enclosure: gi date of trust board november · pdf filedate of trust board 28th november 2012...

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Date of Trust Board 28th November 2012

Title of Report Quality & Risk Report – October 2012 activity

Abstract

The attached 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 1st October – 31st October 2012. 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. The key patient safety indicators are given below. Due to changes in the reporting cycle two months data is included in this report.

October 2012 Numbers

Total No. Serious Incidents reported

37

7 day reports submitted to NHS Norfolk in month outside of timescale

0

Serious Incidents Reported to NHSN in October 2012

45 day reports submitted to NHS Norfolk in month outside of timescale (see report for details)

8

Within the care of NCH&C Grade 3 Grade 4 Total

13 5 18

Pressure Ulcers (PUs) reported as SIRIs in October 2012

Outside the Care of NCH&C Grade 3 Grade 4 Total

13 3 16

PUs – classification by grade

Grade 2 avoidable 3

Grade 2 unavoidable 34

Grade 2 unclassified* 25

Grade 3 avoidable 2


Grade 3 unclassified 7

Grade 4 avoidable 0


Grade 4 unclassified 5

Total avoidable PUs in October (Grades 2 – 4)

5

*unclassified in this context means unclassified as either avoidable or unavoidable

ENCLOSURE: Gi

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Never Events Total number of Never

Events 0

Medication Incidents No. of medication incidents reported

44

Falls No. of inpatient falls

resulting in injury

No. of inpatient near miss falls or no harm

No. of inpatient falls resulting in death

0

No. of incidents reported 773

Grade of incidents:

No harm 285

Low harm 402

Moderate harm 72

Severe harm 10

Death - expected 3

Incidents reported

- unexpected 1

*this includes Grade 1&2 Pressure Ulcers

Complaints and compliments received during October 2012

No. of formal complaints received 19 % acknowledged within 3 days 100% No. responses due in month 12 No. responses completed within 25 days target 9 % of due responses completed in month 75% No. of complainants requesting second response 1 No. of Ombudsman investigation requests 0 No. of formal compliments received 70

Risks and benefits of proposed action

Recommendation

The Trust Board are asked to approve the report

Presented by

Anna Morgan, Director of Nursing, Quality and Operations

Previous consideration by Board Committee or EDT

Appendices 1. Net Promoter report for October 2012

In completing this report, I confirm the following matters have been considered:

a) Implications for the NHS Constitution b) Implications for CQC registration c) Equalities Impact d) Environmental impact

Any material considerations arising from the above are reported below.

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Quality & Risk Report for October 2012

CONTENTS (including references to source, strategy or key performance indicator) GLOSSARY OF TERMS 1. Patient Safety (Annual Plan, Quality Goals, Schedule 16 KPIs) 1.1 Serious Incidents Requiring Investigation (SIRIs) 1.2 Incidents reported during October 2012 1.3 Incidents reported by Degree of Harm 1.4 Medication Errors 1.5 Falls (Quality Goal) 1.6 Pressure Ulcers (Quality Goal) 1.7 Infection prevention and control (Quality Goals, schedule 16, KPI) 2. Safety Thermometer (Quality goal) 3. Patient Experience (Annual Plan, CQuIN, Schedule 16) 3.1 Patient Experience Surveys (Quality Goal, CQuIN) 3.3 Complaints received (Schedule 16 KPI) 3.4 Learning and actions from complaints 3.5 Compliments 3.6 PALS Service enquiries 4 DATIX Risk Register Roll-out Project update

Appendix 1 Net promoter score for October 2012 Glossary of terms C. Diff Clostridium Difficile CQC Care Quality Commission CQuIN Commissioning for Quality and Innovation DPA Data Protection Act (1998) FOIA Freedom of Information Act (2000) HIA High Impact Actions HMP Her Majesty’s Prison IG Toolkit Information Governance Toolkit KPI Key performance indicator MRSA Meticillin-resistant Staphylococcus Aureus NHSLA National Health Service Litigation Authority NPSA National Patient Safety Agency PALS Patient Advice and Liaison Service PET Patient Experience Tool PEAT Patient Environment Action Team QIPP Quality, Innovation, Prevention and Productivity RCA Root Cause Analysis SIRI Serious Incident Requiring Investigation UTI Urinary tract infection VTE Venous Thromboembolism

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1. Patient Safety 1.1 Serious Incidents Requiring Investigation (SIRI) 37 new serious incidents were reported requiring investigation (SIRIs) during October 2012. Of these SIRIs, 18 (compared to 13 in September 2012) relate to grade 3 and 4 pressure ulcers identified as being acquired while under the care of NCH&C. 14 within the Community Nursing Teams and 4 within the inpatient units In addition, 16 grade 3 and 4 pressure ulcers acquired outside the care of NCH&C were reported as a SIRI. These will not require investigation by NCH&C.

