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Public Session

PATIENT SAFETY/QUALITY

ASSURANCE REPORT

NHS ROTHERHAM CCG

February 2014

CONTENTS

1. PATIENT SAFETY ..................................................................................................... 3

2. MORTALITY RATES .................................................................................................. 3

3. SERIOUS INCIDENTS (SI) AND NEVER EVENTS (NE) ............................................ 3

4. CHILDREN'S SAFEGUARDING ................................................................................ 4

5. ADULT SAFEGUARDING .......................................................................................... 5

6. DEPRIVATION OF LIBERTY SAFEGUARDS (DOLS) .............................................. 6

7. CONTINUING HEALTHCARE (CHC) ......................................................................... 7

8. FRACTURED NECK OF FEMUR INDICATOR .......................................................... 7

9. STROKE ..................................................................................................................... 7

10. CQUIN UPDATE ........................................................................................................ 7

11. COMPLAINTS ............................................................................................................ 7

12. ELIMINATING MIXED SEX ACCOMMODATION ....................................................... 8

13. CQC INSPECTIONS ................................................................................................... 8

14. ASSURANCE REPORTS ........................................................................................... 9

APPENDIX A - Quality Assurance Team Annual Report ................................................... 10

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NHS ROTHERHAM

1. PATIENT SAFETY

Healthcare Associated Infection

1.1 RDaSH

There have been no cases of C-Diff, MRSA or MSSA reported for the year to date.

1.2 Hospice

The Hospice has had five patients, year to date, (one each in May, June & July and two in August) who were admitted with MRSA.

1.3 TRFT

MRSA – 0

MSSA – 0

E Coli – 18

C-Difficile

The year-to-date position is 23 against a trajectory of 22. The Trust have provided assurance to the RCCG Contract Quality meeting that the actions previously commended are still in place but concern was expressed that they cannot pinpoint how the cases are occurring. Multi agency Infection prevention and control meetings are being held to review all cases and information relating to current practices and actions.

Every case has been fully investigated and reported upon with multiple meetings of the C diff management group (TRFT) held and actions agreed and completed. Face to face education and training around basic infection and control measures are being rapidly progressed with all appropriate staff and continue to be rolled out by the Infection Prevention and Control Team. In addition, an observational audit of staff practice has been undertaken on the ward associated with the latest case.

2. MORTALITY RATES

The next update on the SHMI data is expected to be published January 2014.

3. SERIOUS INCIDENTS (SI) AND NEVER EVENTS (NE)

Position (01/01/2014 to 27/01/2014)

TRFT RDASH NHSR CCG

Ind. Contractors

Roth residents out of area

YAS

SIs open at beginning of period

9 17 2 0 0 2

Closed during period 1 3 0 0 0 1

New during period 5 2 0 0 2 0

Open at end of period 13 16 2 0 2 1

Never Events (New) 0 0 0 0 0 0

New Trends and themes 0 0 0 0 0 0

RFT

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2013/14 Target = 22

Monthly Actual

1 3 0 0 3 7 3 3 1 2

Monthly Plan

2 2 2 2 1 1 2 2 2 2 2 2

YTD Actual

1 4 4 4 7 14 17 20 21 23

YTD Plan

2 4 6 8 9 10 12 14 16 18 20 22

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4. CHILDREN'S SAFEGUARDING

Bluebell Wood Childrens hospice have received notification from Rotherham LSCB via the consortium that the section 11 assessment has met the required standard assuring compliance, this was positive around their safeguarding arrangements.

Date Discussion Outcome Follow up

April 2013 to present

Following two suicides (Nov 2012, Feb 2013) children and young people at a local school also had to contend with the tragic expected death of a young person (April 2013). Concerns expressed by agencies around the anniversary of second death and the imminent Coroner’s Inquest being considered.

RLSCB have published multi agency practice guidance on handling potential suicide clusters. This document has been shared with other areas as the incidence of adolescents suicide is increasing. The document is to be discussed with the national NHS England Safeguarding Lead.

An Independent Author is to write up the agency lessons learnt and share this widely. The incidence of adolescent suicide appears anecdotally to be on the increase nationally. Rotherham Local Authority have commissioned a Lessons Learnt Report.

Oct 2013 Letter from MP regarding holistic healthcare delivery and impact on family of disjointed care delivery

Letter from MP regarding holistic healthcare delivery and impact on family of disjointed care delivery

RCCG Chief Nurse and SCH Chief nurse in discussions. SY&B Chief Nurse involved.

February Update, SCH still not presented a report to RCCG. A further letter has been received from the MP

Jan 2014 Missing 15 year old girl and 2 15 year old Rotherham males over Christmas period

Males found quickly in Leeds area. Rotherham female and a 15 year old Leeds female remain missing.

Numerous multi agency strategy meetings took place as concerns around sexual exploitation and significant drug misuse

15 year old found by police in Bradford

Numerous arrests and further police work have taken place across Yorkshire region with regard to drug use and sexual exploitation.

Multi agency work to be undertaken with regard to „Missing Young People‟

February 2014

Discussions with RDaSH to include in contract Key Performance Indicators within the Safeguarding Standards. This innovation will be supported with a CQUIN and will provide quarterly data.

Safeguarding within RDaSH will be more transparent and accountable. Data to be shared with NHS England and benchmarked across South Yorkshire and Bassetlaw.

Designated Nurse Safeguarding to discuss with deputy Chief Nurse 22.01.2014

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4.1 Drivers for Change:

Date Discussion Outcome Follow up

October 2013

CQC Inspection of Safeguarding and LAC published. Monthly health economy update meetings commenced, Jan 2014.

Paper to OE 7 October 2013 to be followed up with an update on progress.

Action Plan to be proactive and be monitored via RCCG Designated Nurse. Cases currently being identified are raising some issues with regard to confidentiality and CASH services.

Jan 2014 Multi agency meeting arranged to discuss MASH (Multi Agency Safeguarding Hub) for Rotherham

There is a lot of interest from all agencies to move quickly to a MASH. The teams being suggested include TRFT Safeguarding Community Team and the CSE Team including the Nurse.

Further discussion to take place with TRFT Interim Chief Executive January 2014

4.2 Learning Review

Area Discussion Outcome Output

May 2013

Croydon

TRFT and RDaSH have completed an Individual Managements Report (IMR) for an external LSCB, namely Croydon

The methodology used is Significant Incident Learning Process (SILP).

Letter sent from RLSCB (31.12.2013) regarding closure of Rotherham actions to Croydon LSCB.

Rotherham LSCB is following up local recommendations to ensure compliance via the SCR Panel December 2013, completed actions sent to Croydon LSCB. February 2014 Update from Croydon with regards to publication, it was agreed by Croydon LSCB that the Overview Report required further work. The report is to be scrutinised (Jan 2014) and dependent on the outcome will be published after the Coroner‟s Inquest. This date has yet to be set.

17 October 2013

RLSCB undertook a challenge of partners work around Child Sexual Exploitation (CSE). New recruit from TRFT/Public Health budget has commenced post in CSE team

CSE Strategy in place (multi agency). Multi agency challenge with associated action plan.

CSE Team to have an identified health worker. Post holder commenced10 Dec 2013. RMBC have commissioned a further report on CSE, Designated Nurse being interviewed by Author 23.1.2014.

5. ADULT SAFEGUARDING

Headlines

Agreement by Rotherham Clinical Commissioning Groups, Operational Executive for Prevent Training for all RCCG staff. Training to be delivered via a staff meeting and a top-up date for non-attendees of the staff meeting.

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A Supportive Challenge & Training package has been developed and supported by RCCG Operational Executive. The programme is currently being commenced for primary care service. The programme is being supported by both Children‟s & Adults Safeguarding Boards.

A CQC Inspection of services in RDaSH was completed October 2013, resulting in an all standard met inspection. A synopsis of the report is detailed later in the report.

Domestic Homicide Review (1) Individual Management Reviews commenced preceding Court Case, Perpetrator convicted of the murder of his wife & manslaughter of his daughter.

Domestic Homicide Review (2) Individual Management Reviews commenced, waiting for direction of overview author for submission dates.

