agenda item no: 4.2 date of meeting: 30 january 2014 · 1/30/2014 · outside of hertfordshire,...

Agenda Item No: 4.2

Date of Meeting: 30 January 2014

Paper Title: ENHCCG Performance and Quality Report January 2014

Decision Discussion Information Follow up from last meeting

Report author: Gerry Moir, Assistant Director Performance

James Gleed, Associate Director Quality and Patient Safety Report signed off by: Alan Pond, Director of Finance

John Webster, Director of Commissioning Sheilagh Reavey, Director of Nursing and Quality

Purpose of the paper: To update the Board

Conflicts of Interest involved:

None to note

Recommendations to the Board

The Governing Body is asked to note the current performance and actions described in the paper.

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East and North Hertfordshire CCG Performance and Quality Report

EXECUTIVE SUMMARY

1. Introduction This Performance and Quality report provides an update on the performance of local NHS Trusts in relation to key national performance indicators. It includes quality and performance information from an ENHCCG commissioner view perspective and also from a provider perspective. Published information for November 2013 has been used.

2. Acronyms used in the Report ENHCCG East and North Hertfordshire Clinical Commissioning Group ENHT East and North Herts NHS Trust PAH Princess Alexandra Hospital NHS Trust BCF Barnet and Chase Farm Hospitals NHS Trust HPFT Hertfordshire Partnerships Foundation NHS Trust EEAST East of England Ambulance Service NHS Trust HCT Hertfordshire Community NHS Trust HVCCG Herts Valley Clinical Commissioning Group A&E Accident and Emergency RTT Referral to Treatment QP Quality Premium MRSA Methicillin-resistant Staphylococcus Aureus IAPT Increased Access to Psychological Therapies SI Serious Incident FFT Friends & Family Test TCI To Come In IPC Infection, prevention and control 3. Key Concerns

The key concerns for ENHCCG in relation to performance & quality are as follows:

• Barnet and Chase Farm There are significant issues at BCF particularly in relation to Referral to Treatment times and the number of patients breaching 18 weeks and also 52 weeks. The pace of obtaining dates for these patients to have their procedure either internally or through outsourcing has been very slow and as a consequence the CCG has opted to deal with these patients directly. There are 211 ENHCCG patients who have waited over 18 weeks. An initial cohort of those waiting in excess of 44 weeks has been sent to GP practices for validation. Patients have been contacted to assess whether they still require the procedure and whether they wish to remain on the list for Chase Farm or whether they wish to have their procedure with an alternative provider. The majority of these patients have now been contacted and of the 21, 11 wish to remain on the list for Chase Farm. The remaining patients have either had their procedure, no longer require it and one has asked to be sourced an alternative provider. The CCG is liaising directly with BCF with the outcome of this exercise and will ensure that TCI dates are obtained for those patients still requiring a procedure. The second cohort of patients to include those patients waiting 18-44 weeks has been split by GP practice has been sent to individual GP practices to undergo a similar exercise. It is hoped that these patients can be fully validated by the end of this month, and TCI dates obtained for those still requiring a procedure.

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• Quality Premium The CCG has the potential to earn £5 per registered population which equates to around £2.8m and is then subject to a number of key requirements being met. With confirmation of another MRSA in December, the CCG has now had 3 cases of MRSA assigned to it which means that it will lose 12.5%, worth around £350k. This reduces the amount to £2.45m. This figure is subject to a number of performance metrics being met. Current performance to date for the 8 minute response times by EEAST to Red 1/Red 2 category A calls is 72.26% as at the end of December which is well below the required target of 75%, and the winter months pose more pressures to meeting required response times. As a consequence it is likely that the quality premium due will be reduced by 25% bringing the total due to £1.84m.

4. Commissioner View – Performance against key national indicators and local targets This section highlights the performance from a commissioner perspective for all ENHCCG patients,

irrespective of where they receive their care. In the main this will be local acute trusts, but will also include non-local providers such as London trusts.

Stroke performance remains an area of concern with both ENHT and PAH failing to meet key

metrics and this is detailed in the provider summaries. Specific stroke performance meetings are in place with both ENHT and PAH.

ENHCCG is over trajectory for cases of C.difficile and based on year-to-date performance is

predicted to be significantly so at year end. The CCG Head of Infection Control continues to lead a county wide task and finish group that was convened for the purpose of reducing rates of C diff in Hertfordshire. The group has consistently good attendance from all local providers (including those outside of Hertfordshire, which treat Hertfordshire patients – BCF and PAH), Medicines Management and Public Health, recently links have also been established with primary care and the GP representative has been included in the membership. ENHCCG will monitor performance closely in this area and focuses on IPC issues during assurance visits

5. Provider View – Performance against key national indicators and local targets

ENHHT ENHT has seen a decline in relation to performance of key stroke metrics. Performance continues to be monitored and challenged by the CCG at monthly stroke performance meetings and the Trust is currently reviewing its action plan in light of the under-performance issues. RTT total performance targets are being met although there remain some issues in relation to admitted T&O patients as a consequence of residual Clinicenta issues, although the Trust expect to be back on track by January. All of the cancer targets were met for October and the Trust continues to meet the required targets for A&E 4 hour waits and diagnostic 6 week waits. The Trust has breached its MRSA ceiling with 2 cases to date and is close to breaching the ceiling for C.difficile. It is actively participating in HCAI task force meetings. There has been no new SHMI data released since the last report to the Governing Body. The trust has responded to the CQC regarding the alert for bronchitis and also to the supplementary questions raised. The ENCCG/ENHT hospital mortality review group meets every 2 months and focuses on 9 agreed pathways; the lead clinicians for the relevant services are now also requested to attend. The December mortality group meeting received a presentation from the lead clinicians in respiratory medicine and has proposed that this is the focus both of on-going work within the trust and a CQUIN for 2014-15. The CCG participated in the Trust Development Authority review of mortality at the trust which was generally positive.

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PAH There are concerns around the key areas of stroke performance. A performance improvement plan remains in place but as performance is not improving, discussions are taking place with West Essex CCG as host commissioner to determine the best course of action to take to ensure performance is improved. All but 2 of the cancer targets were met for October although all targets have been met for November. All overall RTT targets were met for November with some issues in T&O and urology and further assurance is being sought from West Essex CCG in addressing this issue against the action plan submitted by the Trust. The ceiling for C.difficile has been breached with a further 2 cases reported in December. Performance against key workforce indicators remains above set thresholds. The trust’s Director of Nursing is conducting an in depth workforce/skill mix review and will share the results once completed. In November 2013 the trust introduced the 'Safer Nursing Care audit Tool' and will audit again using this tool in February. Additional nurses and midwives from the trust's recent overseas recruitment campaign are due to start in post in January.

BCF There are many significant concerns at BCF around the Trust’s continued failure to meet key targets around RTT waits which has already been detailed. The trust is also continuing to fail to meet A&E 4 hour waits although there was an increase in performance for November. In addition the Trust has not reported on UNIFY for November and December due to a technical IT issue which is in the process of being addressed. The trust’s C-section rate increased to 33.6% in November, although BCF is confident that the Barnet, Enfield and Haringey Strategy will have a positive impact, however, advises that the impact will not be immediate. The trust is doing a deep dive to better understand the reasons behind the increase and will share this in January. The trust received a CQC visit to their maternity services at the end of last year and the final report is awaited. EEAST Urgent response times and handover times remain an area of concern and the CCG will be convening a joint meeting with EEAST and ENHT to address some of these issues, particularly given the winter pressures. It is not currently possible to get CCG specific quality data, however the CCG is actively engaging in Quality reviews with EEAST. HPFT

IAPT remains an area of concern with the trust failing to meet required targets for those receiving psychological therapies and required percentage starting treatment. Training has started to increase capacity but the benefits are unlikely to be seen until the January figures. There have previously been a number of safeguarding issues which the Trust has been addressing, two recent CQC inspections of units found the Trust to be compliant including Elizabeth Court

HCT Data quality, responsiveness, sickness absence and staff turnover remain ongoing areas of concern

to ENHCCG, and a workforce deep dive is scheduled for the March contract quality review meeting and a requirement for detailed ward/team level workforce data is being specified in the 2014-2015 contract. A CQUIN regarding workforce is also being included in next year’s contract to support trust improvement in this area.

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HUC HUC have been meeting all agreed NQR requirements, however a slight reduction in performance below target was seen during December against NQR 9 (telephone clinical assessment time). This reduction in performance was due to increased call volumes which were compounded by a number issues including short notice sickness, a flood affecting telephony services and inclement weather. Winter contingency measures are in place and were deployed accordingly by HUC. As part of the programme of Quality Assurance Visits to HUC bases, unannounced visits were undertaken in September 2013 to the Lister base and more recently in January 2014 to the Hemel Hempstead base, the later visit was led by HVCCG and has yet to be reported on. Both visits were generally positive in terms of patient experience, a small number of areas for improvement were identified which are being follow-up with HUC and monitored through the QRMs. The CCG has appointed a Quality Lead who in conjunction with the Clinical Lead is working closely with HUC to develop the detail and quality of future reporting.

. NHS111 Performance continues to be monitored daily and actions are taken to ensure compliance with standards. From April 2014 the performance/activity element of the contract management process will be separated from the quality monitoring requirements for the 111 & OOHs service, in order to bring the contract management of HUC into line with the standard contract management framework that ENHCCG has established for its other providers. As the Contract finishes at the end of September 2015, a programme will shortly be set up to look at the procurement process for the OOHs & 111 service. This will need to commence in April 2014 in order to achieve the timeframe of the procurement process.

