3. clostridium difficile – nch&c current status 2. … · 40 of these relate to pressure...

Enclosure: H

25th March 2015 Date of Board Meeting

Quality Assurance & Risk Report – February 2015 activity

Title of Report

Summary

This attached report was presented to the Quality & Risk Assurance Committee on 16 March 2015. The report provides a summary of the patient safety and quality indicators used by the Trust and external agencies to monitor the quality of care, patient experience and the management of risk. The report covers the incidents reported (not necessarily occurring) during the period 1 February to 28 February 2015. Information is given over time where available, to enable comparisons in reporting levels, improved analysis and identification of themes, trends and learning to improve the safety and quality of care delivery. Key areas to highlight in this month’s report are as follows: 1. Increase in the number of Pressure Ulcer SIRIs 2. Quality Assurance Assessments and outcomes 3. Clostridium Difficile

Risks and benefits of proposed action Recommendation

The Trust Board are asked to receive the report

Anna Morgan, Director of Nursing & Quality Dr Rosalyn Proops, Medical Director

Presented by

Previous consideration by Board Committee or EDT Appendices 1. Clostridium difficile – NCH&C current status

2. Quality Assurance Assessment reports

Quality Assurance & Risk Report of 31


Quality Assurance & Risk Report for February 2015

CONTENTS 1. PATIENT SAFETY 1.1 Serious Incidents Requiring Investigation (SIRIs) 1.2 Incidents reported during February 2015 1.3 Mortality Review 1.4 Quality Issue Reports (QIRs) 2. HARM FREE CARE 2.1 Safety Thermometer 2.2 Venous Thromboembolism (VTE) 2.3 Patient Falls 2.4 Pressure Ulcers 2.5 Infection Prevention and Control 3. PATIENT EXPERIENCE 3.1 Friends and Family Test summary 3.2 Complaints 3.3 Claims 3.4 Compliments 4. QUALITY ASSURANCE ASSESSMENTS 5. SAFER STAFFING 6. RISK MANAGEMENT 6.1 Corporate Risk Register 6.2 Risks overdue review APPENDICES 1. Clostridium difficile – NCH&C current status 2. Quality Assurance Assessment reports

1. PATIENT SAFETY 1.1 Serious Incidents Requiring Investigation (SIRI 1.1.1 New SIRIs 42 new serious incidents requiring investigation (SIRIs) were reported to the Commissioning Support Unit (CSU) during February 2015. Of these 20 were reported to CSU within 2 working days of the incident occurring and 22 outside of this timescale. 40 of these relate to pressure ulcers acquired within the care of NCH&C, 35 acquired while the patient was under the care of Integrated Community teams and 5 while the patient was under the care of an inpatient unit. The remaining 2 SIRIs reported were:-

Unexpected death in inpatient unit (6685.2015) reported by Beech Ward.

Complication (fracture) following tooth extraction (7441.2015) reported by King Street Dental Access Centre.

1.1.2 SIRI reporting trends The following graph shows the number of SIRIs reported to the CSU each month from March 2014 to February 2015

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-14

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-14

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er

Month reported to Commissiong Support Unit

SIRIs reported by type March 2014 to February 2015

Total SIRI's Pressure Ulcers Other

The following graph shows the type of SIRI (excluding pressure ulcers) reported from March 2014 to February 2015


00.5

11.5

22.5

33.5

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-14

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IRIs

Month SIRI reported to CSU

SIRIs reported by Type (excluding Pressure Ulcers)

Unexpected death Information Governance Infection Control

Accident - Slip / Trip / Fall Accident - Other Staffing

Medication Allegation of Abuse Other

1.1.3 3 day reports submitted to the Commissioning Support Unit (CSU) Forty-three, 3 day reports were submitted to the CSU in February 2015, 35 were submitted within agreed timescale and 8 submitted outside agreed timescales due to delays in reports being completed by the operational teams. 1.1.4 45 day RCA reports submitted to the CSU Thirty-two, 45 day reports were submitted to the CSU during February 2015 (30 related to pressure ulcers), all were submitted within timescale. 1.1.5 Outstanding 45 day RCAs There are currently no RCAs overdue. 1.1.6 Pressure Ulcer Validation Group (PUVG) The PUVG continues to meet on a fortnightly basis to review PU RCAs and validate the avoidable/unavoidable decision. The PUVG also identifies learning points which will be included within the overarching Pressure Ulcer Action Plan. The action and learning points arising from the PUVG during February 2015 are:-

Inconsistencies of waterlow scoring Capacity within operational teams

1.1.7 Root Cause Analysis (RCA) – outcomes Fracture following fall (patient) (1037.2015) reported by North Walsham community hospital.

Notable practice

All assessments were complete and nursing care appropriate to patient needs. Seen and reviewed by the doctor regularly and the consultant weekly.

Fracture following fall (patient) (2296.2015) reported by Kelling hospital


Learning / Actions identified

Need to ensure falls care plan regularly reviewed and updated as appropriate. Need to ensure equipment is reviewed and rationale for decisions recorded within

records

1.1.8 Open SIRIs There are currently 143 open SIRIs, the table below shows the status of these SIRIs.

Pressure Ulcer SIRIs

All other SIRIs

Total

49 2 51 Investigation reports sent to CSU - awaiting feedback With NCH&C – within timescale 87 5 92

0 0 0 With NCH&C - 45 day reports overdue TOTAL 136 7 143

1.2 Incidents reported February 2015 1.2.1 The total number of incidents reported during February 2015 was 748 (of which 628 affected patients) The graph below details the number of incidents reported by each Locality / Directorate where the severity is moderate harm, severe harm or death. Of the 121 incidents, 112 affected patients.

27

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36 36

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Locality ‐Norwich

Locality ‐Children's

Locality ‐North

Locality ‐South

Locality ‐Specialist

Locality ‐West

Number of incidents reported

Locality / Directorate

Incidents reported in Februaury 2015 resulting in moderate & above harm

The following graph shows the number of moderate, severe and unexpected death incidents reported from 1 March 2014 to 28 February 2015


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Number of incidents

Incidents reported 1 March 2014 to 28 Februaury 2015 resulting in moderate harm, severe harm or death

Locality ‐ Norwich Locality ‐ Children's

Finance Locality ‐ North

Nursing Quality and Operations Locality ‐ South

Locality ‐ Specialist Locality ‐West

The Integrated community nursing teams reported 374 incidents and the Inpatient units 248 incidents and continue to be the highest reporters. These are the areas where the highest numbers of contacts with patients are made. The top three incident reporting categories for each of these services within February 2015 are detailed below: Integrated Community Teams (ICT)

Pressure Ulcers –235 incidents (63%) Staffing incidents - 16 incidents (4%) Moisture lesion – 14 incidents (4%)

Inpatient units

Slips / Trips & Falls (patients) – 66 incidents (27%) Pressure Ulcers – 42 (17%) Medication incidents – 26 incidents (10%)

1.2.2 Incidents reported by Degree of Harm The graph below shows ALL incidents reported by degree of harm from 1 March 2014 to 28 February 2015


0100200300400500600

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Month incident reported

Incidents reported 1 March 2014 to 28 February 2015 by Degree of harm

No Harm Low harm Moderate harm

Severe harm Unexpected death Expected death

Moderate Harm incidents (NPSA definition: short term harm, patient(s) required further treatment or procedure)

116 (16%), incidents reported in February 2015 (107 of these affected patients) resulted in moderate harm, 84 of these incidents relate to Grade 3 Pressure Ulcers (38 acquired within the care of NCH&C and 46 acquired outside the care of NCH&C). All Grade 3 pressure ulcers acquired within the care of NCH&C are reported to CSU as SIRIs. 5 related to deterioration in the patients’ medical condition whilst the patient was within an inpatient setting and was subsequently returned to an acute hospital for further assessment / treatment. The remaining 27 incidents cover a wide range of incident types. Where a specific issue is identified, staff with additional expertise (e.g. Head of Medicines Management, Adult & Children Safeguarding leads, Health & Safety, Infection Control etc.,) are made aware of them and take appropriate action to support their local management. Themed incidents are also reported to the relevant committee e.g. Medicines Management, Information Governance. Severe harm incidents (NPSA definition: permanent or long term harm)

3 (less than 1%) incidents reported in February 2015 resulted in severe harm:-

o 2 x Grade 4 Pressure Ulcers acquired within the care of NCH&C, which will be reported and investigated through the SIRI process.

o 1 x Grade 4 Pressure Ulcer acquired outside the care of NCH&C

Unexpected Deaths There was one unexpected death reported by Beech Ward in February 2015, this has been reported as a SIRI (see section 1.1.1.) and will be investigated through the SIRI process 1.2.3 Medication incidents for February 2015 There were 44 medication incidents reported in February 2015; 33 were no harm, 10 were low harm and there was one moderate harm incident reported (involving an end of life patient at home having insufficient medicines prescribed to manage symptoms) which is being investigated. The following graph shows the trend of severity since January 2014, and indicates that moderate harm incidents involving medicines are stable at 0.9 per month. Further analysis of the trends in medicines incidents will be reported via the Medication Safety Report.


