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Meeting of the Governing Body Agenda Item 8

Title of Paper Quality and Patient Safety Report for November 2015.

What the Governing Body is being asked to decide or approve

For information and discussion

Executive Summary

The report includes a review of quality performance by providers:

James Paget University Hospitals NHS Foundation Trust (JPUH).

East Coast Community Healthcare (ECCH). Norfolk and Norwich University Hospitals NHS Foundation

Trust (NNUH). Norfolk and Suffolk NHS Foundation Trust (NSFT). Norfolk Community Health & Care (NCH&C). Integrated Care 24 (IC24). East of England Ambulance Service NHS Trust (EEAST). An update on Infection Prevention & Control Performance. GYW CCG Complaints. Care Homes and CQC status of other registered providers.

Risks attached to this proposal/initiative:Not applicableResource implications:None

Name Cath GormanJob Title Director of Commissioning and Quality, Chief NurseDate 23rd November 2015

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1.0 James Paget University Hospital (JPUH)

1.1 Friends and Family Test (FFT) for Inpatients, A&E and Maternity Services:

September 2015

Area Total Responses

Total Eligible

Response Rate

% Recommended

% Not Recommended

A&E 584 4718 12.4% 90% 1%

Inpatients 998 5814 17.2% 95% 2%

Maternity –Antenatal Care 88 Not

Available Not Available 99% 1%

Maternity –Birth 123 172 71.5% 98% 1%

Maternity –Postnatal Ward 42 Not


Maternity –Postnatal Community Provision

44 Not Available Not Available 100% 0%

August 2015


Total Eligible

Response Rate

% Recommended

% Not Recommended

A&E 614 5387 11% 92% 4%

Inpatients 903 5550 16.3% 96% 1%



Maternity –Birth 9 179 5% 89% 0%



Maternity –Postnatal Community Provision

72 Not Available Not Available 96% 3%

For further information, the following link shows the full range of results for FFT by region, Trust, Site and Ward: http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/ .

Note: The FFT data for October 2015 will be published by NHS England on 10 December 2015 and the FFT data for November 2015 will be published by NHS England on 14 January 2016.

1.2 Care Quality Commission (CQC)

The CQC undertook a planned inspection at JPUH week commencing 10 August ‘15. The inspection report was published on 12 November ‘15 where the CQC overall judged JPUH to be Good. The report can be found Here.

CQC Inspection Area RatingsSafe? Requires improvementEffective? GoodCaring? GoodResponsive? GoodWell-led? Good

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http://www.cqc.org.uk/location/RGP75

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

The inspection team reported seeing several areas of outstanding practice including:

• Care of patients requiring thrombolysis in the emergency department, with trained consultants and telemedicine access to a consultant neurologist.

• Patient pathways for GP referrals that resulted in 97% of GP referrals not requiring services of the emergency department.

• Spinal injuries nursing and state of the art equipment for patients with spinal cord injury was excellent.

• A charity funded Eye Clinic Liaison Officer raised awareness about support for patients with macular degeneration.

• The trust had been awarded integration status, with other health partners and social care to pioneer seven day services. This included an Out of Hospital Team chaired by GYW CCG involving social care, the mental health trust and the hospital to identify ways to avoid crises in communities leading to hospital attendance. Data was showing a reduction in admissions.

The neonatal unit had developed a breastfeeding pack to encourage new mums whose babies were on the unit to hand express their breast milk. The pack contained information and tips on hand expressing along with a personal expressing log.

There were also areas of poor practice noted where the trust needs to make improvements. Importantly, the trust must:

• Ensure that all equipment is checked at a frequency as per trust policy including, but not limited to emergency resuscitation equipment.

• Ensure that all patient records are up to date and reflective of patient’s needs.

• Ensure a named Non-Executive Director for end of life care in line with Department of Health Guidance.

• Ensure that all Do Not Attempt Cardio Pulmonary Resuscitation forms are completed fully and in line with national guidance.

• Accelerate the implementation of the approved replacement for the Liverpool Care Pathway for people receiving end of life care.

The Trust is now developing an action plan to address the improvements identified.

1.3 Patient Safety Indicators Published on NHS Choices

From June 2014, all NHS providers are expected to upload and publish data about their nurse staffing levels on their public website. In addition you can also see how hospitals perform on patient safety on NHS Choices. These include how hospitals recognise and report problems with safety, how well they are fulfilling their nurse staffing requirements or if the staff would recommend the hospital to their own family or friends.

The October 2015 position for JPUH is below. The nurse staffing metrics continue to report that only 91% of planned nursing staff was in place; however this is an improved position and the Trust continues to actively recruit locally, nationally and internationally. It should be noted that the Trust is reporting against their enhanced established levels which surpass NICE guidance.

1.4 Mixed Sex Accommodation (MSA)

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There was one occurrence of a reportable mixed sex accommodation breach during October ‘15. This occurred on the acute coronary unit and is currently under investigation.

Serious Incidents (SIs) / Never Events

Serious Incidents reported:

Apr2015

May2015

Jun2015

Jul 2015

Aug 2015

Sept2015

Oct2015

8 5 6 4 4 3 7

No new Never Events have been reported by the Trust since July ’14.

SIs that currently remain open (as at 10.11.15) pending investigation are noted within the following table:

SI number Category Current Status

2015/29419 Formalin spillage Currently under investigation2015/30968 Fall Currently under investigation2015/31933 Delayed Diagnosis Currently under investigation2015/32484 Grade 3 Pressure Ulcer Currently under investigation2015/32782 Fall Currently under investigation2015/34004 Treatment / Procedure Currently under investigation2015/34167 Fall Currently under investigation2015/34682 Treatment / Procedure Currently under investigation2015/34757 Fall Currently under investigation2015/35375 Grade 3 Pressure Ulcer Currently under investigation

The GY&W CCG Patient Safety and Clinical Quality Committee continue to identify SIs to be reviewed in more detail. This focuses on completed RCAs and details behind any delays in submission.

1.5 World Health Organisation (WHO) Surgical Checklist

The Trust continues to audit compliance in operating theatre settings with the WHO Surgical Checklist on a monthly basis and results are received on a 6 monthly basis at the Quality Meetings. The October ‘15 results showed an overall figure of 99.7% compliance.

1.6 Quality Issue Reporting (QIR)

QIRs reported:

Apr2015

May 2015

Jun 2015

Jul2015

Aug 2015

Sept 2015

Oct 2015

15 4 10 7 8 7 2

1.7.1 Open / Closed / Void

From 1st October 2014 to 1st November 2015, 11 QIR remain open pending investigation, 123 QIR have been closed, 7 QIR have been voided and 9 are pending closure.