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CONTENTS

ENHCCG PATIENT SUMMARY

PROVIDER VIEWEast and North Herts NHS TrustPrincess Alexandra NHS TrustBarnet and Chase Farm NHS TrustTrust ComparisonHertfordshire Partnerships University NHS Foundation TrustHertfordshire Community TrustEast of England Ambulance Service NHS TrustHerts Urgent Care - out of HoursNHS111

KeyPerformance better than from previous monthPerformance worse than previous monthNo change in performance from previous month

QUALITY PREMIUM

East and North Herts CCG Performance and Quality Report

January 2014

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ENHCCG SUMMARY

Domain Measure DetailTarget/Threshold Apr May Jun Jul Aug Sep Oct Nov Movement Trend Comments

People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital 90% 51.40% 74.30% 71.43% 47.37% 68.18% 71.43% 72.00% 56.30%

Proportion of people who have had a stroke who spend at least 90% of their time in hospital on a stroke unit 80% 75.00% 76.30% 83.78% 58.14% 68.89% 88.89% 75.50% 74.40%

Proportion of people at high risk of stroke who experience a TIA are assessed and treated within 24 hours 60% 80.00% 80.00% 66.67% 65.71% 42.86% 76.47% 75.00% 76.00%

Non haemorrhagic strokes receive thrombolysis within 3 hours of onset 12% 6.50% 8.80% 14.71% 5.13% 4.55% 18.75% 9.50% 10.00%

Patients with low risk TIA have access to MRI or carotid scan within 7 days 65% 45.50% 59.50% 56.25% 61.90% 66.67% 60.00% 59.20% 55.70%

C.difficle 10 9 13 15 6 4 11 9

MRSA 1 0 0 1 0 0 0 0A further case of MRSA has been reported for December bringing the total YTD figure to 3.

Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP

93% 97.10% 97.30% 96.40% 97.40% 96.20% 95.10% 96.50%

Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected)

93% 94.40% 96.30% 96.20% 97.70% 94.70% 95.90% 96.20%

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers

96% 97.80% 99.50% 98.30% 96.60% 99.40% 98.40% 98.00%

Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% 97.50% 100.00% 100.00% 95.90% 97.70% 95.70% 100.00%

Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regime

98% 100.00% 100.00% 100.00% 100.00% 97.90% 98.50% 100.00%

Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy

94% 97.10% 100.00% 97.70% 98.60% 100.00% 100.00% 95.00%

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer

85% 92.20% 85.70% 88.30% 84.90% 89.20% 91.00% 85.90%

Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers

90% 90.90% 95.20% 93.80% 100.00% 100.00% 75.00% 86.70%

Maximum 62-day wait for first definitive treatment following a consultant's decision to upgrade the priority of the patient (all cancers) 85% 90.50% 100.00% 92.90% 91.70% 100.00% 100.00% 100.00%

RTT - admitted patients to start treatment within a maximum of 18 weeks from referral - ALL

90% 84.29% 88.69% 88.83% 90.84% 90.90% 92.30% 91.20% 91.50%

RTT - Non-admitted patients to start treatment within a maximum of 18 weeks from referral - ALL

95% 96.64% 97.07% 97.16% 96.64% 97.70% 97.30% 96.90% 96.40%

Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral

92% 94.89% 95.26% 95.63% 94.98% 95.50% 94.80% 95.90% 95.50%

Total numbers waiting at the end of the month on an incomplete RTT pathway 24,831 25,118 25,445 20,904 28,162 28,966 26,569 26,598

Number of 52 week breaches 1 0 2 11 13 16 3 0This figure is in the process of being validated for ENHCCG patients waiting in excess of 52 weeks at BCF

Diagnostic test waiting times Patients waiting for a diagnosis test should have been waiting less than 6 weeks from referral

99% 99.01% 99.62% 99.78% 99.65% 99.36% 99.53% 99.40% 99.83%

A&E/Ambulance Handover All handovers between ambulance and A&E must take place within 15 minutes 100% n/a n/a n/a n/a n/a n/a n/a n/a

A&E WaitsPROXY INFO CCG (based on UNIFY data)

Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department

95% 93.57% 95.48% 96.10% 96.15% 95.76% 94.68% 95.53% 95.94%

Referral to Treatment Times

NH

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Cancer waits - 31 days

Cancer waits - 2 week wait

There continues to be stroke performance issues in both ENHT and PAH and these are being addressed through monthly stroke meetings for ENHT and discussions with West Essex CCG for PAH.

Stroke

Incidence of healthcare associated infection

3

5

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EAST AND NORTH HERTS HOSPITALS TRUST

Domain Measure DetailTarget/

Threshold Apr May Jun Jul Aug Sep Oct Nov Movement Trend Comments

Overall SHMI (emergency and elective)100 (national

average) 111.4 113.9 119.9

SHMI- Stroke 100 118.6 128.0 131.1SHMI- COPD 100 104.9 102.4 125.2SHMI- MI 100 135.6 129.6 136.3SHMI- #NOF 100 125.0 123.2 123.0SHMI- Pneumonia 100 122.8 121.2 111.9SHMI- CHF 100 117.3 119.2 110.9SHMI- Renal 100 117.7 107.1 102.2SHMI- Diabetes 100 139.5 114.3 119.2People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital 90% 51.30% 77.40% 75.00% 57.58% 75.00% 73.50% 69.40% 55.60%

Proportion of people who have had a stroke who spend at least 90% of their time in hospital on a stroke unit

Local contractual requirement 90% 73.20% 73.80% 81.80% 64.86% 71.40% 67.60% 82.20% 73.20%

Proportion of people at high risk of stroke who experience a TIA are assessed and treated within 24 hours 60% 61.90% 81.00% 78.90% 70.59% 45.00% 87.50% 66.70% 68.20%



4 Complaints Number of new complaints received For information 80 64 58 62 70 56 46 53Inpatient Friends and Family score For information 72 71 76 79 82 74 77 73A&E Friends and Family Score For information 73 70 72 66 60 47 67 71

4 Mixed Sex Accommodation (MSA) Number of clinically unjustified MSA breaches 0 0 0 0 0 0 0 0 0Number of SIs declared (excluding pressure ulcers) For information 5 7 2 8 0 5 1 2Never Events 0 0 0 0 1 0 0 0 0 See appendix 1 for update on 'Wrong Site Surgery' Never Event

5 VTE VTE Risk Assessment 98% 97.88% 97.50% 96.10% 97.93% 97.41% 98.18% 98.84% 99.27%

Number of Hospital Acquired Pressure Ulcers (Grades 3 and 4) 2 3 4 9 2 4 4 5

Number of pressure ulcers determined to be 'avoidable' 2 1 2 3 0 2 1 0Number of patients diagnosed with C-diff >48 hours post admission Annual ceiling 14 1 2 4 1 2 1 1 1

Number of patients diagnosed with MRSA >48 hours post admission

0 1 0 0 0 0 0 0 0

Percentage Caesarean Section rate (total)26% 27.00% 24.00% 24.00% 20.00% 27.00% 28.00% 26.00% 29.00%

The trust advises a high proportion of these are the women’s choice and each one is approved by two consultants. The trust are auditing practice against their protocol and will share the results of the audit once completed.

Percentage of planned Caesarean Section For information 11% 8% 13% 8% 12% 11% 11% 12%Percentage of unplanned Caesarean Section For information 16% 16% 11% 12% 15% 17% 15% 17%

All CQUIN scheme achievement Percentage of CQUIN scheme paid per quarter as a proportion of total money available

Not available

Percentage sickness absence rate 3.50% 3.44% 3.43% 3.44% 3.46% 3.46% 3.44% 3.40% 3.33%Percentage staff turnover rate 10% 10.29% 10.31% 10.29% 10.07% 10.09% 10.02% 10.00% 10.06%


93% 98.40% 98.10% 97.30% 98.30% 97.70% 96.50% 97.50%


93% 97.10% 99.20% 95.90% 96.50% 96.10% 95.00% 96.80%

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96% 96.80% 97.50% 98.30% 97.70% 99.50% 98.90% 96.10%


Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regime 98% 98.40% 98.50% 100.00% 100.00% 98.10% 98.40% 98.50%

Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy 94% 100.00% 98.30% 98.40% 99.50% 100.00% 98.50% 97.90%

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 85.70% 86.50% 85.10% 85.80% 85.80% 86.50% 85.40%

Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers

90% 100.00% 91.70% 94.10% 88.90% 100.00% 71.70% 100.00%

Maximum 62-day wait for first definitive treatment following a consultant's decision to upgrade the priority of the patient (all cancers)

85% 100.00% 81.80% 95.50% Trust not currently reporting on this metric. Request from CCG that this is included within performance reporting with data expected for December

RTT - admitted patients to start treatment within a maximum of 18 weeks from referral - ALL

90% 90.19% 93.85% 90.97% 93.99% 95.30% 90.70% 90.30% 90.20% Trust meeting target overall but failing in T&O in November although are expected to meet thresholds in January. It is likely that there are residual issues from the transfer of Clinicenta patients.

RTT - Non-admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 95% 96.53% 96.69% 96.94% 96.40% 97.50% 96.60% 96.70% 96.20%


92% 95.21% 95.73% 95.94% 96.00% 96.10% 95.80% 95.50% 95.30%


Number of 52 week breaches0 0 0 0 0 0 2 1 1

The breach for November is in relation to a T&O patient who has now been treated.

