OPERATIONAL PERFORMANCE REPORT: March 2018 Swindon Community Health Services Overview 1.0 Introduction This overview brings to the attention of committee members the key areas of Community Health Service performance in February 2018. 2.0 Staffing: Swindon Community Health Services vacancy levels have decreased from December 59.50 WTE (15.32%), to January 56.57 WTE (14.56%). Nursing are the professional group with the highest vacancy rate of 38.15 WTE (19.67%), with 14 WTE in SwICC. A recruitment event took place on the 24 th February in SwICC however, due to problems with advertising and agreement of the recruitment and retention premia only one candidate attended. A total of 8 student nurses have expressed preference to work in Community Nursing once they qualify in the summer and there are currently only 5 vacancies, so nurses will be offered an opportunity to work within the wards in SwICC until the next vacancy occurs within Community Nursing and will then be automatically shortlisted. A second open day is being organised for May 12 th at the Orbital centre to recruit for the wards within SwICC. HR Systems have finished recalculating Turnover and have confirmed that turnover has decreased since October 2017. The January figure has been rechecked and is now 16.33% which although higher than the Trust target is slightly below Wiltshire Health and Care turnover figure which is a useful comparator for a community service. 3.0 Community Nursing 3.1 Operational delivery: Referrals to the Community Nursing service have remained at last year s level with 3,828 year to date. This is a 1.75% increase from 2016/17. 1,655 referrals were for completely new patients to the service with the remainder re-referrals of patients previously on the case load. The average number of patients on daily caseloads has remained steady and also resemble last year. In 2017/18, 1,628 Referrals have been related to patient wound care and together with Pressure Ulcer constitute nearly half (49%) of all community nurse activity. 36% of referrals are for non-specific reasons with an increasing number of people referred for Assessment Advice and Support. This is the first month we have been able to analyse the break down of referrals and so we now need to better understand the care planning 1
and case load management requirements of this large number of referrals with non specific reasons. The majority of referrals, 48%, are received from GP Surgeries with 15% coming directly from GWH. 23% of all referrals to community Nursing are for an urgent response within 24 hours and we continue to meet our target of 95%. 3.2 Clinical Service updates 3.2.1 Continence Service: There has been a small dip in referrals but the number of new assessments is high at 86. Follow up activity is down significantly from the previous month (318 down from 460). As the service is provided by a team of two, this drop in activity is the impact of annual leave. The data does not reflect the current complexity of the clinical needs of the people accessing the service with increasing numbers of referrals for very vulnerable people requiring an increasing involvement of the continence team in Multidisciplinary meetings and care planning. To better reflect Continence Service clinical activities and developments, the Key Commitments have been revised and now reflects the increasing number of patients requiring support for bowel management. 3.2.2 End of Life Only 6% of the case load was attributed to patients identified as End of Life which appears lower than expected so a review of care plans is underway to ensure reason for referral and primary needs are appropriately recorded. End of Life patients discharged in February had an average spell of 69 days against a year to date average of 131 days. This is a significant change and is currently being investigated to ensure data accuracy and quality of recording 4.0 Swindon Intermediate Care Centre (SwICC) The SwICC improvement action plan has been revised to address the Key Lines of Enquiry and to underpin the community in-patients compliance assurance framework. The newly appointed Clinical Governance facilitator has worked closely with the Matron and Ward managers to identify the actions required to achieve improvement. Staffing levels within SwICC are of concern with 14WTE band 5 vacancies between the two wards. Discussions are taking place around the introduction of 4 Nursing Associates between the wards and as previously mentioned accommodating student nurses who are waiting for community nursing posts. An open day will be advertised on NHS jobs and within the local newspaper with a recruitment and retention premium and positive comments from staff who work in SwICC about what it is like to work there. The academy will also be used to promote posts as there are many opportunities for staff development currently. The two SwICC Ward Manager posts will be advertised as the secondments for the interim Ward Managers are due to come to an end in the next two months. Continuity of robust leadership is key to build on recent improvement is standards of care and patient flow. 4.1 Patient Flow Occupancy remains high within SwICC with Forest Ward at 99% and Orchard Ward at 98% Occupancy in February National benchmarking is 91% for Community Hospitals as Bed occupancy rates of higher than 85% can increase the risk of harm, including hospital-acquired infections like MRSA and Clostridium difficile, therefore occupancy levels need to be carefully monitored and the recent cases of C-Diff are being reviewed to understand the root causes. Trust patient flow to Orchard ward continued to achieve record levels in February with an average of 3 patients discharged from SwICC every day, against an average of 2.2 in 2017/18. 2 30 of 42 patients (71%) were discharged from Orchard Ward within the target time of 21 days, up from 61% last month.