1.7.2 Open QIR reported in 2014/15/16:

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QIR Ref Date Source of QIR Description of Concern Status

JPUH/251 17/12/2014 Cutlers Hill Surgery Community bed capacity. Pending

closure

JPUH/268 14/01/2015 ECCH Poor care and support. Under investigation

JPUH/316 20/04/2015 Park Surgery No discharge summary or instruction for care. Under investigation

JPUH/323 14/05/2015 Cutlers Hill Surgery Incorrect discharge summary and record keeping. Under

investigation

JPUH/326 02/06/2015 ECCH Locked box containing patient records found in a public area. Under investigation

JPUH/328 10/06/2015 Park Surgery Medication issues. Pending closure

JPUH/336 15/07/2015 Alexandra Road Surgery Potential inappropriate discharge. Under

investigation

JPUH/338 15/07/2015 King Street Surgery Information Governance. Pending

closure

JPUH/345 03/08/2015 NCHC Information governance and management. Under investigation

JPUH/347 27/08/2015 Park Surgery No patient identifiable information. Under investigation

JPUH/348 28/08/02015 Beccles Medical Centre Anti-coagulation results. Pending

closure

JPUH/349 28/08/2015 Beccles Medical Centre Anti-coagulation delay. Pending

closure

JPUH/350 08/09/2015 Park Surgery IT issue. Pending closure

JPUH/351 09/09/2015Social Care Centre of Expertise

Inappropriate discharge. Pending closure

JPUH/352 15/09/2015 Beccles Medical Centre Anti-coagulation communication. Under

investigation

JPUH/353 21/09/2015 Bungay Medical Practice Communication failure. Pending

closure

JPUH/354 21/09/2015 Staithe Surgery Discharge summary unclear. Under investigation

JPUH/355 23/09/2015 Alexandra Road Surgery Anti-coagulation issue. Under

investigation

JPUH/356 23/09/2015 Alexandra Road Surgery Communication failure. Under

investigation

JPUH/357 08/10/2015 NCHC Failure to receive discharge summary. Pending closure

JPUH continues to raise concerns directly with ECCH to ensure that these are dealt with at the time and that timely feedback is provided directly to those involved to reduce quality issues from occurring.

1.8 Infection Prevention & Control

The ceiling of maximum c-difficile cases within JPUH for 2015/16 has nationally been determined as no more than 17 avoidable cases.

The Trust has reported 21 cases (including 2 NNCCG cases) up until 11 November ‘15.

Of these 22 cases – 10 have been reviewed and are trajectory, 9 are non-trajectory and 1 is still to be reviewed.

1.9 Stroke Performance (January 2015 – October 2015)

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Standard Target Jan ‘15

Feb ‘15

Mar ‘15

Apr ‘15

May ‘15

Jun ‘15

Jul ‘15

Aug ‘15

Sept ‘15

Oct ‘15

4 hours direct to Stroke Unit

90% 91.9 78.1 85.7 82.5 88.9 75.6 N/A N/A 76.92 N/A

90% of time on the Stroke Unit

80% 92.3 78.1 83.7 76.2 92.6 87.8 N/A N/A 100 N/A

60 minutes to scan 50% 50.0 48.6 55.2 65.9 53.9 63.4 N/A N/A 43.59 N/A

Thrombolysed within 3 hours

12% 16.2 13.8 3.1 10.0 8.3 N/A N/A N/A N/A N/A

Thrombolysed 12% 19.1 20.7 3.1 15.0 16.7 N/A N/A N/A N/A N/A

The CCG does not currently have access to more up to date performance information for stroke.

1.10 Cancer Target Performance (January 2015 – September 2015)

Preventing people from dying prematurely:

Breast symptoms urgent referral to first outpatient appointment (Target – 93%)Target is to achieve a 14 day maximum wait from GP referral to first outpatient appointment with patients with any breast

symptoms except suspected cancer.

Jan Feb Mar Apr May Jun Jul Aug Sep100 96.77 100 95.8 96.8 100 93.3 100 100

Cancer urgent referral to first outpatient appointment (Target – 93%)Target is to maintain a 14 day maximum wait from urgent GP referral to first outpatient appointment for all urgent suspected

cancer referrals.

Jan Feb Mar Apr May Jun Jul Aug Sep97.9 97.9 97.4 96.9 97.2 97.3 96.7 97.6 97.46

Cancer 2 week wait - Monitor combined Breast and urgent referral target (Target – 93%)Performance

Target is to achieve a 14 day maximum wait from GP referral to first outpatient appointment for both patients with any breast symptoms and also urgent suspected cancer referrals

Q4 (14/15) Q1 (15/16) Q2 (15/16) Q3 (15/16) Q4 (15/16)Met Met Met

Cancer urgent referral to treatment 62 day target (Target – 85%)Performance

Target is to achieve a maximum waiting time of 62 days from urgent referral to treatment for all cancersJan Feb Mar Apr May Jun Jul Aug Sep85.7 93.42 78.5 80 75 85.29 83.8 83.3 83.76

Cancer urgent referral to treatment from cancer screening services (Target – 90%)Target is to achieve a maximum time of 62 days from screening services referral to treatment.

Jan Feb Mar Apr May Jun Jul Aug Sep90 96.67 90.9 94.7 100 91.3 100 100 100

Cancer urgent referral to treatment – Consultant upgrade (Target – 85%)Target is to achieve a maximum waiting time of 62 days from Consultant upgrade to treatment.

Jan Feb Mar Apr May Jun Jul Aug Sep80 100 72.7 100 85.7 100 100 40 57.14

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Cancer urgent referral to treatment all 62 day pathways - Monitor target (Target – 85%)Performance

Target is to achieve a maximum waiting time of 62 days from urgent referral to treatment for all cancers across all 62 day pathways combined.

Q4 (14/15) Q1 (15/16) Q2 (15/16) Q3 (15/16) Q4 (15/16)Met Failed Failed

Cancer diagnosis to treatment waiting times – 31 day target (Target – 96%)Target is to ensure a maximum waiting time of 31 days from diagnosis to treatment for all cancers.

Jan Feb Mar Apr May Jun Jul Aug Sep98.8 100 100 97.1 97.1 100 100 100 100

Cancer diagnosis to treatment waiting times – Surgery (Target – 94%)Target is to ensure a maximum waiting time of 31 days from diagnosis to subsequent treatment of surgery.

Jan Feb Mar Apr May Jun Jul Aug Sep100 100 100 100 100 100 100 100 100

Cancer diagnosis to treatment anti-cancer drug regimen (Target – 98%)Target is to ensure a maximum waiting time of 31 days from diagnosis to subsequent treatment or anti-cancer drug regimen.

Jan Feb Mar Apr May Jun Jul Aug Sep100 100 100 100 100 100 100 100 100

Cancer diagnosis to treatment all 31 day pathways - Monitor pathway (Target – 98%)Performance

Target is to achieve a maximum waiting time of 31 days from diagnosis to treatment for cancer across all 31 day pathways combined.

Q4 (14/15) Q1 (15/16) Q2 (15/16) Q3 (15/16) Q4 (15/16)Met Met Met

Cancer is a priority quality standard for the CCG and enhanced scrutiny is being placed on the acute providers to ensure delivery of these key safety standards.

1.11 Pressure Ulcers

Both JPUH and ECCH continue their local CQUIN Indicator in 2015/16 which requires both organisations to track patients with pressure ulcers within the Great Yarmouth and Waveney locality. Progress against these CQUIN local indicators is monitored by the CCG and at relevant monthly meetings with both organisations.

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The above chart shows the number of Grade 3 Hospital Acquired Pressure Ulcers covering the period from August 2014 to July 2015. More recent data is unavailable due to the timings of the completion of the Root Cause Analysis investigations.

1.11 Slips, Trips and Falls (October 2014 to September 2015)

JPUH and ECCH continue to work collaboratively to identify and intervene where patients are at risk of falling. The graph below shows the number of inpatient falls covering the period from October 2014 to September 2015.

1.12 Summary Hospital-level Mortality Indicator (SHMI)

JPUH has been identified, in recently published figures, as having a “higher than expected” SHMI for the period January 2014 to March 2015 with a SHMI of 1.118.

The SHMI relates to patients who have died in hospital or within 30 days of discharge. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.

An update on SHMI is due to be received at the JPUH CQRM on 19 November ’15.