Changes to Pressure Ulcer reporting: effective from 29 October 2012 Pressure ulcers acquired outside the care of the Trust With effect from Monday, October 29, 2012, NCH&C (along with other providers) will no longer be required to report Grade 3 & 4 pressure ulcers acquired outside the care of NCH&C as a Serious Incident Requiring Investigation (SIRI). We will, however, be required to complete a ‘Pressure Ulcer Alert Form’ for these incidents, which must be completed and attached to the DATIX incident record for appropriate incidents. This new alert form will be available when logging the incident through DATIX. Pressure ulcers acquired within the care of the Trust We are still required to report grade 3 & 4 pressure ulcers acquired within the care of NCH&C as a SIRI, you should therefore follow the existing process for these incidents. Changes to DATIX In addition to the above, changes are also being made to the Pressure Ulcer questions within DATIX following consultation with the Trusts Pressure Ulcer leads and team leaders. The remaining 3 SIRIs were:

1. (27438.2012) Pine Cottage, Colman Hospital. Patient had a cardiac arrest, CPR was commenced by the nursing staff and continued by paramedics. Patient responded and was transferred to the NNUH by emergency ambulance. Patient subsequently died at the NNUH

2. (25117.2012) Pricilla Bacon Lodge, Colman Hospital A drug administration error occurred during the patient’s end of life care. A reversal drug was given. Patient died the following morning, coroner informed.

3. (26217.2012) Benjamin Court Following a fall, the patient was transferred back to the NNUH by emergency services. Patient was found to have a fractured clavicle and remains an inpatient at the NNUH

Each of these SIRI’s are being fully investigated to identify the root causes. Once the investigations are complete, they will be reported to the Quality & Risk Assurance Committee to identify learning and discussed at the quarterly Non Executive Director SIRI meetings.

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The following graph shows the number of SIRIs reported to NHS Norfolk & Waveney each month from November 2011 to October 2012.

SIRIs reported November 2011 to October 2012

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Other

Of the 14, 7 day reports due in October 2012, 8 were submitted to NHS Norfolk & Waveney (NHSN&W) outside agreed timescales. There were 15 x 45 day reports submitted to NHSN&W during October 2012, of these 2 were submitted outside timescales, due to capacity pressures. An overarching report on the five deaths on Pineheath Ward, Kelling Hospital during June - September 2012 was finalised and submitted to NHS Norfolk & Waveney and NHS Midlands & East (SHA). This report looked at each of the RCAs and the individual medical reviews and provided detailed information on the complexity of patients admitted to the ward together with workforce information. The recommendations and learning included:-

1. Ensure NEWS (Norfolk Early Warning system) observation chart is filed in the medical records following transfer, discharge or death

2. Review medical assessment form to incorporate sections for diagnosis/problem lists, results of initial investigations and medical management plan

3. Update VTE policy and algorithm in light of new guidance from NICE 4. Increase monitoring of the results of VTE assessments and numbers of VTE

occurring 5. Review and update management of death policy 6. Training to be provided to all staff at Kelling Hospital (including medical staff)

regarding record keeping 7. Business case for the introduction of Advanced Practitioner (ANP) post 8. Clarification and agreement of medical model

9. Undertaking the review of the RCAs alongside the medical reviews has identified a need for further training regarding compiling an RCA that is ‘fit for purpose’

10. To develop a Community Rehabiliation service spec with commissioners 11. NCH&C advises that the LCP is used by all members of the multi-disciplinary team

for patients where it is indicated. A further review is to be conducted by the Director of Nursing, Quality & Operations and the Medical Director, to analyse the recommendations for the team, the service, and the wider organisation.

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It should also be noted that the following notable practice was identified:-

• Excellent evidence to support advance care planning undertaken by the specialist palliative care (SPC) team (e.g. DNACPR and PPoC documents)

• Good communication from SPC team to primary care on initiation of Ketamine syringe driver

• Good clerking on admission by GP and evidence that advice was sought and then acted upon

• Senior healthcare Assistant was able to express concerns on the management of an End of Life patient following a fall prior to death following a fall prior to death

1.2 Incidents reported October 2012 Due to the increase in the number of SIRIs and incidents being reported, the final quality check performed by the Quality & Risk team has not been carried out on all incidents reported, therefore the figures within this section maybe subject to change. The total number of incidents reported during October 2012 was 773 (compared to 733 in September 2012). The graph below details the number of incidents reported by each Locality / Directorate.

Incidents reported by Locality / Directorate in October 2012

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3812 2 2

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The Integrated community nursing teams (476 incidents) and the Inpatient units (192 incidents) continue to be the highest reporters. These are the areas where the highest numbers of contacts with patients are made. The top three reporting categories for these services are detailed below: Integrated Community Nursing Teams Pressure Ulcers –279 incidents (59%) Staffing levels / skill mix – 53 (11%) Medication incidents – 29 (6%)

Inpatient units Slips / Trips & Falls – 54 incidents (28%) Pressure Ulcers – 43 incidents (22%) Medication – 10 incidents (5%)

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1.3 Incidents reported by Degree of Harm The graph below shows all incidents reported by degree of harm from 1 November 2011 to 31 October 2012

Incidents reported by Degree of Harm 1 November 2011 to 31

October 2012

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No Harm Low harm Moderate harm Severe harm Unexpected death

No Harm incidents (definition: No injury, harm or adverse outcome)

285 (37%) of the incidents reported in October 2012 (compared to 44% in September) resulted in ‘No Harm’. Low Harm incidents (definition: required first aid, minor treatment, extra observation or medication) 402 (52%) of the incidents reported in October 2012 (compared to 47% in September) resulted in ‘Low Harm’. Moderate Harm incidents (definition: short term harm, patient(s) required further treatment or procedure)

72 (9%) of incidents reported in October 2012 (compared to 7% in September 2012) resulted in moderate harm. 34 of these incidents relate to Grade 3 Pressure Ulcers (14 acquired within the care of NCH&C and 20 acquired outside the care of NCH&C). All Grade 3 pressure ulcers acquired within the care of NCH&C are reported to NHS Norfolk & Waveney (NHSN&W) as SIRIs. The remaining 38 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 (definition: permanent or long term harm) 10 (less than 3%) incidents reported in October 2012 resulted in severe harm (compared to 4 incidents in September 2012.

