed for support services for PHB holders accessing brokerage, payroll and managed account services. This is currently in discussions with procurement as to the logistics of delivering such a service.

8. JOINT QUALITY IMPROVEMENT GROUP 8.1 The Joint Quality Improvement (JQI) Group (Formerly Joint Quality Monitoring) is a multi-agency board comprising representatives from the CCG, TBC, CQC and Healthwatch Trafford. The JQI virtual team is a combination of commissioners and healthcare professionals who support the services to complete a quality monitoring tool (i-tool). The i-tool is populated by the provider and audited and verified, in partnership with the provider, by the linked JQI Group members. 8.2 The JQI Group analyse all the relevant intelligence including quality selfassessments, observations, safeguarding alerts, specialist practitioner concerns and compliments, social work concerns and compliments, infection control assessments, complaints and service user feedback in consider and agree the areas which require support and identify good practice. The Group s main responsibilities are to: Consider concerns for escalation and immediate action Share intelligence regarding contractual, management and registrations Analyse thematic or systematic issues to focus additional support based on the information available Decide whether a Service Improvement Plan (SIP) should be implemented Decide whether placement suspension is required Provide CQC with data and monitoring information 8.3 The JQI process offers guidance, advice and support regarding the areas for improvement within the service. It will identify good practice and recommendations and actions to improve the quality measures expected. 8.4 The Group will agree timescales for completion, will signpost to support services, and will step-up or step-down support visits in-line with any identified needs. However, it remains the responsibility of the providers registered manager to attain the level of quality expected to meet a good CQC rating. Safeguarding is an integral part of the JQI group and works within the remit of the Care Act 2014. 8.5 Recent data identified that CQC care home ratings in Trafford at 46.8% inadequate or requires improvement. The main CQC key lines of enquiry (KLOE) identified the Well Led domain as the main area of failing, therefore the focus of JQI this winter will be: Trafford wide Joint Quality Improvement Group (Previously Quality Monitoring), refresh of terms of reference to focus on proactive metrics for improvement, using quality improvement methodologies. Increase frequency of quality tool submissions by homes that are rated inadequate and require improvement, development of tool to be web based for ease of return. Establish Excellence in Care Homes Project adopting the principles from the best CCGs in GM and the learning from the GM care home project.

Develop a Care Home Managers Forum to support educate and recruit good leadership Bespoke support at individual care homes with improvement and delivery planning. Proactive risk assessment of care home viability and early intervention for individual residents care planning and delivery and best interest assessment when required. Commissioning review of capacity across Trafford. 8 QIPP 8.1 The QIPP programme focus on the efficient commissioning of quality care for patients who are funded via CHC, and is performing well. Monthly data shows that high cost placement reviews climbed from 13.1% in August to 16.5% in December with the forecast to overachieve the target of 550k by end of year. 8.2 All one to one care reviews have been completed, 88% of high cost placement reviews have been undertaken and out of borough placements and homecare rates continue to be scrutinised to maximise potential QIPP savings. 8.3 The CHC service specification is being revised to define the care required by commissioners within CHC and homecare provision. Work is progressing to classify standard and enhanced models of care with providers to deliver a model to optimise care for patients who require more complex care in environments more suited to their needs. 8.4 The Resource Allocation Panel continues to oversee the allocation of CHC funding, ensuring that patients nearing the end of life are provided with urgent fast track funding, whilst also providing a forum for the discussion of more complex cases and an opportunity to demonstrate a model of integrated multiagency negotiation through QIPP discussions. 8.5 The QIPP group is pursuing a number of quality initiatives. For example, the patient-held record scheme ( Red Bag) will ensure that the patient record is available to all professionals requiring patient information at the point of contact. In addition the Individualised Care department are co-designing leadership training, with Skills for Care, to improve the standard of 24hour care registered managers. 9 INDIVIDUAL FUNDED CARE 9.1 NHS individual healthcare means a package of continuing care that is arranged and funded solely by the NHS to meet physical or mental health needs that have arisen as a result of disability, accident or illness. It is care that is not commissioned as part of universal NHS services i.e. hospital, mental health and primary care. This is generally referred to as CHC. 9.2 The review of CHC was conducted in summer 2017 in accordance with the requirements of the 2017/18 Internal Audit Plan as approved by the Audit