2.0 East Coast Community Healthcare (ECCH)

2.1 Serious Incidents (SIs)

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

14 4 1 1 4 3 1

SIs that currently remain open (as at 10.11.2015) are all being investigated within the contractual time-frame. These are noted within the following table:

SI number Category Current Status

2015/14341 Grade 4 Pressure Ulcer Currently under investigation2015/15411 Fall Currently under investigation2015/18273 Grade 3 Pressure Ulcer Currently under investigation2015/25292 Information Governance Currently under investigation2015/27305 Grade 3 Pressure Ulcer Currently under investigation2015/27315 Grade 4 Pressure Ulcer Currently under investigation

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2015/27582 Grade 3 Pressure Ulcer Currently under investigation2015/28075 Grade 3 Pressure Ulcer Currently under investigation2015/28656 Grade 3 Pressure Ulcer Currently under investigation2015/29125 Grade 3 Pressure Ulcer Currently under investigation2015/29824 Grade 3 Pressure Ulcer Currently under investigation2015/32463 Grade 3 Pressure Ulcer Currently under investigation


QIRs reported against ECCH:

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

1 2 1 1 5 1 2


From 1st October 2014 to 1st November 2015, 3 QIRs remains open, 16 have been closed, 1 QIR has been voided and 1 QIR is pending closure.

The following QIR are open:


ECCH/030

04/06/2015

Nelson Medical Practice

Poor communication relating to the ECCA service. Under investigation

ECCH/039

10/09/2015 JPUH Communication failure. Pending

closure

ECCH/040

30/10/2015 JPUH Failure to take INR. Under

investigation

ECCH/041

20/10/2015 JPUH Failure to take INR. Under

investigation

2.3 ECCH Quality Data

2.3.1 Pressure Ulcers

January February March April May June July0

20

40

60

80

100

120

Developed Pressure Ulcers

Grade 4Grade 3Grade 2

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Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug SepONE 1 0 2 0 2 0 4 3 5 6 8 4 0District Nurses 1 0 1 0 2 0 3 0 5 6 7 3 0

Inpatients 0 0 1 0 0 0 0 0 0 0 0 1 0

TWO 36 46 48 47 55 49 72 78 63 58 58 44 66District Nurses 28 35 42 40 48 45 62 66 53 48 55 38 55

Inpatients 7 8 6 6 7 4 7 10 8 9 3 3 7

THREE 7 11 3 17 8 16 11 21 15 17 19 15 15District Nurses 7 7 3 13 8 13 9 18 15 15 14 13 13

Inpatients 0 3 0 4 0 2 1 3 0 2 3 2 0

FOUR 1 0 2 0 2 3 3 4 0 0 4 3 4District Nurses 0 0 1 0 2 2 2 2 0 0 3 3 3

Inpatients 1 0 1 0 0 1 1 2 0 0 0 0 1Deep Tissue Injury

0 0 0 0 0 0 0 0 0 0 0 0 5

Not all of these pressure ulcers have developed whilst under the care of ECCH; however the Trust continues to report and investigate them. Safeguarding referrals are made to the local authorities, where appropriate. One of the Grade 4 Pressure Ulcers reported in September 2015 developed in the care of ECCH and was unavoidable.

ECCH have implemented on-going staff training in relation to pressure ulcer management which is being developed within the new role of the Tissue Viability Nurse Specialist. ECCH has also offered training to staff in local Care Agencies. In addition ECCH continue to lead on the implementation of a pressure ulcer prevention plan across the health care system.

Note: October data was not available at the time the report was published.

2.3.2 Inpatient Falls

2.3.2 Recorded Patient Falls in Inpatient Areas

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2014 10

2014 11

2014 12

2015 01

2015 02

2015 03

2015 04

2015 05

2015 06

2015 07

2015 08

2015 09

0

5

10

15

20

25

30

3

9 94

85 5 3 5

2 2 2

18 69

5

46

3 9 6

4 3 1

4

0

0

0

0

14

3

32

5

10

2

9 4

1

2

1

1

10 3

0

0

Southwold Hospital Ward

Patrick Stead Hospital Ward

Northgate Hospital Ward

Beccles Hospi-tal Ward

A number of initiatives continue underway in ECCH in the on-going prevention and management of falls. This includes:

Development of a falls training pack for use with staff, Exploring the potential benefit of additional assistive technology, Purchase of two new low-rise beds for Northgate Hospital.

2.4 Care Quality Commission (CQC)

Beccles Hospital

The CQC inspected Beccles Hospital, on 15 August ‘14, in response to concerns that one of more of the essential standards of quality and safety were not being met. At this time the hospital was meeting the standard for care and welfare of people who use services but was not meeting the standard for assessing and monitoring the quality of service provision (Outcome 16). The level of non-compliance was judged to have been at a ‘Moderate Impact’ and therefore action was needed. Improvements were required in relation to the leadership at ward level and the systems in place that allowed the service to monitor and assess the quality of the services provided.

The CQC re-inspected the hospital on 27 August ‘15 to ensure that actions had been taken and published the inspection report on 28 September ‘15. It was found that the hospital had completed and implemented an action plan and improvements had been made. It was therefore judged that Beccles Hospital is now meeting required standards.

A full copy of the report can be accessed via: http://www.cqc.org.uk/sites/default/files/new_reports/AAAE1283.pdf


The ceiling of maximum c-difficile cases with ECCH for 2015/16 has been locally agreed as no more than 4 avoidable cases.

ECCH has reported 2 cases this year. Of these one has been agreed as unavoidable as it occurred even with best clinical practice being in place and the other was avoidable.

3.0 Norfolk & Norwich University Hospital (NNUH)

3.1 Serious Incidents (SIs) for GYW patients

Apr2015

May2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Aug 2015

0 0 0 0 0 0 0

3.2 Never Events

Two Never Events have been reported by the Trust since April ’15:One was reported in June ’15 within the ophthalmology department, not a GYW patient.One was reported in November ‘15 within the high dependency unit, a GYW patient.

3.3 Quality Issue Reporting (QIR) for GYW patients

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http://www.cqc.org.uk/sites/default/files/new_reports/AAAE1283.pdf

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

1 2 0 0 1 3 1

Open / Closed / Void

From 1st October 2014 to 1st November 2015, 16 QIRs remain open pending investigation, and 1 QIR has been voided.

The following QIR are open and relate to GY&W patients:


NNUFT/378 18/11/14 High Street Surgery No notification of procedure to GP. Under investigation

NNUFT/379 20/11/14 ECCH Poor referral details. Under investigation

NNUFT/380 24/12/14 ECCH Poor discharge. Under investigation

NNUFT/381 24/12/14 ECCH Failure to receive test results. Under investigation

NNUFT/382 06/01/15 ECCH Inappropriate discharge. Under investigation

NNUFT/383 12/02/15 Cutlers Hill Surgery Medication prescription delay. Under investigation

NNUFT/384 16/03/15 ECCH Inadequate issuing of disposal equipment. Under investigation

NNUFT/385 10/04/15 Park Surgery Medication issues. Under investigation

NNUFT/386 06/05/15 Cutlers Hill Surgery

Incorrect advice given regarding GP responsibilities. Under investigation

NNUFT/387 22/05/15 Cutlers Hill Surgery No discharge summary. Under investigation

NNUFT/388 11/08/15 ECCH No drug chart was sent with medication. Under investigation

NNUFT/389 28/09/15 Cutlers Hill Surgery No discharge summary. Under investigation

NNUFT/390 28/09/15 Park Surgery Out of date medicine provided on discharge. Under investigation

NNUFT/391 29/09/15 Park Surgery Alleged patient care concerns. Under investigation

NNUFT/392 23/10/15 Beccles Medical Centre Discharge summary unclear. Under investigation

Delays in responding to QIRs by the Trust has been raised by the CCG’s Director of Commissioning and Quality at the NNUH CQRM.