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The incidents are detailed below:-

• 7 x Grade 4 Pressure Ulcers acquired outside the care of NCH&C. All Grade 4 pressure ulcers acquired within the care of NCH&C are reported as SIRIs.

• 1 x Grade 4 Pressure Ulcers acquired outside the care of NCH&C which has been reported as a SIRI, to be investigated by the organisation as being attributed to where the pressure ulcer was acquired

• 1 x deterioration of medical condition, patient transferred to A&E. This incident has been reported as a SIRI (See section 1.1 for further detail)

• 1 x Children’s Safeguarding, the NCH&C Children’s Safeguarding lead is in liaison with Children’s Services and key health professionals involved with this family. Consideration is currently be given as to if this incident meets the SIRI reporting criteria.

Unexpected death incidents One unexpected death was reported in October 2012 at Pine Cottage, Colman Hospital (27438.2012). (see page 4) 1.4 Medication Incidents (October 2012) There were 44 medication incidents reported in October; 33 were no harm, 10 were low harm and there was one moderate harm incident (involving the incorrect administration of a controlled drug via a syringe driver). There were no severe harm incidents reported. This represents a very small proportion of the activity involving medicines within the Trust. The following graph shows the trend of severity since April 2011, and indicates that moderate harm incidents are stable at between 1 to 3 per month (mean = 1). The trend for the last 6 months in terms of numbers of incidents, albeit with monthly variations, is fairly flat (a marginal increase in low harm incidents reported). Fig 1: Breakdown of incident trends by severity

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The following graph shows the breakdown of incidents reported by locality:

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Fig 2: Incidents by locality (May12-Oct12)

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An even distribution would not be expected due as services are not evenly distributed, but this distribution has been discussed at the medicines management committee and work is underway to ensure that it reflects accurately the incidents occurring, particularly what could be seen as low reporting from the West locality, and the variations in reporting in the South locality.

The following graph shows the breakdown of incidents by incident type over the last 3 months: Fig 3: Incidents by incident type (top 20) August – October 2012

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Further analysis of incident breakdown can be found in the Trust’s Medication Safety Report that is reviewed at the bi-monthly Medicines Management Committee. Controlled Drugs Incidents There were 11 incidents involving controlled drugs reported during October, including one moderate harm incident involving the incorrect administration of a controlled drug via a syringe driver. There were no severe harm incidents.

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The 2 low harm incidents in October involved a supply problem from community pharmacy and missing diamorphine in a patient’s home. All incidents were reviewed to ensure that they were resolved and any lessons are put into practice.

Fig 4: Controlled drug incidents by month and severity – April 2011 – October 2012.

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Due to a series of incidents involving controlled drugs in Pricilla Bacon Lodge, three incident review and calculation refresher sessions were undertaken by the Head of Medicines Management during September/October. These sessions encouraged the team to discuss past medication errors and review them in line with risk management theories. The outputs of these sessions will be followed up at ward meetings.

1.6 Patient Falls – (Quality Goal; reduction in the levels of injurious falls in our inpatient units to 4.0 per occupied bed day) 54 (compared to 42 in September 2012) inpatient falls were reported in October 2012. 35 resulted in no harm and 19 in low harm. The table below shows the number and degree of harm of the falls within each unit

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Alder Ward 1 2 0 0 0 3

Beech Ward 3 3 0 0 0 6

Benjamin Court 9 4 0 0 0 13

Caroline House 1 1 0 0 0 2

Cranmer House 2 0 0 0 0 2

Foxley Ward 1 0 0 0 0 1

Kelling Hospital 1 2 0 0 0 3

North Walsham (Community Rehab) 6 1 0 0 0 7

Ogden Court 5 0 0 0 0 5

PBL - Inpatients 1 2 0 0 0 3

PBL - Rowan Day Centre 0 1 0 0 0 1

Pine Cottage 3 2 0 0 0 5

Swaffham 2 1 0 0 0 3

Totals: 35 19 0 0 0 54

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The following graph shows the degree of harm of patient falls from November 2011 to October 2012

Inpatient Patient - patient slips / Trips / Falls reported 1

November 2011 to 31 October 2012 by Degree of Harm

0102030405060708090

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The table below shows the number of patient injurious falls by occupied bed days within inpatient units

Falls/OBS Performance - Inpatient Units

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2012/13 performance 2012/13 Target

These are broken down by inpatient unit as follows:- October's Figures Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

Benjamin Court 5.9 2.0 2.0 1.9 2.0 0.0 7.8

Cranmer House 0.0 2.5 10.8 12.9 0.0 0.0 0.0

Kelling 1.3 2.7 1.7 4.8 3.5 4.9 2.9

North Walsham 1.5 0.0 3.0 3.0 1.5

St Michaels 0.0 0.0

Dereham 1.5 1.4 6.4 7.2 2.0 5.6 0.0

Ogden Court 9.4 4.5 0.0 10.4 0.0 0.0 0.0

Alder Ward 0.0 10.1 1.6 4.4 1.4 6.5 3.4

Beech Ward 4.8 5.6 0.0 1.4 0.0 1.6 4.9

Swaffham 0.0 2.1 4.7 5.9 0.0 2.2 2.1

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Caroline House 2.1 1.9 0.0 0.0 3.9 0.0 1.9

Pine Cottage 5.1 0.0 5.0 4.3 0.0 0.0 9.0

PBL 9.2 2.3 4.7 0.0 4.5 4.6 7.6

Total for Inpatient Units 3.58 3.39 2.78 4.07 1.78 2.54 3.36

1.7 Pressure Ulcers – (Quality Goal – elimination of all avoidable pressure ulcers acquired within the care of NCH&C by December 2012) The following table shows the number of incidents reported in respect of pressure ulcers acquired within the care of NCH&C.