Pending – one police investigation regarding alleged falsification of qualifications. Integrated quality visit between Rotherham Metropolitan Borough Councils contracting team & Rotherham Clinical Commissioning Groups Safeguarding Adults & Clinical Quality Lead to a nursing home where several issues have been raised. The Safeguarding Adults lead was happy to report that an improvement was noted from previous visits. RMBC are currently planning a meeting with the home to discuss contracting compliance issues. The Continuing Health Care team has completed a safe & wellbeing check to ensure findings were replicated across the home. A pending report is awaited on the outcome of this visit

Care Home update.

This table identifies a synopsis of intelligence from across Rotherham, where information is used to identify key issues/concerns in Nursing homes and domiciliary care providers. This anonymised information is obtained from a shared database that is completed by several health and social care organisations.

Category Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Active reports under scrutiny

33

CQC Default 1

CQC Compliance Action 13

RMBC Default 6

RMBC Admission Restriction

1

Safeguarding Alerts – New & Ongoing

19

CHC Safe & Wellbeing Checks

1

6. DEPRIVATION OF LIBERTY SAFEGUARDS (DOLS)

Deprivation of Liberty Applications –

Care Homes Loxley Court, Sheffield (1), Authorised

Neville Court, Barnsley (1), Not Authorised

Forest Hill, Worksop (1), Authorised

Laureate Court (1), Authorised

On-going Deprivation Of Liberty

Care Homes Longley Park View, Sheffield (1), Swinton Grange (2), Waterside Grange (2) Meadow View (1), Ladyfield House (1), Silverwood (1), Athorpe Lodge (1), Cherry Trees (1) Laureate Court (2), Flower Park, Doncaster (1)

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7. CONTINUING HEALTHCARE (CHC)

One patient who had been served notice by a care home due to the behaviour of the family remains resident in the care home. This patient is no longer eligible for CHC, as per the National Framework, and requires Funded Nursing Care (FNC). Case management of this patient has now passed to the Local Authority.

A patient formerly resident in the Rotherham Hospice whose partner wanted them moved closer to home is now at home. A safeguarding conference identified that no abuse was substantiated.

CHC completed Safe and Well Checks at regarding 12 residents at Byron Lodge. Some minor issues were identified and actions required have been agreed with the care home. CHC and RCCG Safeguarding Adults are monitoring progress against the actions.

8. FRACTURED NECK OF FEMUR INDICATOR

The Trust are achieving target year-to-date, with actual numbers seen being 10% below trajectory. Q3 data is due at the end of January which will give a better indication of position through the winter months.

9. STROKE

In November the data for the stroke metric, 90% of time spent on a stroke ward met the target of 80%, achieving 81.81% (27/33). This brings the latest YTD position to 83.33% (225/270).

10. CQUIN UPDATE

10.1 RDaSH

Awaiting Quarter 3 reports. Negotiations ongoing for 2014/15 CQUINs

10.2 Hospice

Awaiting Quarter 3 reports. Negotiations ongoing for 2014/15 CQUINs.

10.3 TRFT

All CQUIN indicators for Q2 have been achieved, year-end forecast after two quarters indicates 95.6% achievement overall, this is being closely monitored. Q3 data is due at the end of January which will give a better indication of potential year-end achievement bearing in mind winter pressures in some services.

Early indications show that the NHS Safety Thermometer remains a significant challenge and it is anticipated that TRFT will only reach partial achievement of 40-59% reduction on baseline.

The Dementia target also remains at significant risk of achievement and discussion with the Trust is ongoing. It is expected that by year end there will be significant improvement due to the employment of the new Dementia Lead in December, and the Trust hopes to achieve 95% in February and March.

The Friends and Family Test is indicated to have dropped in December but is still above trajectory, ratification of final figures is awaited.

Clinical Referrals Management Committee audits are planned to take place for Q4 on follow up attendances in Trauma & Orthopaedics and General Medicine, and review of emergency admissions for Paediatrics. These will be completed by mid-March 2014.

Negotiations are to commence with TRFT on the CQUIN indicators for 14/15 after consultation with CCG members. There are three national goals – Friends and Family Test, NHS Safety Thermometer and Dementia - which are varied slightly from previous year. It is anticipated that there will be three local goals with 8 indicators spread across these.

11. COMPLAINTS

No new complaints received and no updates to add to last month‟s report

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12. ELIMINATING MIXED SEX ACCOMMODATION

There were no Mixed Sex Accommodation breached reported for the month of December for TRFT or RDaSH.

13. CQC INSPECTIONS

RDaSH

The CQC carried out an unannounced inspection of the Tickhill Road, Doncaster site of RDaSH during October, 2013. Overall, the report from the visit is positive. There were a few areas of minor concern reflected in the report, but otherwise there were no “themes” evident.

Whilst the site visited is in Doncaster and predominantly for Doncaster patients, at any time it is quite likely that a Rotherham patient will have been admitted because of how RDaSH utilise their resources across commissioners.

Overview of CQC Inspection report for Rotherham Doncaster and South Humber NHS Foundation Trust.

The following standards were assessed as part of a routine inspection -

Consent to care and treatment, Care and welfare of people who use services, Cooperating with other providers, Safeguarding people who use services from abuse, Staffing, Supporting workers, and Assessing and monitoring the quality of service provision. On this visit all standards where met.

Overall the CQC inspection report is a positive in the delivery of the above standards; there are however some minor points for commissioners to consider in this report from a quality perspective as detailed below.

Consent to care and treatment

One record was found to not have consent documented within relation to care planning, and that at least two patients were aware they had a care plan, they were unaware of how to access it and some had not signed there care plan.

A locked door in a day service unit was not seen by the manager of the unit as restriction on service users, the door was looked to restrict entry not exit was noted, no formal risl assessments were noted, thus CQC felt that this could „liable to unnecessarily restrict people's movements‟.

Care and welfare of people who use services

CQC found that in a low secure area that access to fresh air was restricted. People said there were restrictions on times they could go outside, for fresh air or to smoke. We noted there was no outside space that people could gain access to easily. To get to the secure outside area where there was a smoking shelter staff had to accompany people through two locked doors. Assurance was given that practise change & refurbishment was underway in this area to ensure less restrictive.

Safeguarding people who use services from abuse

The manager responsible for the Doncaster safeguarding board who told us there were differences in the way the threshold for safeguarding alerts were managed between the trust and the local authority. They felt that in some instances incidents were being investigated as clinical incidents rather than safeguarding alerts. However, the trust told us that all incidents of suspected safeguarding were investigated appropriately. In order to manage safeguarding appropriately it is important that the trust and safeguarding board agree on the most appropriate way to manage the process.

Supporting workers

CQC reviewed electronic evidence of training provided by the trust's Organisational Management Learning system. Although it gave a breakdown of training the trust informed CQC it was not accurate and could not provide assurance as to staff attendance at training courses.

However, CQC also reviewed training records held by business divisions. When all sources were combined it showed that the trust was providing a sufficient level of training to its staff in order to allow them to meet people's needs. CQC commented that The provider may find it useful to note that the

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Organisational Management Learning system was unable to provide an accurate up-to-date picture of training completed by staff.

Assessing and monitoring the quality of service Provision

CQC spoke with staff in the areas we visited some of them told us they did not know who the executive directors or the chairperson were, and had not seen them in their wards. The provider might find it useful to note that not all staff we spoke with had experience of visits from the chairperson or executive directors.

The Rotherham Hospice

No visits undertaken

Chesterfield Royal Hospital Foundation Trust

A letter was received from the CQC to Chesterfield Royal regarding non-compliance in some areas of quality of care following CQC inspection. There have been 590 Rotherham patients seen during 13/14, it is not anticipated that these were affected in the specialties where non-compliance has been flagged. A copy of the response from the hospital to the CQC has been requested and will be shared with Associates after February‟s quality assurance group meeting at Derbyshire CCG.

Bluebell Wood Childrens Hospice

Following a visit by the CQC Bluebell Wood were declare compliant with the Standards that were inspected.