Fig 1: Breakdown of medication incident trends by severity Jan 14 – Feb 15

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Feb2014

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No Harm

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Moderate harm

Total

Controlled Drugs Incidents There were 8 incidents involving controlled drugs reported during February, 7 no harm incidents: 1 prescribing issue, 4 administration issues, and 2 storage issues. There was one moderate harm incident involving an end of life patient at home having insufficient medicines prescribed to manage symptoms. Fig 2: Controlled drug incidents by month and severity – Jan 2014 – Feb 2015

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Moderate harm

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1.3 Mortality Reviews Deaths across each of the units for Q1, Q2 , Q3 for 2014, January and February 2015 were as follows

Qtr 1 Qtr 2 Qtr 3 January February Total

Hospital Measure All

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Discharges 78 71 71 65 92 86 32 32 24 22 297 276

Deaths 8 3 7 3 9 3 2 2 2 1 28 12

% Deaths 10.3% 4.2% 9.9% 4.6% 9.8% 3.5% 6.3% 6.3% 8.3% 4.5% 9.4% 4.3%

Discharges 66 55 47 41 64 54 16 13 17 15 210 178

Deaths 9 1 7 1 9 1 3 1 2 1 30 5

% Deaths 13.6% 1.8% 14.9% 2.4% 14.1% 1.9% 18.8% 7.7% 11.8% 6.7% 14.3% 2.8%

Discharges 40 36 52 46 50 46 20 18 19 17 181 163

Deaths 5 1 7 2 1 1 2 0 2 1 17 5

% Deaths 12.5% 2.8% 13.5% 4.3% 2.0% 2.2% 10.0% 0.0% 10.5% 5.9% 9.4% 3.1%

Discharges 87 81 83 74 76 71 27 27 28 23 301 276

Deaths 6 1 5 0 5 2 0 0 5 0 21 3

% Deaths 6.9% 1.2% 6.0% 0.0% 6.6% 2.8% 0.0% 0.0% 17.9% 0.0% 7.0% 1.1%

Discharges 109 104 92 87 116 105 26 24 36 33 379 353

Deaths 4 0 8 6 9 3 3 1 4 1 28 11

% Deaths 3.7% 0.0% 8.7% 6.9% 7.8% 2.9% 11.5% 4.2% 11.1% 3.0% 7.4% 3.1%

Discharges 81 69 76 70 77 66 19 14 25 20 278 239

Deaths 9 0 6 1 9 3 4 0 5 1 33 5

% Deaths 11.1% 0.0% 7.9% 1.4% 11.7% 4.5% 21.1% 0.0% 20.0% 5.0% 11.9% 2.1%

Discharges 52 44 65 56 56 50 22 18 18 15 213 183

Deaths 10 2 8 0 5 0 3 0 1 0 27 2

% Deaths 19.2% 4.5% 12.3% 0.0% 8.9% 0.0% 13.6% 0.0% 5.6% 0.0% 12.7% 1.1%

Discharges 95 89 48 45 91 83 21 19 21 20 276 256

Deaths 4 1 2 0 6 0 1 0 2 1 15 2

% Deaths 4.2% 1.1% 4.2% 0.0% 6.6% 0.0% 4.8% 0.0% 9.5% 5.0% 5.4% 0.8%

Discharges 67 67 64 64 75 75 20 20 21 21 247 247

Deaths 1 1 0 0 0 0 2 2 1 1 4 4

% Deaths 1.5% 1.5% 0.0% 0.0% 0.0% 0.0% 10.0% 10.0% 4.8% 4.8% 1.6% 1.6%

Discharges 22 22 15 15 15 15 5 5 6 6 63 63

Deaths 0 0 0 0 0 0 0 0 0 0 0 0

% Deaths 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Discharges 0 0 0 0 0 0 0 0 0 0 0 0

Deaths 0 0 0 0 0 0 0 0 0 0 0 0

% Deaths 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Discharges 34 34 26 26 37 37 10 10 9 9 116 116

Deaths 0 0 0 0 0 0 0 0 0 0 0 0

% Deaths 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Discharges 80 0 64 0 90 0 25 0 25 0 284 0

Deaths 42 0 39 0 52 0 14 0 17 0 164 0

% Deaths 52.5% 0.0% 60.9% 0.0% 57.8% 0.0% 56.0% 0.0% 68.0% 0.0% 57.7% 0.0%

Discharges 811 672 703 589 839 688 243 200 249 201 2845 2350

Deaths 98 10 89 13 105 13 34 6 41 7 367 49

% Deaths 12.1% 1.5% 12.7% 2.2% 12.5% 1.9% 14.0% 3.0% 16.5% 3.5% 12.9% 2.1%

Discharges 731 672 639 589 749 688 218 200 224 201 2561 2350

Deaths 56 10 50 13 53 13 20 6 24 7 203 49

% Deaths 7.7% 1.5% 7.8% 2.2% 7.1% 1.9% 9.2% 3.0% 10.7% 3.5% 7.9% 2.1%

Kelling

North Walsham

Ogden Court

Swaffham

Alder Ward

Benjamin Court

Cranmer House

Dereham

Priscilla Bacon Centre

Total of ALL

Total (excl PBC)

Beech Ward

Caroline House

Caroline House Long Stay & Respite

Pine Cottage


1.3.1 Unexpected Deaths (Inpatient units) Unexpected deaths across each of the Inpatient units in the months March 2014– February 2015 were as follows:

Mar

201

4

Ap

r 20

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May

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e 20

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g 2

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Benjamin Court (incl Step Up)

Cranmer House

Kelling Hospital

1 North Walsham Hosp (incl Step Up)

1 Dereham Hospital

Ogden Court (NHS)

Caroline House

Pine Cottage

Swaffham Hospital

Mulberry Unit (Alder)

1 Mulberry Unit (Beech)

Priscilla Bacon Centre

1 0 0 0 0 0 0 1 0 0 0 1 Total

There was one inpatient unexpected death reported in February 2015. 1.3.2 Mortality Review Group (MRG) Following attendance at a Trust Development Authority meeting involving all community trusts, there is an expectation to continue with Mortality Reviews of all inpatients. The scheme used by NCH&C is seen as appropriate. Further national work is in progress around data collection and analysis. There is no national expectation currently to develop the Mortality review process to include patients in the community, patients who die in their own homes or care settings. NCHC reviews continue and there have been no issues highlighted in February 2015. 1.4 Quality Issue Reports (QIRs) The following 9 QIRs have been received from CSU during February 2015.

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rth

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Hub Services 3 Staffing issues 1 1 1 Medication Issue Failure to visit patient 1 Record Keeping 1 Information Governance 1 Total 9


Each QIR is being investigated by the appropriate Locality, a response will be submitted to the CSU which includes any actions required to address these issues. The implementation of action plans will be monitored at locality governance meetings. Four responses were submitted to CSU during February 2015, 1 within 25 day timescale and 3 outside the timescale. There are currently 24 QIRs where the response to CSU is overdue. The following graph shows the number of QIRs received from July 2014 to February 2015

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Month received

QIRs received from Commissioners July 2014 - February 2015

During the month of February 2015, NCH&C did not raise any QIRs to CSU. 2. HARM FREE CARE 2.1 Safety Thermometer briefing February 2015 It is important to note that the Safety Thermometer is a point prevalence survey, so does not provide information regarding incidence. It is often the case that the ‘rates’ of the indicators are fairly static - our harm free rate increased to 91.3% in February. Overall, the harm indicators remained generally static again for February and within the specified tolerance levels, surveys were collated and processed for all relevant teams and wards, although there is always the possibility of some further late surveys that will be collated and processed in the following month, which has happened in previous months, although we always endeavour to key all data on time.


(NB: data in the chart and tables above are expressed as percentages) There remained a constant level trend in the harm free rate, similar to rates seen in 2014, but to provide some context, if upper and lower control limits are applied to the data through a robust statistical process control, then we can see from the chart below that the ‘harm free’ values continue to remain well within the normal tolerance levels.