Grade Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12

1 avoidable 3 5 4 7 5 4 3

1 unavoidable 10 16 23 18 24 27 17

1 unclassified 4 2 0 0 0 1 13

1 Total 17 23 27 25 29 32 33

2 avoidable 4 14 4 5 14 11 3

2 unavoidable 30 69 57 65 46 69 34


2 Total 40 83 62 70 61 88 62

3 avoidable 2 2 5 5 0 2 2

3 unavoidable 8 15 9 16 19 12 5


3 Total 10 17 14 21 19 14 14

4 avoidable 0 0 1 0 0 0 0

4 unavoidable 4 1 3 3 4 0 3


4 Total 4 1 4 3 4 0 8

all avoidable 9 21 14 17 19 17 8

all unavoidable 52 101 92 102 93 108 59

all unclassified 10 2 1 0 1 9 50

all Total 71 124 107 119 113 134 117

* Avoidable / unavoidable data is only available for incidents reported from 17 April 2012 * Please note that 1 of the July incidents, 37 August, 64 September and 106 October incidents have not yet had the avoidable / unavoidable decision verified

The table shows that the vast majority of all reported pressure ulcers are unavoidable mainly as a result of a patients condition e.g. end of life with multiple co-morbidities. The numbers of avoidable pressure ulcers have fallen in October. Targeted training for staff in specialist teams and/or new staff in community nursing continues. Awareness raising for patients, carers and public across all services continues with the support of our newly designed leaflets and posters.

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1.8 Infection Prevention and Control (Schedule 16 KPI, Quality Goal) 1.8.1 MRSA Bacteraemia (contractual ceiling of 1)

To date NCH&C have reported 2 cases of MRSA bacteraemia against our contractual ceiling of 1. Full RCAs have been carried out on both cases and any learning shared not only with the units in question but all our inpatient units. NCH&C monthly pre 48 hour MRSA bacteraemia cases against cumulative trajectory

1.8.2 Clostridium Difficile (C. Diff) (contractual ceiling of 9) NCH&C has had 1 case of Clostridium difficile identified in Pricilla Bacon Lodge, Colman Hospital in October. This occurred in a patient who had been on this inpatient unit for over 48 hours and it is therefore attributable to NCH&C. A full root cause analysis is being conducted, however early indications are that NCH&C staff followed all guidelines as required and escalated the issue at the earliest opportunity. The patient’s clinical history shows no obvious root cause for attribution of spores however there were several unavoidable trigger factors i.e. antibiotics, gastric acid suppressive agent and steroids, chemotherapy which had an impact. The following graph shows the trajectory of cases against our ceiling of 9 for 2012/13.

1.8.3 Water Quality Following refurbishment of Foxley Ward kitchen under the instruction of the EHO the required water quality testing needed prior to re-opening of any facility has been cause for concern. The Dereham Hospital site has had several issues with the water supply since June 2012 such as flushing of fire hydrants, a burst mains supply, fitting of new water storage tanks and historically poor water flow to Foxley Ward itself and a poor water infrastructure generally which has led to the possible disturbance of biofilm within the

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system. This has led to erroneous water quality results in the form of Total Viable Counts (TVCs) across the site, latterly water sampling has shown pseudomonas in particular to be an issue for Foxley Ward. NCH&C have been working with a number of contractors; SERCO, Hydrop, H2O solutions, PALL and AWA to rectify the situation. An incident management group has been in place since July led by Director of Finance with daily ‘sit reps’ updating the necessary people of current issues and any required changes to clinical practice to ensure the safety of both patients and staff. All possible solutions with patient’s in-situ have been explored but it has now concluded that as from 5th October 2012 Foxley Ward would close and patients and staff would be relocated across other NCH&C sites in order to carry out a high dose chlorination of the system. A comprehensive action plan is in place and it is expected that Foxley Ward will remain closed for up to 12 weeks. At no stage have patients or staff been placed at any risk from water quality.

Estates works are running to plan and the expected date to re-open Foxley Ward (assuming further water sampling is satisfactory following all works) is 7th January 2013. All media interest in this issue has been handled by our Communications Team and the Care Quality Commission have been informed of the situation. 1.8.4 Catheter Acquired Urinary Tract Infections (CAUTIs) (Quality Goal – 50% reduction by December 2012) NCH&C are required to reduce CAUTIs by 50% by December 2012 across all areas except Nursing Homes. The Infection Prevention and Control Team has been working closely with the Continence Team to help deliver this target. Data collection for inpatients began in July 2012 however Community Teams have only begun to collect data October 2012. The delay has been due to the ability to assure System 1 template training for staff. Community teams pose another issue for data collection as they are unable to see any results of specimens that they may send as this is sent directly to the patients GP not the community teams. This has required the IPAC team to run a monthly System 1 report and then follow up any positive CSU result and contact GPs to establish whether or not a patient was treated. For October this will be 187 patient tests to follow up and document.