14. ASSURANCE REPORTS

TRFT

Clinically Led Visits

The second of three agreed clinically led visits was undertaken in January with the Physiotherapy Service. It was a positive visit and the final report is being collated this will be discussed with the Trust prior to submission to CCG Governing Body and TRFT Board.

CCG clinicians visited three areas of physiotherapy – a GP Surgery, Park Rehabilitation and Community Health Centre. Following the visit detailed feedback was given during a face-to-face meeting with senior managers and clinicians from TRFT.

A&E

Current year-to-date position as at 22nd January is 94.84%, Q4 position is 94.54%. TRFT achieved Q3 performance at 96.13% and the action plan for A&E that was developed in Q3 is being monitored through the Contract and Unscheduled Care Management Committee. A year-end target of 95% is still achievable based on current trajectories.

Emergency Preparedness, Resilience and Response Letter

Assurance was sought from TRFT on the areas for action that had been highlighted. Confirmation was received that the Trust has a robust action plan in place and is working towards completing all outstanding actions by the March deadline, the CCG were satisfied with progress.

Sue Cassin – Chief Nurse February 2014

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APPENDIX A - Quality Assurance Team Annual Report

The Quality Assurance Team Annual Report

2012 - 2013

Rachel Garrison, Quality Assurance Manager Page 2 of 13

1 Introduction .................................................................................................................... 2

2 Summary of Clinical Effectiveness Activity ..................................................................... 2

3 The Local Incentive Scheme .......................................................................................... 3

4 The Quality Handover and Legacy Project ..................................................................... 4

5 GP Reporting Programme 2012/13 ................................................................................ 5

6 Ophthalmology Reporting Programme 2012/13 ............................................................. 6

7 Coroners Reports ........................................................................................................... 6

8 Rotherham Suicides & Deaths from Undetermined Intent .............................................. 8

9 The Multi-Source Feedback Project ............................................................................. 11

10 Conclusion ................................................................................................................... 12

1 Introduction

In 2012/13 the remit of the Quality Assurance Team was to continue to facilitate and undertake high quality clinical effectiveness projects that have a direct impact on making real improvements to patient care, both for commissioning and independent contractors. Our overall goal was to promote, develop, implement, and deliver clinical effectiveness activity by delivering training, guidance and practical facilitation and support where individuals or organisations needed it, whilst recognising the transition from Primary Care Trust to Clinical Commissioning Group (CCG). The team consists of a Quality Assurance Manager, a Quality Assurance Officer, and two Quality Assurance Support Officers, at bands 4 to 6 with a whole time equivalent of 2.92, and sits within the team of the Chief Nurse. As the role of the organisation has changed over the last 12 months, so the role of the team has continued to evolve and we find ourselves completing an increasing variety of work further removed from the traditional clinical effectiveness workload. Leading on projects such as multi-source feedback to support GP revalidation with the Medical Director, and the Quality Handover and Legacy Project, we work less to support independent contractors and more to facilitate quality commissioning. In the coming year our remit will change again to include taking on the management, monitoring, and quality assurance of a large number of enhanced services, widening our skill base further and providing further opportunities for development for the whole team.

2 Summary of Clinical Effectiveness Activity It is not possible to report clinical effectiveness activity in the way we have done traditionally i.e. by provider, or by practice, because as a CCG we no longer have a remit to monitor this activity. In 2012/13 we continued to provide a support service to General Practice as and when requested, but activity was minimal due to the impact of the Local Incentive Scheme (LIS); the LIS contained a mandatory audit element, so there was little additional work carried out. In the main, the only other effectiveness work we are aware of in General Practice involved assessment of the key standards for Care Quality Commission (CQC) registration. For a handful of practices, the team helped to establish their current


performance against a range of patient centred benchmarks. Further pieces of work were then carried out after improvement programmes had been implemented. There were no requests for training and due to the voluntary redundancy of the Clinical Audit Facilitator who historically led the Open College Network course, this did not run.

3 The Local Incentive Scheme

The Local Incentive Scheme for GPs in 2012/13 contained a clinical audit element designed to improve the quality of GP audit overall. One audit had to be chosen and submitted for approval to meet targets for standards and progress. The submissions were reviewed at the end of each quarter and feedback was given to the practice. All projects were completed on time and to the required standard.

QA Team Number Name Audit Title

Rachel Garrison C87007 Stag COPD & Asthma

Rachel Garrison C87009 Brinsworth Obesity audit

Rachel Garrison C87014 Treeton Heart Failure

Rachel Garrison C87610 Canklow Road RCHS Paediatric admissions

Rachel Garrison C87612 Surgery of Light Ambulatory BP Monitoring

Rachel Garrison C87621 Broom Valley Road COPD and flare-up plans

Rachel Garrison C87622 Gate RCHS Hepatitis audit

Rachel Garrison Y02616 Chantry Bridge COPD Audit

Rachel Garrison C87002 Dinnington Osteoporosis audit

Rachel Garrison C87004 Kiveton Park Gastroenterology referral audit

Rachel Garrison C87008 Swallownest Audit of Orthopaedic Referrals to OPD

Rachel Garrison C87022 Village COPD Care

Rachel Garrison C87609 Rosehill RCHS Non-elective medicines for elderly admissions

Lesley McNeill C87006 Magna Group Gout

Lesley McNeill C87018 High Street Vitamin D

Lesley McNeill C87023 Dalton Consent

Lesley McNeill C87608 Shakespeare Road Vitamin B12

Lesley McNeill C87617 Thrybergh A&E Attendance

Lesley McNeill C87005 St Ann's Fatty Liver Pathway

Lesley McNeill C87017 Clifton PAD in Diabetes

Emma Charnock C87003 Woodstock Bower Glycaemic control diabetes

Emma Charnock C87012 Broom Lane Cancer Referral

Emma Charnock C87020 Greenside Cancer diagnosis

Emma Charnock C87603 Greasbrough Cancer Referral

Emma Charnock C87029 Market Glucose strips

Emma Charnock C87030 Crown Street Atrial Fibrillation

Emma Charnock C87010 York Road COPD

Emma Charnock C87013 Parkgate COPD

Emma Charnock C87024 Rawmarsh COPD

Emma Charnock C87604 Thorpe Hesley COPD

Ian Baker C87015 Wickersley Audit of Combined Contraceptive Prescribing

Ian Baker C87016 Morthen Road Hypertension Medication Prevention of Risk of Type II Diabetes

Ian Baker C87031 Shrivastava Audit of breast clinic referrals

Ian Baker C87606 Queen's NSAID Prescribing

Ian Baker C87616 Blyth Road Audit of outpatient referrals to Elderly Medicine

Ian Baker C87620 Manor Field Audit of Out patient referrals to Trauma and Orthopaedics


4 The Quality Handover and Legacy Project The Quality Handover and Legacy Project was a piece of work designed to ensure the corporate memory of NHS Rotherham PCT was not lost during the transition to NHS Rotherham CCG, and to form the basis of the legal transfer of people, functions, responsibilities, and data, to newly formed organisations. It was internally led by the Quality Assurance Manager and overseen by the NHS England Local Area Team and two Management Consultants who were hired by NHS England to assist. The project began by identifying key members of staff within NHS Rotherham PCT who held documents that were critical to business continuity e.g. clinical contracts, financial programmes, databases etc. An electronic archive was created to hold all these documents in one place so NHS Rotherham CCG and other nominated receivers could access/receive copies as necessary. The archive was then populated by the key members of staff so the location of these documents was known should the member of staff subsequently transfer elsewhere or choose to leave the organisation. A Legacy Document containing facts, population demographics and other essential information was also created, following national guidance, and a copy was issued to each organisation that were listed to gain responsibilities and/or functions following the dissolution of NHS Rotherham PCT. The project then compiled a spread sheet of the assets and liabilities of NHS Rotherham PCT detailed in over 1,800 lines of data under the following categories, drawn from each team in the PCT who were responsible for outlining everything they owned/used/had responsibility for:

- Clinical Contracts - Commissioning - Corporate - Estates & Facilities - Finance - Human Resources - IT Infrastructure - Planning & Performance - Primary Care - Public Health - Quality - Records Management

And covering the following sub-categories:

- Equipment - Hardware - Insurance - Intellectual Property - Legal Claims - Memorandums of Understanding - Non-healthcare Contracts - Records - Software - Systems and Information

These assets and liabilities were then examined in detail to ensure they were assigned to the correct organisation, forming the contracts and Business Transfer Agreements in the legal process of transfer.