33 of 34 patients (97%) were discharged from Forest non-stroke beds within the target time of 36 days 5.4% of bed days were lost as the result of delayed discharges The national average is 13% 87% Discharge directly home or where they once resided National average is 61% 4.2 Older Persons Pathway We continue to make progress and during the Five Day No Delay project, SCHS conducted a trial on TOPSSU with a community matron visiting each day to review the patients with the TOPSSU consultant. This will assist in raising the profile and skill set of community matrons and trial a proactive medical and matron decision-making in discharge planning. Work has commenced in the community to include the Rockwood Frailty Tool within the therapy and nursing assessment with plans to share frailty scores across the older persons pathway. 4.3. Delayed transfers of Care: The number of days attributable to delayed transfers of care decreased significantly in February 45 from 155 in January. This is the lowest figure for over two years. 44% were attributed to social care delays which have increased from January which was 33% - this is mainly down to one OOA patient. However, this is good progress and evidence of the improved whole system working and in particular between SCHS and Swindon Borough Counci. In 2017/18, the majority of delays (475 days, 23%) have been due to E. Awaiting care package in own home. In the last quarter, 25% of delays have been due to G: Patient or Family Choice there is an escalation process to be followed to support wards with difficult conversation (further work is needed at ward level) and this trend continues with 14 days being attributable in February. This month, 9 delayed days came from out of area (Oxfordshire) with a patient awaiting assessment. Complex stroke patient discharges accounted for 35 days (78%) The area of focus for the following months is to analyse the readmissions directly to GWH to SWICC and SWICC discharges to community readmitted to GWH. 5.0 Specialist Teams 5.1 Stroke Pathway Our key commitment is to ensure a reduction in % of transfers >24 hours when deemed medically stable for management at SWICC from Falcon and we are establishing Systems to monitor this effectively in partnership with Unscheduled Care Colleagues. 93% of transfers to Forest happen on the day medically stable to transfer. The flow onwards has also much improved and is reflected in the overall discharges for SWICC. 80% of transfers from Falcon Ward take place before 17:00 and 39% of strokes were discharged from Forest before 12:00 supporting the availability of an acute Stroke bed In January and February, 20 admissions (61%) to SwiCC had received new patient assessments within 24 hours in line with SSNAP Guidelines. 4 patients had stayed for longer than 31 days with the average length of stay among those discharged being 38 days. The longest stay of any stroke patient discharged in February was 113 days At the end of February, none of the stroke patients still in SwICC had stayed for over 31 days and 10 stroke patients were discharged to their usual place of residence. The Community Stroke Therapists completed 144 face to face contacts with SwICC patients in February, equating to 7.2 sessions per day. 17 patients were discharged from the Acute ward to the Swindon Community stroke team with 69% of the referrals seen within 24 hours with an average wait of 3 days.this reflects the gap in service provision due to the absence of seven day working. Since January additional therapy cover was provided over the weekend period with a total increase of 90 hours. The additional resource resulted in 3 weekend discharges from Falcon, 23 initial new patient assessments and 20 rehabilitation sessions. This will contribute to an improvement in SSNAP performance and demonstrates added value 3
from seven day working. The enhanced service has been funded from winter monies and will stop at end of March. There is a system wide stroke Improvement programme and in future we expect to report jointly with Unscheduled care on the stroke performance and so work is currently underway with informatics colleagues to combine SystemOne and Medway data to produce a whole pathway performance report 5.2 Podiatry Referrals can still be made to Podiatry via the E-referral service and through letters direct to the service. Podiatry continues to refine the process working closely with choose and book team as and when issues occur: Podiatry waiting times Month MSK Community Triage Total MSK week waits Jan 190 163 59 353 23 20 March 203 158 44 361 15 8 Community week waits Whilst the numbers of patients waiting remains high, the level of referrals into the service, (those triaged weekly are increasing). The waiting times for community assessment have decreased from 20 weeks in January to 8 weeks. MSK has reduced from 23 weeks to 15 weeks in February. Lost Appointments due to DNA Our MSK patients have fed back in Patients Comments picker cards that they would like text alerts. Our MSK caseload has some of our highest DNA rates and it is also the service with the longest waits. As a result of this feedback and our desire to improve performance the Podiatry Lead is working with the SystmOne team to investigate the possibility of introducing text alerts. This is something that SystmOne could support but currently it is not part of the Swindon community Licence agreement. Diabetic Foot Care Pathway A communication has recently gone out in the GP bulletin to up-date GPs on the Diabetic Foot Pathway. Foot attack clinics and follow up appointments are now being held at GWH for these high risk complex patients. Root cause analysis of those who have gone through to amputation will re-start with the first meeting scheduled for 20 th March 2018 TVN collaboration The Podiatry Head of service and TVN Lead meet on a Monday morning to discuss many shared patients. TVN lead has also been invited to join the monthly MDfT clinic and will attend the first one in March. Following the move out of Moredon, it is hoped that the TVN service will be co-located alongside podiatry in Swindon and West Swindon health Centre which will support improved communication with the teams and improved outcomes for patients. Recruitment Following successful Band 5 interviews held on 14 th March, we were able to offer the posts to 2 final year podiatry students, they are due to graduate in July and will be offered bank band 3 posts prior to graduating. The interviews for the second Band 7 were also successful and the new member of staff is due to start on 9th April. 