Catheter activity data from Community teams is summarised below

Period - Apr - Sept 2012 Apr May Jun Jul Aug Sept

No. of patients 39 40 75 817 943 965

No. of contacts 219 225 268 1902 2247 2256

Average no. contacts per patient 5.6 5.6 3.6 2.3 2.4 2.3

2.0 Safety Thermometer (Quality goal- Implement safety thermometer in 4 key

areas) The NHS safety thermometer has been designed to be used by frontline healthcare professionals to measure a snapshot of harm once a month from pressure ulcers, falls, urinary infection in patients with catheters and treatment for VTE. The Department of Health incentivises the collection of data on all patients once a month. The NHS Safety thermometer takes only minimum sets of data that help to signal where individuals, teams and organisations might need to focus more detailed measurement, training and improvement.

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The Chief Nursing Officers bulletin published an update on the progress of the safety thermometer and stated that the tool was designed to measure local improvement over time and should not be used to compare organisations. There are differences in data collection methods and patient mix, which can invalidate comparison across organisations. For example, trusts with a high percentage of older patients or specialist services are likely to present more harms on this measure. After nine months of data collection our figures show an improvement in the level of harm free care delivered to our patients. October has shown an increase in the harm free rate to just under 92%.

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The table on page 15 shows a reduction in the number of new pressure ulcers reported via the safety thermometer. The Midlands and East SHA report that after six months of work across many work streams new pressure ulcers have seen a reduction of 30% between April and August 2012. 3.0 Patient Experience 3.1 Patient Experience Surveys (Quality Goal – Implement Friends and Family test using the Net Promoter Score) NPS “How likely is it that you would recommend this service to friends and family?” went live in all inpatient areas during May 2012. Patients are being given a feedback card on the day of discharge to rate their score between 1 and 10 and leave any comments as to why they gave that score. A minimum survey size of 10% of all patients discharged has been set and this has been achieved for May and June 2012. Baseline results from May and June indicate an overall NPS for NCH&C Inpatients of 52%. Results from July – October 2012 are as follows:-

Month No of Responses NPS score

July 39 84%

August 67 81%

September 30 73%

October 67 73%

These results remain in the top quartile of 71% or more which is the target set for acute hospitals. (see appendix 1 for NPS report for October) There is an optional free text section for patients to leave their comments, and the following are the top three themes from each of the promoters, detractors and neutral/passives; Top 3 Themes from 44 ‘promoters’ are:-

• Excellent care/well looked after

• Staff caring, kind and helpful

• Food good There were only 3 detractors, comments were:-

• Noisy at night, food started quite good but deteriorated

• Nurses fine but one or two wouldn’t listen and ignored [my] painful condition, food was tasteless

• Nurses doing drug round abrupt with patients Top 3 themes from 9 ‘neutral/passives’ are:-

• Staff helpful and kind

• Treatment and care good

• Food very good 3.3 Complaints received during October 2012

NCH&C received 19 formal complaints during October 2012. 100% were acknowledged within the target time of 3 days. Of the 12 responses due in October 2012, 9 were responded to within the target time of 25 days = 75% 3 were responded to outside the target 2 due to complaints manager’s annual leave and one due to a delay in report being sent to complaints manager

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Complaints received by Locality and subject – October 2012 Locality Total Appt delay Care &

Treatment Policy Staff

attitude Other

Children 2 1 1

Norwich 4 3 1

North 1 1

South 7 3 2 2

West 2 1 1

Specialist 2 1 1

Estates, Corporate

1 1

Total 19 4 8 1 4 2

Policy: Specialist: regarding Lymphoedema bandaging Other: South: 1 x Privacy and dignity (continence products)

1 = Failure to follow procedures (needle stick)

3.4 Learning and actions from complaints completed during October 2012 Children: A complaint highlighted that decisions were taken before service users were

told of the results of a consultation. Action has been taken to avoid this error in future.

South: Following a complaint that a nominated ‘Next of Kin’ was contacted too soon, reasonable effort will be taken in future to contact patient before resorted to alternative methods of contact.

Single Point of Referral staff will check referrals more carefully to ensure they are appropriate (a service provided by this Trust) before accepting them.

Specialist: Action has been taken within Foot Health (West area) to ensure answer-phone messages are acted upon in a timely way.

Foot Health Team Lead given dedicated time to deal with urgent appointments each day.

3.5 Compliments 70 compliments were received in October 2012 Norwich Locality – 34; South Locality – 3; North Locality – 18; West Locality 3; Children’s Locality – 1 and Specialist Locality – 11 Examples include:

“Words just don’t cut it. Really you were all BRILLIANT!!”

“You work through the night, you work through the day, someone is there when loved ones are away.”

Alder Ward, Norwich “My unsung heroes, I do not know what I would have done without them”

CAST Team, St James clinic, Kings Lynn We very much appreciated all your love and care for him – and us as well actually.”

Cranmer House, Fakenham “Thank you for all the advice and practical aids. I feel much more confident now to maintain independent living.”

City 4 Nursing Team

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3.6 PALS Service Enquiries during October 2012 Norfolk Community Health and Care PALS received a total of 42 enquiries during October. All enquiries were acknowledged within one day by phone or email. A breakdown of enquiries for October 2012 as entered on Datix is detailed below. Signposting/Advice (12 including)

• Alarm pendant to Norfolk County Council

• Thorough dental examination for young daughter to Norfolk PCT PALS

• Fall advice Great Yarmouth to East Coast community healthcare PALS

• Wishing to write to Speech and Language therapist in area to contacted service lead for the area

• Respite care to Norfolk county council

• Query about daughters mumps to advised return to GP surgery

• Daughter in New Zealand wishes to contact Father in Norwich Community hospital to contacted ward manager to advise.