The Quality Handover and Legacy Project will continue into 2013/14 to finalise transfers, assign documents from the Cintas Archive Facility, and remove files no longer owned NHS Rotherham CCG from the network before passing them to their legal owner. This process is anticipated to take up to a year.

5 GP Reporting Programme 2012/13 In 2012/13 we continued to provide data reporting for the organisation to monitor key standards and performance measures. Data relating to Infant Feeding Status was provided for Integrated Performance Measures Return (IPMR) on a quarterly basis. Data relating to CVD Assessments was provided for Primary Care Commissioning on a monthly basis for processing payments to GP’s for the LES. Data relating to Secondary to Primary Care Transfer – Removal of Sutures was provided for Primary Care Commissioning on a quarterly basis for processing payments to GP’s for the LES.

GP Reporting Detail

Title Query

Infant Feeding

Run on a quarterly basis

National Standard or Initiative: VSMR

a) Total children age 10 weeks in current Quarter

b) Total children age 10 weeks, breast fed – latest status recorded age 5 – 10 weeks

c) Total children age 10 weeks, partially breast fed – latest status recorded age 5 – 10 weeks

d) Total children age 10 weeks, bottle fed – latest status recorded age 5 – 10 weeks

e) Total children age 10 weeks, feeding status not recorded – between age 5 – 10 weeks

f) Analysis of outcomes

LES - CVD

Run on a monthly basis

National Standard or Initiative: LES

a) Eligible Population

b) Historic Health Checks with Explanation, 1st April 2006 to 31st March 2011

c) Health Checks with Explanation in Month

d) Coverage (%)

e) Checks to be Paid at 45% and above Coverage Rate

f) Checks to be Paid at Below 45% Coverage Rate

g) Patients Invited for a Health Check within Month

h) Patients put on Statins

i) Patients put on Statins since 2006

j) Analysis of outcomes

LES - Secondary to Primary Care Transfer – Removal of Sutures



a) Total patients who have had a post-operative suture removal service for patients who have had treatment in secondary care.

b) Analysis of outcomes


6 Ophthalmology Reporting Programme 2012/13 The Quality Assurance Team took on the function of recording and reporting of Ophthalmology Cataract Assessment Referrals and Post Operation Assessments. The activity was collected and reported to Primary Care Commissioning on a monthly basis. We also reported on Ophthalmology Ocular Hypertension Refinement Scheme Referral and Non Referrals. The activity was collated and reported to Primary Care Commissioning on a monthly basis.

Ophthalmology Reporting Detail

Title Query

Cataract Referral and Post Operation Assessments

Reported on a monthly basis

a) Total referral assessments

b) Total post operation assessments

c) Analysis of outcomes

Ocular Hypertension Refinement Scheme Referral and Non Referrals


d) Total assessments resulting in referral

e) Total assessments resulting in Non-referral


7 Coroners Reports Between 01 April 2012 and 31 March 2013 the Quality Assurance Team received 486 coroners’ reports. Of these, 416 were for patients registered with Rotherham GPs:

Practice Code Practice Reporting Name Total Number of

Reports Percentage of

Reports

C87002 Dinnington 32 8%

C87003 Woodstock Bower 17 4%

C87004 Kiveton Park 19 5%

C87005 St Ann's 37 9%

C87006 Magna Group 18 4%

C87007 Stag 17 4%

C87008 Swallownest 28 7%

C87009 Brinsworth 6 1%

C87010 York Road 11 3%

C87012 Broom Lane 16 4%

C87013 Parkgate 12 3%

C87014 Treeton 8 2%

C87015 Wickersley 5 1%

C87016 Morthen Road 13 3%

C87017 Clifton 26 6%

C87018 High Street 9 2%

C87019 Wath 1 0%

C87020 Greenside 13 3%


C87022 Village 16 4%

C87023 Dalton 4 1%

C87024 Rawmarsh 9 2%

C87029 Market 18 4%

C87030 Crown Street 19 5%

C87031 Shrivastava 7 2%

C87603 Greasbrough 9 2%

C87604 Thorpe Hesley 7 2%

C87606 Queen's 2 0%

C87608 Shakespeare Road 3 1%

C87609 Rosehill RCHS 8 2%

C87610 Canklow Road RCHS 1 0%

C87612 Surgery of Light 2 0%

C87616 Blyth Road 13 3%

C87617 Thrybergh 1 0%

C87620 Manor Field 7 2%

C87621 Broom Valley Road 1 0%

Y02616 Chantry Bridge 1 0%


The coroners’ reports are sent to the Quality Assurance Team from the HM Coroner, Doncaster in batches of on average 38 reports. Over the year the team has received 11 batches.

April 2012 66

May 2012 31

June 2012 28

July 2012 52

August 2012 27

September 2012 0

October 2012 61

November 2012 22

December 2012 0

January 2013 50

February 2013 79

March 2013 0

Each report has to be checked on Open Exeter. This System contains up to date demographic information on all patients in any specific area. We have four checks to verify we have selected the right patient; name, address, date of birth, and date of death. We note the patients GP practice and current GP if found. If no information is located we create a record on our system and forward the reports to South Riding Health Services Support Agency (SRHSSA). The team receives two types of coroner reports; post-mortems and inquest verdicts. In 2012/13, 349 (84%) reports received were post mortem and 67 (16%) were inquest verdicts. The inquest verdicts are then categorised depending on the verdict of death:


Neither 1 1%

Open Verdict 62 93%

Suicide 4 6%

70 of the reports were sent to South Riding Health Services Support Agency (SRHSSA) as the patient was not registered with a Rotherham GP. Each Rotherham patient’s basic details (name, GP, report type, verdict, and date of death) are then input onto our database, to ensure we have a record of processed data. The report is then sent to the registered GP for their information. We ensure all reports are sent within 2 working days of receipt to make certain the GP has access to the information as soon as possible.

8 Rotherham Suicides & Deaths from Undetermined Intent

The detail of this report has been taken from information made available from The Rotherham Coroner, South Yorkshire Police, and GP Practices. The content of this report includes information on all reported cases of deaths by undetermined intent between April 2012 and March 2013. A system is in place where the Quality Assurance Team at NHS Rotherham is informed as soon as possible when the coroner’s office becomes aware of a death by undetermined intent by a resident registered with a Rotherham GP.

In the first instance Quality Assurance staff receive notification from the coroner’s office on any relevant deaths, usually within a few working days of the occurrence.

Quality Assurance staff inform the Practice Manager at the deceased’s General Practice on the same day that they are notified of the death. This is so that not only are they are aware of the death, but also to allow them to support the bereaved as appropriate. GP practices hold in-house Significant Event Audits where and when appropriate, actions are agreed at MDT Meetings held within GP practices, not at PCT.

Quality Assurance staff arrange with the Practice Manager to complete the minimum data set, via the ‘Suicide Audit in Primary Care Trust Localities: Data Collection Proforma’

Quality Assurance staff contact named persons at RDaSH, Primary Care Mental Health Service, and Public Health, to ensure they have been made aware of the incident.

All information collected is input into the National Suicide Audit Toolkit Database. This is an electronic database that was provided at the launch of the National Suicide Audit (2007) and is still used to record the information as it is a good tool allowing the easy extraction of information for analysis.

A list of ‘Inquests Concluded in Rotherham’ are received on a monthly basis and consequently the database is updated to reflect the verdict.