3.4 Patient Safety Indicators published on NHS Choices

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The October 2015 position for NNUH published on NHS Choices is below. To note, the CQC standards are not met as a result of previously reported non-compliance.

The nurse staffing metrics report that 95% of planned nursing staff were in place.

3.5 Friends and Family Test

September 2015


Total Eligible

Response Rate

% Recommended

% Not Recommended

A&E 494 7108 6.9% 93% 4%

Inpatients 877 13064 6.7% 96% 2%


AvailableNot Available 95% 5%

Maternity – Birth 46 488 9.4% 98% 2%



Maternity – Postnatal Community Provision 35 Not


August 2015


Total Eligible

Response Rate

% Recommended

% Not Recommended

A&E 453 7891 6% 90% 5%

Inpatients 856 12642 6.8% 96% 2%



Maternity – Birth 62 624 11.8% 95% 2%



Maternity – Postnatal Community Provision 12 Not


Note: The FFT data for October 2015 will be published by NHS England on 10 December 2015 and the FFT data for November 2015 will be published by NHS England on 14 January 2016.

3.6 Stroke Performance

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The Trust’s stroke performance remains below the required standard.

Standard Target Oct ‘14

Nov ‘14

Dec ‘14

Jan ‘15

Feb ‘15

Mar ‘15

Apr ‘15

May ‘15

Jun ‘15

July ‘15

Aug ‘15

Sept ‘15

4 hours direct to Stroke Unit

90% 71.4 84.5 72.4 71.4 67.7 69.9 76.9 80.9 71.4 N/A 67.5 N/A

90% of time on the Stroke Unit

80% 74.7 86.2 84.7 66.7 76.6 83.7 79.1 69.8 75.9 N/A 86.3 N/A

60 minutes to scan

90% 89.2 87.5 84.3 88.0 77.8 90.3 85.2 88.1 88.1 N/A 79.5 N/A

Door to needle time of 60 minutes for all eligible thrombolysis

70% 71.4 83.5 81.5 88.9 100 98.9 77.8 66.7 90.9 N/A 58.3 N/A

*The above data is included within the Trust’s Contractual and Key Performance Indicators reported to Trust Board on a monthly basis. No further data is provided by the Trust to the Lead Commissioning CCG.

3.7 Cancer Target Performance

Maximum waiting time of 31 days for subsequent treatments for all cancers –Surgery (Target – 94%)

Q1 Q2 Q3 Q488.7% N/A

Maximum waiting time of 31 days for subsequent treatments for all cancers –Anti-Cancer Drugs (Target – 98%)

Q1 Q2 Q3 Q499.0% N/A

Maximum waiting time of 31 days for subsequent treatments for all cancers –Radiotherapy (Target – 94%)

Q1 Q2 Q3 Q498.5% N/A

Maximum waiting time of 62 days for subsequent treatments for all cancers –GP Referral (Target – 85%)

Q1 Q2 Q3 Q4

75.4% N/A

Maximum waiting time of 62 days for subsequent treatments for all cancers –Consultant Screening Service (Target – 90%)

Q1 Q2 Q3 Q4

93.8% N/A

2 week wait from referral to date first seen –All Cancers (Target – 93%)

Q1 Q2 Q3 Q4

94% N/A

2 week wait from referral to date first seen –Symptomatic Breast Cancers (Target – 93%)

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Q1 Q2 Q3 Q4

97.9% N/A

The CCG has raised concerns about cancer performance and monitors GYW patient pathways on a weekly basis with intervention as required. The CCG continues to attend the Cancer PTL meetings and bi-weekly outcomes review meeting led by the lead commissioner. The CCG has been clear in our dissatisfaction with poor cancer performance.

3.8 Monitor Investigation

Monitor commenced a formal review of NNUH, with particular attention on breaches in C.Difficile, A&E 4 hour standard, Referral To Treatment and some cancer standards. The Trust has been found to be in Breach of their Licence.

Monitor published the outcomes of their investigation and particularly noted the need for improvements in A&E performance, cancer standards, RTT, leadership and governance. The formal notifications are published and can be found within the following hyperlinks:

Enforcement undertakings issued 24th April 2015https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425078/Norfolk_and_Norwich_Enforcement_Undertakings.pdf

Additional Licence condition issued 29th April 2015https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425073/Norfolk_and_Norwich_Additional_Licence_Condition.pdf

Monitor is continuing to work with the Trust in making sustainable improvements towards both performance and financial recovery.

3.9 CQC

The CQC undertook an unannounced responsive inspection in March ‘15.

The CQC published a partial report on 21st May with narrative information about their findings into the three services they reviewed, Urgent & Emergency Services, Medical Care and Surgery.

This was followed by a further report on 11th June which determined that the hospital was not meeting its legal requirements, namely Regulation 17 HSCA (RA) Regulations 2014 Good governance.

That is that “systems and processes were not established and operated effectively to enable the provider to assess, monitor and improve the quality and safety of the service provided or to mitigate the risks relating to the health safety and welfare of service users and other who may be at risk”.

Although there was no determination of the ratings for these services, the CQC undertook a full planned inspection in November 2015.

3.10 Referral To Treatment (RTT)

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https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425073/Norfolk_and_Norwich_Additional_Licence_Condition.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425073/Norfolk_and_Norwich_Additional_Licence_Condition.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425078/Norfolk_and_Norwich_Enforcement_Undertakings.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425078/Norfolk_and_Norwich_Enforcement_Undertakings.pdf

The CCG is concerned about Referral to Treatment (RTT) waiting times at the NNUH and continues to work closely with the lead commissioner, North Norfolk CCG, and the Trust to gain assurance regarding GY&W patients.

4.0 Norfolk and Suffolk NHS Foundation Trust (NSFT)

4.1 Care Quality Commission (CQC) and Monitor

The Care Quality Commission (CQC) undertook an inspection of the Trust and overall judged NSFT to be Inadequate.

CQC Inspection Area RatingsSafe InadequateEffective Requires ImprovementCaring GoodResponsive Requires ImprovementWell-led Inadequate

This has resulted in the Trust being placed in Special Measures.

NSFT has developed a comprehensive improvement plan and is being managed by Monitor who has appointed an Improvement Director within the organisation. Monthly Stakeholder Meetings continue with the Trust, which the CCG attends, where the Trust is required to present an updated position against the agreed improvement plan. NSFT has placed the improvement plan within the Trust’s Project Management Office structure, mapped against the CQC’s five domains.

NSFT has also developed a dashboard cross referenced to the whole of the improvement plan which has been submitted for review to the lead commissioner, SNCCG.

4.2 Serious Incidents / Never Events for GYW patients

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

4 2 2 2 0 5 2

4.2.1 Current Open Serious Incidents (SIs) reported for GY&W CCG patients:

SIs that currently remain open (as at 10.11.2015) are all being investigated within the contractual time-frame. They are noted within the following table:SI Number Category Current Status2014/33818

Unexpected Death of Inpatient (in receipt) Pending closure

2015/1398 Allegation against HC non-Professional Currently under investigation2015/7458 Serious Incident by Outpatient (in receipt) Currently under investigation2015/14996 Unexpected Death of Community Patient (in receipt) Currently under investigation

2015/29267

Unexpected Death - Outpatient Currently under investigation

2015/29340


2015/29727


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2015/30175

Unexpected Death of Community Patient (in receipt) Currently under investigation

2015/31274

Safeguarding - Vulnerable Adults Currently under investigation

2015/31697


2015/33583


2015/34710

Unexpected Death of Community Patient (not in receipt)

Currently under investigation

2015/35182

Fall Currently under investigation


Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

1 0 0 0 2 3 2


There are 3 QIRs pending closure, 11 QIRs have been closed and 2 QIRs have been voided.