Concerns (2 including)

• District Nurse visiting issue (Service contacted and they will address the issue mentioned)

Help/Support (18 including)

• Letter received concerning missed appointment, that client didn’t know that they had

• Refusal of hospital transport (error made )

• Cancellation of Physiotherapy classes

• Referred for anxiety management classes a while ago, has not heard anything

• Has not been able to visit relative in North Walsham hospital, through ill health. Wants to make sure he is getting on okay

• Needing to cancel appointment, unable to get through to central booking

• Advised by phone that equipment would be delivered. Nothing has turned up

• Non delivery of continence products

• Feels concern for son with mental and physical health issues, not being fully acknowledged by health services. Continence in particular

• Son has been waiting for appointment with Paediatrician for seven months

• Mother would like to be visited by a different health visitor.

Outcome Contacted all the services involved with these enquiries. Staff going to contact enquirers directly. All enquirers happy for them to do so Information (10 including)

• Trust membership details

• Shower protection aids (Foot surgery)

• Various services contact numbers Email Correspondence (29 received including)

• Appointment cancellations

• Organisation details

• Trust membership information

• Service information

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4. DATIX Risk Register Roll-out Project update As part of the implementation plan, Directors & Assistant Directors were asked to identify staff responsible for managing risk registers by the end June 2012 to enable a training programme to be established. A training programme was subsequently established by the Q&R team with a contingency to allow for late notification of an additional 20 staff. At the time of this report, 116 staff who were identified as risk register holders have completed the DATIX risk training. A further 19 staff who were booked into specific training sessions did not attend. In addition, a significant number of staff were identified in late September and early October as also requiring the risk training, therefore there are 59 staff who are currently awaiting training. A further 10 training sessions are in the process of being organised, to accommodate those already identified as requiring training, however these will not enable all identified staff to be trained by the end of November 2012 as originally planned. The impact of this will be that not all teams will have their risk registers uploaded onto DATIX by the end of November 2012.

NCOGD 01/10/2012 13:00

NCALD 03/10/2012 11:47

NCSWA 03/10/2012 11:48

NCSWA 03/10/2012 11:49

NCALD 03/10/2012 11:50

NCDERE 05/10/2012 8:59

NCSWA 05/10/2012 9:00

NCNWA 05/10/2012 9:00

NCBEN 05/10/2012 9:01

NCBEN 05/10/2012 9:02

NCALD 05/10/2012 9:02

NCBEN 05/10/2012 12:34

NCCRA 05/10/2012 12:36

NCALD 05/10/2012 12:39

NCPRI 05/10/2012 12:42

NCCRA 05/10/2012 12:42

NCDERE 05/10/2012 12:46

NCALD 05/10/2012 12:47

NCOGD 05/10/2012 12:47

NCNWA 05/10/2012 12:48

NCKEL 05/10/2012 12:49

NCSWA 05/10/2012 12:51

NCPRI 08/10/2012 10:36

Back

NCH&C FRIENDS AND FAMILY TEST – FRIENDS AND FAMILY REPORT (SCREEN)

GENERATED ON: 07/11/2012 13:31. FOR DATA BETWEEN 01/10/2012 AND 31/10/2012 FOR NODES:

Promoters

Because Ive been looked after very well.

Very comfortable and well looked after.

Very very good care and food is marvelous.

I was in Kings Lyn hospital 10 days. Everyone kind and helpful. Swaffham Cottage Hospital just over 4 wks.

One could not find fault with anything at all. Kindness, food so excellent.

Excellent care but would like to have been told more about my illness and treatment.

Why not 10? Very few things are perfect! Why so high as 9? From my first need in Oct 2011 I have had

wonderful help and care from all who came and wherever I went. The incontinence team with such caring and lack of embarrassment were a real

revelation, and delivery of pads a boon. The ambulance drivers + helpers were reassuring and even taking me home tomorrow my husband telling my

husband to be ready and welcome me. At both N+N and Foxley Ward Ive had a truly worthwhile experience. I’ve never been to a cleaner place in spite

of the water supply that has long been a problem. A great deal of pure drinking water had to be bought. I had not been in hospital for so long for a very

long time, since 1953 in face when a corker of a slipped disc. I have greatly admired the teamwork done, nurses and all the staff. Food and drink

excellent, bed comfortable.

Kind and helpful staff who were patient with me. Nice good and friendly atmosphere.

Very happy with the care given to me at NW – wonderful.

The staff both day and night were very kind and helpful.

Wishes or requests were carried out to my complete satisfaction.

I like this hospital the best, I enjoyed it. Food fine, wonderful staff, no complaints.

Excellent treatment from the nurses and all staff.

The staff are so kind helpful and always cheerful. The food is excellent. I could not have had better treatment.

Lot better than N&N and far more friendly. All help available when needed. Fantastic food v good. Mature staff

more caring.

The staff are caring considerate all very nice people and will do all they can for you. Nice atmosphere. Food is

very good. Services available are very good.

I was cared for very well.

My wife as been in hospital about 3 weeks. She has had excellent care and attention. The nurses have created

a pleasant and caring and relaxing atmosphere. I must compliment Foxley ward and all involved in the efficient way and friendly way daily chores are

done, and the cleanliness is second to none. Many thanks.

I cant find fault got lonely on my own. Staff lovely and friendly. Food average, room comfortable.

Happy here.