Since the launch of the cross-government Suicide Prevention Strategy in 2012, Suicide Prevention, and Self Harm Group Meetings are now held to bring together knowledge about the deaths. This group is chaired by Director of Public Health and members include Public Health (RMBC), Chair of the Health and Wellbeing Board, Rotherham CCG, Rotherham and Barnsley Mind, Children and Young People’s Services (RMBC), RDaSH, Rotherham Foundation Hospital Trust, Neighbourhoods and Adult Service


(RMBC) Rotherham Samaritans, South Yorkshire Police and a local college. This group is developing an action plan which will address the themes outlined in the national strategy.

A smaller group chaired by Director of Public Health meets to look at all the reported deaths where suicide is suspected for the purposes of identifying any trends and to look at any preventative measures which need to be introduced. Group members include Public Health, Rotherham CCG, South Yorkshire Police, and RDaSH.

Between 1ST April 2012 and 31ST March 2013 the Quality Assurance Team has been informed of 18 deaths. GENDER

AGE

4

14

0

2

4

6

8

10

12

14

16

Female Male

1

2

3

5

4

0

3

0

1

2

3

4

5

6

15-19 20-29 30-39 40-49 50-59 60-69 70+


METHOD

LOCATION OF EVENT

MONTH OF EVENT

13

1 1 1 1 1

0

2

4

6

8

10

12

14

15

2 1

0

2

4

6

8

10

12

14

16

Home Address (various locations)

Woods Motorway Bridge

0 0

1

3

1

2 2

1

2

1

4

1

0

1

2

3

4

5



Of the 18 deaths, 12 are still awaiting a verdict. The verdicts concluded are as follows:

4 = ‘Suicide’ 1 = ‘Took own life’ 1 = ‘Open Verdict’

The number of Coroner Rule 43’s was not collected for 2012/2013, however the team will look at the feasibility of collecting this data in future.

9 The Multi-Source Feedback Project

In 2012/13 NHS Rotherham provided a programme of multi-source feedback (MSF) to business critical GPs to ensure they met a key requirement for revalidation. Later, the scheme was rolled out to other GPs who had expressed interest and in total 62 GPs from 10 practices took part and received a personal report.

All doctors who wish to practise medicine in the United Kingdom need to be registered with and licensed by the General Medical Council (GMC). To retain their license with the GMC, doctors are also required to revalidate on a regular basis to demonstrate that they are still ‘fit to practice’ medicine. The project was designed as a learning and development tool by the GMC to identify strengths and areas for improvement in a doctors practice to inform their professional development. It was also one of several pieces of information that, when considered together, will inform the decision as to whether a doctor should be recommended for revalidation. All doctors are expected to seek such feedback from colleagues and patients (where appropriate) at least once every revalidation cycle. Seeking feedback in this way is designed to enable colleague and patient views about a doctors behaviour and performance to be gathered in a more systematic way. It provides the opportunity for patient, non-medical co-workers (including other health professionals, managers and administrators) and medical colleagues (including trainees and juniors) to reflect on the professional skills and behaviour of a doctor. The GMC developed template questionnaires which we adapted locally and piloted at Market Surgery to ensure they were effective. There were three different questionnaires; colleague, patient, and self. Colleague: The GMC recommended that the doctor nominate 20 colleagues (10 medical and 10 non-medical) to provide feedback on their professional performance. In Rotherham, we decided to take a slightly difference approach and send the questionnaire to all staff in the GP practice to ensure everyone had a fair chance to participate, rather than select respondents. Where the doctor worked in a small practice or not in general practice at all, they were asked to help to identify a sufficient number of clinical and non clinical colleagues from which we could randomly select a sample. Colleagues were then sent a link to an electronic questionnaire via email, and were asked to complete it within a set period of time. The GMC guidance stated that a minimum of 15 colleague questionnaires must be returned to achieve a reliable result. Patient: The GMC recommended that 45 questionnaires were distributed to consecutive patients at the time of their appointment with the aim of receiving 34 returned to ensure the


results were reliable. The local pilot project suggested more than this needed to be distributed in order to ensure the minimum number was received; 55 to 75 was preferable. The local pilot project used electronic stands placed in the practices to collate patients view, but this proved problematic; some people began but didn’t complete the questionnaire, meaning it had to be discounted, some were clearly completed by children, and some weren’t completed at all as people played with machines rather than answered the questions. To try to prevent this, paper was found to be a more controllable method of data collection. It also ensured we were aware of how many questionnaires had been distributed, as a set number were sent by the Quality Assurance Team for each doctor, and they were handed to each patient seen until they are all gone. Completed questionnaires were then placed in a sealed box on reception or respondents were given an envelope they could seal and hand back to reception staff so they felt able to express their views honestly, without worrying about having to pass their responses back to a person. Self: In order to provide comparison between a doctors perception of their practice and how others view them, a link to an electronic self questionnaire was emailed to each doctor for completion within a set period of time. The Quality Assurance Team organised the set up of the project with the Manager of each Practice and conducted all the resulting data analysis and reporting, but practice cooperation was needed to ensure it was successful. Either GPs needed to distribute their own questionnaires and explain how important it was for patients to complete them and return them to reception, or reception staff had to hand them out. The choice of method largely depended on how patients booked in when they arrived for their appointments, but the response rate was higher if the doctor made the request. Analysis of the data collected was carried out electronically using Survey Monkey as this removed the chance for human error in calculations. Data was produced for the individual and gave a personal and practice average score for each question, as well as the comparison to the self assessment. Ordinarily, the only people to see the results were members of the Quality Assurance Team and the doctor in question. However, in the unlikely event of serious patient safety concerns being raised then these would have been brought to the attention of the Medical Director. Data held on Survey Monkey servers was labelled by initials only, and the report issued was saved on a secure server. All hard copies of data or the report were destroyed. Reports were sent to the doctor by email in PDF format, and acknowledgement of receipt was required.

The responsibility for Revalidation passed to the NHS Commissioning Board on 1st April 2013 so the programme has now closed.

10 Conclusion The volume of work undertaken by the team this year has been substantial, and for the first time has varied considerably from our historical workload. In addition to the projects outlined in this report the Quality Assurance Team provided ongoing support to Protected Learning Time events, provided ad hoc assistance to the other members of the larger team of the Chief Nurse, and led on the Quality Handover, Legacy and Transition programme of NHS England.


The forthcoming 12 months marks another shift in remit as we take over managing a number of enhanced services. We plan to manage this new workload as follows:

Work Project Lead Supported by Further assistance if necessary

Enhanced Services: Cataract, Glaucoma, DMARDs, Anti-coagulation, Aural Care, Acupuncture, Cryotherapy, Secondary to Primary Care Transfer

Rachel Garrison

Lesley McNeill / Ian Baker

Emma Charnock

CCG Commissioned Services and Dementia Prevalence Report for Operational Executive: Quarterly Reporting of Anti –coagulation, DMARDs, Case Management, Dementia and Choose & Book activity

Ian Baker

Lesley McNeill

Emma Charnock

Local Incentive Scheme Referral Audit: Co-ordination of data collection and analysis of activity

Ian Baker

Lesley McNeill

Emma Charnock

Local Incentive Scheme: Evidence, surveys, Practice Managers Forum, quarterly tracking

Emma Charnock

Lesley McNeill

Ian Baker

Case Management: Survey Monkey, request & chase responses, analyse data, produce report

Emma Charnock

Lesley McNeill

Ian Baker

CQUINS: Quarterly data collection, analyse data, produce report

Rachel Garrison / Emma Charnock

Lesley McNeill

Ian Baker

Protected Learning Time: Analyse data, produce results, distribute letters, attend meetings

Lesley McNeill

Emma Charnock

Ian Baker

Suicide: Receive & report suicides, monthly meetings, annual report

Lesley McNeill

Ian Baker

Emma Charnock

Coroners Reports: Input & disseminate reports, annual report

Lesley McNeill

Emma Charnock

Ian Baker

In addition, we have a number of projects planned jointly with The Rotherham Foundation Trust: No. Title Project aim

1 Management of leg ulcers To address inconsistency in quality of management in primary care and the community in comparison to TRFT

2 Infertility and miscarriage proforma

An audit to assess compliance with infertility and miscarriage proforma

3 HMB Pathway A re-audit to assess compliance with the HMB pathway

4 Spinal and facet join injections

A six monthly audit to monitor downward trend

5 Spinal pathway An audit of 50 referrals to assess adherence to the spinal pathway

6 MSK conversion rates An audit of MSK conversion rates

7 Fitness for surgery An assessment of how many patients not fit for surgery and why e.g. BP / HbA1C following inclusion in BiteSize May 2012

8 Opthalmology referrals An assessment of 50 referrals to examine conditions referred and review how many could have been managed in the community

9 Consultant to Consultant referrals

A re-audit of 50 patients to assess compliance with the consultant to consultant referral policy

We will also continue to provide support and assistance to rest of the organisation and its stakeholders on an ad hoc basis wherever necessary, and to General Practice where capacity allows.