89.6

90.4 90.3 90.490.1

89.0

90.090.2

90.7

90.2

88.7

91.3

85

86

87

88

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90

91

92

93

Mar‐2014

Apr‐2014

May‐2014

Jun‐2014

Jul‐2014

Aug‐2014

Sep‐2014

Oct‐2014

Nov‐2014

Dec‐2014

Jan‐2015

Feb‐2015

UCL (92.2)

+2 SD

Measurement

Mean (90.1)

‐2 SD

LCL (88.0)


2.2 Venous Thromboembolisms (VTEs) There was 1 new incidence of VTE reported in February 2015. 2.3 Patient Falls 65 inpatient falls were reported in February 2015. 43 resulted in no harm and 22 resulted in low harm. Of these falls, 43 patients fell once, 8 patients fell twice and two patients fell three times. The following table shows injurious patient falls within each Inpatient:

Mar

-14

Apr

-14

May

-14

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14

Jul-1

4

Aug

-14

Sep

-14

Oct

-14

Nov

-14

Dec

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15

Feb

-15

Tot

al

Benjamin Court 0.0 2.0 2.0 7.0 3.9 0.0 0.0 0.0 4.1 4.0 5.6 0.0 2.3 Cranmer House 10.8 2.8 0.0 8.6 11.5 3.0 5.5 0.0 0.0 5.3 5.4 0.0 4.4

Kelling 1.4 6.3 8.2 0.0 1.6 4.4 4.8 6.1 4.5 11.1 5.0 2.9 4.7 North Walsham 6.0 3.0 1.5 1.5 0.0 2.9 1.5 5.7 7.3 4.2 2.8 3.1 3.3

Dereham 2.8 5.7 6.1 3.0 5.4 8.1 3.3 2.7 1.4 0.0 3.4 2.5 3.7 Ogden Court 3.6 0.0 7.5 5.3 1.8 3.4 0.0 3.2 1.7 3.3 8.0 5.2 3.6

Alder Ward 9.0 2.9 5.9 3.1 1.4 11.8 4.5 13.6 1.5 8.4 1.4 4.6 5.7 Beech Ward 4.1 5.9 2.8 2.9 1.4 2.8 1.5 0.0 1.5 1.5 1.4 9.4 2.9

Swaffham 2.0 0.0 0.0 4.6 4.3 0.0 6.1 1.9 0.0 4.2 0.0 4.2 2.3 Caroline House 3.8 5.2 3.3 1.7 1.6 0.0 0.0 0.0 5.1 0.0 0.0 0.0 1.7

Pine Cottage 4.5 4.5 0.0 4.4 0.0 4.7 4.2 4.4 0.0 4.2 0.0 4.4 2.9 PBL 5.2 2.3 6.5 0.0 11.2 8.3 6.5 4.7 4.4 4.3 8.4 2.4 5.4


Total 4.3 3.6 4.0 3.2 3.3 4.5 2.9 3.7 2.9 4.3 3.5 3.4 3.6 Target 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0 4.0

Average 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 3.6 The following graph shows the degree of harm of ALL inpatient patient falls from 1 March 2014 to 28 February 2015

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Inpatient patient falls reported 1 March 2014 to 28 February 2015 by Degree of Harm

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The table below shows the number of patient injurious falls by 1,000 occupied bed days

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Injurious Falls per 1000/OBDs Performance - Inpatient Units

Monthly Performance

2.4 Pressure Ulcers – (to maintain zero avoidable within inpatients) The following table shows the number of avoidable Grade2, 3 & 4 pressure ulcers broken down by Inpatient / Community acquired. Breakdown of avoidable pressure ulcers (Grades 2, 3 and 4)

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul 2014

Aug 14

Sep 14

Oct 2014

Nov 2014

Dec 2014

Jan 2015

Feb 2015

0 0 0 1 0 0 0 0 0 0 0 0 2* 0 1* Inpatient

7 6 11 7 5

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3 12 8 8 5

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Community ‐ Residential Home

10 18 19 16 10 15 7 8 11 8 5 8 13 7 6 Total

* Not yet validated The following tables shows the number of avoidable ulcers, broken down by grade of pressure ulcer

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2201

4 02

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6 10 15 10 6 12 5 4 4 3 1 2 6 1 0Grade 2

4 8 4 6 4 3 2 4 7 4 3 6 5 5 6Grade 3

0 0 0 0 0 0 0 0 0 1 1 0 2 1 0Grade 4

10 18 19 16 10 15 7 8 11 8 5 8 13 7 6Totals:


The following table shows the number of unavoidable pressure ulcers, Grade 2, 3 & 4 acquired within the care of NCH&C

2013

12

2014

01

2014

02

2014

03

2014

04

2014

05

2014

06

2014

07

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08

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11

2014

12

2015

01

2015

02


Grade Two 75 74 77 91 66 80 88 67 48 69 66 66 75 88 52Grade Three 20 30 18 20 13 21 12 21 12 25 19 24 16 35 23Grade Four 2 0 1 2 1 2 1 2 0 1 0 1 1 2 2Totals: 97 104 96 113 80 103 101 90 60 95 85 91 92 125 77

Key Figures Validated

Some figures not yet validated

All Figures not validated 2.5 Infection Prevention and Control 2.5.1 MRSA Bacteraemia (contractual ceiling of 0) The ceiling for 2014-15 follows the national ambition of zero MRSA bacteraemia for all NHS organisations. To date NCH&C have reported no MRSA bacteraemia and NCH&C finish the year within trajectory

NCH&C monthly pre 48 hour MRSA bacteraemia cases against cumulative trajectory

2.5.2 Clostridium Difficile (C. Diff) (contractual ceiling of 5) The ceiling for NCH&C through 2014-15 has been set at 5 cases of Clostridium difficile. NCH&C are 3 cases over trajectory with 8 cases attributed to NCH&C. NCHC have successfully appealed one case from Caroline House in the last month which was an out of area case. We have had one case from Pine Cottage attributed to NCHC this was mainly due to poor communication. We are now awaiting the outcome of the latest case from Caroline House. The meeting has been held and the decision is now awaited from Public Health. If successful NCHC attribution will be 7 rather than 8 as stated above.

The following graph shows the trajectory of cases against our ceiling of 5 for 2013/14

NCH&C has seen great reductions in cases of C. diff over the last 10+ years: Year

Number of C. diff for the year

2004-5 143 2005-6 15 2006-7 19 2007-8 36 2008-9 13 2009-10 19 2010-11 9 2011-12 8 2012-13 3 2013-14 3 2014-15 Year to date 7 NCH&C have followed the national trend in reduction of C diff figures, through increased training, increased IPAC team, heightened awareness and a greatly improved environment. Our 7 cases for 2014-15 have shown a disappointing rise, however this has been a common trend locally and nationally. This has been recognised in the release of the new 2015-16 ceilings which have increased across the board with the exception of one provider in Norfolk. NCH&C have had 12 post 72 hour cases to date 4 of which have been successfully appealed, 7 are on NCH&C trajectory and 1 is outstanding a verdict on its appeal. Quality Assurance & Risk Report of 31

3.1 PATIENT EXPERIENCE AND INVOLVEMENT REPORT 3.1.1 Friends and Family Test (FFT) The overall Trust FFT score for February was 97 and YTD was 97. The total number of feedback cards received from patients was 476, with 446 comments left.

Trust Recommend % Trust 2014/15 YTD Trust Breakdown

National reporting of our data has now commenced and locally, in addition to the usual monthly Board report summarising all responses, locality reports are now available. Named contacts for the individual services can also access their own data, respond to comments/feedback and print ‘you said we did’ posters to display and feedback to patients and staff. Overall the comments are extremely positive and far outweigh any negative feedback, however there are still areas for improvement. This month care/ treatment, attitude and communication received the largest number of positive comments, but there was an increase in negative comments or areas for improvement for time/appointment delays and facilities. This follows the same pattern as last month. Below is a breakdown of the key categories we received feedback on giving the number of positive and negative/areas for improvement comments for each category.

Category

Positive

Negative/areas for

improvement

Care/Treatment 320 3

Attitude 233 1

Time/Appt delay 33 39

Policy 3 3

Communication 177 6

Aids/Equipment 4 0

Facilities 21 16

Other 25 6 Quality Assurance & Risk Report of 31


Examples:-

Category Positive Negative/areas for improvement Care/Treatment

Fantastic service! Very helpful with good explanations. Sensitive approach for potentially embarrassing condition. Combines humour and understanding well (Continence service – Norwich)

The individual nurses were kind and helpful but they seemed busy writing most of the time. Communication between shifts was poor. I became quite sore having gone three weeks without a shower. Actions regarding my care were not implemented until my wife checked up with the nurses. Improvements: General old fashioned nursing care (Ward -unknown)

Attitude

I was taken care of with such professionalism. I retained my dignity at every juncture. Every member of the team treated me with such sensitivity. I put my full trust in them. I cannot praise them high enough (CT Coastal – West)

The receptionists at the surgery need training in customer care. They are grumpy and make you feel like you are wasting their time when booking in. I hate to think how they would make you feel if you had to change an appointment. (MSK Physio – Norwich)

Time/Appt delay

I was able to ask for an appointment that suited me. I did not have to wait long. The help and advice given was helpful. The atmosphere was pleasant. I was given encouragement and was assured of further help if needed (MSK OT)

I did have to wait 3 months for an appointment then I had 2 weeks to reply from postage date, in which I was on holiday. Sadly the patient is then taken off the waiting list and has to be re-referred (another 3 month wait). Therefore I didn’t get treated for 6 months (MSK Physio Thetford)

Communication

They listen and put me at ease and put things into perspective (Children’s SaLT)

Improvements: I didn’t know palliative care by the virtual team continued for 6 days and was then handed onto the hospice care. The pre-information on palliative care that was missing for us.

Aids/Equipment

Staff are friendly, able to understand my needs. Delivery time of wheelchair was good and member of team came out to show me how to use wheelchair and explained different parts of the chair (Wheelchair Services)

N/A

Facilities

Lovely and warm temperature in room. Quiet and friendly for babies. (Short Breaks – Little Acorns)

Ghastly choice of food and not very much of it (Foxley Ward) 2 further negative comments received in February also about the food – passed on to Food Services Manager for follow up.