NSFT/214 24/09/15 Hellesdon Hospital Beds unavailable. Pending closure

NSFT/215 13/10/15 EEAST Potential inappropriate discharge. Pending closure

NSFT/216 22/10/15 Hellesdon Hospital Beds unavailable. Pending closure

4.4 GYW Patients Placed Out of Area by NSFT

As at 10th September 2015, 12.00 there were 15 patients placed outside of the NSFT geographical area, 1 of these was a GYW patient.


NSFT have had 1 case of C. Difficile this year which was unavoidable. At the review it was identified that previous learning from a prior case last year had been fully embedded and implemented.

5.0 Norfolk Community Health & Care (NCH&C)

5.1 Serious Incidents

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

0 0 0 0 0 0 0

5.2 Quality Issue Reporting (QIR) for GYW patients

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Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

0 0 0 0 0


NCH&C have reported 1 C-Diff case in 2015-16 for a GYW resident. This has been reviewed with the CCG and it has been agreed this is a non-trajectory case.

6.0 Integrated Care 24

6.1 Serious Incidents

There has been 1 SI reported by IC24 in 2015/16, reported in June ‘15.


Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

1 0 2 2 0 2 1


From 1st October 2014 to 1st November 2015, 4 QIRs remain open pending investigation, 14 QIRs have been closed and 1 QIR voided.


IC24/031 06/01/15 ECCH On call doctor delay Under investigation

IC24/038 29/06/15 EEAST Inappropriate call transferring Under investigation

IC24/041 04/09/15 EEAST Patient refused ambulance transfer Under investigation

IC24/043 20/10/15 JPUH INR results delay Under investigation

6.3 Clinical Quality and Patient Safety Report

IC24 continues to develop the format of the monthly Clinical Quality and Safety Report to ensure that sufficient assurance is provided regarding trends and theme analysis, lessons learned and shared, and to present an equitable approach between OOH and 111 issues.

6.4 Annual Quality Assessment

The Annual Quality Assessment is a Statutory Requirement for which IC24 provides an annual report. This report is conjoined with a Work / Audit Plan which is monitored at the monthly Quality Meetings.


In September a new process was implemented between IC24 and the Microbiology laboratory to improve the management and treatment of C-diff and Glutamate

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dehydrogenase (GDH) positive cases identified out of hours. This is in place across the whole of the Norfolk and Great Yarmouth and Waveney Health systems.

7.0 East of England Ambulance Service NHS Trust (EEAST)

7.1 SIs for GY&W Patients

There have been four SIs for GY&W CCG in 2015/16 to 13th November 2015.

The SIs that currently remain open are as below:

There have been no Never Events from 1st April 2015 to 12th October 2015.

7.2 Performance

Indicator Name Item Apr-15 May -15 Jun-15 Jul 15 Aug -15 Sep-15

Category A Red 1 responses ≤ 8 minutes

Actual 84.5% 83.3% 72.4% 73.2% 75.3% 77.0%

Plan 75.0% 75.0% 75.0% 75.0% 75.0% 75.0%

>8 min 11 10 16 22 22 20

<8 min 60 50 42 60 67 67

Total 71 60 58 82 89 87

Category A Red 2 responses ≤ 8 minutes

Actual 78.3% 75.7% 70.4% 70.2% 67.7% 66.1%

Plan 75.0% 75.0% 75.0% 75.0% 75.0% 75.0%

>8 min 247 277 341 340 412 393

<8 min 892 861 810 802 863 766

Total 1139 1138 1151 1142 1275 1159

Category A19 responses ≤ 19 minutes

Actual 96.1% 96.7% 93.9% 93.5% 91.2% 92.3%

Plan 95% 95% 95% 95% 95% 95%

>19 min 46 39 73 79 120 96

<19 min 1161 1156 1129 1135 1238 1143

Total 1207 1195 1202 1214 1358 1239

EEAST has improved on performance in response times in GY&W CCG over the last two months for Category A Red 1. However, over the last 4 months there has been a deterioration in performance for Category A Red 2 and A19 responses.

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SI Number Category Current Status

2015/26269 Non conveyance Currently under investigation

2015/31937 Non conveyance Currently under investigation

On 14th September ‘15, the consortium Co-ordinating Commissioner, Ipswich and East CCG, issued a contractual performance notice to EEAST on behalf of all 19 consortium CCGs. This relates to the current and forecast performance on two key standards, Category Red 2 and Category Red 19. A remedial action plan for these is in discussion and has yet to be agreed. Actions which are already in place with EEAST are a Hospital Liaison Officer is to be appointed for JPUH; there is a GP based in the Emergency Operations Centre who gives advice to crews on scene which is resulting in fewer conveyances; student paramedic recruitment continues and a number of staff are being up-skilled. 7.3 CQC position

EEAST were inspected by the CQC in December ‘13 and to date has had no further inspections. The outcomes of this inspection were:

Non-Compliant for Outcome 4 – Care and welfare of people who use services (Moderate Impact).

Compliant for Outcome 11 – Safety, availability and suitability of equipment. Compliant for Outcome 12 – Requirements relating to workers. Non-Compliant for Outcome 13 – Staffing (Moderate Impact). Compliant for Outcome 14 – Supporting staff. Compliant for Outcome 16 – Assessing and monitoring the quality of service provision. Compliant for Outcome 17 – Complaints.

However EEAST have recently formed a focus group for Key lines of Enquiry (KLOE) compliance; the ambitious plan, including support by Non-Executive Directors is to visit every station throughout the year by the beginning of 2016 to engage with staff, support any clinical ideas or suggestions and review for compliance against the KLOE’s in as many areas as possible.

7.4 Quality and Patient Safety

EEAST has developed a Quality and Patient Safety Strategy which was launched in July 2015. This is centred upon the five pledges set out in the Sign up to Safety Initiative.

8.0 Healthcare Associated Infections (HCAI)

In the event of C-diff cases being assessed following Root Cause Analysis that they are either unavoidable (with evidence of excellent practice) or a recurrence, cases can be reviewed and, if appropriate, can be considered to not count within the local trajectory. The case reviews that are successful will still be included in the national numbers, however not for the purposes of performance management.

Root cause analysis is undertaken on every single case and opportunities for learning are shared, reviewed within the local CDI case review team and learning incorporated within the local system wide CDI improvement plan. This provides an over-arching forum to ensure best practice is shared across the local GYW CCG health system.

8.1 Clostridium Difficile 2015/16

The GY&W CCG C. Difficile Infection (CDI) trajectory for 2015/16 is 70 cases.

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From April to 11th November 2015, there have been 62 reported cases. Accountability for these cases are as follows:

21 cases James Paget University Hospital (including 2 NNCCG cases) – 9 cases have been reviewed and are trajectory, 9 are non-trajectory and 1 has still to be reviewed.

35 cases GY&W Primary Care – 9 cases are trajectory, 24 cases are non-trajectory and 2 have still to be reviewed.