The Quality Assurance Team Annual Report

2012 - 2013


1 Introduction .................................................................................................................... 2

2 Summary of Clinical Effectiveness Activity ..................................................................... 2

3 The Local Incentive Scheme .......................................................................................... 3

4 The Quality Handover and Legacy Project ..................................................................... 4

5 GP Reporting Programme 2012/13 ................................................................................ 5

6 Ophthalmology Reporting Programme 2012/13 ............................................................. 6

7 Coroners Reports ........................................................................................................... 6

8 Rotherham Suicides & Deaths from Undetermined Intent .............................................. 8

9 The Multi-Source Feedback Project ............................................................................. 11

10 Conclusion ................................................................................................................... 12

1 Introduction

In 2012/13 the remit of the Quality Assurance Team was to continue to facilitate and undertake high quality clinical effectiveness projects that have a direct impact on making real improvements to patient care, both for commissioning and independent contractors. Our overall goal was to promote, develop, implement, and deliver clinical effectiveness activity by delivering training, guidance and practical facilitation and support where individuals or organisations needed it, whilst recognising the transition from Primary Care Trust to Clinical Commissioning Group (CCG). The team consists of a Quality Assurance Manager, a Quality Assurance Officer, and two Quality Assurance Support Officers, at bands 4 to 6 with a whole time equivalent of 2.92, and sits within the team of the Chief Nurse. As the role of the organisation has changed over the last 12 months, so the role of the team has continued to evolve and we find ourselves completing an increasing variety of work further removed from the traditional clinical effectiveness workload. Leading on projects such as multi-source feedback to support GP revalidation with the Medical Director, and the Quality Handover and Legacy Project, we work less to support independent contractors and more to facilitate quality commissioning. In the coming year our remit will change again to include taking on the management, monitoring, and quality assurance of a large number of enhanced services, widening our skill base further and providing further opportunities for development for the whole team.

2 Summary of Clinical Effectiveness Activity It is not possible to report clinical effectiveness activity in the way we have done traditionally i.e. by provider, or by practice, because as a CCG we no longer have a remit to monitor this activity. In 2012/13 we continued to provide a support service to General Practice as and when requested, but activity was minimal due to the impact of the Local Incentive Scheme (LIS); the LIS contained a mandatory audit element, so there was little additional work carried out. In the main, the only other effectiveness work we are aware of in General Practice involved assessment of the key standards for Care Quality Commission (CQC) registration. For a handful of practices, the team helped to establish their current


performance against a range of patient centred benchmarks. Further pieces of work were then carried out after improvement programmes had been implemented. There were no requests for training and due to the voluntary redundancy of the Clinical Audit Facilitator who historically led the Open College Network course, this did not run.

3 The Local Incentive Scheme

The Local Incentive Scheme for GPs in 2012/13 contained a clinical audit element designed to improve the quality of GP audit overall. One audit had to be chosen and submitted for approval to meet targets for standards and progress. The submissions were reviewed at the end of each quarter and feedback was given to the practice. All projects were completed on time and to the required standard.

QA Team Number Name Audit Title

Rachel Garrison C87007 Stag COPD & Asthma

Rachel Garrison C87009 Brinsworth Obesity audit

Rachel Garrison C87014 Treeton Heart Failure

Rachel Garrison C87610 Canklow Road RCHS Paediatric admissions

Rachel Garrison C87612 Surgery of Light Ambulatory BP Monitoring

Rachel Garrison C87621 Broom Valley Road COPD and flare-up plans

Rachel Garrison C87622 Gate RCHS Hepatitis audit

Rachel Garrison Y02616 Chantry Bridge COPD Audit

Rachel Garrison C87002 Dinnington Osteoporosis audit

Rachel Garrison C87004 Kiveton Park Gastroenterology referral audit

Rachel Garrison C87008 Swallownest Audit of Orthopaedic Referrals to OPD

Rachel Garrison C87022 Village COPD Care

Rachel Garrison C87609 Rosehill RCHS Non-elective medicines for elderly admissions

Lesley McNeill C87006 Magna Group Gout

Lesley McNeill C87018 High Street Vitamin D

Lesley McNeill C87023 Dalton Consent

Lesley McNeill C87608 Shakespeare Road Vitamin B12

Lesley McNeill C87617 Thrybergh A&E Attendance

Lesley McNeill C87005 St Ann's Fatty Liver Pathway

Lesley McNeill C87017 Clifton PAD in Diabetes

Emma Charnock C87003 Woodstock Bower Glycaemic control diabetes

Emma Charnock C87012 Broom Lane Cancer Referral

Emma Charnock C87020 Greenside Cancer diagnosis

Emma Charnock C87603 Greasbrough Cancer Referral

Emma Charnock C87029 Market Glucose strips

Emma Charnock C87030 Crown Street Atrial Fibrillation

Emma Charnock C87010 York Road COPD

Emma Charnock C87013 Parkgate COPD

Emma Charnock C87024 Rawmarsh COPD

Emma Charnock C87604 Thorpe Hesley COPD

Ian Baker C87015 Wickersley Audit of Combined Contraceptive Prescribing

Ian Baker C87016 Morthen Road Hypertension Medication Prevention of Risk of Type II Diabetes

Ian Baker C87031 Shrivastava Audit of breast clinic referrals

Ian Baker C87606 Queen's NSAID Prescribing

Ian Baker C87616 Blyth Road Audit of outpatient referrals to Elderly Medicine

Ian Baker C87620 Manor Field Audit of Out patient referrals to Trauma and Orthopaedics


4 The Quality Handover and Legacy Project The Quality Handover and Legacy Project was a piece of work designed to ensure the corporate memory of NHS Rotherham PCT was not lost during the transition to NHS Rotherham CCG, and to form the basis of the legal transfer of people, functions, responsibilities, and data, to newly formed organisations. It was internally led by the Quality Assurance Manager and overseen by the NHS England Local Area Team and two Management Consultants who were hired by NHS England to assist. The project began by identifying key members of staff within NHS Rotherham PCT who held documents that were critical to business continuity e.g. clinical contracts, financial programmes, databases etc. An electronic archive was created to hold all these documents in one place so NHS Rotherham CCG and other nominated receivers could access/receive copies as necessary. The archive was then populated by the key members of staff so the location of these documents was known should the member of staff subsequently transfer elsewhere or choose to leave the organisation. A Legacy Document containing facts, population demographics and other essential information was also created, following national guidance, and a copy was issued to each organisation that were listed to gain responsibilities and/or functions following the dissolution of NHS Rotherham PCT. The project then compiled a spread sheet of the assets and liabilities of NHS Rotherham PCT detailed in over 1,800 lines of data under the following categories, drawn from each team in the PCT who were responsible for outlining everything they owned/used/had responsibility for:

- Clinical Contracts - Commissioning - Corporate - Estates & Facilities - Finance - Human Resources - IT Infrastructure - Planning & Performance - Primary Care - Public Health - Quality - Records Management

And covering the following sub-categories:

- Equipment - Hardware - Insurance - Intellectual Property - Legal Claims - Memorandums of Understanding - Non-healthcare Contracts - Records - Software - Systems and Information

These assets and liabilities were then examined in detail to ensure they were assigned to the correct organisation, forming the contracts and Business Transfer Agreements in the legal process of transfer.