Other

Surprisingly easy to join in. Environment so comfortable and in chatting the time passed very quickly (Rowan Day Unit)

Improvements: It would be more helpful if I could contact the department directly, especially if I am experiencing problems in between appointments. Instead I have to phone central bookings which can take time. (Podiatry)

Now the FFT is underway across NCH&C services the focus needs to shift to closer monitoring of the results, any improvements that need to be addressed or action taken as a result of the feedback. To assist with this the PE team will be setting up a monthly monitoring programme and a regular feature will also go in the exchange highlighting services who are doing particularly well.


An easy read version and translation of the FFT it into other languages is underway and the monthly Board report is now posted onto the NCH&C website. 3.1.2 Patient Opinion There was five stories on Patient Opinion www.patientopinion.org.uk this month, 3 stories of praise and thanks to Pine Cottage Amputee Rehabilitation, Physiotherapy, and Swaffham Community Hospital. Of the other 2 stories, one related to Health Visiting and an unsatisfactory assessment and diagnosis of tongue tie. Following and initial response and acknowledgement from NCH&C, this story was reviewed and responded to directly by our Health Visiting Lead who has had contact from the mother and will be following up directly with her on actions taken and how best to support parents in a similar situation in the future. The other story related to a perceived shortage of District Nursing. All stories are responded to online and contact details of PALS are given to support further investigation where a story is of concern. NHS Choices - There were no stories on NHS Choices this month 3.1.3 Other Patient Experience Activity Patient Voice at Board This month, the Board heard from a former patient who described her positive experience of rehabilitation, at Dereham Hospital, and how important this community facility is. After fracturing a wrist and leg following a fall at home in September 2014, the patient requested a transfer to Dereham Hospital, after treatment at NNUH. She described her experience from the paramedic arriving to assess her injury to finally returning home after her period of rehabilitation. Describing how she was encouraged to get up and dress before breakfast and to think clearly for herself and her objectives, the Board was told about how she observed nurses and health care assistants carrying out tasks with kindness, patience and encouragement; received clear instruction in being able to walk safely and strengthen her muscles; and was also impressed with a good choice of food and the accommodation of her dairy free diet, in a spotlessly clean hospital. We also heard the patient express concerns about the pressure staff appeared to be under to maintain staffing and accommodate increasing demands on their time; for example, while they were supporting the CQC team during their recent inspection. Service led surveys and bespoke projects Pine Cottage, Amputee Rehabilitation Service run a patient satisfaction survey on discharge in addition to delivering FFT. The results for February showed that all 8 of patients felt they were very much treated with dignity and respect and felt very safe and secure. 7 out of the 8 patients reported to being overall very satisfied. All other topics patients responded with the highest score for equipment, information and communication but with the areas of discussing medication and concerns, 3 patients had responded “fairly good”. There were no areas of dissatisfaction and comments praised the staff for their care and professionalism. Patient and carer involvement in service redesign We received an evaluation form the South locality of a recent “Getting to Grips” course which was a collaboration between the Neurology Nurses, local MS Society staff and MS Society Dereham branch.

http://www.patientopinion.org.uk/


The course ran over 4 weeks, there were an average 15 participants at every session. The Course was extremely successful with good attendance and positive feedback. Each session covered two topics per evening these with topics included and overview of MS, symptoms, managing fatigue and practical assistance and advice with CAB and information on Alternative Therapies. Topics for future courses will be planned to include ideas from the course attendees. 3.1.4 PALS During the month of February PALS received 2 comments, 7 concerns, 5 complaints, 67 compliments and 39 Guidance related enquiries, a total of 120 enquiries. The concerns received this month included;

Conduct of reception staff at the Siskin Centre, leaving reception unmanned and overheard having conversations, and the decision to not be treated by the dentist and passed to a specialist, patient felt this relationship breakdown could have been avoided if she had not raised her concerns about reception staff. We liaised with the Siskin Centre and following investigation we followed up with the patient and offered the complaints procedure as the next step. She was appreciative of our service so far.

Concern regarding being discharged from the foot health clinic as felt they should offer the nail cutting service. They were advised to book another appointment with their GP.

A concern regarding the wait to get a continence referral was highlighted and as a result of talking to the service a patient was offered an appointment the following week due to a cancellation rather than waiting the usual four weeks

All of these concerns were discussed with a more appropriate person (such as someone from the direct service) and resolved.

We continued to work closely with our Complaints Manager and any that go on to datix are cross referenced in our database. The 5 complaints received were passed to the complaints manager.

3.2 Complaints and Claims – February 2015 Key performance indicators:

15 complaints were received during February 2015 100% of complaints received this month were acknowledged within 3 days. 100% of complaint responses due in February met the 25-day target. No complaints were received about the complaint process.

No particular themes emerged this month, although a further complaint about continence products was received, which was an emerging theme in January. A complaint was also received about the withdrawal of the community intravenous service from the South Complaints received in previous months

August 2014

September 2014

October 2014

November 2014

December 2014

January 2015

24 30 36 18 20 18 Quarterly Complaints Figures

Q4 2012/13

Q1 2013/14

Q2 2013/14

Q3 2013/14

Q4 2013/14

Q1 2014/15

Q2 2014/15

Q3 2014/15

44 33 41 81 52 64 71 74

Active at February month end 18

Responses due in February 2015: 17


Responded within target

17 = 100%

Responded outside target

0

Due this month - still ongoing

Second responses requested this month 0 Referrals to Ombudsman this month 0

Locality Total Appt

delay Care &

Treatment Policy Staff

attitude Communication Aids &

Equipment Other

Children (see breakdown below)

3 1 2

Norwich 4 3 1 North 2 1 1 South 1 1 West 2 1 1 Specialist (see breakdown below)

1 1

Estates and Corporate

2 1 1

Total

15 3 3 2 3 3 1

Specialist Services One complaint was received in Specialist services during February. This was categorised as follows: Service Number Received Specialist Rehabilitation 1 Learning Disabilities and Vulnerable Adults 0 Long Term Care 0 Dental 0 Specialist Treatment Services 0 Childrens Services Three complaints were received in Children’s services during February. These were sub-divided as follows: Service Number Received Disability and Specialist Health Pathway 1 Healthy Child Pathway 2 Example of Complaint Comments for February (these are intended to give a flavour of a sample of complaints received this month as requested by Quality and Risk Assurance Committee. Please note that they will not have been investigated and resolved by the time this report is presented) I was very concerned at the lack of “actual” treatment on offer. I consider it an utter waste of NHS resources to not offer treatment for the relief of pain. It is provided in the private sector, why not NHS? Physiotherapy / Downham Market


I do not have any complaints about the treatment X has received or the staff attending, my concern is about the general disregard for the needs of the patient and carer and the apparent lack of communication within the service and with me, continuity of staff treating X and the organisation relating to visits. CN&T / Norwich X used to get Tena level 3 pads. He now gets ID level 2 pads for men. When I queried it I was told they are more absorbent. Absolutely not! Continence / North Learnings received during February (these relate to complaints received during the preceding months) Date received

Service Locality Complaint Category

Summary of Complaint

Learning

11.02.15 Neurology West Communication

Complaint about confidentiality issues when discussing the complainant's daughter

- To improve communication at every stage of assessment using reports to clarify what has been assessed/planned and reasons why

- To clarify expectations of carers for team involvement and clarify what our service can offer in order to manage those expectations

- Understand consensual arrangements with particular patients and ensure at initial contact what is expected for that particular individual

11.02.15 Epilepsy South Communication

Complaint about confidentiality issues when discussing the complainant's daughter

- Update practice to ensure that permission is gained at each consultation with a patient to share relevant information

3.3 Claims No new claims were received during February 2015. 3.4 Compliments

Locality - Norwich

Locality - Childrens

Locality - North

Locality - South

Locality - West

Locality - Specialist Total

Compliment 9

2 16 18 19

3 67 Quotations from Compliments received during February 2015 “Thank you for caring for X during her final days, she could not have received any more dedicated and professional care. Her family and I greatly appreciate it” Ogden Court Nursing Unit "I was diagnosed with MS in 2012 at the age of 64, it was a shock and a new way of life to get used to. The MS nurses I have seen in Beccles and Kings Lynn have been an enormous help to me. I appreciate their advice and the time they give. Their knowledge of MS is extensive and I know that should I need to discuss something they are there to help, often when doctors aren't or cannot. My recent visit was at Swaffham which was a great help to me as we live nearby. Please keep this much valued service going. Many thanks.” West Neuro Team “I would like to thank you for all the care and attention with humour, that you gave my mother in July (whilst on holiday). You and those working with you are great!”

Rapid Assessment Team West


“A very big thank you to you all for the wonderful work you do but most especially for the help you have given to X and I since his stroke. You all worked tirelessly with him. Personally I am too grateful for the help you have given me at a time when I wasn’t sure what the future would hold”.