1 case Norfolk & Suffolk Foundation Trust – non-trajectory.

2 cases East Coast Community Healthcare –1 case is trajectory and 1 case is non-trajectory.

1 case Cambridge University Hospitals Foundation Trust – non trajectory.

2 cases Norfolk and Norwich University Hospital – 1 case is trajectory and 1 case to be reviewed.

8.2 MRSA

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There has been 1 case of MRSA bacteraemia identified in the JPUH this year. On Post Infection Review (PIR) it was determined that this was most likely a ‘contaminant’ and not a MRSA bacteraemia.

9.0 GYW Complaints

The CCG has 1 complaint outstanding from 2014/15 and has received 34 complaints for the period 1 April to 31 October ’15 as follows:

Quarter 1 (1 April to 30 June ’15):

Received Response Date Working Days Primary Complaint Upheld / Not Upheld /

Partially Upheld01/04/15 24/04/15 15 CHC Assessment Upheld

09/04/15 24/04/15 11 CHC Assessment Upheld

13/04/15 22/06/15 49 CHC Care Upheld

21/04/15 26/05/15 23 IC24 (OOH) Not upheld

04/05/15 01/10/15 106 James Paget University Hospitals NHS Foundation Trust Partially upheld

05/05/15 10/07/15 47 Patient Transport Services (EEAST) Not upheld

14/05/15 07/08/15 59 IC24 (111) Partially upheld

04/06/15 01/10/15 80 James Paget University Hospitals NHS Foundation Trust Not upheld

08/06/15 04/09/15 62 James Paget University Hospitals NHS Foundation Trust Partially upheld

16/06/15 29/06/15 9 CHC Retrospective Claim Partially upheld

17/06/15 06/11/15 95 Multi-agency Partially upheld

26/06/15 Closed n/a IC24 (111) Consent not received

30/06/15 27/07/15 18 CHC Retrospective Claim Partially upheld

Quarter 2 (1 July to 30 September ’15):

Received Response Date Working Days Primary Complaint Upheld / Not Upheld / Partially Upheld

21/07/15 16/10/15 59 CHC Care Partially upheld

30/07/15 03/08/15 2 CHC Assessment N/A

17/07/15 23/07/15 4 CHC Care Not upheld

10/08/15 OngoingJames Paget University Hospitals NHS Foundation Trust and CHC Assessment

24/08/15 25/08/15 1 Commissioning N/A

24/08/15 Ongoing 58 NNUH Upheld

27/08/15 Ongoing 53 IC24 (OOH) Upheld

03/09/15 06/11/15 44 East Coast Community Healthcare Partially upheld

07/09/15 Ongoing CHC Assessment

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18/09/15 23/09/15 4 CHC Funding Partially upheld

21/09/15 Ongoing Multi-agency

October ‘15

Eight complaints were received in October 2015, six of which are ongoing. The closed complaint relating to James Paget University Hospitals NHS Foundation Trust was due to consent not being received from the complainant.

Received Response Date Working Days Primary Complaint Upheld / Not Upheld / Partially Upheld



09/10/15 22/10/15 10 Commissioning Partially upheld

12/10/15 Ongoing James Paget University Hospitals NHS Foundation Trust

15/10/15 Closed N/A James Paget University Hospitals NHS Foundation Trust Consent not received

16/10/15 Ongoing CHC Funding

21/10/15 Ongoing Commissioning

26/10/15 Ongoing BMI Sandringham

9.1 Common Themes

Complaints associated with Continuing Healthcare (CHC) continue to be the main theme in particular regarding the assessment process, care provision and funding.

There have also been a number of complaints received involving IC24, the provider of the 111 and Out of Hours services.

9.1.1 CHC

The CHC Team have an ongoing process to deliver an extensive training programme to hospital and community nursing colleagues and continue to progress this. Communication has been identified and recognised as an issue regarding CHC Assessments and Processes.

In response to this, the CHC team have drafted a leaflet to inform patients and their representatives of the locally delivered NHS CHC process. Representative expectations continue to be a significant challenge within the CHC Team and they have experienced increasing episodes of conflict during discussions relating to eligibility, funding and care packages.

All complaints associated with CHC are investigated and overseen by the Head of Quality in Care. The Director of Commissioning and Quality also reviews all complaints and responses to ensure optimal opportunities for learning and improvement.

9.1.2 James Paget University Hospitals NHS Foundation Trust

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Complaints received regarding James Paget University Hospitals NHS Foundation Trust relate to the care and treatment provided, and discharge.

9.1.3 IC24Complaints regarding Integrated Care 24 (IC24) relate to the 111 service and in particular the lack of call back from the provider and the Out of Hours service at the James Paget Hospital.

9.1.4 CommissioningThe complaints categorised as commissioning have related to the CCG’s decisions, in particular regarding funding of current, and future, services.

10.0 Care Provider CQC Overview

The CQC publish the compliance status of all registered providers on their website; however this is not available in a dashboard in order to be able to review the position across all of the providers. The full table of all care homes and domiciliary care providers in Great Yarmouth and Waveney is presented.

The following provides explanation of the symbols used by the CQC found within the Appendix tables:

This means that the standard was being met in that the provider was compliant with the regulation.

Min

This means that the standard was not being met in that the provider was non-compliant with the regulation. People who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed of resolved quickly.

Mod

This means that the standard was not being met in that the provider was non-compliant with the regulation. People who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be managed of resolved quickly.

Maj

This means that the standard was not being met in that the provider was non-compliant with the regulation. People who use the service experienced poor care that had a serious current or long term impact on their health, safety or welfare or there was a risk of this happening. The matter needs to be resolved quickly.

En

If the breach of the regulation was more serious, or there have been several or continual breaches, the CQC have a range of actions that they take using the criminal and/or civil procedures in the Health and Social Care Act (2008) and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager of provider. These enforcement powers are set out in law and mean that they can take swift, targeted action where services are failing people.

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The CQC has changed the methodology used when inspecting services. The CQC inspectors use professional judgement, supported by objective measures and evidence, to assess services against five key questions:

Are they safe? You are protected from abuse and avoidable harm.Are they effective? Your care, treatment and support achieves good outcomes, helps you to

maintain quality of life and is based on the best available evidence.Are they caring? Staff involve and treat you with compassion, kindness, dignity and respect.Are they responsive to people’s needs?

Services are organised so that they meet your needs.

Are they well-led? The leadership, management and governance of the organisation make sure it's providing high-quality care that's based around your individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.

The CQC also rate services to help people to compare services and to highlight where care is outstanding, good, requires improvement or inadequate. This approach has been developed by the CQC over time and through consultation with providers, stakeholders, care professionals, the public, and people who use services.

The tables to display the results have been separated to distinguish between the services which have been inspected using the new methodology and the services which are yet to be inspected using the new methodology.

Care and Residential Homes (New Methodology) – Page 29Care and Residential Homes (Pre-existing Methodology) – Pages 32

GP Practices, Acute Hospitals, Mental Health & Community Services (New Methodology) – Page 36GP Practices, Acute Hospitals, Mental Health & Community Services (Pre-existing Methodology) – Page 38

Key:

10.1 Current Significant Concerns about Care Providers

The Dell, Oulton Broad, Lowestoft (run by Wellbeing Care Limited):

The CQC have undertaken a number of inspections this year which have resulted in a number of concerns. The most recent inspection has determined that the provider ‘requires improvement’.