The trust is reviewing its action plan in light of the fact that previoulsy proposed trajectories by the trust have not been met. Monthly performance review meetings have been taking place although the trust has cancelled the latest meeting as a consequence of clinical pressures. The next meeting will be in early February and will continue until at least August subject to any significant improvements in performance. Initial figures for December show some inprovement.

See below

With a zero tolerance, the trust has exceeded its MRSA ceiling and is close to breaching the ceiling for C Difficile. The trust reported an additional MRSA bacteraemia in January 2014 bringing the total to 2 ytd. The trust continue to effectively participate in the Herts C.diff task force.The Trust has had 1 internal and 2 external audits in the last two years, which have looked at C-diff. The NHSTDA recently reviewed procesess, policies, laboratories, testing and equipment and the findings were positive.

1

Patient Survey4

3

Mortality- SHMIStandardised at National mean (100%).

Computed in respect of actual death rates (per condition) of patients dying in hospital and 30 days after discharge. This is reported against expected death rates (for the same condition) adjusted for local population demographics.

All data from National Website published April 13. All mortality data has long lags in its reporting.

Workforce

Maternity Services

Serious Incidents (SI)

Healthcare Acquired Infections (HCAI)

Stroke

5

Pressure Ulcers5

5


All

5




NH

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EAST AND NORTH HERTS HOSPITALS TRUST



Diagnostic test waiting timesPatients waiting for a diagnosis test should have been waiting less than 6 weeks from referral 99% 99.03% 99.85% 100.00% 99.79% 99.45% 99.65% 99.42% 99.61%

A&E/Ambulance Handover All handovers between ambulance and A&E must take place within 15 minutes

100% 50.10% 51.10% 52.50% 53.90% 60.50% 55.20% 54.00% 56.90% In order to improve performance in this area, a meeting is being convened to include EEAST and ENHT to jointly agree a plan to address the issues causing underperformance.

A&E Waits (Source UNIFY2)Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department 95% 94.01% 95.77% 96.57% 97.38% 96.45% 95.60% 97.30% 96.00%

Mortality rates There has been no new SHMI data released since the last report to the Governing Body. The trust has responded to the CQC regarding the alert for bronchitis and also to the supplementary questions raised. The December mortality group meeting received a presentation from the lead clinicians in respiratory medicine and has proposed that this is the focus both of on-going work within the trust and a CQUIN for 2014-15. The CCG is preparing for next month’s meeting which will focus on a recent trust audit of patients who are unexpectedly admitted to ITU, and on septicaemia.

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PRINCESS ALEXANDRA HOSPITAL NHS TRUST



Overall SHMI (emergency and elective) 100 (national average) 106.2 105.0 102.3

SHMI- Stroke 100 121.1 118.7 112.0SHMI- COPD 100 86.4 113.3 101.1SHMI- MI 100 103.3 105.7 107.6SHMI- #NOF 100 87.7 100.2 100.1SHMI- Pneumonia 100 108.8 103.0 98.2SHMI- CHF 100 110.3 110.7 117.4SHMI- Renal 100 113.1 94.9 98.3SHMI- Diabetes 100 120.5 115.0 143.4

People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital 90% 68.80% 65.00% 52.90% 68.80% 91.70% 90.90% 86.70% 76.90%


Proportion of people at high risk of stroke who experience a TIA are assessed and treated within 24 hours

70% 20.00% 40.00% 46.20% 20.00% 66.70% 50.00% 100.00% 62.50%



4 Complaints Number of new complaints received For information 33 26 15 25 24 31 33 36Inpatient Friends and Family score For information 85 75 82 69 81 81 81 90A&E Friends and Family Score For information 72 72 80 86 85 89 77 73

4 Mixed Sex Accommodation (MSA) Number of clinically unjustified MSA breaches 0 0 0 0 0 0 0 0 0

Number of SIs declared (excluding pressure ulcers) For information 4 8 10 20 17 7 10 13

h 0 0 1 0 0 0 0 0 05 VTE VTE Risk Assessment 97% 95.92% 96.11% 96.30% 96.28% 96.21% 98.10% 98.42% n/a

Number of Hospital Acquired Pressure Ulcers (Grades 3 and 4) <5 per quarter 12 24 15 11 13 2 5 7

All of the 7 pressure ulcers in November were deemed unavoidable following presentation at the trust's essential care scrutiny panel. The trust's 'Challenge Zero' - a strategy for eliminating avoidable pressure ulcers continues.

Number of pressure ulcers determined to be 'avoidable' 3 4 2 5 3 5 0 0

Number of patients diagnosed with C-diff >48 hours post admission Annual ceiling 9 3 1 3 3 2 1 1 0 The C Difficile ceiling has been breached with a further 2 cases reported in

December. The trust are participating in the Herts C.diff task force.Number of patients diagnosed with MRSA >48 hours post admission 0 0 0 0 0 0 0 0 0

Percentage Caesarean Section rate (total)25% from 1 April to 30 Sep. From 1 Oct

it is 24%25.00% 24.10% 25.30% 26.30% 25.70% 24.40% 32.00% 22.20%

Percentage of planned Caesarean Section 10% 12.30% 10.90% 9.10% 10.60% 11.90% 9.80% 12.20% 8.10%Percentage of unplanned Caesarean Section 14% 12.90% 13.20% 16.20% 15.70% 13.60% 16.00% 18.50% 13.40%

All CQUIN scheme achievement Percentage of CQUIN scheme paid per quarter as a proportion of total money available

Percentage sickness absence rate <3% 4.54% 4.46% n/a 4.35% 3.36% n/a 4.20%

Percentage staff turnover rate <12% 12.60% 12.60% n/a n/a 13.20% 13.00% 13.00%


93% 95.30% 95.60% 94.10% 93.10% 93.70% 93.70% 93.60%


93% 91.50% 94.40% 95.40% 95.00% 94.90% 93.00% 96.30%

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96% 98.40% 100.00% 100.00% 98.60% 99.00% 98.90% 97.60%


This relates to an increase in the numbers of patients on the tracking list in dermatology for the month of September which has had an effect on capacity for the service. This target was achieved for November.

5 Pressure Ulcers

5 Healthcare Acquired Infections (HCAI)

5 Maternity Services

All Workforce

The trust Director of Nursing is conducting an in depth workforce/skill mix review and will share the results once completed. In November 2013 the trust introduced the 'Safer Nursing Care audit Tool' and will audit again in February. Additional nurses and midwives from the trust's recent overseas recruitment campaign are due to start in post in January.



A performance improvement plan remains in place. However, performance has not improved. A discussion is taking place with West Essex to determine the best course of action to bring about improvements.

4 Patient Survey

5 Serious Incidents (SI)

1




(data qublished quarterly)

(data published quarterly)

3 Stroke

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PRINCESS ALEXANDRA HOSPITAL NHS TRUST




Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy 94% n/a n/a n/a n/a n/a n/a 100.00%

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 87.03% 78.80% 90.30% 85.60% 89.30% 78.20% 87.20%

Maximum 62-day wait from referral from an NHS scseening service to first definitive treatment for all cancers

90% 90.90% 100.00% 100.00% 84.60% 100.00% 100.00% 87.50% This related to one West Essex patient on a breast pathway who chose to wait until day 64 for treatment - patient choice. Achieved 100% for November


85% 91.80% 98.00% 93.90% 96.50% 96.10% 95.50% 95.10%

RTT - admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 90% 93.20% 93.80% 95.10% 93.60% 91.00% 92.10% 89.30% 90.40% Trust exceed total target but failed for T&O, urology and opthalmology. Action plan is

in place but further assurance being sought from West Essex CCG

RTT - Non-admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 95% 98.15% 98.45% 98.26% 97.90% 98.20% 98.00% 97.50% 96.90%

Trust exceeded total target but failed for urology and T&O


92% 97.56% 97.89% 97.75% 97.60% 97.20% 96.80% 97.20% 97.50%


Number of 52 week breaches 0 0 2 0 0 1 2 2One patient is an ENHCCG patient and we are awaiting confirmation of outcome of a follow-up appointment in January. Weekly conference calls continue with West Essex, ENHCCG and PAH and this will now have regular representation from ENHCCG.

Diagnostic test waiting times Patients waiting for a diagnosis test should have been waiting less than 6 weeks from referral 99% 99.44% 99.65% 99.69% 99.66% 99.60% 99.60% 99.40% 99.60% Trust met overall target but failed to meet standard for colonoscopy, gastroscopy, flexi-

sigmoidoscopy and DEXA due to increased demand and revised criteria

A&E/Ambulance Handover All handovers between ambulance and A&E must take place within 15 minutes 100% 55.00% 56.00% 62.00% 55.00% 58.00% 60.00% 56.60% 48.50%

There is currently no tripartite in place between EEAST and PAH and PAH are unwilling to accpet the data from EEAST. A briefing paper is currently with West Essex CCG Executive for consideration around financial penalties. A Hospital Liaison Officer employed by EEAST is now based in the A&E to facilitate quicker turnaround times.

A&E Waits (Source UNIFY2) Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department 95% 94.30% 96.60% 97.50% 95.00% 96.90% 94.50% 95.05% 95.17%

External maternity review: the report has now been reviewed by ENHCCG and a conference call is being arranged to discuss the findings with West Essex CCG.