ESD Suffolk “I would like to say the Phlebotomy staff are wonderful, almost look forward to my regular blood test. Please change nothing.” Phlebotomy Norwich “My family are most grateful for the wonderful care you take in your work. Thank you so much”.

Alder Ward Norwich “Thank you for the wonderful care that you gave to my husband for the past few weeks. It is an award winning hospital. Certainly deserving of a gold medal. My husband has really enjoyed his stay with you.” Pine Heath Ward North “X had been fanatically helpful in giving me advice about my son’s sleeping & eating problems. I was really at my wit’s end but have found their advice has made a huge difference to our lives and wellbeing”. Nursery Nurse South “Lymphoedema Service which I highly recommend excellent service caring nurses who are considerate, helpful in every way possible”. Lymphoedema Service Norwich “Thank you very much for the care you gave to my aunt. There was a lovely atmosphere on the wards and that was particularly nice as my aunt worked for many years before retiring at Dereham Hospital”. Foxley Ward South “I just wanted to say thank you for all you have done to help me. You have persevered with me and I really appreciate it. You were the only person that has helped me with my problem and for that I am so thankful. Thank you for all your advice its really, really worked”. Continence South 4. CQC compliance - Quality Assurance Assessments Building on the CQC inspection success a new self-assessment process for monitoring compliance against CQC standards is being developed. This will be rolled out across the organisation and will replace the current programme of quality assurance visits to all services. In the Quality Assurance Managers work will be directed by the Quality Surveillance group, chaired by the Director of Nursing and Quality, to target areas of concern within the organisation. The programme of quality assurance assessments for all teams and services is nearing completion and the Quality Assurance Managers have been tasked with other quality priorities so there are fewer assessments to report. 4.1 Quality Assurance Assessment Reports (For further detail on recommendations please see appendix 2) 4.1.1 Norwich Locality City 2 Community Nursing Team 3rd November 2014

We carried out this routine assessment of the service to review the safety, care, responsiveness, effectiveness and leadership by assessing the CQC outcomes 4 (caring), 8 (infection control), 12, 13, 14 (staffing), and 16 (quality). We spoke to patients, the team leader, members of staff and made observations of patient care within patient’s homes.

The team presented as positive and proud of the care they provide, however the nursing part of the team had a lower morale that the therapy staff since transformation, and loss of staff resulting increased pressure of work; there have been several staff who have left the team recently and the team has higher than average levels of sickness. Staff were observed to be professional and appropriate. Staff said that they worked well as a team


and provide support to each other, and that they feel they are “still able to do a good job” The team leader was proud of their staff and team cohesion was seen to be good.

The assessors found the assessment visit a positive experience and had a good impression of the service overall. Staff were very experienced and we heard positive feedback from service users. Therapy staff are well supported for development with supervision every 6-8 weeks which is recorded. Nursing staff are reported to have an allocated supervisor but there is no evidence that supervision is being accessed. The team do not have a handover meeting, unlike the other city teams, which provides an opportunity to discuss patient’s clinical needs and gain advice and support. The team has monthly team meetings and ad hoc team debriefs where there have been critical incidents to share learning . The clinical lead has observed practice within the team.

There is an action plan in place to address the recommendations.

4.1.2 Amputee Rehabilitation Service, Pine Cottage 12.11.14

We carried out this routine assessment of the service to review the safety, care, responsiveness, effectiveness and leadership by assessing the CQC outcomes 1 (respecting and involving people who use service), 4 (care and welfare), 12, 13, 14 (staffing), and 16 (quality). We spoke to the senior staff nurse, members of staff from the MDT, patients and carers and observed practice. The team provide specialist multidisciplinary inpatient and outreach amputee care and rehabilitation. Staff said that they loved working within the service, and experienced high levels of job satisfaction. Staff appeared to take great pride in their work and describe “being part of a team” as integral to this. Staff reported that they feel patients get excellent care and good outcomes from rehabilitation. Staff particularly enjoy patients maintaining a relationship with the service post discharge and that they see the long term results for patients’ lives. Staff were very positive and were very open to discussion of new ways of doing things to further improve the services provided. The Ward Manager and Senior Staff nurse’s leadership and clarity of communication was appreciated by the team. The assessors spoke with all of the current patients. They were all very positive about the treatment and care they were receiving, this is detailed below in this report.


4.1.3 City 3 Community Nursing team 28/10/15

We carried out this routine assessment of the service to review the safety, care, responsiveness, effectiveness and leadership by assessing the CQC outcomes 4 (care and welfare), 8 (infection control), 12, 13, 14 (staffing), and 16 (quality). We spoke to the team leader, members of staff, patients and carers and observed practice. Staff said that they felt well supported by their team leader, but that work was less satisfying since transformation and they had concerns for patients regarding continuity of care. We saw evidence of good team support. We were impressed by the feedback that patients gave, one patient said they were “delighted” by the care one of the nurses provided and another patient said nurses provided “first-class care” however patients also said they were frustrated by the lack of continuity of care, about lack of communication re results of swabs, some cancellations of scheduled visits and their inability to talk to a named nurse on telephone if they are having a problem. We saw evidence of good IPAC standards, skilful catheter care and excellence in the maintenance of patient’s privacy and dignity.



4.1.4 Norwich Locality: Community Occupational Therapy, Community Physiotherapy and Musculoskeletal Physiotherapy Services 18/11/14

We carried out this routine assessment of the service to review the safety, care, responsiveness, effectiveness and leadership by assessing the CQC outcomes 4 (caring), 12, 13, 14 (staffing), 16 (quality) and 21 (records). We spoke to patients, the operations manager, team leaders, members of staff from MSK PT, Community OT and Community PT teams and the hub, reviewed patient and staff records and made observations of patient care and contemporaneous record keeping within the clinic setting and patient’s homes.

The team presented as positive and proud of the care they provide. The community OT and PT teams have recently transferred to therapy leadership and the assessors found that processes were well established for the MSK service and are still developing for the community therapists. Staff were observed to be professional and appropriate. The team leaders were proud of their staff and the way they have adapted to recent changes. We saw evidence of some good processes and systems in place. The assessors found the assessment visit a positive experience and had a good impression of the services overall. We heard positive feedback from service users. The service is supported well, with a good therapy leadership structure to the level of operations manager. Staff are well supported for development and supervision. Staff provide care in a flexible and responsive way. There is an action plan in place to address the recommendations.

4.1.5 Specialist Neurological Rehabilitation Services (inpatient unit, out-patient clinics

and outreach services) 26/11/14

We carried out this routine assessment of the service to review the safety, care, responsiveness, effectiveness and leadership by assessing the CQC outcomes 4 (caring), 9 (medicines management) 12, 13, 14 (staffing), and 16 (quality). We spoke to patients, the service manager, members of staff from all professions within the MDT, reviewed patients records and made observations (including patient care, drug round and case conference) within the inpatient service and the outreach and day service a clinic. The team presented as a highly specialist dedicated to providing high quality interdisciplinary patient focused care with clear goal setting and use of outcome measures. We saw evidence of some good processes and systems in place. The service is well established whilst also maintaining a culture of refection and positive action for service improvement. Staff support each other and are committed to patient focused care. Reflective practice is well supported across the disciplines. There is an action plan in place to address the recommendations.

4.1.6 Children’s Services - North Lynn Children’s Centres

We carried out this routine assessment of the service to review the safety, care, responsiveness, effectiveness and leadership by assessing the CQC outcomes 4, (caring), 7, (safeguarding), 12, 13, 14 (staffing), and 16 (quality). We spoke to the team leader, members of staff, made observations and attended a clinic. The North Lynn Children’s Centre team are based in the staff offices at St James, Kings Lynn, approximately one mile from the start of the area that the team cover. This means that parents cannot access staff as easily as in some of the children’s centres. Staff and parents and children would benefit from a centre within the patch so it is more accessible,


visible and to enable services to be delivered more effectively. The current premises are a temporary measure, and the centre is linked in with strategic discussions between partner agencies involved in planning the creation of an early help hub alongside local residential and service developments. The team leader explained that they are working with the county council to explore options. Currently a potential delivery base has been identified. NCH&C Estates representatives and the Centre Leader are working with providers to identify how the building can be altered to achieve an appropriate space to deliver the services and the cost. In the meantime advice is also being sought from NCH&C staff in terms of Infection Control, Health and Safety, and support services to ensure the project can keep momentum.

However despite the lack of building this centre has 100% new births registered which is the highest in the county, and one of the highest rates of contact with children in the County, especially in the most deprived area. The head teacher of the primary school in North Lynn has also noted that the ‘school readiness’ of children entering the school has improved since NCH&C took the lead for the centre, with a significant increase in the number of children with pre-school experience. The team were generally positive when talking about their roles and the team. We spoke to several members of the team, one said they were proud of the positive professional attitude within the team, and one member of staff said it was a “great team”. We spoke to a student who was really positive about the team and would like to come back to work in the team when they are qualified. We asked staff what they would like to improve and they said having a new children’s centre building to deliver the services from. The Healthwatch representative attended a health visitor clinic at a local chapel. They commented that members of staff were efficient and professional. They noted that there were no information leaflets available and that they felt the environment did not seem appropriate for delivering the session, (for example, no rooms available for privacy and no facility for the staff to wash their hands). The Assessor also spoke to parents at review session and the feedback was good. We saw evidence of some good processes and systems in place however these need to be continuously monitored to ensure they remain effective. The main recommendation is for the team to have its own building to deliver services. There is an action plan in place to address the recommendations.