Overall rating for this service Requires ImprovementDomainsIs the service safe? Requires ImprovementIs the service effective? Requires ImprovementIs the service caring? Good

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O OutstandingG Good (No action required)R.I Requires ImprovementI Inadequate

http://www.cqc.org.uk/provider/1-137861712

Is the service responsive? Requires ImprovementIs the service well led? Inadequate

As a result of their inspections, the CQC raised seven Safeguarding alerts with Suffolk County Council.

Wellbeing Care Support Services, Oulton Broad, Lowestoft (run by Wellbeing Care Limited):

The service provides personal care and support to adults with a learning disability who live in flats owned by the provider. The provider was inspected on the 2 April ‘15 and the report was published on the 12 June ‘15 in which it stated that the provider was being placed into Special Measures.

The CQC undertook a focused inspection of Wellbeing Support Services on 21 July ‘15. This inspection was completed to check that people were safe after they had received information of concern. They also checked that improvement to meet legal requirements planned by the provider after the 2 April 2015 inspection had been made.

Overall rating for this service InadequateDomainsIs the service safe? Requires ImprovementIs the service effective? InadequateIs the service caring? Requires ImprovementIs the service responsive? InadequateIs the service well led? Inadequate

Salisbury Residential Home, Great Yarmouth (run by Dr Nagpal and Partners):

The CQC undertook an unannounced inspection using the new methodology on 26 November ’14 for which the final report was published on 26 January ’15.

The CQC deemed Salisbury Residential Home to be Inadequate overall and rated that the Residential Home needed to make improvements across all five domains as follows:

Overall rating for this service InadequateDomainsIs the service safe? InadequateIs the service effective? Requires ImprovementIs the service caring? Requires ImprovementIs the service responsive? InadequateIs the service well-led? Inadequate

10.2 Current Significant Concerns about GP Practices

Oulton Medical Centre and Marine Parade Surgery, Lowestoft:

On 13 October ’15 the Care Quality Commission (CQC) took urgent legal action to protect the safety and welfare of patients at these surgeries. The Oulton Medical Centre site was

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immediately closed and patients were redirected to Bridge Road Surgery. Marine Parade Surgery, located at Kirkley Mill, remained open but with the care of patients transferring to Victoria Road Surgery.The CCG worked very closely with NHS England to put in place replacement GP services to ensure that appointments of all patients with an urgent medical need were available. Some patients with routine appointments may be contacted to have their appointments cancelled in the short term whilst the CCG works with NHS England to put permanent arrangements in place.

The CCG is asking anyone affected by the closure of Oulton Medical Centre and Marine Parade Surgery to fill in an online questionnaire by the end of November ’15 to share their feedback on the impact the closure has had on them and to help shape the GP service they receive in the future.

Family Health Centre, Gorleston-on-Sea (run by Dr Maleki):

The CQC carried out an announced comprehensive inspection on 14 September 2015. This followed an inspection in October 2014 that placed the practice into special measures due to its rating of inadequate.

The outcome of this inspection has identified that the practice has improved and is now rated as Requires Improvement overall:

Overall rating for this service Requires ImprovementDomainsIs the service safe? Requires ImprovementIs the service effective? Requires ImprovementIs the service caring? GoodIs the service responsive? Requires ImprovementIs the service well-led? Requires Improvement

11.0 Recommendations The Governing Body note the content of this report.

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Care and Residential Homes (New Methodology)

DomainsSafe Effective Caring Responsive Well-led Overall rating Date of report

Abbeville Residential Care Home, Great Yarmouth R.I G G R.I G Requires

Improvement 09 September 2015

Abbeville Sands, Great Yarmouth R.I R.I R.I R.I R.I Requires Improvement 09 October 2015

Amber Lodge, Lowestoft G G G G G Good 30 October 2015

Avery Lodge, Great Yarmouth R.I R.I G G G Requires Improvement 06 July 2015

Beech House Residential Home, Halesworth G G G G G Good 05 May 2015

Blyford Residential Home, Lowestoft This service, provided by Eastern Healthcare Ltd, has not yet been inspected since it was registered by CQC on 23 February 2015.

Britten Court, Lowestoft R.I R.I G R.I R.I Requires Improvement 26 June 2015

Burgh House, Burgh Castle, Great Yarmouth G R.I G G G Good 08 January 2015

Cherry Lodge, Lowestoft G G G G G Good 15 May 2015

Chevington Lodge, Bungay This service, provided by Cygnet Care Limited, has not yet been inspected since it was registered by CQC on 12 April 2014.

Clarence Lodge,Gorleston R.I R.I G R.I R.I Requires

Improvement 19 August 2015

Eastview, Lowestoft G G G G G Good 03 August 2015

Estherene House, Lowestoft This service, provided by QH (Rosewood) Limited, has not yet been inspected since it was registered by CQC on 16 October 2015.

Eversley Nursing Home, Great Yarmouth G G G G G Good 06 November 2015

Holmwood Residential Home, Bungay This service, run by Holmwood Care Limited, has not yet been inspected since it was registered by CQC on 10 October 2014.

John Turner House (Leading Lives), Lowestoft G G G G G Good 09 October 2015

Joseph House, Reedham, Norwich G G G G G Good 29 May 2015

Kirkley Manor, Lowestoft G G G G G Good 04 September 2015

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Lound Hall Nursing Home, Lowestoft G G G G G Good 30 October 2015

Lydia Eva Court, Gorleston, Great Yarmouth This service, run by Norse Care Services (Limited), has not yet been inspected since it was registered by CQC on 12 June 2014.

Manor Farm, Kessingland, Lowestoft G G G G G Good 10 February 2015

Marine Court, Great Yarmouth G G G G G Good 09 November 2015

Marlborough House, Lowestoft G G G G G Good 09 October 2015

Marram Green, Kessingland, Lowestoft G G G G G Good 07 July 2015

Martham Lodge, Martham, Great Yarmouth This service, run by Hollyman Care Homes Limited, has not yet been inspected since it was registered by CQC on 01 January 2015.

Oaklands Residential Home, Reydon R.I G G R.I R.I Requires Improvement 06 October 2015

Ritson Lodge, Hopton, Great Yarmouth G G G G G Good 11 August 2015

Roseland Lodge, Great Yarmouth G G G G G Good 14 September 2015

Royal Avenue Residential Home, Lowestoft G R.I R.I R.I R.I Requires

Improvement 07 July 2015

Salisbury, Great Yarmouth I I G G I Requires Improvement 09 October 2015

Seahorses, Gorleston, Great Yarmouth G G G G G Good 20 March 2015

Shaftesbury Court Residential Home, Lowestoft This service, run by Sanctuary Care Home Limited, has not yet been inspected since it was registered by CQC on 03 July 2014.

St Barnabus, Southwold This service, run by St Barnabus Southwold, has not yet been inspected since it was registered by CQC on 01 October 2015.

St David’s Residential Home, Great Yarmouth G R.I G G R.I Requires

Improvement 25 February 2015

St Edmunds, Gorleston, Great Yarmouth G G G G G Good 20 March 2015

St Georges Care Home, Beccles G R.I G G R.I Requires Improvement 30 July 2015

St Marys House, BungayThis service, run by Innomary Limited, has not yet been inspected since it was registered by CQC on 01 July 2015.

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Stradbroke Court, Lowestoft This service, run by Aps Care Limited, has not yet been inspected since it was registered by CQC on 04 September 2015.