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Overall SHMI (emergency and elective) 100 (national average) 85.3 84.8 85.8

SHMI- Stroke 100 80.5 77.1 83.1SHMI- COPD 100 80.0 87.5 89.4SHMI- MI 100 78.4 73.9 68.0SHMI- #NOF 100 86.7 78.8 78.8SHMI- Pneumonia 100 78.0 82.8 84.5SHMI- CHF 100 77.8 75.1 81.6SHMI- Renal 100 72.8 72.6 77.3SHMI- Diabetes 100 105.8 90.7 45.2People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital 90% 68.00% 68.00% 89.00% 88.00% 94.00% 76.00% 86.00%


Proportion of people at high risk of stroke who experience a TIA are assessed and treated within 24 hours 60% n/a n/a n/a n/a 86.00% 81.00% 86.00% 100.00%

Non haemorrhagic strokes receive thrombolysis within 3 hours of onset 12% n/a n/a n/a n/a n/a n/a n/a n/a n/aPatients with low risk TIA have access to MRI or carotid scan within 7 days 65% n/a n/a n/a n/a n/a 82.00% 77.00% 60.00%

4 Complaints Number of new complaints received For information 35 29 26 28 17 35 n/a n/aInpatient Friends and Family score For information 55 54 52 53 53 64 52 51

A&E Friends and Family Score For information 6 -2 -13 -17 42 28 34 35

4 Mixed Sex Accommodation (MSA) Number of clinically unjustified MSA breaches 0 18 19 7 18 22 31 29 21

4 of the 21 breaches in November involved ENHT patients. All breaches occurred in Recovery wards where patients were nursed overnight before admitting to a ward. The Trust believe that the BEH strategy is expected to have a positive impact as no elective site at CFH will reduce the impact on beds.

Number of SIs declared (excluding pressure ulcers) For information 5 7 n/a n/a n/a n/a n/a n/a n/aNever Events 0 0 1 0 0 0 0 0 0

5 VTE VTE Risk Assessment 90% 95.31% 95.39% 95.50% 95.53% 95.20% 94.14% 95.60% 93.32%

Number of Hospital Acquired Pressure Ulcers (Grades 3 and 4) 3 n/a n/a n/a n/a n/a n/a n/a n/a Serious Incident report is expected for quality review meeting in January and remains an area of concern due to lack of information

Number of pressure ulcers determined to be 'avoidable' n/a n/a n/a n/a n/a n/a n/a n/a n/a

Number of patients diagnosed with C-diff >48 hours post admission Annual ceiling 25 3 2 0 3 1 1 3 2

Number of patients diagnosed with MRSA >48 hours post admission 0 1 0 0 0 0 0 1 1

Percentage Caesarean Section rate (total) 26% 25.40% 34.70% 32.50% 31.70% 32.60% 28.20% 32.50% 33.60%

The trust is confident the Barnet, Enfield and Haringey Strategy will have a positive impact on their C-Section rate, however the impact will not be immediate. The trust is doing a deep dive and will share this in January

Percentage of planned Caesarean Section For information 18.90% 26.10% 21.00% 22.40% 24.60% 20.60% 12.79% 12.10%Percentage of unplanned Caesarean Section For information 6.50% 8.60% 11.50% 9.30% 8.00% 7.60% 19.70% 21.00%

All CQUIN scheme achievement Percentage of CQUIN scheme paid per quarter as a proportion of total money availablePercentage sickness absence rate 3.25% 2.90% 2.92% 2.86% 3.09% 2.89% 3.28% 2.98% 3.30%

Percentage staff turnover rate For information 13.00% 13.47% 13.85% 13.83% 14.56% 14.26% 14.05% 14.40%

Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP 93% 93.09% 93.01% 94.11% 91.98% 93.13% 93.62% 94.66%


93% 93.70% 93.50% 95.10% 90.72% 93.20% 94.74% 94.41%

FFT response rates and scores continue to improve in November for A&E

The trust is taking a number of steps in regards to improving workforce performance; progress is monitored and discussed at quality review meetings

The trust reported 2 additional case of C-Difficile in November, bringing the total to 15 ytd and one further case of MRSA bringing the total ytd to 3. The trust are participating in the Herts C.diff task and finish group.




All Workforce

4 Patient Survey


5 Pressure Ulcers

1




3 Stroke

(data published quarterly)

(data rublished quarterly)

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BARNET AND CHASE FARM HOSPITALS NHS TRUST


Threshold Apr May Jun Jul Aug Sep Oct Nov Movement Trend CommentsMaximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96% 100.00% 99.10% 98.10% 100.00% 98.26% 100.00% 98.44%



Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy 94% n/a n/a n/a n/a n/a n/a n/a n/aMaximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% 86.10% 85.00% 88.20% 88.24% 86.49% 89.92% 86.36%

Maximum 62-day wait from referral from an NHS scseening service to first definitive treatment for all cancers 90% 90.00% 100.00% 91.30% 100.00% 95.35% 100.00% 86.50%

The Trust had 2 breaches internally and 1 shared breach with another provider. Of the internal breaches, one was due to a patient being on a complex pathway requiring diagnostics and the other was due to patinet choice. The trust is on track to meet th etarget for November.


90% 100.00% 100.00% 94.20% 98.86% 94.94% 100.00% 97.20%

RTT - admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 90% 90.81% 93.17% 92.60% 90.95% 92.70% 97.80% n/a n/a

RTT - Non-admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 95% 97.90% 98.77% 98.90% 98.63% 99.40% 99.90% n/a n/a


92% 89.72% 90.16% 90.64% 87.72% 87.70% 85.80% n/a n/a

Total numbers waiting at the end of the month on an incomplete RTT pathway 20,049 20,748 19,872 19,562 23,489 24,392 n/a n/a

Number of 52 week breaches 0 1 0 0 178 13 13 n/a n/a

Diagnostic test waiting times Patients waiting for a diagnosis test should have been waiting less than 6 weeks from referral 99% 94.87% 96.77% 96.91% 97.73% 98.57% 99.70% 99.05% 99.43%

A&E/Ambulance Handover All handovers between ambulance and A&E must take place within 15 minutes 100% n/a n/a n/a n/a n/a n/a n/a n/a n/a

A&E Waits (Source UNIFY2) Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department 95% 90.32% 91.52% 89.90% 90.64% 89.11% 86.20% 86.80% 92.16%

There was a slight increase in performance for November but the Trust has still failed to meet the target of 95% although remains on trajectory within its recovery plan.

There are issues around the validity of this information given the size of the backlog of patients that have breached. This information is being reviewed retrospectively and will be fully validated prior to any further UNIFY submissions.

The Trust continues to validate the numbers involved and this remains an area of concern as it has not submitted to UNIFY for November. There continues to be large numbers of patients waiting in excess of 18 weeks and 52 weeks for procedures. The trust last reported position to UNIFY was in September where it submitted a post validated position of 178 patients breaching 52 weeks. As at 31 December this number is 181. ENHCCG is addressing the RTT issues specifically for its own patients through a thorough process of validation in conjunction with GP practices.In relation to the CQC recent maternity visit, a copy of the final report is awaited.

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NHS ACUTE TRUST COMPARISON


Threshold Month ENHHT PAH BCF

Overall SHMI (emergency and elective)100 (national

average) Oct 119.9 102.3 85.8

SHMI- Stroke 100 Oct 131.1 112.0 83.1SHMI- COPD 100 Oct 125.2 101.1 89.4SHMI- MI 100 Oct 136.3 107.6 68SHMI- #NOF 100 Oct 123.0 100.1 78.8SHMI- Pneumonia 100 Oct 111.9 98.2 84.5SHMI- CHF 100 Oct 110.9 117.4 81.6SHMI- Renal 100 Oct 102.2 98.3 77.3SHMI- Diabetes 100 Oct 119.2 143.4 45.2People who have had a stroke and are admitted to an acute stroke unit within four hours of arrival to hospital 90% Nov 55.60% 76.90%

Proportion of people who have had a stroke who spend at least 90% of their time in hospital on a stroke unit 80% Nov 73.20% 76.50% 95.0%

Proportion of people at high risk of stroke who experience a TIA are assessed and treated within 24 hours 60%

Nov 68.20% 62.50% 100.0%

Non haemorrhagic strokes receive thrombolysis within 3 hours of onset 12% Nov 13.20% 5.90% n/a

Patients with low risk TIA have access to MRI or carotid scan within 7 days 65% Nov 50.00% 100.00% 60.0%

4 Complaints Number of new complaints received For information Nov 53 36 n/aInpatient Friends and Family score For information Nov 73 90 51A&E Friends and Family Score For information Nov 71 73 35

4 Mixed Sex Accommodation (MSA) Number of clinically unjustified MSA breaches 0 Nov 0 0 21Number of SIs declared (excluding pressure ulcers) For information Nov 2 13 n/aNever Events 0 Nov 0 0 0

5 VTE VTE Risk Assessment E98% P97% B90% Nov 99.27% n/a 93.32%

Number of Hospital Acquired Pressure Ulcers (Grades 3 and 4) Nov 5 7 n/a

Number of pressure ulcers determined to be 'avoidable' 0 0 n/aNumber of patients diagnosed with C-diff >48 hours post admission Annual ceiling 25 Nov 1 0 2

Number of patients diagnosed with MRSA >48 hours post admission 0 Nov 0 0 1

Percentage Caesarean Section rate (total) 26% Nov 29.00% 22.20% 33.60%Percentage of planned Caesarean Section For information Nov 12% 8.10% 12.1%Percentage of unplanned Caesarean Section For information Nov 17% 13.40% 21.0%

All CQUIN scheme achievement Percentage of CQUIN scheme paid per quarter as a proportion of total money available Nov

Percentage sickness absence rateE3.5% P3%

B3.25% Nov 3.33% 3.30%

Percentage staff turnover rate For information Nov 10.06% 14.40%

Maximum two-week wait for first outpatient appointment for patients referred urgently with suspected cancer by a GP 93%