4.1.7 East City Health Visiting team 3/12/15

We carried out this routine assessment of the service to review the safety, care, responsiveness, effectiveness and leadership by assessing the CQC outcomes 4, (caring), 7, (safeguarding), 12, 13, 14 (staffing), and 16 (quality). During the visit we spoke to the team leader, spoke to members of staff, attended a clinic and observed appointments. We saw evidence of effective verbal communication at the allocation meeting. Staff were welcoming to all of the assessors and were professional in their engagement with the assessment process. The team presented as supportive of each other. Staff reported that they liked working in the team and valued the support of their colleagues. One member of staff said they were “proud of being in the team”. The Healthwatch representative commented that staff were friendly and considerate. The parents told Healthwatch that they were very happy with the way their children were treated at the clinic and if they had any problems they could talk to the team in the room where the children were weighed provided adequate privacy.


The main recommendations are for the team to build on the caring, staffing and quality outcomes including the risk register, clinical supervision, locally resolved complaints, audit and patient experience work. There is an action plan in place to address the recommendations.

4.1.8 Thetford Children’s Centre 25/11/14

We carried out this routine assessment of the service to review the safety, care, responsiveness, effectiveness and leadership by assessing the CQC outcomes 4, (caring), 7, (safeguarding), 12, 13, 14 (staffing), and 16 (quality). We spoke to the team leader, members of staff, made observations and attended a clinic. We went out on three visits with two health visitors. We spoke to health visitors, the early help social worker, the health visitor assistant, a student health visitor, a nursery nurse and the Manager. Most staff reported that they liked working in the team and valued the support of their colleagues. The team said they were a “very good team who go that extra mile” and felt that have an open, supportive culture. One member of staff said “the team provides a fantastic service to Thetford families and I am proud to be in this team.” The Healthwatch represented commented that the centre was “very well equipped and clean with hygiene between patients good. It was a friendly, warm and pleasant environment.” They felt that the centre was unknown in the area and underused as there were less parents than normal attending the clinic on that day. We noted some good practice for example good communication with the midwifery team including planning to reduce the increasing teenage pregnancy rates, working with the Trusts Infant Feeding Lead to increase breastfeeding rates, attending GP liaison meetings and offering evening clinics. There is good evidence of patient experience and evidence of learning through audit. The team has recently launched a dedicated website which gives families lots of information about the Centre. We were impressed that there were complaints leaflets in different languages on the reception desk in the Sure start Centre. The main recommendations were for the team to ensure they capture the good work they are doing and to ensure that this, and the learning is recorded at team meetings. There is an action plan in place to address the recommendations.

Recent Quality Assurance Assessments:

1) Vancouver, Nair & Coast Health Visiting teams 2) IV Team (North, Central and South) 3) Norwich Unplanned care and Care at Home teams 4) Norwich Out of Hours 5) Phlebotomy and Leg Ulcer Clinics

Quality Assurance Assessments planned for March 2015

1) City 1 Community Nursing Team 2) Community Liaison Team and Pull Out Case Managers NNUH 3) Cranmer House


5. SAFER STAFFING This report provides information on safe staffing for the period of February 2015. The graph below outlines the staffing activity across inpatient and respite units. During February levels have been maintained within appropriate levels of 95% except at the following units where local actions were taken to ensure safe staffing is maintained at all times as listed below: Swaffham Community Hospital Average fill of unqualified staff 82.9% - During this period unit supported by the Virtual ward band 2, Community Nurses, the IV team, and Ward manager. Cranmer House Average fill of qualified staff 86.6% - During this period Cranmer has a vacancy of 0.45 wte RGN and 1.00 wte RGN off long term sick. Therefore when other units require 1 staff nurse may be moved to work elsewhere. Staffing issues are listed on the risk register. Pineheath Ward Average fill of qualified staff 86.6% - During this period cover was provided from Cramner House and the Ward manager. Mill Lodge Average fill of unqualified staff 88.5% - During this period 6 staff (out of 18 staff) developed sickness resulting in 4 of these being off. A RN was off sick at the same time. Due to the inability to safely staff the unit, it was closed for several days (sporadic) to maintain a safe service. Due to the complexity of patients it was a not deemed appropriate to just cover the RN with bank staff.

Only complete sites your

organisation is accountable for

Specialty 1 Specialty 2

Total monthly planned staff hours

Total monthly actual staff hours

Total monthly

planned staff hours

Total monthly

actual staff hours

Total monthly

planned staff hours

Total monthly

actual staff hours

Total monthly

planned staff hours

Total monthly

actual staff hours

Alder Ward430 - GERIATRIC MEDICINE

315 - PALLIATIVE MEDICINE

1130 1220 2020 2250 430 530 250 290 108.0% 111.4% 123.3% 116.0%

Beech Ward430 - GERIATRIC MEDICINE

1680 1600 2600 2520 560 570 670 650 95.2% 96.9% 101.8% 97.0%

Benjamin Court Ward430 - GERIATRIC MEDICINE


1120 1140 1400 1320 560 560 280 270 101.8% 94.3% 100.0% 96.4%

Cranmer House Ward430 - GERIATRIC MEDICINE


760 660 1400 1380 280 260 280 280 86.8% 98.6% 92.9% 100.0%

Pineheath Ward430 - GERIATRIC MEDICINE


1280 1080 2780 2620 560 560 560 510 84.4% 94.2% 100.0% 91.1%

North Walsham Ward430 - GERIATRIC MEDICINE


1220 1160 2170 2170 560 550 560 530 95.1% 100.0% 98.2% 94.6%

Swaffham Ward430 - GERIATRIC MEDICINE


1120 1350 1400 1160 560 570 280 330 120.5% 82.9% 101.8% 117.9%

Foxley Ward430 - GERIATRIC MEDICINE


1680 1560 2800 3040 560 560 560 690 92.9% 108.6% 100.0% 123.2%

Ogden Court430 - GERIATRIC MEDICINE


1190 1160 2170 1960 570 560 280 280 97.5% 90.3% 98.2% 100.0%

Caroline House 314 - REHABILITATION 1400 1930 2470 2330 560 570 560 730 137.9% 94.3% 101.8% 130.4%

Pine Cottage 314 - REHABILITATION430 - GERIATRIC MEDICINE

830 770 840 990 280 280 280 290 92.8% 117.9% 100.0% 103.6%

Priscilla Bacon Centre315 - PALLIATIVE MEDICINE

1590 1560 1970 1960 560 560 560 560 98.1% 99.5% 100.0% 100.0%

Little Acorns Ward 420 - PAEDIATRICS 887.5 900 837.5 825 200 200 400 400 101.4% 98.5% 100.0% 100.0%

Mill Lodge Ward700- LEARNING DISABILITY

634.25 752.5 1032 913.75 279.5 279.5 279.5 279.5 118.6% 88.5% 100.0% 100.0%

Squirrels Ward 420 - PAEDIATRICS 1062.5 1037.5 1112.5 1150 275 275 550 537.5 97.6% 103.4% 100.0% 97.7%

Main 2 Specialties on each ward

Night

Ward name

Registered midwives/nurses

Registered midwives/nurses

Care Staff Care Staff

Day Day Night

Average fill rate - care

staff (%)

Average fill rate -

registered nurses/midwiv

es (%)

Average fill rate - care

staff (%)

Average fill rate -

registered nurses/midwiv

es (%)



6. RISK MANAGEMENT 6.1 Board Assurance Framework & Risk Management Internal Audit The internal audit report and action plan resulting from the PricewaterhouseCoopers audit carried out in January 2015 has been finalised. The report shows a marked improvement from the review carried out in September 2014 and now has a Medium risk overall (previously high risk rating) The Quality & Risk Assurance Committee & Trust Board will be updated on the progress of the action plan on a monthly basis. 6.2 Corporate Risk Register (CRR) The following table shows the current breakdown of risks which are captured on the Corporate Risk Register (as at 3 February 2015) by directorate/business unit and by type of risk.

