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<p>SOUTH WARWICKSHIRE NHS FOUNDATION TRUST </p> <p>Meeting Board of Directors </p> <p>Date 28 January 2016 </p> <p>Subject Patient Experience Quarterly Report </p> <p>Enclosure H </p> <p>Nature of item For information For approval For decision </p> <p>Decision required (if any) </p> <p>The Board is asked to receive and note this report. </p> <p>General Information </p> <p>Report Author Patient Experience Team Lead Director Helen Lancaster, Director of Nursing </p> <p>Received or approved by </p> <p>Meeting Date </p> <p>Resource Implications </p> <p>Revenue Capital Workforce Use of Estate Funding Source </p> <p>Applicable Quality Improvement Priorities </p> <p>Care Quality Commission Rating Nurse Staffing Levels Paperless Working Electronic Requesting Food Delivery Dementia Complaints Feedback </p> <p>Freedom of Information </p> <p>Confidential (Y/N) (if yes, give reasons) </p> <p>No </p> <p>Final/draft format </p> <p>Final </p> <p>Ownership </p> <p>Trust </p> <p>Intended for release to the public </p> <p>Yes </p> <p>South Warwickshire NHS Foundation Trust </p> <p>Report to Board of Directors 28 January 2016 </p> <p>Patient Experience Quarterly Report </p> <p>Executive Opinion This report provides an assuring picture on activity relating to patient experience across the Trust. With the expansion of the Patient Experience Key Performance Indicators (KPIs), we can see a reassuring picture of elements which can impact patients experience. Ward and service staff continue to review and learn from feedback and complaints, in particular the upheld complaints. Notably, patient recommendations in the Friends and Family Test (FFT) continue to be high. Executive Summary Complaints Activity </p> <p> comparable number of complaints recorded in comparison to previous month, with no untoward theme identified in subjects or grading of complaints; </p> <p> all complaints were acknowledged within the 3 days timescales and a previous administrative error was rectified, which led to a decline in performance last month; </p> <p> whilst performance has improved significantly, investigation leads can frequently fail to keep the Patient Experience Team informed of developments and progress, leading to duplicated efforts. This has been escalated to Associate Directors of Operations through Audit and Operational Governance Group (AOGG) meetings; </p> <p> no complaints were escalated to the parliamentary ombudsman, and learning and themes have been disseminated to wards including a new quality </p> <p>briefing paper which is issued to all staff. This paper includes a section on feedback from patient feedback and lessons learnt from complaints, which will enable better triangulation and also support wards to learn from patient feedback. </p> <p> Patient Feedback </p> <p> A&amp;E Response Rates whilst patient recommendation continues to be notably high in all areas when compared to regional and national rates, there has been a decline over the last two months in response rates in A&amp;E. The response rate has improved slightly in comparison to previous months, however still remains below past performance which has been in excess of 28%. The FFT survey remains a critical element of a patients journey and is the only tool used in A&amp;E to measure patient satisfaction. Actions being taken to address this comprise of: - Targeted awareness campaign including floor-walks to be carried out by the </p> <p>Trust FFT lead and Deputy Director of Nursing to engage with staff and patients. - A&amp;E reception staff hand out survey forms with any paperwork they provide </p> <p>patients - Weekly collection and monitoring of surveys to resume as previously done when </p> <p>patient participation declined. Helen Lancaster Director of Nursing </p> <p>Patient Experience Quarterly Report Complaints and Patient Feedback </p> <p>Data extracted 15 January 2016 </p> <p>Data source Datix Risk