Oct 97.50% 93.60% 94.66%

Maximum two-week wait for first outpatient appointment for patients referred urgently with breast symptoms (where cancer was not initially suspected) 93%

Oct 96.80% 96.30% 94.41%

Maximum one month (31-day) wait from diagnosis to first definitive treatment for all cancers 96% Oct 96.10% 97.60% 98.44%

Maximum 31-day wait for subsequent treatment where that treatment is surgery 94% Oct 100.00% 90.90% 100.00%

Maximum 31-day wait for subsequent treatment where that treatment is an anti-cancer drug regime 98% Oct 98.50% 100.00% 100.00%

Maximum 31-day wait for subsequent treatment where that treatment is a course of radiotherapy 94% Oct 97.90% 100.00% n/a

Maximum two month (62-day) wait from urgent GP referral to first definitive treatment for cancer 85% Oct 85.40% 87.20% 86.36%

Maximum 62-day wait from referral from an NHS screening service to first definitive treatment for all cancers 90%

Oct 100.00% 87.50% 86.50%

Maximum 62-day wait for first definitive treatment following a consultant's decision to upgrade the priority of the patient (all cancers) 85%

Oct 95.50% 95.10% 97.20%

RTT - admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 90% Oct 90.20% 90.40% n/a

RTT - Non-admitted patients to start treatment within a maximum of 18 weeks from referral - ALL 95% Nov 96.20% 96.90% n/a

Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral 92%

Nov 95.30% 97.50% n/a

Total numbers waiting at the end of the month on an incomplete RTT pathway Nov 18,633 9,424 n/a

52 week breaches Nov 1 2 n/a

Diagnostic test waiting times Patients waiting for a diagnosis test should have been waiting less than 6 weeks from referral 99% Nov 99.61% 99.60% 99.43%

A&E/Ambulance Handover All handovers between ambulance and A&E must take place within 15 minutes 100% Nov 56.90% 48.50% n/a

A&E Waits Patients should be admitted, transferred or discharged within 4 hours of their arrival at an A&E department 95% Nov 96.00% 95.17% 92.16%

Mortality- SHMI

3 Stroke

4 Patient Survey

1




Pressure Ulcers5

All Workforce

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HERTFORDSHIRE PARTNERSHIPS UNIVERSITY NHS FOUNDATION TRUST



3Proportion of people with depression and/or anxiety disorders who received psychological therapies 6581 362 378 320 393 321 343 382 397 Trust estimate 4,258 by year end

3 % Prevalence Starting Treatment 10% 0.55% 0.57% 0.49% 0.60% 0.49% 0.52% 0.58% 0.60% Trust estimate 6.5% by year end. Training for extra capacity has started but benefits will not be seen until January.

3 The proportion of people who are moving to recovery 50% 58.0% 64.0% 59.0% 51.0% 50.0% 54.0% 57.0% 55.0%

4 Complaints Number of new complaints received For information 72 53 The trust are reporting a total of 52 complaints for Q2 which is the drop back down from the Q1 position.

4 Mixed Sex Accommodation (MSA) Number of clinically unjustified MSA breaches 0 0 0 0 0 0 0 0 0For information 2 1 4 n/a n/a n/a n/a 6

ENHCCG 0 0 1 n/a n/a n/a 0 3Never Events 0 0 0 0 0 0 0 0 0

5 Pressure Ulcers Incidence of newly acquired category 3 and 4 pressure ulcers 0 0 0 0 0 0 0 1 HVCCG Patient

5 Number of cases of MRSA occurring on the providers premises where onset of symptoms is 2 days following admission Zero 0 0 0 0 0 0 0 0

5 Number of cases of C Diff occurring on the providers premises where onset of symptoms is 2 days following admission <2 per quarter 0 0 0 0 0 0 0 0

All CQUIN scheme achievement Percentage of CQUIN scheme paid per quarter as a proportion of total money available 63.8% 76.7%

Percentage sictness absence rate <4% 4.10% 4.50%Percentage staff turnover rate For information 16% 11%

Number of SIs declared (excluding pressure ulcers)

Reported Quartlerly

Reported Quartlerly

IAPT

All Wortforce

Reported Quartlerly

Reported Quartlerly

Serious Incidents (SI)5

Healthcare Acquired Infections (HCAI)

Reported Quartlerly

Reported Quartlerly Reported Quarterly

See appendix 1

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HERTFORDSHIRE COMMUNITY NHS TRUST


Threshold Apr May Jun Jul Aug Sep Oct Nov Movement Trend Comments4 Complaints Number of new complaints received For information 23 19 9 20 9 12 6 14

4 Mixed Sex Accommodation (MSA) Number of clinically unjustified MSA breaches 0 0 0 0 0 0 0 0 0For information 9 3 7 n/a n/a n/a n/a n/a n/a

ENHCCG 3 1 2 3 2 5 9 9Never Events 0 0 0 0 0 0 0 0 0

5 VTE VTE Risk Assessment 100% 100% 99% 100% 100% 100% 100% 100% 100%

For information 19 17 10 11 10 18 n/a 8

ENHCCG 8 5 3 5 3 8 14 3

0 0 1 1 3 2 1 n/a n/a

ENHCCG 0 0 0 2 2 0 0 0

Number of patients diagnosed with C-diff >48 hours post admission Annual ceiling 14 4 0 1 1 1 1 1 2

There has been a further c-diff case reported for Decmber meaning that 12 cases have now been declared out of a ceiling of 14, the Trust are at risk of breaching this ceiling. The trust actively participate in the Hertfordshire c diff task and finish group.

Number of patients diagnosed with MRSA >48 hours post admission 0 0 0 0 0 0 0 0 0

all CQUIN scheme achievement Percentage of CQUIN scheme paid per quarter as a proportion of total money available 97%Percentage sickness absence rate > 4% 4.54% 4.53% 4.52% 4.52% 4.53% 4.53% 4.50% 4.45%

Percentage staff turnover rate > 12% 15.50% 16.40% 16.40% 17.00% 17.00% 17.40% 16.80% 18.60%


A workforce deep dive is due to take place at the March contract quality review meeting

Within HCT the pressure ulcer delivery plan is shared across all services, and performance in relation to pressure ulcers is discussed during business unit reviews. Visits to teams are undertaken, and learning is shared across the system.The pressure ulcer delivery plan continues to be monitored through the Quality Review Meetings.

Number of Acquired Pressure Ulcers (Grades 3 and 4)

Number of pressure ulcers determined to be 'avoidable'

Number of SIs declared (excluding pressure ulcers)

all Workforce

5 Pressure Ulcers

From October 2013, only ENCCG figures will be reported rather than county wide.


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EAST OF ENGLAND AMBULANCE SERVICE


95% 96.2% 94.8% 95.0% 95.3% 95.8% 96.1% 94.5%

West Sector 96.8% 94.7% 96.7% 95.7% 96.6% 96.8% 96.5%

56% 43.3% 58.8% 49.6% 52.8% 53.4% 51.4% 54.1%West Sector 37.8% 64.1% 56.6% 57.4% 53.8% 53.4% 52.3%

4 ComplaintsNumber of new complaints received

For information 85 62 80 61 56 54 86 47When compared to the previous year Q1 and Q2, Patient Transport Services complaints and concern numbers have increased from 76 to 178.

Number of SIs declared For information 2 1 2 2 2 2 8 3 Delays continue to be a theme across the region

Never Events 0 0 0 0 0 0 0 0 0

5 Incidents Number of incidents reported For information 500 439 427 n/a n/a n/a n/aPercentage sickness absence rate 5% 6.99% 6.25% 6.11% 6.10% 6.08% 6.02% 6.34% 6.24%Percentage rate of leavers

21.5% 20.6% 20.1% 19.0% 15.4% 27.4% 23.1% 25.0% 18.2%

West Sector n/a 14.1% 23.2% 18.2% 31.9% 14.6% 24.0% n/a

6.0% 7.5% 5.5% 5.9% 5.9% 8.0% 4.9% 1.9% 3.6%West Sector n/a 5.1% 9.1% 9.1% 8.0% 4.9% 3.4% n/a

Percentage of patients suffering a STEMI who are directly transferred to a centre capable of delivering PPCI (Primary Percutaneous Coronary Intervention) and receive angioplasty within 150 minutes of call

95.0% 80.40% 82.10% 96.20% 95.20% 75.68% 90.00% 93.88% n/a

80.0% 79.5% 82.2% 86.9% 82.9% 88.1% 88.1% 80.0% 86.4%West Sector n/a 81.0% 87.9% 79.6% 83.3% 86.9% 82.8%

Percentage of calls abandoned before answered 1.50% 0.53% 0.58% 0.75% 0.87% 0.91% 0.70% 0.00%Time to answer call (median) 3 seconds 1 1 1 1 1 2 0Telephone advice (hear and treat) 5% 7.21% 7.21% 7.53% 8.13% 7.83% n/a 0.00% n/aTotal station cleanliness 95% 97.21% n/a 98.10% n/a 95.80% n/a 0.00% n/aTotal vehicle cleanliness 95% 98.10% 95.00% 97.97% 97.83% 98.27% 97.30% 0.00%Hand hygiene cleanliness 95% n/a 88.30% 95.20%Uniform audit compliance 95% n/a 96.20% 96.20%Category A calls resulting in an emergency response arriving within 8 minutes (Red 1 Critical) 75% 75.77% 79.64% 72.32% 71.91% 74.52% 75.39% 74.30% 74.52%