Co

mp

lian

ce /

Sta

tuto

ry D

uty

Fin

ance

Oth

er

Pat

ien

t S

afet

y &

Q

ual

ity

Ser

vice

Del

iver

y

Su

stai

nab

ility

Wo

rkfo

rce

To

tal

Strategy and Transformation 0 0 0 0 0 2 0 2 Locality - Norwich 0 0 0 1 0 0 1 2 Locality - Children's 1 0 0 1 1 0 0 3 Finance 0 1 0 0 0 0 0 1 Human Resources 0 0 0 2 0 0 1 3 Medical Directorate 0 0 0 2 0 0 0 2 Nursing Quality and Operations 3 0 0 3 1 0 0 7 Performance and Information 0 2 1 0 0 1 0 4 Locality - South 0 0 0 4 3 0 0 7 Locality - Specialist 1 3 0 2 2 0 1 9 Locality - West 0 0 0 0 0 0 1 1 Totals: 5 6 1 15 7 3 4 41

6.2.1 Corporate Risks overdue review Of the 41 risks, 9 are overdue review (the oldest with a next review date of January 2015) 6.2.2 Target dates for achieving acceptable level of risks Of the 41 risks, 8 have a target date for achieving an acceptable level of risk which have been exceeded (the oldest target date being January 2015) 6.2.3 Risks with a residual risk score of 12 which have not been escalated to Corporate

Risk Register Currently there are 16 risks which have a residual risk score of 12 and above which have not been escalated to CRR, 11 of these were reported more than 1 month ago.


The residual risk scores for these risks are as follows:-

Residual risk score

Number of risks

12 8 15 6 16 0 20 2

6.3 Risks overdue for review As at 5 March 2015, 136 risks were overdue review.

2014

01

2014

02

2014

03

2014

06

2014

09

2014

11

2014

12

2015

01

2015

02

2015

03

To

tal

Strategy and Transformation 0 0 0 0 0 0 0 0 1 0 1 Locality - Norwich 0 0 0 0 0 0 0 5 7 0 12 Locality - Children's 0 0 0 0 2 2 2 11 12 0 29 Medical Directorate 0 0 0 0 0 0 0 0 0 3 3 Locality - North 0 0 0 0 0 0 0 0 4 0 4 Nursing Quality and Operations 0 0 0 0 0 0 0 0 2 1 3 Performance and Information 0 0 0 0 0 0 0 18 2 0 20 Locality - South 0 0 0 0 0 0 0 0 4 0 4 Locality - Specialist 4 3 1 1 1 1 4 12 28 0 55 Locality - West 0 0 0 0 0 0 0 0 5 0 5 Totals: 4 3 1 1 3 3 6 46 65 4 136

6.4 Closed risks During February 2015, 90 risks were closed by the following Directorates / localities:- Strategy and Transformation 1Locality - Norwich 6Locality - Children's 11Estates, Facilities and Procurement 31Finance 4Locality - North 7Nursing Quality and Operations 1Locality - South 13Locality - Specialist 12Locality - West 4Totals: 90

Clostridium difficile – NCHC current status Month Clostridium

difficile MRSA bacteraemia

Unit Reason Appeal Failed / Learning

April 1 (non-trajectory) 0 Beech May 1 0 Ogden Court Doctor prescribed loperamide despite suspecting infectious diarrhoea June 0 0 July 2 0 Ogden Ct

Alder OC relapse of May case.Cleaning scores were suboptimal. Alder patient bay managed by students and clinical staff did not note bowel changes and there was a delay in sending specimen

August 1 0 NWCH Cleaning scores were suboptimal and staff did not send specimen in a timely way

September 1 0 Foxley Cleaning scores were suboptimal October 2 (both non-

trajectory) 0 PBL

PBL

November 1 0 NWCH Staff did not isolate when sending specimen and therefore suspecting infectious diarrhoea.

Caroline House 1 case from Caroline House has passed appeal. Caroline House Waiting outcome

December 3 (1 non-trajectory / outcome of other 2 still outstanding)

0

Pine Cottage Attributed to NCHC due to poor communication between medical and nursing staff. This led to the significance of altered bowel habit not being addressed in a timely way

January 0 0 February March YTD 6 + (possible) 2 0 Key learning / Action Plan:

Documentation is essential. We are still finding poorly documented bowel charts across the board with some key hot spots Medical knowledge is variable across our units. This has led to poorly informed prescription (eg. Loperamide) and the relevance of

Pseudo membranous colitis Cleaning – two cases were lost based on cleaning scores recorded. IPAC team have continued working closely with the Trust Estate

team to ensure that weekly monitoring of cleaning standards is maintained and all audit failures are rectified within contract performance thresholds. Where rectification is not achieved within performance times, this has been escalated and addressed through monthly service contract meetings to prevent recurrence.

Nursing staff must be more timely in both sending specimens and isolating. Ongoing training being delivered at ward level.

Appendix 2 Quality Assurance Assessment Reports: Detail on Recommendations Norwich Locality City 2 Community Nursing Team 3rd November 2014 The main recommendations are as follows:

To review the support and supervision of nursing practice to ensure safe effective care

To review communication for continuity of care within the team To clear out inappropriate and out of date stock, reorganise cupboards and allocate

responsibility to maintain stock To ensure clinic rooms met IPAC standards To review assessment practice at PDR To provide the team with a safeguarding update/ opportunity to consider and share

effective safeguarding in practice at a team development session Conduct record keeping audit and implement learning, ensure completion of the

details care and ensure staff access this for continuity of care Ensure that the hub screen referrals effectively to ensure SSD referrals are directed

appropriately and therefore efficient use of the trust’s staffing resource Provide staff with Waterlow refresher training/development to ensure consistency of

assessment Review systems to ensure staff have the appropriate equipment to deliver care for

each visit Audit dressings practice and observe practice as part of the competency assessment

at PDR Review ANTT policy standards at team meeting and audit practice Review IPAC policy re cleaning of laptops at team meeting and audit Ensure staff have access to new uniforms as required Review stock for equipment and remove products no longer in use (e.g. detergent

wipes) and replace with approved stock to ensure IPAC standards are met. Implement system for stock management to ensure information governance and appropriate product provision to patients

Agree responsibility for maintaining clinic rooms, remove blue tack on walls and replace curtain

Ensure IPAC standards are maintained and use a non-fabric tourniquet which is cleaned between patients or single use disposable tourniquets, and review standards at team meeting

Manage risks associated with low morale Implement work plan for team meetings and agreed alternate chair to ensure planned

meetings take place and include a review of the risk register Develop a SOP to formalise lone worker system and ensure safety Audit of clinical incidents to better understand the profile of clinical incidents in the

team for potential learning and action Ensure that team leader is routinely in the communication loop for staffing to enable

effective management of staffing cover and support to staff Set up a system to monitor mandatory training and monitor regularly and at

individuals PDR Evaluate clinical incidents and patient feedback to identify audit topics, develop and

audit plan, and ensure audit findings are feedback to the team at team meetings with clear action plan and learning


1

Amputee Rehabilitation Service, Pine Cottage 12.11.14 The main recommendations are as follows:

Review of security by the Trusts Health, Safety and Security Manager to consider security of patients and staff outside of office hours and at weekends

Review of the branding of the service to reflect the purpose and function of the service, rather than the name of the building and a review of signage

Review of patient information displayed in reception area and refresh paintwork in reception

Investigate provision of Wi-fi access for patients Review of security by the trusts Health, Safety and Security Manager Review HR processes to ensure safe staffing is maintained Review staffing risk assessment to ensure it describes all of the controls in current

use on the unit Set up database for monitoring and evidence of compliance for clinical mandatory

training There is an action plan in place to address the recommendations. City 3 Community Nursing team 28/10/15 Findings and recommendations:

Some staff said that they did not have torches to assess pressure areas. To ensure available to all staff

Staff reported that the teams are less inter grated with OT and PT than before, which made communication harder.

We observed good use of gloves, packs, aware of correct disposal of dressings, car clean, safe storage, hand sanitizer used at each patients and good awareness of when to use soap and water. However staff were observed to perform aseptic dressings on floor. Staff were observed not to clean laptop after visit and were not sure of protocol. IPAC to provide update training to team

Staff to have access to spillage kits and eye protection in their cars Replace INR bags which are visibly dirty and have holes in the bottom – consider

the use of the nurses red boxes that are not currently being used Ensure audit record on sharps boxes is completed to enable tracking and

learning from any issues Ensure sharps bins are taken to the designated collection point when full and not

stored in staff office The office was very unclean with food scattered on the floor, dirty cups on the

desks and dirty keyboards - Report poor standard of office cleaning via datix incident report on each occasion that the office is visibly unclean to enable estates to ensure G4S achieve the standards set in the cleaning contract and to prevent potential problems with vermin and report dirty office fans to maintenance for cleaning

Replace old ear irrigation equipment with new and ensure cleaning standards are maintained

Staff are up to date with most IPAC mandatory training however to ensure all staff have completed mandatory aseptic technique training within the last 12 months.

Sharps bins were stored in the office when full Staff were observed to clean laptops between visits with soap and water or wipes

in line with the trusts standards To conduct and audit of the trusts uniform and sharps standards There was no alcohol gel for staff to use on return to the office

2

HR prompt the team leader when registration is about to lapse. However it is not clear re. responsibility for monitoring re-registration is achieved

Outcome 12 Team leader to access recruitment and selection training There is not an up to date record of mandatory training for the team; this

means that the team leader cannot monitor compliance. To ensure mandatory training records are accessible to the team leader

Outcome 13 The team leader reports that staffing levels are adequate according to a

“demand profile” recently completed, however the team have increased demand as they are often asked to take on extra work and support other teams work, which compromises work on the ledger. Staffing levels to be reviewed to ensure they match demand

Staff felt that staffing levels were not adequate to meet the needs of patients Outcome 14

PAT test labels indicted that equipment PAT tests were up to date, however some equipment did not have PAT test labels attached

Consider security of staff relating to posting off-duty on the office wall and review the security of the french doors into the office.