The Quality Handover and Legacy Project will continue into 2013/14 to finalise transfers, assign documents from the Cintas Archive Facility, and remove files no longer owned NHS Rotherham CCG from the network before passing them to their legal owner. This process is anticipated to take up to a year.

5 GP Reporting Programme 2012/13 In 2012/13 we continued to provide data reporting for the organisation to monitor key standards and performance measures. Data relating to Infant Feeding Status was provided for Integrated Performance Measures Return (IPMR) on a quarterly basis. Data relating to CVD Assessments was provided for Primary Care Commissioning on a monthly basis for processing payments to GP’s for the LES. Data relating to Secondary to Primary Care Transfer – Removal of Sutures was provided for Primary Care Commissioning on a quarterly basis for processing payments to GP’s for the LES.

GP Reporting Detail

Title Query

Infant Feeding


National Standard or Initiative: VSMR

a) Total children age 10 weeks in current Quarter

b) Total children age 10 weeks, breast fed – latest status recorded age 5 – 10 weeks

c) Total children age 10 weeks, partially breast fed – latest status recorded age 5 – 10 weeks

d) Total children age 10 weeks, bottle fed – latest status recorded age 5 – 10 weeks

e) Total children age 10 weeks, feeding status not recorded – between age 5 – 10 weeks


LES - CVD

Run on a monthly basis


a) Eligible Population

b) Historic Health Checks with Explanation, 1st April 2006 to 31st March 2011

c) Health Checks with Explanation in Month

d) Coverage (%)

e) Checks to be Paid at 45% and above Coverage Rate

f) Checks to be Paid at Below 45% Coverage Rate

g) Patients Invited for a Health Check within Month

h) Patients put on Statins

i) Patients put on Statins since 2006

j) Analysis of outcomes

LES - Secondary to Primary Care Transfer – Removal of Sutures



a) Total patients who have had a post-operative suture removal service for patients who have had treatment in secondary care.

b) Analysis of outcomes


6 Ophthalmology Reporting Programme 2012/13 The Quality Assurance Team took on the function of recording and reporting of Ophthalmology Cataract Assessment Referrals and Post Operation Assessments. The activity was collected and reported to Primary Care Commissioning on a monthly basis. We also reported on Ophthalmology Ocular Hypertension Refinement Scheme Referral and Non Referrals. The activity was collated and reported to Primary Care Commissioning on a monthly basis.

Ophthalmology Reporting Detail

Title Query

Cataract Referral and Post Operation Assessments


a) Total referral assessments

b) Total post operation assessments

c) Analysis of outcomes

Ocular Hypertension Refinement Scheme Referral and Non Referrals


d) Total assessments resulting in referral

e) Total assessments resulting in Non-referral


7 Coroners Reports Between 01 April 2012 and 31 March 2013 the Quality Assurance Team received 486 coroners’ reports. Of these, 416 were for patients registered with Rotherham GPs:

Practice Code Practice Reporting Name Total Number of

Reports Percentage of

Reports


C87003 Woodstock Bower 17 4%

C87004 Kiveton Park 19 5%

C87005 St Ann's 37 9%

C87006 Magna Group 18 4%

C87007 Stag 17 4%

C87008 Swallownest 28 7%

C87009 Brinsworth 6 1%

C87010 York Road 11 3%

C87012 Broom Lane 16 4%

C87013 Parkgate 12 3%

C87014 Treeton 8 2%

C87015 Wickersley 5 1%

C87016 Morthen Road 13 3%

C87017 Clifton 26 6%

C87018 High Street 9 2%

C87019 Wath 1 0%

C87020 Greenside 13 3%


C87022 Village 16 4%

C87023 Dalton 4 1%

C87024 Rawmarsh 9 2%

C87029 Market 18 4%

C87030 Crown Street 19 5%

C87031 Shrivastava 7 2%

C87603 Greasbrough 9 2%

C87604 Thorpe Hesley 7 2%

C87606 Queen's 2 0%

C87608 Shakespeare Road 3 1%

C87609 Rosehill RCHS 8 2%

C87610 Canklow Road RCHS 1 0%

C87612 Surgery of Light 2 0%

C87616 Blyth Road 13 3%

C87617 Thrybergh 1 0%

C87620 Manor Field 7 2%

C87621 Broom Valley Road 1 0%

Y02616 Chantry Bridge 1 0%


The coroners’ reports are sent to the Quality Assurance Team from the HM Coroner, Doncaster in batches of on average 38 reports. Over the year the team has received 11 batches.

April 2012 66

May 2012 31

June 2012 28

July 2012 52

August 2012 27

September 2012 0

October 2012 61

November 2012 22

December 2012 0

January 2013 50

February 2013 79

March 2013 0

Each report has to be checked on Open Exeter. This System contains up to date demographic information on all patients in any specific area. We have four checks to verify we have selected the right patient; name, address, date of birth, and date of death. We note the patients GP practice and current GP if found. If no information is located we create a record on our system and forward the reports to South Riding Health Services Support Agency (SRHSSA). The team receives two types of coroner reports; post-mortems and inquest verdicts. In 2012/13, 349 (84%) reports received were post mortem and 67 (16%) were inquest verdicts. The inquest verdicts are then categorised depending on the verdict of death:


Neither 1 1%

Open Verdict 62 93%

Suicide 4 6%

70 of the reports were sent to South Riding Health Services Support Agency (SRHSSA) as the patient was not registered with a Rotherham GP. Each Rotherham patient’s basic details (name, GP, report type, verdict, and date of death) are then input onto our database, to ensure we have a record of processed data. The report is then sent to the registered GP for their information. We ensure all reports are sent within 2 working days of receipt to make certain the GP has access to the information as soon as possible.

8 Rotherham Suicides & Deaths from Undetermined Intent

The detail of this report has been taken from information made available from The Rotherham Coroner, South Yorkshire Police, and GP Practices. The content of this report includes information on all reported cases of deaths by undetermined intent between April 2012 and March 2013. A system is in place where the Quality Assurance Team at NHS Rotherham is informed as soon as possible when the coroner’s office becomes aware of a death by undetermined intent by a resident registered with a Rotherham GP.

In the first instance Quality Assurance staff receive notification from the coroner’s office on any relevant deaths, usually within a few working days of the occurrence.

Quality Assurance staff inform the Practice Manager at the deceased’s General Practice on the same day that they are notified of the death. This is so that not only are they are aware of the death, but also to allow them to support the bereaved as appropriate. GP practices hold in-house Significant Event Audits where and when appropriate, actions are agreed at MDT Meetings held within GP practices, not at PCT.

Quality Assurance staff arrange with the Practice Manager to complete the minimum data set, via the ‘Suicide Audit in Primary Care Trust Localities: Data Collection Proforma’

Quality Assurance staff contact named persons at RDaSH, Primary Care Mental Health Service, and Public Health, to ensure they have been made aware of the incident.

All information collected is input into the National Suicide Audit Toolkit Database. This is an electronic database that was provided at the launch of the National Suicide Audit (2007) and is still used to record the information as it is a good tool allowing the easy extraction of information for analysis.

A list of ‘Inquests Concluded in Rotherham’ are received on a monthly basis and consequently the database is updated to reflect the verdict.

Since the launch of the cross-government Suicide Prevention Strategy in 2012, Suicide Prevention, and Self Harm Group Meetings are now held to bring together knowledge about the deaths. This group is chaired by Director of Public Health and members include Public Health (RMBC), Chair of the Health and Wellbeing Board, Rotherham CCG, Rotherham and Barnsley Mind, Children and Young People’s Services (RMBC), RDaSH, Rotherham Foundation Hospital Trust, Neighbourhoods and Adult Service


(RMBC) Rotherham Samaritans, South Yorkshire Police and a local college. This group is developing an action plan which will address the themes outlined in the national strategy.

A smaller group chaired by Director of Public Health meets to look at all the reported deaths where suicide is suspected for the purposes of identifying any trends and to look at any preventative measures which need to be introduced. Group members include Public Health, Rotherham CCG, South Yorkshire Police, and RDaSH.