Excellent care. Nurses and other staff respect and care about their patients. Because of this care it ended quick

recovery.

Kelling is set in peaceful surroundings and the staff are kind and very helpful. My stay here was equipped me

with all I need to continue my recovery in my own home. I cannot thank to staff enough.

All were pleased to help in every way I would not have worried if I had to come again for any reason.

Everyone was so kind to me.

1) Management – high level of management skills in the running of this unit and in the preparatory work. 2)

Organisation – a ready ability to show flexibility in a non standard situation. 3) Personal care – a very high standard shown in all aspects undertaken. 4)

Flexibility in coping with situations not seen prior to admission. Ability to pick up on and deal with acute situations such as serious pain. Also, providing

care to pressure areas when needed. 5) Ability to identify and arrange continuing care at the unit and beyond nursing home. All of the above qualify for

a 10. Priscilla Bacon lodge to be highly commended on all counts.

Survey Results Comments/Actions etc Help & Information

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NCPRI 08/10/2012 13:06

NCDERE 10/10/2012 17:01

NCALD 10/10/2012 17:02

NCCAR 10/10/2012 17:05

NCBEN 10/10/2012 17:06

NCALD 10/10/2012 17:08

NCOGD 11/10/2012 14:41

NCKEL 11/10/2012 14:41

NCCRA 11/10/2012 14:43

NCCAR 14/10/2012 16:32

NCALD 14/10/2012 16:32

NCCAR 14/10/2012 16:35

NCNWA 14/10/2012 16:36

NCALD 15/10/2012 11:04

NCALD 26/10/2012 10:26

NCALD 22/10/2012 10:40

NCALD 22/10/2012 10:41

NCPRI 22/10/2012 10:56

NCALD 26/10/2012 10:26

NCPRI 30/10/2012 9:02

NCPINE 11/10/2012 11:11

NCALD 10/10/2012 17:02

NCBEN 10/10/2012 17:04

NCALD 11/10/2012 14:42

NCNWA 03/10/2012 11:47

NCALD 05/10/2012 8:51

NCALD 05/10/2012 12:38

NCKEL 05/10/2012 12:41

NCSWA 05/10/2012 12:51

NCDERE 05/10/2012 12:52

NCCRA 14/10/2012 16:32

NCALD 14/10/2012 16:37

NCALD 26/10/2012 10:27

Care – second to none. Compassion from all staff, care and sympathy at such a difficult time. Care to loved

ones not only the patient, cheerfulness from the staff evident that they loved doing their job. Wonderful, exceptional place. THANK YOU!

Would recommend straight away!

Been lovely, enjoyed it. Food good. Comfortable. Had good laugh with all the nurses. Couldn’t see TV. Clean.

Treated with dignity.

Excellent care at Pine Cottage.

If I had been the queen I couldn’t have been treated better.

I do like it here. Friendly staff. Treated with respect. Better food than other hospital. Comfortable. Loved the

night drinks. Beautiful and clean.

This is an excellent service for patients who are not quite ready to return home. Ogden Court is well run by a

truly professional team. There is a good balance between care, kindness, good humour, not always easy after the too long 14 hour shifts. There is an ex

exemplary attitude to cleanliness, clean towels, bedding, spotless environment and fresh smells. Individuals are shown respect and dignity remains

intact. I found just one aspect of the service disappointing – after care support. I would like to have seen more consideration for some short term

support when Mum left Ogden Court. She was very anxious about how she was going to cope following the stroke, leaving with a catheter. The was no

prior proper professional discharge meeting to discuss aftercare. It had already been arranged without family views being taken into account.

I have been very well looked after. Everybody has been very kind.

Everything is wonderful, the staff are excellent and very caring. Thank you very much for having me.

Friendly staff, good could improve.

Food better than in NNUH

My only complaint was the alarms going off constantly and some of the men and women screaming out which

cant be helped, the later one but surely the nurses can carry an alarm bell that would god off with the room no on it. My visitors and patients have all

talked about this. The other complaint is all the food that is wasted, when the staff are on 11 hour day and have to have sandwiches. Also I give the

food + service 100%. Well done to everyone who looked after me.

Cos you work very hard.

Excellent care. Very happy.

I enjoyed it, very kind people better than N&N. Food good, sweets lovely and steak and kidney good. Staff

excellent.

Everything first class. Need an arm rest on right hand side in toilet. Food good choice. Ten out of ten for staff!

First class!

Wonderful made me very welcome, no complaints, staff have been excellent. Good excellent I have been well

looked after. Ten out of ten.

All staff at the hospital gave above and beyond what was expected of them. Kindness, consideration and tact in

equal measure. I only wish this service had been available when my mother died of cancer. All staff deserve to be given a very heartfelt thank you.

Staff are very good, cleanliness good comfort very good. Noisy at night.

All staff at the Priscilla Bacon lodge Norwich were always helpful and kind. Nothing was too much trouble and I

enjoyed my stay here very much. The treatment I received was also excellent and good was also very good. Well done to all.

I have been treated with utmost love and care. I couldnt ask for anything more. Wonderful, thanks to every

one concerned.

Detractors

Alright. Noisy at night especially staff. Food started quite good but deteriorated. Clean enough. Most staff

treated me with respect and dignity.

Accommodation: 10. Rooms well organised and kept clean. Care: 4, the nurses on the whole were fine,

however one or two wouldn’t listen and ignored my painful condition. Some long delays due to overwork. Food: 4. Food was tasteless could be

nauseating. Vegetables overcooked.

