Item 18.74aii Quality and Assurance Dashboard Executive summary and Provider Indicator report The Information in the report is based on the June and July 2018 data available as of 12 September 2018 1
Key Messages 1) The standard of the QEH Root Cause Analysis (RCA) has reduced leading to a backlog of RCA s being signed off. 2) The QEH reported there were 4 serious incidents declared at the QEH during July. All 4 incidents occurred in Maternity. 3) The QEH report Falls and Pressure Ulcers have both increased 1) WNCCG has written a detailed letter to the Trust highlighting the concerns regarding the Quality of RCA s and are awaiting a formal response. 2) The Trust have been issued with a Section 29a and Section 31 Notice on 19th July detailing 10 conditions for the regulated activity of Maternity and Midwifery Services. The Trust have developed an improvement action plan. 3) Training is now reverted back to being delivered by Specialist staff 2
In summary, assurance ratings have been assessed by the NHS West Norfolk CCG Patient Safety and Clinical Quality Committee as defined in the indicators below. Assurance reduced CQC reported as in adequate. Placed in special measures. Assurance Improved CQC reported as outstanding Assurance reduced CQC revisit found lack of improvement No change to assurance Rating No change to assurance Rating No change to assurance Rating No change to assurance Rating 3
THE QUEEN ELIZABETH HOSPITAL Never Events, Serious Incidents and QIR s Month Never Events Serious Incidents June 1 2 16 July 0 4 18 QIR s The Trust declared a Never Event in June which related to a Long Line insertion. The standard of the Root Cause Analysis (RCA) has reduced leading to a backlog of RCA s to be signed off. WNCCG had completed a quality visit of Theatres in following previous Never Events which provided assurance regarding lesson learnt. The Never Event in June and we need to await the final report to understand the learning. WNCCG has written a detailed letter to the Trust highlighting the concerns regarding the Quality of RCA s and are awaiting a formal response. In the interim, WNCCG has met with the Trust to revise the inpatient falls template to ensure a more robust investigation which will be implemented with immediate effect. The Trust has also arranged additional training for investigators to improve the quality. 4
THE QUEEN ELIZABETH HOSPITAL There were 4 serious incidents declared during July. 3 of these were reported late as the incident had occurred during May/June. All 4 incidents occurred in Maternity. The Trust was issued a Section 29A Warning Notice for Maternity and Midwifery Services on 17th May following the CQC s on site inspections. Following further significant concerns, the Trust was issued with a Section 31 Notice on 19th July detailing 10 conditions for the regulated activity of Maternity and Midwifery Services. In response the Trust has developed a Maternity Quality Improvement Plan. The Trust also communicated to the CCG to advise they have received extra intensive Maternity support in the short term whilst it works through its Improvement Plan. 5
THE QUEEN ELIZABETH HOSPITAL Falls Pressure Ulcers 6
THE QUEEN ELIZABETH HOSPITAL Falls and Pressure Ulcers cont d There has been an increase in falls from the previous month from 3.92 to 5.72 per 1000 bed days. This does remain below national falls rate of 6.63. A WNCCG quality visit of falls was undertaken in July which highlighted some of the good practice which was being delivered particularly around post falls care. There was a concern that this was not demonstrated in the RCA process and a subsequent meeting to identify further support between WNCCG and the Trust has since happened. There has been a slow increase in hospital acquired pressure ulcers over the year with the Trust reporting July being higher than normal (0.77 per 1000 bed days). A WNCCG quality visit of pressure ulcers was undertaken in July. Staff raised concerns that the training had become diluted as was being delivered by the Practice Development Team and not the specialist staff. The Trust actioned this by a reverting back to TVN s delivering this training with immediate effect. The Chief Nurse continues to meet with Ward Managers to review all avoidable HAPUs. 7
THE QUEEN ELIZABETH HOSPITAL Infection, Prevention and Control The Trust have reported 8 cases of Clostridium Difficile and 2 cases of MRSA during 2018/19. NHSI Peer review visit completed on 12 th June and the CCG are waiting for the Trust to share the report. The deep clean programme is continuing across the Trust. Elm Ward is the next ward to be undertaken and this will be closed for a period of 4 weeks as a storage area is being converted into an extra sluice for SAU to use. Elm has previously had transmission of C diff and concerns re both SAU and Elm using 1 sluice at the end of the ward were identified. WNCCG facilitated a recent Antimicrobial Prescribing GP forum with Elizabeth Beech from NHSI presenting. 8
THE QUEEN ELIZABETH HOSPITAL Cancer 62 Day performance May June (please note 0.5 breaches relate to Tertiary referrals) Themes of the 104 day breaches reported by the Trust; Delay in diagnostics and reporting Delay in histology reporting Multiple sites Complex pathways- needing many investigations Patient Choice 9
THE QUEEN ELIZABETH HOSPITAL Cancer 62 day cont d Recent WNCCG quality visit identified questions relating to the governance/process behind the harm reviews of patients who breach the 62 day standard and how trends and themes are identified. Furthermore, whilst QEH report themes to their Board, it is difficult to articulate the work being undertaken to address the identified themes. Eliminating Mixed Sex Accommodation WNCCG has contacted the Trust to explore these issues and are awaiting a formal response. WNCCG will also raise this as an Agenda Item for discussion at the Cancer Delivery Board on 20 th September 2018. Intensive Support Team (NHSI) is due to visit the QEH in September 2018. 10