Review the security of the office doors, there was confidential patient information on the table of the office and no key code lock on the doors into the office (the other community teams have key code office doors)

Staff reported that travel is frustrating; they are allocated 10 minutes travel for each visit and find that the way work is allocated they could be travelling to an area of the patch on more than one occasion in a day. Staff feel that this is not an efficient use of their time and would prefer to be responsible for an area. Staff reported that they used to be allocated to a patch and surgery and knew the patients within the patch, they felt that they were able to offer continuity of care. Staff reported they had a “sense of achievement at the end of the day” but that this was no longer the case

Staff reported that allocation of tasks does not always give staff enough time to carry out all the care needed; for example a visit for Deltaparin but the care plan showed other care booked (Waterlow) but not allowed therefore differed to the next day increasing the number of visits to the patient and reducing efficiency. It was reported that the hub have been made aware to check all the care plans needed for a patient when allocating.

We observed that staff are not looking back for the detail of patients previous care on SystmOne, this presents a clinical risk for continuity of care and also a risk to staff re lone working and lack of awareness of any record of warnings on the record

Outcome 16 The team should have a shared drive for storage of quality activity using the 16

relevant CQC standards, this should be accessible to all staff The team is to be involved in the monthly review of risks (which is currently

undertaken by the team leader) Complaints are mostly about lack of continuity of care and that care has become

task focused. Complaints have increased since transformation and are currently a focus for the team leaders time

The team do not currently have an audit plan; to evaluate complaints/incidents/risks/etc and identify audits which the team should conduct and develop a plan for the coming financial year

The health records audit conducted last year has not been feedback to the team and therefore no learning or action has been taken. To ensure the team audit in January as required and gain feedback for the 2014 and 2015 audits

3

The team leader reported that they conduct RCA’s for moderate and high risk incidents as per trust policy but do not record these with the incident on Datix. RCA’s to be recorded for all Moderate and high risk incidents and learning shared with the teams and at the locality governance meeting

Computer in team office was left without being locked and the office does not have a key code lock (unlike the other city teams offices) - review of office security and IT security

The team use a system of placing notes into a box folder on the desk in the middle of the office for paperwork that needs to go out with staff on their next visit – the box contained confidential information that was only stored securely at the end of the working day and the paperwork was very old, indicating the system is not being used successfully – to review to ensure IG and efficacy of care

Blood forms are kept out on the middle table – as the office is often not occupied during the day and the office does not have a key code lock this information is not being stored in line with the trusts IG standards


Norwich Locality: Community Occupational Therapy, Community Physiotherapy and Musculoskeletal Physiotherapy Services 18/11/14 The main recommendations are as follows:

NICE neurological standards to be implemented Review MCA policy and monitor implementation Review effectiveness of management of staff concerns regarding patient safety in the

therapy gym waiting area To ensure availability of chaperone if requested To review hub workers awareness of criteria for SSD v NHS OT involvement to

maximise capacity Consider offering patients discharge summary Review practice in relation to identification of dementia patients to ensure appropriate

support Ensure recently updated community therapy leaflet is available to staff and given to

patients on the first visit FFT leaflet to be given at discharge Conduct audit of privacy and dignity in MSK PT Reduce MSK waiting times by using staffing resource for Norwich locality only (i.e.

consider ceasing practice of providing staff to maintain response times in other localities and ensuring bank availability

Review methodology in the use of MYMOT outcome measures Consider implementation of caseloads for community therapists to give improved

continuity of care Clarify monitoring of re-registration to ensure evidence of compliance Assess and manage risks for MSK staff in relation to transformation and possible

future tendering. Define the scope of the operations manager role within therapy in the locality (i.e.

relationship with therapy staff in UCC, winter pressures beds and virtual ward) Re-instate therapy assistant roles (as agreed with AD) Operations Manager to attend Community OT and Community PT team meetings Community teams to implement CQC structured agendas, work plan and terms of

reference for their monthly team meetings FFT data to be produced for the community therapy teams separate from community

nursing and implement therapy specific actions and “you said, we did”. – the PE team advise that a code has been set up to facilitate this

4

Review SystmOne care plans regarding recording of care given in best interests Implement text facility to remind patients of appointments following SystmOne

optimisation. Ensure staff are fully aware of safety alerts are on the SystmOne home page Investigate incidents where staff have lost work on SystmOne and implement action Explore improvements to make care plans easier for staff to follow and reports of

staff having health problems do to use of SystmOne Ensure MSK patients records do not remain live on SystmOne once the patient has

finished treatment There is an action plan in place to address the recommendations. Specialist Neurological Rehabilitation Services (inpatient unit, out-patient clinics and outreach services) 26/11/14 The main recommendations are as follows:

Pressure care refresher training for staff Chain Oxygen cylinder to wall Improve fridge monitoring Replace drug trolley and keep BNF on drug trolley Review practice in relation to crushing of tablets and stock of liquid medication Review of drug round process Review medicines management training Audit against information governance standards Develop SOP for botulinum toxin Review of bank to ensure it meets the services needs and supports it’s staff Review of supervision with the unregistered nursing staff Connectivity on site to be reviewed by IT Set up planned risk meeting to facilitate monthly review of the services risk register Review roll out of risk refresher training to all disciplines leads and check that each

team are conducting a monthly review of risks at the team meetings for every discipline within the service

Review the all team meetings to ensure that they use a CQC outcomes structured agenda

Ensure that each team use action plans in datix to record action taken to reduce risks Ensure that RCA’s are conducted by all handlers of incidents (across the disciplines)

for incidents which are risk assessed as moderate or high Support the engagement of medical staff in reporting and managing incidents

There is an action plan in place to address the recommendations. Children’s Services: North Lynn Children’s Centres Recommendations Outcome 4 Sessions should be delivered in appropriate child focused environments. The Team should develop a business continuity plan. Ensure breastfeeding posters are visible in all clinics.

Outcome 7 Ensure that there are safeguarding adults posters on display with contact

details for the safeguarding lead at NCH&C. Outcomes 12,13,14 Ensure the local mandatory training spreadsheet is up to date. Monitor access to clinical supervision is as per trust policy. Continue to embed the early year’s social worker post within the team to

maximise outcomes.

5

Outcome 16 • The risk register should be discussed at every team meeting. • The team should develop an audit plan and track what audit the team

have done and what the learning was. • Patient experience results and outcomes should be shared with

parents including “you said we did” in clinics and via the newsletter. • Explore ways to revitalise the Parents Forum and parental

membership on the Advisory Board. • Review how informal complaints are recorded and learning shared

within the team. • Ensure all staff are carrying the Trusts complaints leaflets.

There is an action plan in place to address the recommendations. East City Health Visiting team 3/12/15 Recommendations Outcome 4 Consider how privacy and dignity can be maintained when weighing babies in the

weighing room at the East City Children’s Centre. Ensure all staff are adhering to the infection control policy regarding wrist watches and

stoned rings. Consider if the information governance risk of bulk person identifiable data help in paper

diaries should be articulated on the risk register. Outcome 7 continue to explore group safeguarding supervision for the Health Visitor Assistant. Outcome 12,13,14 Team leader to monitor the access to clinical supervision to ensure it is in accordance

with Trust policy. The team reported that communication with senior management was an issue. Staff

suggested the information should be discussed at a team meeting clearly identifying it on the agenda.

Outcome 16 Ensure Friends and Family feedback is given to members of the team and displayed in a

“you said we did” format at clinics. Consider other methods to increase patient experience feedback. Develop a log to capture locally resolved complaints for learning and evidence. Continue to build on developing the relationship with the East City Children’s Centre

including continued attendance at the Advisory Board, Children’s Centre family support workers attending monthly meetings and carrying out 2 year checks at the children’s centre.

Ensure that the risk register is discussed at every team meeting and consider whether not meeting some KPIs should be identified on the risk register.

Capture audit activity on a log for learning and evidence. There is an action plan in place to address the recommendations. Thetford Children’s Centre 25/11/14 Recommendations Outcome 4 Spot checks to ensure staff are not wearing wrist watches and stoned rings. Record informal complaints for learning and future evidence. Develop a business continuity plan. Outcome 12,13,14

6

7

There have been issues in the team and they have had support from an expert in team building to address team dynamics, improve communication and staff satisfaction. This is monitored and discussed continually.

The Team Lead needs to ensure they are monitoring clinical supervision as per Trust policy.

Outcome 16 Encourage incident reporting in the team. Capture audits on a spreadsheet recording and sharing learning. Implement the plans for the “You said we did” patient feedback at both of the Children’s

Centres. Revise the parent’s forum. The team should consider using the Trusts quality agenda to ensure that quality items

are regularly discussed at team meetings including risk, incidents, patient experience and audit.


3. clostridium difficile – nch&c current status 2. … · 40 of these relate to pressure...

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