Would have scored higher by nurses doing drug round too abrupt with patients.

Neutral/Passives

It is very good.

Would recommend. Excellent treatment. Food very good. Maybe bigger TV in a better position?

Against other hospitals Ive been in here the care is silver service. The staff being more mature are more

understanding. Atmosphere in my room with own toilets and only 4 people was like a good hotel. Nurses handover can be a noisy time. Good food

ample and well presented.

After a stay in one of the counties, the relief and different atmosphere at Kelling was a revelation. The friendly

and sympathetic treatment to me, then at a low ebb did much to give my partial recovery and return to my only home a boost. Kelling is fortunate.

Everything was fine.

Done their best to get me to walk. Nice staff, nurses are wonderful. Very clean. Food is nice.

All staff were helpful, kind and pleasant, food good.

Cleanliness is excellent. Staff on the whole are very patient. The only thing Anthony had problems with his

food – he could have done with having some help as on the whole, he enjoyed the meals but he wasnt able to feed himself totally and dropped food into

his lap. Also an apron could have been more useful.

Noisy builders etc otherwise pleasurable, nurses are brilliant. Food excellent, therapy excellent.

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SUBJECT Chair’s Report for Quality & Risk Committee (QRAC): Nov 2012 PRESENTED BY Alex Robinson – Chair of Quality & Risk Assurance Committee SUBMITTED TO NCH&C Trust Board 28 November, 2012 PURPOSE OF PAPER To receive and note

Key Issues and Actions Agreed

• The ‘spotlight’ session looked in detail at the Safety Thermometer (ST) and the use of data. It was noted that ST data provides a snapshot and should be used with caution, for example the DH has advised that ST data should not be used to make comparisons between units. The data is intended to show improvements over time. The interim Medical Director emphasised that as well as showing the current position for each of the harms observed, the ST data also serves as a “proxy indicator” of underlying care and higher rates of harm could indicate deeper systemic problems. None of the NCHC measures are showing high rates of harm and results over the last 6 months show improvements.

• Pressure ulcer (PU) reporting shows that awareness remains high. Recent training and improvements in clinical practice give assurance that we are on course for our ambition of zero avoidable PUs in inpatient units, but this remains a challenging target. It will be more difficult to achieve our ambition in Community Nursing where many factors beyond our control can influence the patient. Demand for pressure relieving equipment remains very high and this is leading to budget overspend in Equipment Services. The delivery of equipment is generally timely when sufficient notice is given, for example prior to planned discharge from acute care, but lack of notice can lead to a delay in the transfer of care.

• A C.Difficile case has been recorded at an inpatient unit. Investigations are under way and a report will be produced and reviewed at QRAC. This is the first case this year and is under our ‘ceiling’ of nine cases.

• NEDs challenged whether more can be done to reduce incidents relating to medicines and controlled drugs. The number of low harm incidents has stopped reducing after falling earlier in the year. The number of medium and severe harm incidents remains very low. This will be reviewed at a future meeting.

• The committee noted that the roll out of Datix training for risk recording is taking longer than anticipated because more people have requested training. Assurance was given that existing (non-Datix) recording will continue until all training is complete.

• 50% of seven-day incident reports were submitted late this month to NHSN&W. The committee were told that this was due to the complexity of the process and a staff shortfall. The process is under review and the staffing issues should be resolved shortly.

• The recommendations from the initial review of unexpected deaths at Pineheath ward were noted. NEDs requested that as many aspects as possible of the wider review should be presented in public, but acknowledged that some proposals would require consultation before any changes are recommended.

• QRAC supported proposals to de-escalate three risks from the Board Assurance Framework (BAF), but agreed that one risk relating to the pressure ulcer ambition should remain on the BAF with a reduced risk rating because it was volatile and of

ENCLOSURE: Gii

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strategic importance. NEDs gained assurance that clinical risk arising from the Admin Review was being mitigated, but noted advice from the interim Medial Director that the risk was still highly volatile and would be monitored through operational reporting.

• The Corporate Risk Register (CRR) was reviewed. All risks with a rating of 15 or above were scrutinised. It was agreed that a risk relating to the disposal of clinical waste in patients’ homes should be escalated to the BAF because mitigation had not improved despite executive action. A small number of other risks rated 15 were not escalated because it was felt that current executive action would be sufficient to mitigate them within the reporting period.

• The QRAC chair undertook to advise the Finance Director about delays in mitigating a health and safety (H&S) risk relating to storage of medical gases which appeared in the H&S Committee minutes.

• The revised framework for Board Escalation and Assurance (BAEF) was reviewed and approved for submission to the Board subject to a small number of amendments. It was noted that the NCH&C framework was being promoted as a best practice example to other trusts by an external consultancy.

• A NED challenged whether or not the BAF provided adequate assurance in line with the purpose stated in the BAEF. It was agreed that the BAF provided assurance about risk mitigation, but did not provide broader assurance about progress to achieve strategic aims. Two NEDs and the Company Secretary agreed to meet to test how the BAF could be strengthened.

• The internal audit report into Business Continuity was discussed. It was agreed that QRAC would review progress against the action plan in February 2013.

• The committee ratified 7 clinical strategies and noted the minutes from 12 sub-committees and groups. It was agreed that a short report about the role of the Clinical Ethics group would be given in January, after the QRAC chair has attended a meeting of the group.

Recommendation: The board is asked to note the report from the Quality and Risk Assurance Committee.

enclosure: gi date of trust board november · pdf filedate of trust board 28th november 2012...

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