Category A calls resulting in an emergency response arriving within 8 minutes (Red 2 serious) 75% 72.63% 74.15% 71.95% 69.83% 73.44% 70.24% 68.20% 68.47%

Category A calls resulting in an emergency response arriving within 8 minutes (Red 1/Red 2 serious) 75% 72.78% 74.48% 71.95% 69.94% 73.49% 70.48% 68.49% 68.75%

Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95% 93.87% 94.56% 93.71% 92.65% 93.78% 92.93% 92.60% 92.82%

Provider Level at Lister 100% 72.80% 48.80% 49.90% 53.50% 40.10% 54.90% 36.24% 59.80%

Provider Level at QEII 100% 73.10% 71.20% 59.70% 58.90% 49.40% 60.90% 50.37% 70.60%

Provider Level at PAH 100% 75.40% 62.10% 65.60% 59.60% 36.30% 63.40% 36.05% 55.20%A Hospital Liaison Officer is now based within the A&E department at PAH to facilitate timely turnaround times

Category A calls resulting in an emergency response arriving within 8 minutes (Red 1 Critical) 75% 70.00% 75.53% 67.71% 80.52% 74.36% 74.60% 73.79% 70.13%

Category A calls resulting in an emergency response arriving within 8 minutes (Red 2 serious) 75% 75.04% 77.14% 72.16% 70.49% 75.31% 72.52% 68.57% 72.31%

Category A calls resulting in an emergency response arriving within 8 minutes (Red 1/Red 2)

75% 74.81% 77.06% 71.91% 70.93% 75.26% 72.60% 68.85% 72.21%

The YTD cumulative position as at end of December is 72.26%. Given winter pressures this figure is unlikely to significantly improve and as a consequence, the CCG is likely to lose 25% of its potential Quality Premium payment.

Category A calls resulting in an ambulance arriving at the scene within 19 minutes 95% 97.19% 97.18% 96.94% 96.95% 96.30% 95.34% 95.34% 96.48%

The CCG has given additional funding to EEAST to alleviate winter pressures and some of this is currently being used to fund 4 private ambulance vehicles to increase capacity.

Provider Level

Perfo

rman

ce

Workforce

ENHCCG Patients

All handovers to clear must take place within 15 minutes. % cleared within 15 minutes.

Outcome from cardiac arrest measured by ROSC (Return of spontaneous circulation) at point of handover of the patient to hospitalCardiac arrest

Percentage of STEMI patients receiving appropriate care bundle

EEAST has employed a Hospital Liaison Officer at ENHT who started early in November to be based at Lister to address this issue. In addition a meeting is being convened by the CCG to facilitate discussions around handover times and responsibilities with both EEAST and ENHT.

Following EEAST previously writing out to HEI partners regarding accommodating pre-registration paramedics they are about to enter into a memorandum of understanding with 5 universities to host a BSc; EEAST wants to create Paramedics that will meet the needs of Keogh and be able to deliver more treatment in the community setting; this is part of EEAST's 'twin track' approach to resolving its workforce issues - pursuing both longer-term solutions and also adressing immediate needs. The CQC report from the recent visit is with the trust for factual accuracy checking. Quality data is not yet available at a CCG level which will be addressed under the new consortia arrangements.

All

Stroke3

4

Serious Incidents (SI)

Infection prevention and control

5

5

Call handling

1

STEMI (ST segment elevation myocardial infarction)

3

Percentage of patients who survive cardiac arrest to discharge from hospital

Percentage of suspected stroke patients who received appropriate care bundle

Percentage of FAST positive stroke patients who arrived at a hyper acute stroke centre within 60 minutes of call

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HERTS URGENT CARE


For informationOOH 3 7 1 2 4 4 10 7

NHS111 11 15 4 2 1 6 5 4Number of SIs declared For information n/a n/a 2 0 0 n/a 0 0Never Events 0 0 0 0 0 0 0 0 0Percentage of calls answered within 60 seconds 95% 89.00% 96.00% 98.00% 98.00% 99.00% 98.00% 97.00% 96.00%Total number of abandoned calls <5% 5.20% 4.70% 4.40% 3.21% 2.69% 2.63% 1.00% 1.40%Longest wait for call back (minutes) For information 0:43:24 1:00:05 0:35:42 0:12:58 0:34:57 0:44:50 0:34:49 01:11:03Average waiting time for call back (minutes) For information 0:11:09 0:07:35 0:06:32 0:06:42 0:04:14 0:06:28 0:05:11 00:07:39Urgent visits undertaken within 2 hours 95% 98.00% 96.00% 97.00% 97.00% 95.00% 99.00% 96.00% 98.00%Routine visits undertaken within 6 hours 95% 97.00% 97.00% 99.00% 96.00% 98.00% 99.00% 98.00% 98.50%Urgent consultations undertaken within 2 hours 95% 91.00% 97.00% 97.00% 98.00% 97.00% 96.00% 97.00% 97.00%

Routine consultations undertaken within 6 hours 95% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00% 100.00%

Urgent clinical assessment within 20 minutes of patient arriving 95% 57.00% 71.00% 100.00% 14.30% 66.70% 85.70% 50.00% 66.70%

The failure to meet the target involves a very small number of patients

Routine clinical assessment within 60 minutes of patient arriving 95% 75.00% 78.00% 79.00% 80.30% 74.50% 87.30% 83.70% 85.80%

Urgent calls: definitive clinical assessment commenced within 20 minutes 95% 97.00% 97.00% 98.00% 96.00% 98.00% 97.00% 97.00% 96.00%

Routine calls: definitive clinical assessment commenced within 60 minutes 95% 96.00% 96.00% 97.00% 95.00% 97.00% 98.00% 95.00% 96.00%

Ambulance dispatch as a percentage of total calls offered For information 5% 5% 5% 5% 4% 6% 6% 6%

Total number of non conveyed 999 dispatches For information 463 500 382 471 447 478 505 5485

5

5

5

Ambulance dispatch

Home visits

Telephone clinical assessment

Base face to face walk in clinical assessment5

Base face to face consultations following definitive clinical assessment

4 Complaints Number of new complaints received

Call Handling4


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NHS 111

Domain Measure Detail Target/Threshold Apr May Jun Jul Aug Sep Oct Nov Movement Trend Comments

Total number of calls answered within 60 seconds 20,976 22,139 20,762 21,282 21,482 19,655 20,733 21,755

Total answered calls within 60 seconds as a percentage of total 95% 89% 96% 98% 98% 99% 98% 97% 96%

Longest wait for an answer (seconds) n/a 1,710 907 755 660 1,433 843 727

Longest wait for call back (hh:mm:ss) 10 Mins n/a 01:00:05 00:35:42 01:39:22 00:34:57 00:44:50 00:34:49 01:11:03 The staff rotas continue to be reviewed & revised in order to ensure sufficient capacity to meet demand

Total number of calls answered 23,490 23,027 21,215 21,734 21,733 28,221 21,436 22590Total number of abandoned calls ringing for over 30 seconds n/a 193 142 165 90 134 231 335

Abandoned calls as a percentage of total <5% 5.0% 0.8% 0.6% 0.7% 0.4% 0.6% 1.0% 1.4%

5Ambulance Dispatch Ambulance dispatch as a percentage of total

Area Team indicator <10% 5% 5% 5% 5% 6% 6% 6% 6%

A&E Referrals as a % of total calls offered n/a 11% 11% 12% 12% 12% 12% 11%Warm transfers as a percentage of total directed to Clinical Advisor 100% n/a 82% 83% 81% 86% 83% 83% 76%

As above, the staff rotas continue to be revised

Call Handling4

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East and North Herts CCGQuality PremiumMonth 01 November 2014Population 560,129 Sum per head of Population £5Quality Premium £2,800,645Quality Preimium Due YTD £1,837,923

Ref Domain/Area Detail Threshold 100% Value £000's Baseline position Target Timing Apr May Jun Jul Aug Sep Oct Nov 2013-14 YTD Status

1a.i1a.ii

Domain 1

Preventing people from dying prematurely

Potential years of life lost (PYLL) from causes considered amenable to healthcare: adults, children and young people

Potential years of life lost (adjusted for sex and age) from amenable mortality for CCG population will need to reduce by at least 3.2% between 2013 and 2014.This is based on the 10 year average reduction in potential years of life lost from amenable mortality

12.5% 350,081 1975 1912 Annual - Calendar year Annual info

2.3.i Unplanned hospitalisation for chronic ambulatory care sensitive conditions

719 719 Monthly 187 171 167 200 155 154 173 162 1,369

2.3.ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under 19s

227 227 Monthly 14 30 18 30 24 34 21 22 193

3a Emergency admissions for acute conditions that should not usually require hospital admission

821 821 Monthly 136 143 126 157 138 121 156 115 1,092

3.2 Emergency admissions for children with lower respiratory tract infection

222 222 Monthly

(provisional) Quarterly (HES)

18 12 7 9 2 9 20 58 135

Assurance that all relevant local providers of services commissioned by a CCG have delivered the nationally agreed roll-out plan to the national timetable

ENHT

PAH

BCF

4c ENHT Inpatient

72 71 76 79 82 74 77 76 607

ENHT A&E

73 70 72 66 60 47 67 71 526

PAH Inpatient

84 74 81 68 81 81 81 90 640

PAH A&E

70 71 79 86 81 89 77 73 626

BCF Inpatient

55 54 52 53 53 64 52 21 404

BCF A&E 6 2- 13- 17- 42 28 34 35 113

5.2.i Incidence of healthcare associated infection (HCAI) i) MRSA

1.58 per 100,000 0 Monthly 1 0 0 1 0 0 0 0 2ENHCCG has failed this element of the Quality Premium worth £350k) as a consequence of MRSA being assigned to the CCG

5.2.ii Incidence of healthcare associated infection (HCAI) ii) C.difficile

15.1 per 100,000 = 84 cases 15.1/100,000 = 84 cases

Monthly 10 9 13 15 6 4 11 9 77

Local measure 190% of patients newly diagnosed with Diabetes undertake an accredited and structured education programme (DAFNE and DESMOND).