Management System </p> <p>2 </p> <p>Patient Experience Performance summary 2015/16 Quarter 3 </p> <p>3 </p> <p>Overview of Complaints Data </p> <p> During December 2015 the Trust received 6 formal complaints, making the total number of 40 formal complaints received during Quarter 3 2015/16 To enable a better review of data and to identify trends, the charts below provide an overview of activity for recent months. </p> <p>Complaints by Grade Oct 2015 Dec 2015: </p> <p>Amber, 20 Dark </p> <p>Amber, 9 </p> <p>Green, 7 </p> <p>Red, 3 </p> <p>Complaints by Subject: </p> <p>5 4 </p> <p>3 </p> <p>13 </p> <p>2 1 1 </p> <p>4 2 </p> <p>02468</p> <p>101214</p> <p>Complaints by Division by Quarter: </p> <p>21 </p> <p>34 </p> <p>8 4 </p> <p>0 05</p> <p>10152025303540</p> <p>Elective Care EmergencyCare</p> <p>Integratedand</p> <p>CommunityCare</p> <p>SupportServices</p> <p>Corporate</p> <p>15/16 Q1</p> <p>15/16 Q2</p> <p>15/16 Q3</p> <p>Number of Formal Complaints Received: </p> <p>0</p> <p>5</p> <p>10</p> <p>15</p> <p>20</p> <p>25</p> <p>30</p> <p>Jan2015</p> <p>Feb2015</p> <p>Mar2015</p> <p>Apr2015</p> <p>May2015</p> <p>Jun2015</p> <p>Jul2015</p> <p>Aug2015</p> <p>Sep2015</p> <p>Oct2015</p> <p>Nov2015</p> <p>Dec2015</p> <p>4 </p> <p>Quarter 3 Overview: of Area Activity Report This area activity report shows the status for Q3 2015-16. As the monthly number of complaints are low, data has been aggregated for the Quarter to enable </p> <p>better scrutiny of performance </p> <p>Ward/Area Total Q3 2015-16 Red D Amber Amber Green </p> <p>2014/15 Q2 Activity </p> <p>No % indicates no complaint </p> <p>received </p> <p>2015/16 Q3 Activity % </p> <p>Antenatal Assessment Unit 1 0 0 1 0 0.02% 0.01% </p> <p>Accident &amp; Emergency 6 0 1 4 1 0.6% 0.4% </p> <p>Avon Ward 2 0 0 2 0 0.13% 0.11% </p> <p>Castle Ward 1 0 0 1 0 0.03% 0.03% </p> <p>Dermatology Day Unit 1 0 0 1 0 0.09% 0.08% </p> <p>ENT 1 0 0 0 1 0.3% </p> <p>Integrated Health Team 2 0 1 1 0 0.19% 0.19% </p> <p>Mary Ward 1 0 0 1 0 0.09% 0.08% </p> <p>Machen Eye Unit 8 0 3 1 3 0.09% 0.09% </p> <p>MAU/Fairfax 3 1 0 1 1 0.81% 0.63% </p> <p>Midwifery 1 0 0 1 0 0.19% </p> <p>Oken Ward 1 0 1 0 0 0.03% 0.03% </p> <p>Outpatients Department 1 0 0 0 1 0.13% 0.11% </p> <p>Physiotherapy 1 0 0 1 0 0.15% 0.11% </p> <p>Victoria Ward 1 0 0 1 0 0.19% 0.15% </p> <p>5 </p> <p>New Complaints Received: December 2015 </p> <p> ID First received Description Division Ward/Site Subject (primary) Grade </p> <p>3266 22/12/2015 </p> <p>Brother complained that his sister has received yellow &amp; red cards from the hospital, he demands an explanation and alleges that his sister has been bullied and intimidated by the Trust, making fabricated allegations against her. Concerns include: Clinical care, communication, staff attitude, attitude of the Trust, red &amp; yellow carding, failure to refer for counselling or psychology, failure to provide support, allegations made by the Trust, failure to provide video recordings of incidents which would vindicate patients behaviour, victimisation of patient, assault of patient, failure to treat with dignity &amp; respect, failure to treat pain following accident, escorting patient from Trust premises &amp; leaving her outside, fabricating information given to family members 25 miles away, unacceptable conduct by the Trust. </p> <p>Trustwide Trustwide Clinical Care Amber </p> <p>3265 22/12/2015 </p> <p>Patient unhappy with appointment in Machen Eye Unit, unhappy with the way tests carried out and feels kept waiting too long to see Consultant, also feels staff were unhelpful and would not find out how much longer he should wait. Patient left and went home without seeing the Consultant. </p> <p>Elective Care Machen Eye Unit Waiting Times - clinic Green </p> <p>In the month of December 2015 the Trust received 6 new complaints. Below is a list containing details of the new complaints received. These complaints are currently under investigation. </p> <p>6 </p> <p>3269 18/12/2015 </p> <p>Complaint about nursing care. Patient states that the healthcare assistance on night shift looked after her young grand children during her shift. This disturbed the patient and meant that she did not receive the nursing care she should have. </p> <p>Emergency Care Avon Ward Nursing Care Amber </p> <p>3268 16/12/2015 </p> <p>Damage to patients bladder caused during a gynaecological repair. Patient was not made aware of the problem that happened during surgery. </p> <p>Emergency Care Oken Ward Clinical Care </p> <p>Dark Amber </p> <p>3261 04/12/2015 </p> <p>Family complaint regarding problems with District Nursing team in Rugby not knowing where key-safe is or injection equipment in secure box is to be able to treat diabetic father. Incorrect medication doses given resulting in patient losing driving licence </p> <p>Integrated and Community Care </p> <p>Patients Home Medication - administration Amber </p> <p>3260 07/12/2015 </p> <p>Daughter attended A&amp;E on 11/5/15 with a deep laceration to the left eyebrow Parents had given daughter pain killers at 0735 hrs - pain observations were recorded as zero indicating no pain - not given further pain relief. Sent to UHCW for suturing as would be in layers to give a good cosmetic finish. </p> <p>Emergency Care </p> <p>Accident &amp; Emergency </p> <p>Communication (verbal) Green </p> <p>7 </p> <p>Complaints Closed: December 2015 A total of 11 complaints were closed during the month of December 2015. The listing below provides details of these closed complaints. </p> <p>ID First received Closed Ward/Site Subject (primary) Sub-subject (primary) Grade </p> <p>3226 14/10/2015 09/12/2015 Machen Eye Unit Appointments Delay Amber </p> <p>3243 04/11/2015 11/12/2015 MAU/Fairfax Ward Nursing Care Basic nursing care Dark Amber </p> <p>3208 08/10/2015 09/12/2015 Midwifery Communication (verbal) Insufficient Amber </p> <p>3233 23/10/2015 29/12/2015 Outpatients Dept Appointments Delay Green </p> <p>3257 27/11/2015 29/12/2015 Accident &amp; Emergency Clinical Care Diagnosis Amber </p> <p>3248 11/11/2015 14/12/2015 Victoria Ward Communication (verbal) Insufficient Amber </p> <p>3216 14/09/2015 29/12/2015 Guy Ward Discharge Support services Dark Amber </p> <p>3263 19/11/2015 11/12/2015 Accident &amp; Emergency Communication (written) Healthcare documentation Green </p> <p>3262 30/11/2015 10/12/2015 Machen Eye Unit Appointments Cancellation Dark Amber </p> <p>3225 19/10/2015 04/12/2015 Willoughby Ward Clinical Care Dark Amber </p> <p>3238 26/10/2015 16/12/2015 Castle Ward Clinical Care Clinical review Amber </p> <p>8 </p> <p>Lessons Learnt: Quarter 3 2015/16 </p> <p>Datix ID: 3258 Helen Clarke Suite Post Radiotherapy Breast Cancer patient information leaflet due to be reviewed in the next 4 weeks </p> <p>(November 2015). </p> <p>Datix ID: 3201 Continence Service The Continence service has been asked to ensure confirmation letters are sent to confirm bookings and </p> <p>to ensure staff have been advised of these times. All Continence staff has been reminded of the importance of clearly introducing themselves and any </p> <p>other staff/students present and obtain consent if necessary. Documentation for an interpreter if required should be completed. Continence staff have been </p> <p>reminded to comply with this requirement. The comment "you have an answer for everything" was made and although not intended to be </p> <p>derogatory in any way the Manager of the Continence service has advised her staff to not use this phrase again. </p> <p>Datix ID: 3175 Pathology Procedure within the pathology reporting has been reviewed and as a consequence - the procedure of </p> <p>copy and pasting of core biopsy results into a final pathology report has been stopped. The Oncotype test in now available to NHS patients An audit of 20 patients having similar tests were checked </p> <p>Datix ID: 3214 District Nursing Verbal complaints taken by ISPA have strengthened