5.3 Community Equipment Services Wheelchair Service: The waiting List for this service has increased which subsequently has resulted in an increase in the active caseload. The over 18 week wait is expected due to the current short term staffing reduction due to maternity leave. Replacement cover has been resolved and there is a recovery plan in place to address the backlog. Equipment Service Deliveries 4
The community equipment service delivers and manages the delivery, collection and maintenance of equipment essential to enable people to live independently safely. The national standard for community equipment services is for 97% of items to be delivered within 7 Days to support both patients being discharged home and people remaining in their homes. In January, SCES stores achieved a 96.8% rate. During the winter the service has increased delivery and collection slots to enable more same day, next day and three day deliveries in support of hospital discharges and admission avoidance. Reporting on the performance of this service is limited as they are dependent on a legacy system managed by SBC. Funding of this service is via a pooled budget between SBC, CCG and GWH with collective oversight through a Community Equipment Board. The board have commissioned a service review as there has been a lack of strategic direction or investment in recent years. 6.0 Due Diligence update In 2016-17 when GWH took caretaking responsibility for Swindon Community Services detailed service reviews were undertaken and a due diligence report provided to Trust Board. The due diligence process identified five clinical service areas as high risk (Red) and in need of a prioritised approach to improve clinical quality and financial stability : Podiatry, CIVT, SwICC, Community Nursing and COPD After a twelve month sustained improvement period. These Five high risk services are more stable with clear and realistic development plans CIVT Progress The CIVT service has a senior nurse leader CIVT service is now supported by the urgent nursing team providing greater resilience in the community Financial review has identified resource to recruit additional staff and it is expected to have 3.6 wte in post by June 2018 Service will relocate to SwICC and co-locate with the hospital OPAT team to provide greater resilience to discharge pathway Work has begun with secondary care colleagues to strengthen the IV Pathways to ensure increased capacity by Winter 2018. The new Pharmacy lead for SCHS is working with the Assoc Director of Nursing to clarify the local Cellulitis pathway Service will be re-launched to local GPs to provide a robust and reliable alternative to secondary care referrals or ED attendances for lower limb cellulites Podiatry Progress A new Head of Podiatry is in post overseeing secondary and community podiatric services 2wte Band 7 specialist podiatrists have been appointed with additional Band 5s recruited to commence summer 2018 which will complete recruitment Foot attack clinic now in place managing high risk diabetic foot problems Waiting lists reducing with greater visibility and tighter monitoring Actively listening to patient feedback Working closely with CCG and Primary care to build confidence in clinical pathways SwICC 5
Recruitment remains a challenge but there is new leadership team and staffing levels have been maintained through bank and non premium agency Mandatory training and appraisal levels are significantly improved Clarification on Patient pathways and dedicated patient flow team have improved discharge and transfers with an average transfer rate of 3 patients per day however there is more to do in terms of improving stroke rehabilitation and integrating the older persons pathway across the system New equipment such as beds and hoists have been ordered and arrangements are now in place with the equipment library team to provide support going forward The contract with Carillion will transfer to Serco and has yet to be finalised and there are on-going problems with NHS Property Services in relation to the building heating, Fire Safety Good progress with the Compliance Assurance Framework in line with KLOE. Community Nursing Strong clinical leadership with Deputy Head of Nursing, Band7s and Band 6 Recruitment remains strong but need to work on retention strategy No concerns regarding missed visits as data quality now reliable and effective systems and processes in place Complaints have dropped significantly and no current outstanding complaints or concerns More proactive case management and case finding due to strong leadership and coordinated management Significant improvement in relationship and confidence with Primary care COPD and Oxygen Service Team leader in post Development of shared skills in ll team members to create greater resilience Appointment of a band 4 assistant practitioner adding additional capacity and efficiency On discharge, patients have long term support and self-management plans to maintain health and well-being and service now offer open door policy to enable patients to access support againat any time in the future Careful monitoring of caseload ensures any non-elective admissions are followed up to support timely discharge 6