Committee. The audit reported significant assurance for those processes audited. 9.3 The overall objective of this review is to ensure that Trafford CCG has a robust process in place to comply with legislative requirements and guidance in respect of CHC and also to ensure that budget monitoring systems and reporting lines are in place. 9.4 In 2017/18 the CCG s budget for CHC is 13m and at and expenditure is within the profiled budget for this period as the numbers of people eligible continues to reduce as a result of improved performance for undertaking three and six month reviews. 9.5 There are 2 national CHC QIPP targets. 1) At least 80% of eligibility recommendations are completed within 28 days of the receipt of screening checklist and 2) Less than 15% of full assessments are completed in acute settings 9.6 Both national targets were not been met in January 2017. Initial intensive work with the hospital discharge teams and social services improved QIPP target 2 and we reported in May 2017 that we had achieved less than 10% of full assessments completed in acute setting which has remained within target level as it is a cumulative target over a 3 month period. See also 8.9 8.13 for more recent NHSE reporting requirements. 9.7 Trafford CCG was in the bottom 10% nationally for QIPP target 2 and we were asked for an improvement plan. This was implemented in September and we have seen good improvement and for the first time we have achieved over 80% of eligibility recommendations within 28 days of receipt of checklist. 9.8 To enable effective monitoring of national targets and team performance objectives were set and reported on a monthly basis by the Patient Data Management Officer to the SIP Lead and the team at the monthly team meeting. These objectives continue to be developed for continuous improvement. 9.9 All CCG s received a letter from NHS England Plans to improve NHS Continuing Healthcare assessment processes Publications Gateway Reference No.07091 17 August 2017. The overall emphasis was further tightening systems and process to improve the DToC national agenda 9.10 CCGs are now required to submit a plan for improving the number of CHC Assessments (MDTs/DSTs) taking place in hospital and acute settings to less than 15% by March 2018. The plan should include key milestones, barriers and mitigating actions that align to the Better Care Fund (BCF) plans submitted in September. Trafford CCG Has consistently with one exception achieved this target with a 0% of assessments taking place in acute setting in November 2017. 9.11 CCG Governing Body should publically commit to reporting on the proportion of assessments in an acute location and to verifying decisions within 2 working days; progress should be monitored at CCG public board meetings. Trafford CCG are presently redesigning its CHC process to achieve the 2 working days

and have committed 1 WTE nurse to the DToC Control Room to support this target. 9.12 % of assessments (MDT s) completed in acute care Target < 15%. 10. TRAINEE NURSE ASSOCIATES 10.1 Trafford CCG is one of the very few CCG s to support Trainee Nurse Associates. The vision is to attract this new role into care homes, GP practices and CHC. There have been a number of recent contractual difficulties as they commenced spoke placements in other settings, these have now been resolved. Unfortunately one of our trainees has dropped out of the course. Greater Manchester Health & Social Care Partnership (GMHSCP) will commission a further cohort of TNAs in 2017 and there is now national agreement this will be using the Apprentice Levy for funding. Trafford CCG is keen to continue with this programme and to expand the remit to offer placements for graduate student nurses. 11. PATIENT EXPERIENCE 11.1 Patient Experience Matters continue to respond to, and highlight, patient and people's voices through a number of different channels to ensure opinions are heard and feedback is listened to and acted upon. 11.2 Trafford CCGs calendar of engagement activity was approved at Governing Body on 25 July 2017. At the same time, agreement for a budget of 15,000 to support Trafford Talks Health (TTH) and other similar public engagement events was obtained. The calendar provides evidence of how the organisation engages with the public, our stakeholders, partners and staff. 11.3 The programme of Governing Body patient stories continues following July s story Being Transgender in Trafford. From this, we have identified areas of learning which will be taken forward by CCG leads.