the process for passing on. Staff to have additional training when dealing with challenging families and identify crises points Families should be made aware of acceptable behaviour for their staff to tolerate. Staff to work more closely with partners and escalate concerns raised by families when requesting </p> <p>support. </p> <p>The following actions have been implemented in response to a complaint received by the Trust which the investigation showed the complaint to be upheld and lessons learnt identified in the form of an action plan. Below shows the lessons learnt from complaints closed during Quarter 3 2015/2015. </p> <p>9 </p> <p>Datix ID: 3242 Accident &amp; Emergency Staff told to wear gloves when hands are stained and cannot be removed with washing. Also discussed </p> <p>about including patients relative with dosage of medication. Datix ID: 3255 Ante Assessment Unit </p> <p> Patient/receptionist conversations to only take place at reception desk. Reception personnel to address staff by their correct title and name. Installation of signs advising patient to wait their turn before approaching reception desk All staff to ensure up to date training with Governance e-training specifically covering data protection </p> <p>and patient confidentiality. Datix ID: 3229 Machen Eye Unit </p> <p> Additional clinics arranged to accommodate the number of patients that need to be seen. Recruiting medical staff to support injection and medical retinal service. New booking system implemented. Patients to receive next appointment within five working days of their last attendance. </p> <p>Datix ID: 3221 Machen Eye Unit The member of staff who was rude to patient has been disciplined in line with Trust policy. </p> <p>Datix ID: 3206 Physiotherapy Patient is now having physiotherapy with a previous therapist although he has to have his appointment </p> <p>in school time. Datix ID: 3198 Machen Eye Unit </p> <p> Additional clinics arranged to accommodate the number of patients that need to be seen. Recruiting medical staff to support injection and medical retinal service. New booking system implemented. Patients to receive next appointment within five working days of their last attendance. </p> <p>Datix ID: 3131 Integrated Care An action plan was instigated to improve the staffing issues in the Alcester Integrated Team, and </p> <p>additional staff have been recruited. Datix ID: 3045 Avon Ward </p> <p> Discussed with staff to highlight better communication would have made a considerable difference to family, the assistance available to the patient and may have resulted in the family not making a complaint. </p> <p>Datix ID: 3262 Machen Eye Unit Machen Eye Unit are working with the Patient Access team to improve the answering of telephone </p> <p>contact regarding appointments. </p> <p>10 </p> <p>Patient Advice and Liaison Service (PALS) </p> <p> Number of PALS Contacts </p> <p>Oct-Dec 2015 </p> <p>Top Subjects of Contacts December 2015 </p> <p>05</p> <p>1015202530354045</p> <p>Oct 2015 Nov 2015 Dec 2015</p> <p>24 </p> <p>5 </p> <p>5 </p> <p>5 </p> <p>7 </p> <p>5 2 </p> <p>Appointments</p> <p>Clinical care</p> <p>Communication</p> <p>Discharge</p> <p>Information</p> <p>Patient property</p> <p>Transport</p> <p>The PALS is an independent and confidential advice and support service for patients and their relatives/friends. It offers the opportunity to raise concerns enabling appropriate intervention at an early stage. The service works closely with patients, relatives and staff to identify where the Trust can improve the patient experience. </p> <p>11 </p> <p>Dementia Carers survey As part of the broader suite of CQUINs for dementia, providers must demonstrate that they have undertaken a monthly audit of carers of people with dementia to test whether they feel supported and report the results to the Board. Frequency of reporting to SWCCG is bi-...</p>

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