Between 1ST April 2012 and 31ST March 2013 the Quality Assurance Team has been informed of 18 deaths. GENDER

AGE

4

14

0

2

4

6

8

10

12

14

16

Female Male

1

2

3

5

4

0

3

0

1

2

3

4

5

6

15-19 20-29 30-39 40-49 50-59 60-69 70+


METHOD

LOCATION OF EVENT

MONTH OF EVENT

13

1 1 1 1 1

0

2

4

6

8

10

12

14

15

2 1

0

2

4

6

8

10

12

14

16

Home Address (various locations)

Woods Motorway Bridge

0 0

1

3

1

2 2

1

2

1

4

1

0

1

2

3

4

5



Of the 18 deaths, 12 are still awaiting a verdict. The verdicts concluded are as follows:

4 = ‘Suicide’ 1 = ‘Took own life’ 1 = ‘Open Verdict’

The number of Coroner Rule 43’s was not collected for 2012/2013, however the team will look at the feasibility of collecting this data in future.

9 The Multi-Source Feedback Project

In 2012/13 NHS Rotherham provided a programme of multi-source feedback (MSF) to business critical GPs to ensure they met a key requirement for revalidation. Later, the scheme was rolled out to other GPs who had expressed interest and in total 62 GPs from 10 practices took part and received a personal report.

All doctors who wish to practise medicine in the United Kingdom need to be registered with and licensed by the General Medical Council (GMC). To retain their license with the GMC, doctors are also required to revalidate on a regular basis to demonstrate that they are still ‘fit to practice’ medicine. The project was designed as a learning and development tool by the GMC to identify strengths and areas for improvement in a doctors practice to inform their professional development. It was also one of several pieces of information that, when considered together, will inform the decision as to whether a doctor should be recommended for revalidation. All doctors are expected to seek such feedback from colleagues and patients (where appropriate) at least once every revalidation cycle. Seeking feedback in this way is designed to enable colleague and patient views about a doctors behaviour and performance to be gathered in a more systematic way. It provides the opportunity for patient, non-medical co-workers (including other health professionals, managers and administrators) and medical colleagues (including trainees and juniors) to reflect on the professional skills and behaviour of a doctor. The GMC developed template questionnaires which we adapted locally and piloted at Market Surgery to ensure they were effective. There were three different questionnaires; colleague, patient, and self. Colleague: The GMC recommended that the doctor nominate 20 colleagues (10 medical and 10 non-medical) to provide feedback on their professional performance. In Rotherham, we decided to take a slightly difference approach and send the questionnaire to all staff in the GP practice to ensure everyone had a fair chance to participate, rather than select respondents. Where the doctor worked in a small practice or not in general practice at all, they were asked to help to identify a sufficient number of clinical and non clinical colleagues from which we could randomly select a sample. Colleagues were then sent a link to an electronic questionnaire via email, and were asked to complete it within a set period of time. The GMC guidance stated that a minimum of 15 colleague questionnaires must be returned to achieve a reliable result. Patient: The GMC recommended that 45 questionnaires were distributed to consecutive patients at the time of their appointment with the aim of receiving 34 returned to ensure the


results were reliable. The local pilot project suggested more than this needed to be distributed in order to ensure the minimum number was received; 55 to 75 was preferable. The local pilot project used electronic stands placed in the practices to collate patients view, but this proved problematic; some people began but didn’t complete the questionnaire, meaning it had to be discounted, some were clearly completed by children, and some weren’t completed at all as people played with machines rather than answered the questions. To try to prevent this, paper was found to be a more controllable method of data collection. It also ensured we were aware of how many questionnaires had been distributed, as a set number were sent by the Quality Assurance Team for each doctor, and they were handed to each patient seen until they are all gone. Completed questionnaires were then placed in a sealed box on reception or respondents were given an envelope they could seal and hand back to reception staff so they felt able to express their views honestly, without worrying about having to pass their responses back to a person. Self: In order to provide comparison between a doctors perception of their practice and how others view them, a link to an electronic self questionnaire was emailed to each doctor for completion within a set period of time. The Quality Assurance Team organised the set up of the project with the Manager of each Practice and conducted all the resulting data analysis and reporting, but practice cooperation was needed to ensure it was successful. Either GPs needed to distribute their own questionnaires and explain how important it was for patients to complete them and return them to reception, or reception staff had to hand them out. The choice of method largely depended on how patients booked in when they arrived for their appointments, but the response rate was higher if the doctor made the request. Analysis of the data collected was carried out electronically using Survey Monkey as this removed the chance for human error in calculations. Data was produced for the individual and gave a personal and practice average score for each question, as well as the comparison to the self assessment. Ordinarily, the only people to see the results were members of the Quality Assurance Team and the doctor in question. However, in the unlikely event of serious patient safety concerns being raised then these would have been brought to the attention of the Medical Director. Data held on Survey Monkey servers was labelled by initials only, and the report issued was saved on a secure server. All hard copies of data or the report were destroyed. Reports were sent to the doctor by email in PDF format, and acknowledgement of receipt was required.

The responsibility for Revalidation passed to the NHS Commissioning Board on 1st April 2013 so the programme has now closed.

10 Conclusion The volume of work undertaken by the team this year has been substantial, and for the first time has varied considerably from our historical workload. In addition to the projects outlined in this report the Quality Assurance Team provided ongoing support to Protected Learning Time events, provided ad hoc assistance to the other members of the larger team of the Chief Nurse, and led on the Quality Handover, Legacy and Transition programme of NHS England.


The forthcoming 12 months marks another shift in remit as we take over managing a number of enhanced services. We plan to manage this new workload as follows:

Work Project Lead Supported by Further assistance if necessary

Enhanced Services: Cataract, Glaucoma, DMARDs, Anti-coagulation, Aural Care, Acupuncture, Cryotherapy, Secondary to Primary Care Transfer

Rachel Garrison

Lesley McNeill / Ian Baker

Emma Charnock

CCG Commissioned Services and Dementia Prevalence Report for Operational Executive: Quarterly Reporting of Anti –coagulation, DMARDs, Case Management, Dementia and Choose & Book activity

Ian Baker

Lesley McNeill

Emma Charnock

Local Incentive Scheme Referral Audit: Co-ordination of data collection and analysis of activity

Ian Baker

Lesley McNeill

Emma Charnock

Local Incentive Scheme: Evidence, surveys, Practice Managers Forum, quarterly tracking

Emma Charnock

Lesley McNeill

Ian Baker

Case Management: Survey Monkey, request & chase responses, analyse data, produce report

Emma Charnock

Lesley McNeill

Ian Baker

CQUINS: Quarterly data collection, analyse data, produce report

Rachel Garrison / Emma Charnock

Lesley McNeill

Ian Baker

Protected Learning Time: Analyse data, produce results, distribute letters, attend meetings

Lesley McNeill

Emma Charnock

Ian Baker

Suicide: Receive & report suicides, monthly meetings, annual report

Lesley McNeill

Ian Baker

Emma Charnock

Coroners Reports: Input & disseminate reports, annual report

Lesley McNeill

Emma Charnock

Ian Baker

In addition, we have a number of projects planned jointly with The Rotherham Foundation Trust: No. Title Project aim

1 Management of leg ulcers To address inconsistency in quality of management in primary care and the community in comparison to TRFT

2 Infertility and miscarriage proforma

An audit to assess compliance with infertility and miscarriage proforma

3 HMB Pathway A re-audit to assess compliance with the HMB pathway

4 Spinal and facet join injections

A six monthly audit to monitor downward trend

5 Spinal pathway An audit of 50 referrals to assess adherence to the spinal pathway

6 MSK conversion rates An audit of MSK conversion rates

7 Fitness for surgery An assessment of how many patients not fit for surgery and why e.g. BP / HbA1C following inclusion in BiteSize May 2012

8 Opthalmology referrals An assessment of 50 referrals to examine conditions referred and review how many could have been managed in the community

9 Consultant to Consultant referrals

A re-audit of 50 patients to assess compliance with the consultant to consultant referral policy

We will also continue to provide support and assistance to rest of the organisation and its stakeholders on an ad hoc basis wherever necessary, and to General Practice where capacity allows.

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