12.5% 350,081

Number of diabetes patients in East & North Herts CCG (from QOF registers 2011/12) = 22,971

NICE suggest 189 patients per 100,000 population are newly diagnosed each year (Type 2), for this CCG this would be 1045 patients

90% of newly diagnosed patients

941 patients diagnosed with Diabetes (Type 1 and 2) will be offered a structured education programme

Quarterly 128 567

Sept/Oct Data combines Q2 & Q3 figures. An independent company (X-PEERT Health) has been commissioned to provide additional capacity. This new provider started delivery in mid January - 33 patients attended the first 2 sessions. X-PERT is contracted to provide structured education to 460 patients with T2 diabetes between mid January and end of March 2014

Local Measure 2 Diabetes 1731 5692

COPD 195 1816

Total 1926 7508

Local Measure 3

National find your 1% campaign to ensure practice end of life registers are representative of all end of life patients, not just those with malignant illness.

Advanced Care Planning is completed for 50% of patients identified to be in the last 12 months of the end of their life

12.5% 350,081 1% of CCG practice population (552,900) = 5,529

50% of practice 1% End of Life registers (5,529) have an Advanced Care Plan

2,765 patients to be in the last 12 months of the end of their life have Advanced Care Plans initiated

Quarterly 212 1287

Sept/Oct Data combines Q2 & Q3 figures.The position at Q3 this is 1478 plans adrift of the target of 2,765.ACPs continue to be a challenging area for both Clinicians, patients and carers.An advert has been placed for an EoL clinical lead for the EoL workstream.

£2,450,564Reduction % if target not met

90% Admitted 90% Monthly 84.29% 88.69% 88.83% 90.84% 90.90% 92.30% 91.20% 91.50% 89.82%

95% Non-Admitted 95% 96.64% 97.07% 97.16% 96.64% 97.70% 97.30% 96.90% 96.40% 96.98%

Maximum 4 hour waits in A&E Departments (Proxy) 95% 25% 612,641 95% Monthly 95.48% 96.10% 96.15% 95.76% 95.76% 94.68% 95.53% 95.94% 95.68%

Maximum 62 day waits from urgent GP referral to first definitive treatment for cancer 85% 25% 612,641 85% Monthly 92.20% 85.70% 88.30% 84.90% 89.20% 91.00% 85.90% 88.17%

Maximum 8 minute responses to Category A red ambulance calls (Red 1 and Red 2)

EOE Ambulance Service 75% 25% 612,641 Red 1/Red 2 75% Monthly 74.81% 77.06% 71.91% 70.93% 75.26% 72.60% 68.85% 72.21% 72.95%

Cumulative YTD position as at end of December is 72.26% which is below the required 75%. It is unlikely that this will be improved sufficiently to bring about a year end position in excess of 75%

CCG RegulationsCCG to manage within its total resource envelope for 2013/14 and does not exceed the agreed level of surplus drawdown

100% 2,450,564 Pre-qualifying criterion for any payment On track to deliver

Total QP Due YTD £1,837,923

Sept/Oct Data combines Q2 & Q3 figures.

439

3961

1075

Care planning is completed for 20% of the practice population diagnosed with Diabetes and COPD

12.5% 350,081

Number of patients diagnosed with diabetes in East & North Herts CCG (from QOF registers 2011/12) = 22,971

Number of patients diagnosed with COPD in East & North Herts CCG (from QOF registers 2011/12) = 8,231

20% of patients with COPD and Diabetes have a care plan initiated

Diabetes = 4,594COPD = 1,646

6,420 care plans initiated

Quarterly 1621

5582

Domain 2

Enhancing quality of life for people with long term conditions

A reduction or a 0% change in emergency admissions for these conditions for a CCG population between 2013/14 and 2014/15 25% 700,161

Domain 3

Helping people to recover from episodes of ill health or following injury

NHS Constitution Rights/Pledges

Maximum 18-week waits from referral to treatment 25%

Domain 5

Treating and caring for people in a safe environment and protecting them from avoidable harm

No cases of MRSA bacteraemia for the CCG's population; andC.difficile cases are at or below defined thresholds for the CCGs 12.5% 0

612,641

Supporting the management of patients with long term conditions through the promotion of self- management, and the implementation of personal health plans.

Currently undertaking further analysis of these figures and clarifying target position to assess position

Domain 4

Ensuring that people have a positive experience of care

Patient experience for acute inpatient care and A&E services, as measured by the Friends and family Test

An improvement in average FFT scores for acute inpatient care and A&E services between Q1 2013/14 and Q1 2014/15 for acute hospitals that serve a CCG population

12.5% 350,081

72

Roll out of Friends and Family TestA CCG's local providers deliver the nationally agreed roll-out plan to the national timetable - maternity services by the end of October 2013 and additional services (TBC) by the end of March 2014

TBC

The current FFT requirements have been to- Continue FFT in inpatient areas- Roll out to A&E from April 2013- Roll out to maternity from October 2013

Additionally evidence of A&E and inpatient FFT through UNIFY reporting and NHS England publications. (From 1st April 2014 Trusts will need to have rolled out FFT to staff, however full guidance has not yet been published regarding this. Additionally the 2014/15 CQUIN will also require roll out to outpatient and day case departments by 1st October 2014)

Assurance sought through Quality Review Meetings and review of provider Quality and Safety Committee Reports.

Assurance sought through Quality Review Meetings and review of provider Risk and Quality Committee reports. Additional assurance sought regarding maternity roll out during maternity services Quality Assurance Visit in September 2013.

Assurance sought through Quality Review Meetings and review of provider Patient Experience and Engagement Reports.

TBC

Notes: The CCG has lost £350,081 of its potential QP as a consequence of cases of MRSA being assigned to the CCG. Of the total QP due, it is likely that the CCG will lose a further quarter of the QP as the current YTD position of EEAST in relation to the combined category A Red 1/2 8 minute ambulance response times as at December is 72.26% which is unlikely to improve sufficiently over the winter months. to bring the figure up to the required 75%.

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Appendix One – Serious Incidents (SIs)

1. Terms/ Acronyms used in report CATT CCG CMHT CRI CSU DoN E&NHT ENCCG HCC HCT HPFT HUC

Crisis Assessment and Treatment Team Clinical Commissioning Group Community Mental Health Team Crime Reduction Initiative Commissioning Support Unit Director of Nursing East & North Hertfordshire NHS Trust East & North Clinical Commissioning Group Hertfordshire County Council Hertfordshire Community Trust Hertfordshire Partnership Foundation Trust Herts Urgent Care

HVCCG IFR IG JCT MP PAH PALS PHSO Q1,Q2,Q3,Q4 QRM SI

Herts Valleys CCG Individual Funding Request Information Governance Joint Commissioning Team Member of Parliament Princess Alexandra Hospital Trust Patient Advice and Liaison Service Parliamentary Health Service Ombudsman Quarter 1, Quarter 2, Quarter 3, Quarter 4 Quality Review Meeting Serious Incident

2. Serious Incident: Themes and Trends 2.1 Introduction The information below details the number and type of SIs reported by each provider as well as updates regarding any key cases reported. In total 60 SIs were reported in Q3 relating to ENCCG.

2.2 East & North Herts Trust In Q3 E&NHT reported a total of 24 SIs, with the majority relating to Grade 3 pressure ulcers. A breakdown of the types of incident reported in 2013/14 to date can be found below.

In October’s Part-2 paper it was reported that there had been a Never Event reported relating to a surgical error. Following review of the 45 day report a director level meeting was held with E&NHT to ensure all key actions and learning had been identified. E&NHT are currently writing a revised report and action plan.

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A potential wrong site surgery Never Event was also reported. Following review of the final report it was agreed this case did not meet the Never Event definition.

The safeguarding adults case was reported following concerns regarding how a procedure was undertaken. The investigation into this case is on-going.

2.3 Hertfordshire Community NHS Trust HCT reported 54 SIs across the organisation in Q3, 23 of which fell under the management of ENCCG.

Of the 23 ENCCG cases, the highest proportion (14) related to Grade 3 and 4 pressure uIcers. There has been a decrease in the number of grade 3 pressure ulcers compared to Q2 and an increase in grade 4 pressure ulcers. It should be noted that of the total ENCCG pressure ulcer SIs, three investigations are outstanding but the rest have been determined as unavoidable.

2.4 Hertfordshire Partnership NHS Foundation Trust

In Q3, HPFT has reported 14 SIs, 4 of which relate to ENCCG patients or services. There has been an increase in the number of suspected suicides reported. This is

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currently being reviewed by the CCG and JCT to determine whether this is a seasonal trend.

Through the SI and safeguarding processes concerns have been raised regarding Seward Lodge. These continue to be addressed by HPFT, and the CCG and JCT have also undertaken an unannounced visit to assess progress. Following the meeting between the CCG Accountable Officer, DoN and the Trust Chief Executive further meetings have been held by the Head of Adult Safeguarding to develop Safeguarding SI reporting thresholds. 2.5 Herts Urgent Care

The number of SIs reported by HUC continues to be small with only 1 SI reported during Q3 and this case related to NHS Cambridgeshire and Peterborough CCG.