THE QUEEN ELIZABETH HOSPITAL EMSA cont d There has been considerable deterioration in the number of breaches for July. All the EMSA breaches continue to be centred around flow within the hospital. CCG to continue to work with Trust on improving patient flow. WNCCG continue to review all RCA s attributed to EMSA breaches The Trust have completed a patient experience survey to understand impact on patients. The Trust have developed a duty of candour process to inform patients and record in records. The Trust has purchased screens for ITU, which are just short of floor to ceiling, therefore the Trust consider they do not meet EMSA requirements. The CCG has reviewed the screens and can confirm they are NOT compliant for EMSA To be fully compliant the QEH will require a complete refurbishment- to be considered as part of capital funding. 11
THE QUEEN ELIZABETH HOSPITAL Friends and Family Test A&E are still finding it difficult to achieve the response rate target. All other areas have met the target during A&E is continuing to promote the collection of FFT feedback with the support of Patient Experience as well as undertaking a fortnightly walkabout involving the Matron, Patient Experience Lead and a Governor to improve aspects of the patient experience to hopefully benefit future patients. 12
THE QUEEN ELIZABETH HOSPITAL Workforce Workforce remains a challenged situation with increased vacancies, turnover and sickness. WNCCG has formally requested the Trust provide a Workforce Plan. The new reporting template does not include Mandatory training subject specific data. WNCCG have written to the Trust to ask how they will be sighted on this information going forward and to request their Workforce strategy. o0o 13
NORFOLK COMMUNITY HEALTH & CARE NHS TRUST (NCH&C) Never Events, Serious Incidents, QIRs Month Never Events Serious Incidents June 0 3 4 July 0 3 3 QIR s All of the serious incidents relate to pressure ulcers. WNCCG continue to review all RCA s and feedback to the Lead Commissioner prior to sign off. 14
NORFOLK COMMUNITY HEALTH & CARE NHS TRUST (NCH&C) Patient Experience 100% of patients who responded to the FFT during July 2018 would recommend NCH&C services in the West locality. Overall 136 patients responded during the month compared to 131 last month WNCCG continue to monitor this and attend the Clinical Quality Review Group. 15
NORFOLK COMMUNITY HEALTH & CARE NHS TRUST (NCH&C) Workforce 16
NORFOLK COMMUNITY HEALTH & CARE NHS TRUST (NCH&C) Workforce cont d Turnover remains above the 12% target (14%) and Appraisal rate remains below 90 % target (82%). WNCCG will raise this via the Lead commissioner at the next Clinical Quality Review Group. o0o 17
NORFOLK AND SUFFOLK NHS FOUNDATION TRUST (NSFT) CQC- Quality Improvement Plan Following the unannounced follow up CQC inspection in June, an updated 29a was received which has focused on: Access to services in the community and in crisis Staffing levels in community services Risk assessment and care planning across the Trust Seclusion environments and seclusion practice The Trust have developed the following: CPA There has been a multidisciplinary workshop held on the 17 th July to review existing initiatives, to recognise risks and gaps and identify new improvement activities. A formal outcomes paper will be available 3 rd August 2018. Restrictive Practice Restraint/Seclusion/Rapid Tranquilisation Weekly restrictive practice group meets weekly to review all episodes and reason for poor compliance. Supervision New approach agreed by Executive Team and communication sent to staff Environmental Risks Alarms, blinds and cords, toilet works to be completed by End of August. Sound proofing completed Waiting times Dedicated waiting time task and finish group, referral management caseload profile introduced, reporting and escalation processes established, remedial action plans for each locality 18
NORFOLK AND SUFFOLK NHS FOUNDATION TRUST (NSFT) Never Events, Serious Incidents and QIR s. Month Never Events Serious Incidents QIR s June 0 0 1 July 0 2 3 There were two serious incidents declared in July and both related to unexpected deaths. WNCCG will continue to review all RCA s and provide feedback to the lead commissioner prior to sign off. 19
NORFOLK AND SUFFOLK NHS FOUNDATION TRUST (NSFT) Workforce West Locality o0o Local sickness rates have remained relatively consistent and under Trust target however sickness absence increased above Trust target. The vacancy rate has improved locally but still above Trust target however Appraisal rate and Mandatory training are both above Trust target. WNCCG will continue to monitor this and raise concerns via the Lead commissioner at the Clinical Quality Review Group. 20
NURSING CARE HOMES Amberley Hall Nursing Home (Athena Care Homes UK Ltd): (CQC inspection January 2017 Good) Downham Grange (Kingsley Care Homes Ltd): (CQC inspection January 2017 - Good) Goodwins Hall Nursing Home (Athena Care Homes UK Ltd): (CQC inspection July 2016, report published October 2016 Good) Holmwood House (Integrated Nursing Homes Ltd): (CQC inspection January 2018- Requires Improvement) Lower Farm Care Home (Archers Healthcare Ltd): (CQC inspection September 2017 Requires Improvement) Two of the eight homes are rated as Requires Improvement however of the remaining six, five are rated good and one is Outstanding. WNCCG will continue to work with NCC to monitor the quality of Nursing homes with NCC. Meadow House Nursing Home (Healthcare Homes Group Ltd): (CQC inspection May 2016 Outstanding) Paddocks Care Home (Castlemeadow Care): (CQC inspection 13 th June 2017 Overall rating Good) Park House Hotel (Leonard Cheshire Disability Group): (CQC inspection March 2017, report published June 2017 Good) 21