11.4 Each month our Engagement Specialist attends PRAP to communicate information and provide updates regarding engagement opportunities. 11.5 The PEACH (Patient s and People s Experience and Continuing Healthcare) pilot has concluded. The intention is for this work to continue in Trafford and steps are being taken to progress this. The changes so far, as a direct result of feedback from the PEACH surveys, are:- Outcome letters to have a named case manager on them A case manager to contact the person on receipt of a referral to explain the process and give an expected time frame and provide progress updates All letters are now addressed to patients rather than a family member/representative. 11.6 Complaints and Patient Advice and Liaison Service (PALS) statistics for this quarter are as follows: PALS enquiries = 31 Complaints = 27 Other enquiries = 10 MP enquiries = 6 Compliments = 2 (one compliment related to the CCG GP education event) 11.7 The method of receipt was 51 written (letter or email) and 25 verbal, the complexity of cases varies. 11.8 There have been 16 CCG incidents (not managed via the shared quality and performance team), with 10 relating to nursing home incidents. These are shared internally and closed as the provider takes these forward under their own process. Three of the 16 incidents relate to Trafford CCG, the others relate to UHSM, CMFT (now known at MFT), TBC, Trafford Co-ordination Centre and another provider. 11.9 The Patient Experience Support Officer started on 10 October 2017 to help the team across all functions, with another team member moving on, recruitment will commence soon. 11.10 PCFT Trafford Division Patient Experience Outcomes Framework developed by the Head of Patient Experience has been agreed with the provider who will implement this. Confirmation is awaited on when this will commence. 11.11 The GP/practice staff survey for Special Educational Needs and Disability (SEND) went live in October. A further survey will be sent to practice managers. 11.12 During July and August the CCG commenced a series of interactive public events called Trafford Talks Health (TTH) to kick-start conversations with the Trafford population around health priorities for Trafford. The events were codesigned with Healthwatch Trafford for each of the neighbourhoods (North,

South, Central and West). A further two TTH events took place; one after the CCG s AGM, with over 70 people attending and another at a CCG staff event in October. All of these have focussed on the CCG s commissioning intentions. Findings from these events were shared with commissioners and will be used in discussions to plan for the 2018/19 commissioning intentions. 11.13 Healthwatch Trafford liaison meetings took place in July and September (we collaborated with Healthwatch to plan the TTH summer public conversations). 11.14 Trafford CCG has recently supported Trafford Council Health Scrutiny Committee s loneliness task and finish group by sharing details about how the CCG support s those at risk of loneliness. 11.15 Our Engagement Specialist attended the launch of Healthwatch Trafford s Advisory Group. The group brings together the public, providers and commissioners to look at collective health and social care topics affecting Trafford residents. It is hoped that the group will enable Healthwatch to identify and address specific areas of concern, good practice and areas where there is a lack of service provision and then work together with commissioners/providers to address these. 12. WHAT IS AHEAD FOR PATIENT EXPERIENCE 12.1 Further Trafford Talks Health conversations will be undertaken. 12.2 CCG leads will be asked to let the team know about any engagement activity they have undertaken/have planned for the calendar of engagement activity, please see recommendations. 12.3 The next patient story is being planned for December s governing body. 12.4 Information relating to the PCFT division outcomes framework should start to be received for review along with further provider reports around patient experience and complaints. 12.5 Further Healthwatch Trafford liaison meetings are to be planned. 12.6 It is hoped that any required Discloure and Barring Services check will be in place and further Public Reference and Advisory Panel (PRAP) members will be recruited to commence provider quality walk rounds with the shared quality team. 12.7 A mid-year report is expected from one of the CCG s small ophthalmic providers, will be received in respect of the Patient Experience CQUIN (Commissioning for Quality and Innovation). The aim is to demonstrate that the provider is working to improve the experience of those using services/their representatives. 13 SUMMARY The Nursing Directorate continues to provide support education and engagement for the health services and patients of Trafford. Against a backdrop of the challenges of care home provision, winter pressures and

increasing elderly frail residents, the directorate is moving from a reactive to proactive whole system approach to Quality Improving (QI), by introducing metrics and QI methodologies. Nursing and public patient experience endeavours to capture the voice of our residents at every opportunity so we may listen and responded in the commissioning of our services. The directorate is well placed to move along the journey for integration and transformation. 14 RECOMMENDATIONS The NHS Trafford CCG Governing Body is asked to: Note the information in this update from the Chief Nurse Continue to support the completion of the engagement calendar for Patient Experience Matters Note the requirement to report % of CHC assessments in acute setting to the Governing Body