2.6 Spectrum (CRI) Spectrum is commissioned by Public Health and the CCG has therefore handed over responsibility for management of their SIs to the Public Health Team and JCT. The CCG will continue to work closely with the JCT in relation to any SIs where a service user may have been known to both HPFT and CRI. 2.7 Learning Please find below examples of learning and actions implemented from recently closed SIs. Provider Type of SI Learning E&NHT Fracture following a

fall Induction checklist was devised for bank and agency staff to ensure they have been fully orientated to the ward. This will include a specific information section for staff who are utilised to ‘special patients’. Low rise beds to be ordered immediately for any restless patients with delirium who are at a high risk of fall who try to get out bed.

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Surgical error Senior clinical support for guidance – examples of difficult cases discussed at audit with senior clinical input. Reinforce importance of keeping patients fully informed about surgery and any changes in plan clearly documented. Re-circulation of local protocol regarding standard operating procedure relevant for delivery of patient care safely and efficiently.

Delayed diagnosis Paediatric and Emergency dept trainee doctors to be given further refresher training in identifying atypical presentations of Meningococcal infections in children. Case to be presented and discussed at the Clinical Governance Rolling Half Day programme in paediatrics. Nursing staff to be updated or refreshed in how to recognise indicators of serious illness in children.

HCT IG Breach Discussion to be held at next Data Quality Meeting regarding an auditable system for checking printed records before they are sent to Child Health to ensure only appropriate information is included. Staff training required.

Patient fall Whilst all falls risk measures were in place, incident to be shared at the local falls group meeting to share good practice and identify where improvements can be made.

Infection Control (Herts & Essex Hospital)

To ensure that any suspicious looking rashes or infections are reported to the Unit Director/Nurse as soon as possible. To improve communication between unit staff and the infection control team. All new admissions to have their skin checked thoroughly as soon as they arrive on the ward.

HPFT Community Suicide Risk assessments to include current and relevant contingency plan in line with the policy. In the event of concern about a Service User’s whereabouts and clinical risks, the responsible team member should take a lead and request a welfare check. Clear recording of interventions and care plan when referring to CATT.

HUC No HUC SIs were closed in Q3 CRI Death of a Service

User Locality Deputy Manager to review the process for reporting deaths in their allocated cluster and how deaths are verified when this information is received from a third party.

Failure to refer a patient to CMHT

In the absence of a team leader, alternative arrangements for the provision of supervision should be made by deputy service managers.

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The Spectrum County Service Manager and Deputy Service Managers should ensure that in all cases of long term absence of a team leader, alternative leadership support is put in place. Locality Team Leader to use the case as an example of enhancing the use of team meetings, particularly morning meetings to ensure real time communication takes place about risk.

3. SI Performance 3.1 Delayed reporting of SIs

The above graph details the number of SIs where there has been a delay in reporting by the provider. The SI policy states that an SI should be reported to the CCG within 2 working days of the incident occurring or being identified.

In Q3, 96% of all HCT SIs relating to ENCCG patients were reported after two working days of the original incident. As previously reported, a number of these cases relate to pressure ulcers where the Locality Managers are reviewing the pressure ulcer incidents in batches resulting in the delay. The Quality Team are continuing to raise this issue with HCT via the Quality Review Meetings.

In total, 38% of E&NHT SIs were reported late and these delays continue to be raised with the Trust on an individual basis; this is an improvement on previous quarters. The Quality Team continue to monitor the overall reporting performance to ensure there are no emerging theme and trends. Should any be identified this will be raised with the Trust through the appropriate channels such as the Quality Review Meetings.

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4.Complaints and PALS (Q3) 4.1 ENCCG Complaints and PALS Figures

The following table details the number of Complaints and PALS received by ENCCG in 2013/14 to date;

Please note that Complaints and MP Enquiry figures are currently counted together. In the Q4 report, following the implementation of the Quality Team database, these figures will be presented separately to better reflect the issues the Quality Team receive.

During Q3, the Quality Team received 33 complaints/MP Enquiries relating to ENCCG patients; this is an 83% increase compared to the previous quarter. It should be noted that 13 cases related to ENCCG provider organisations and therefore the complaint is being investigated by the Trust’s own complaints team. The Quality Team recognise this contact as positive as it enables soft intelligence to be recorded as well as providing the opportunity to monitor provider’s complaints handling. Please note that these figures do not include those complaints sent incorrectly to ENCCG which were for the Area Team or Herts Valleys Clinical Commissioning Group.

The number of PALS Enquiries received in Q3 decreased compared to those received in the previous quarters. No reason for the downward trend has been identified although it is expected that the Quality Team will deal with more complaints than PALS enquiries due to the areas of responsibility the CCG covers.

In the past 3 months, the Quality Team has received 2 compliments; one relating to the care provided at Pinehill Hospital and one regarding the Quality Team’s handling and assistance with regards to a complaint.

During Q3, no ENCCG complaints files were requested by the PHSO and no cases are currently being investigated.

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4.2 Themes and Trends Please find below a table showing the main areas of Speciality and Subjects for ENCCG Complaints investigated in Q3.

Speciality Subjects IFR 7 Provision of service 10 Screening 2 Funding 7 Commissioning decisions 3 Continuing Healthcare Assessment 2 Continuing Healthcare 2 Prescribing 1 Physiotherapy 2 CRI Drug and Alcohol Service 2 Transport 1 Prescribing 1 4.3 Provider Complaints At the time of reporting, full Q3 figures for provider complaints were unavailable. Therefore please find below a breakdown of provider complaints figures to date; E&NHT E&NHT has seen an increase in the number of PALS Enquiries received in Q3 and a reduction in the number of complaints received in the same time period.

The Trust’s main complaint themes for this quarter are delays, communication and attitude of staff. There has been a significant drop in the number of complaints relating to treatment received since August. PAH Please note that full Q3 figures were unavailable at the time of reporting with December figures yet to be reported.

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PAH has reported that the complaints about attitudes of staff and poor communication make up 30% of all cases. This has been attributed to operational winter pressures with the same trends shown during the previous year. In Q3 another key theme relates to medical care provided.

HCT Please note that full Q3 figures were unavailable at the time of reporting with December figures yet to be published.

HCT has reported 26 complaints received during October and November. HCT continue to work to an agreed response rate of 80% to ensure that all complaints receive a response within the agreed timescale. In October, HCT reported 100% achievement of this metric.

Themes of complaints across the organisation remain consistent with standard of care, staff attitude and behaviour and communication of information as the most frequent issues. HPFT In Q3, HPFT have seen a decrease in the number of complaints received which is the lowest quarterly recording in over a year. This figure is reflected in the increase

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in PALS Enquiries dealt with during this time period which would indicate that HPFT are resolving more enquiries at the informal stage.

Themes of complaints remain consistent with the top four subjects relating to systems and procedures, clinical practice, staff attitude and communication. As part of the Quality Team’s monitoring of complaints handling by provider organisations, ENCCG’s Acting Quality Manager is continuing to work with all of the CCG’s providers and undertakes regular visits to their complaints teams. In addition, all provider complaints received by ENCCG are reviewed and necessary action taken, such as a serious complaint prompting an unannounced Quality Assurance Visit by the CCG to that ward/service. 4.4 Learning Please find below a list of learning and actions as a result of ENCCG and provider led complaints; Provider Learning ENCCG/CSU Following a number of concerns raised regarding the delays in the

Continuing Care team dealing with Retrospective Reviews, it has been agreed that the fee normally charged to applicants for the patient’s records to be accessed will be waived.

ENCCG/CSU The Medicines Management Team redistributed the list of Hertfordshire pharmacies that stock Just in Case medication to GP Surgeries, HCT and HUC.

E&NHT Sister in A&E has issued a memo to all Emergency Staff stating that they should make sure that an unaccompanied patient who has an epileptic fit, irrespective of age, should be discharged with a responsible adult being made aware where possible

E&NHT Following a delay in answering call bells, unannounced spot checks have been introduced on the ward concerned.

HCT All community nursing teams have been reminded of their responsibility to ensure that any prescription requests are followed up.

HCT All staff have been reminded of the need to inform HUC of palliative care patients.

HCT The Trust has provided all community nurses with an excerpt from the

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Palliative Guideline Book to increase their awareness of Just in Case Medication and to assist in discussions with other clinicians. This information has also been shared with HUC.

HUC The Trust is involved in a project to access more patient detailed information which is being supported by the CCG.

HUC The Trust are to ensure they feedback to both GP Surgeries and to the CCG Locality Meetings when they identify a palliative care patient who wasn’t previously known or alerted to them.

HUC Following a human error in the prescribing of medication, HUC are liaising with their Software Supplier to ensure that the full name of the medication is available to the clinician.

HUC The Trust has arranged for a Psychiatric Consultant to attend one of their training sessions following a complaint involving the assessment of an elderly patient with dementia.

HCC/HUC/HPFT It has been reiterated to all staff the responsibility they have to ensure that all cases are followed through. This follows a complaint involving a patient requiring an out of hours mental health assessment whereby there was issues between all of the organisations involved.

HPFT The Trust has re-circulated the contact details for the Single Point of Access service.

HCC The prioritisation of the Local Authority’s Out of Hours Mental Health cases has been reviewed.

HCC The Local Authority are undertaking a review regarding their capacity particularly for out of hours.

JCT Toolkits are currently being developing regarding mental health which will be shared with HUC upon completion as part of their training resources.

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agenda item no: 4.2 date of meeting: 30 january 2014 · 1/30/2014 · outside of hertfordshire,...

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