Squirrel Lodge, Lowestoft G G G G G Good 18 August 2015

The Coach House, Hemsby, Great Yarmouth R.I R.I R.I G R.I Requires

Improvement 30 July 2015

The Dell – Residential Home, Oulton Broad, Lowestoft R.I R.I G R.I I Requires

Improvement 08 October 2015

Wellbeing Care Support Services, Oulton Broad, Lowestoft R.I I R.I I I Inadequate 04 September 2015

The Depperhaugh, Hoxne R.I G G R.I G Requires Improvement 02 September 2015

The Elms, Gorleston, Great Yarmouth G G G G G Good 29 April 2015

The Grove, Lowestoft G G G G G Good 04 June 2015

The Moorings, Earsham, Bungay G G G G G Good 21 August 2015

The Old Rectory, Acle, Norwich R.I R.I R.I R.I R.I Requires Improvement

09 October 2015

The Old Rectory, Winterton-on-Sea, Great Yarmouth G G G G G Good 17 April 2015

Windmill Residential Home, Rollesby, Great Yarmouth G G G G G Good 09 July 2015

Woody Point, Brampton, Beccles G G G G G Good 04 June 2015

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Care and Residential Homes (Pre-existing Methodology)

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1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsAll Hallows Healthcare Trust,Ditchingham, Bungay – Nursing Beds

Last inspection report 27 March 2014

Bungay House, Bungay Last inspection report 13 March 2014

Abbeville Lodge,Great Yarmouth Last inspection report 11 January 2014

Alexandra House,Great Yarmouth Last inspection report 22 May 2014

All Hallows Nursing Home,Bungay

Last inspection report 08 January 2014

Allied Healthcare Lowestoft, Beccles Last inspection report 28 January 2015

Amber House, Gorleston Last inspection report 04 December 2013

Ashurst Care Home, Lowestoft Last inspection report 09 November 2013

Broadlands, Oulton Broad, Lowestoft Last inspection report 02 May 2013

Broadview Residential Home, Great Yarmouth

Last inspection report 14 February 2014

Brooke House, Norwich Last inspection report 29 July 2014

Carlton Hall Residential Home, Lowestoft


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1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsDecoy Farm, Browston, Great Yarmouth

Last inspection report 30 September 2014

Ealing House, Martham, Great Yarmouth

Last inspection report 23 May 2014

Florence House, Great Yarmouth Last inspection report 30 October 2013

Genesis Residential Home, Great Yarmouth Last inspection report 19 February 2014

Georgina House, Great Yarmouth Last inspection report 07 February 2014

Gresham Nursing Home, Gorleston Last inspection report 25 June 2014

Hales Lodge, Winterton-On-Sea, Great Yarmouth

Last inspection report 18 February 2014

Harleston House, Lowestoft Last inspection report 11 June 2013

Highfield, Halesworth Last inspection report 25 July 2014

Imber House, Lowestoft Last inspection report 28 June 2013

Ivydene Residential Home, Ormesby, Great Yarmouth


Levington Court, Lowestoft Last inspection report 08 November 2013

Lilac Lodge & Lavender Cottage, Lowestoft


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1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsLynfield, Ditchingham, Bungay Last inspection report 06 November 2013

Newnham Green, Gorleston Last inspection report 20 September 2014

North Bay House, Oulton Broad Last inspection report 13 November 2013

Oliver Court Great Yarmouth Last inspection report 05 December 2013

Orchards Residential Home, Bradwell Last inspection report 28 January 2014

Oulton Park, Oulton Broad, Lowestoft Last inspection report 03 October 2013

Park House, Great Yarmouth Last inspection report 16 May 2014

Pine Lodge, Great Yarmouth Last inspection report 24 June 2014

Pitches View, Reydon, Southwold Last inspection report 14 September 2013

The Claremont, Caister-On-Sea, Great Yarmouth

Last inspection report 18 March 2014

The Gables Residential Home, Gorleston, Great Yarmouth


The Heathers, Bradwell, Great Yarmouth


The Laurels,Lowestoft Last inspection report 15 February 2014

The Vineries, Hemsby, Last inspection report 05 April 2014

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1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsGreat YarmouthWainford House, Beccles Last inspection report 06 June 2014

White House Residential Home, Beccles

Last inspection report 27 April 2013

Windsor House, Lowestoft Last inspection report 20 June 2014

GP Practices, Acute Hospitals and Community Hospitals (New Methodology)

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DomainsSafe Effective Caring Responsive Well-led Overall rating Date of report

Alexandra Road Surgery (Alexandra and Crestview Surgeries), Lowestoft G G G G G Good 27 August 2015

Andaman Surgery, Lowestoft This service has not yet been inspected since it was registered by CQC on 01 April 2013.

Beccles Hospital, Beccles See ECCH section in main body of report for inspection details.

Beccles Medical Centre, Beccles G G G G O Good 19 March 2015

Bridge Road Surgery, Oulton Broad, Lowestoft G G G G G Good 03 September 2015

Bungay Medical Centre, Bungay R.I G G G G Good 08 October 2015

Central Surgery, Gorleston Great Yarmouth G G G G G Good 31 March 2015

Coastal Villages Practice (Ormesby Practice), Great Yarmouth G G G G G Good 19 February 2015

Cutlers Hill Surgery, Halesworth G G G G G Good 17 September 2015

Falkland Surgery, Bradwell, Great Yarmouth G G G G G Good 05 March 2015

Family Health Centre, Gorleston, Great Yarmouth R.I R.I G R.I R.I Requires

Improvement 12 November 2015

Gorleston Medical Centre, Gorleston, Great Yarmouth G G G G G Good 22 January 2015

Greyfriars Health Centre, Great Yarmouth G G G G G Good 22 January 2015

High Street Surgery, Lowestoft R.I G G G R.I Requires Improvement 08 October 2015

James Paget University Hospital (JPUH), Gorleston, Great Yarmouth R.I G G G G Good 12 November 2015

Kirkley Mill, Lowestoft G G R.I G G Good 20 August 2015

Lighthouse Medical Centre (King Street and South Quay Surgery), Great Yarmouth This service, part of Eastern Norfolk Medical Practice, has not yet been inspected by CQC. The service commenced on 24 August 2015.

Longshore Surgeries, Kessingland, Lowestoft G G G G G Good 19 March 2015

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Millwood Surgery, Bradwell, Great Yarmouth

G G G G G Good 13 August 2015

Newtown Surgery, (Newtown and Caister Medical Practice) Great Yarmouth G G G G O Good 05 February 2015

Norfolk Community Health and Care, (NCHC), Norwich RI G G G G Good 19 Dec 2014

Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) See NNUH section in main body of report for inspection details.

Norfolk and Suffolk Foundation Trust (NSFT) I R.I G R.I I In Special Measures 03 February 2015

Park Surgery, Great Yarmouth This service has not yet been inspected since it was registered by CQC on 01 April 2013.

Rosedale Surgery, Carlton Colville, Lowestoft G G G G G Good 22 January 2015

Sole Bay Health Centre, Reydon, Southwold This service has not yet been inspected since it was registered by the CQC on 13 May 2015.

Victoria Road Surgery, Oulton Broad, Lowestoft This service has not yet been inspected since it was registered by CQC on 01 April 2013.

Westwood Surgery, Lowestoft This service has not yet been inspected since it was registered by CQC on 01 April 2013.

GP Practices, Acute Hospitals and Community Hospitals (Pre-existing Methodology)

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1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsPatrick Stead Hospital, Halesworth Last inspection report 01 May 2013

Southwold Hospital, Southwold Last inspection report 27 February 2014

Beccles House- Community Service Last inspection report 21 December 2013

Fleggburgh Surgery, Great Yarmouth Last inspection report 13 March 2014

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