PATIENT SAFETY/QUALITY ASSURANCE REPORT NHS ROTHERHAM CCG Body Papers/Nove… · Final Reports...
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Public Session PATIENT SAFETY/QUALITY ASSURANCE REPORT NHS ROTHERHAM CCG 2 nd November 2016
Transcript of PATIENT SAFETY/QUALITY ASSURANCE REPORT NHS ROTHERHAM CCG Body Papers/Nove… · Final Reports...
Public Session
PATIENT SAFETY/QUALITY
ASSURANCE REPORT
NHS ROTHERHAM CCG
2nd
November 2016
CONTENTS
1. HEALTHCARE ASSOCIATED INFECTION ............................................................... 3
2. MORTALITY RATES .................................................................................................. 5
3. SERIOUS INCIDENTS (SI) AND NEVER EVENTS (NE) ............................................ 5
4. CHILDREN'S SAFEGUARDING ................................................................................ 5
5. ADULT SAFEGUARDING .......................................................................................... 8
6. DELAYED TRANSFER OF CARE (DToC) ................................................................. 8
7. LEARNING DISABILITY MORTALITY REVIEW (LEDER) PILOT – YORKSHIRE AND THE HUMBER ............................................................................. 9
8. DEPRIVATION OF LIBERTY SAFEGUARDS (DOLS) .............................................. 9
9. ADULT CONTINUING HEALTHCARE (CHC) ............................................................ 10
10. CHILDREN’S CONTINUING HEALTHCARE ............................................................. 11
11. PERSONAL HEALTH BUDGETS (PHB) FOR PATIENTS IN RECEIPT OF CONTINUING HEALTHCARE .................................................................................... 11
12. PREVIOUSLY UNASSESSED PERIODS OF CARE (PUPoC) .................................. 11
13. FRACTURED NECK OF FEMUR INDICATOR .......................................................... 11
14. STROKE ..................................................................................................................... 11
15. CQUIN UPDATE ........................................................................................................ 12
16. COMPLAINTS ............................................................................................................ 12
17. ELIMINATING MIXED SEX ACCOMMODATION ....................................................... 12
18. CQC INSPECTIONS ................................................................................................... 12
19. ASSURANCE REPORTS ........................................................................................... 14
20. CARE AND TREATMENT REVIEWS ......................................................................... 16
21. WINTERBOURNE SUBMISSION ............................................................................... 16
APPENDIX 1 - LD MORTALITY REVIEW PILOT – Y&H ....................................................... 17
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1. HEALTHCARE ASSOCIATED INFECTION
RDaSH: There have been no cases of Health Care Associated Infection so far this year.
Hospice: There have been no cases of Health Care Associated Infection so far this year.
TRFT :
MRSA – 0
MSSA – 1
E Coli – 104
C-Difficile:
TRFT C Diff Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2016/17 Target = 26
Monthly Actual 0 0 2 2 1 2
Monthly Plan 1 4 2 2 1 4 2 2 2 2 2 2
YTD Actual 0 0 2 4 5 7
YTD Plan 1 5 7 9 10 14 16 18 20 22 24 26
NHSR:
MRSA – 4 – For Rotherham residents. Of these:
0 – Attributed to Rotherham CCG
2 - Attributed to ‘Third Party’
1 - Attributed to Doncaster and Bassetlaw Hospitals Foundation Trust (DBHFT)
1 – Awaiting Attribution – provisionally allocated to NHS Rotherham CCG however following Post Infection Review the case has been sent to arbitration panel to be considered as third party as it was felt that the attribution is not allocated correctly in relation to the care provision.
The initial 3 cases are confirmed as final attribution of the cases. This has been determined and documented by PHE and NHSE.
MSSA – 25
E Coli – 128
C-Difficile:
NHSR C Diff Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2016/17 Target = 63
Monthly Actual
1 5 4 7 6 8
Monthly Plan 6 7 6 7 7 6 4 4 4 4 4 4
YTD Actual 1 6 10 17 23 31
YTD Plan 6 13 19 26 33 39 43 47 51 55 59 63
Signed off data up to end of September 2016.
Clostridium Difficile Infections (CDI)
Post infection reviews are being undertaken on all cases of Clostridium Difficile within Rotherham. This will be a continual and reviewed process. The process will highlight any lapses in quality of care and any learning outcomes within both community and acute trusts. Any common themes will be addressed as identified.
[NB A ‘lapse in care’ - would be indicated by evidence that policies and procedures were not followed. The lack of compliance with this or any of the elements identified in ‘clostridium difficile infection objectives for NHS organisations in 2016/17 and guidance on sanction implementation’
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(NHS England) checklist would not indicate the infection was caused by the lapse, but that best practice was not followed. The first and foremost aim is to learn any lessons necessary to continually improve patient safety.]
Post Infection Review (PIR) Meeting
Last meeting held on Wednesday 24th August, next meeting to be held on Thursday 26th October (N.B the September meeting was cancelled due to unforeseen circumstances.)
So far there have been 31 cases highlighted as NHSR Cases.
4 cases are from patients treated as an inpatient at Sheffield Teaching Hospitals (STH),
7 +1 cases are from patients treated as an inpatient at The Rotherham Foundation Trust (TRFT)(( the +1 case relates to a patient who had been an inpatient, was discharged and readmitted within 2 days and had a positive sample on readmission – although the case is attributed to RCCG TRFT are admitting that they are responsible and will investigate the case)),
20 cases are from patients undergoing GP care at the time of samples, although there may have been recent inpatient admissions.
4 GP case have been highlighted as having ‘lapse in care’ with learning outcomes that have been discussed with the relevant GP and recorded for monitoring and improvement review purposes.
3 GP case has been highlighted as having ‘no lapse in care’
1 GP case has been deferred to the next meeting due to the complex nature of the case and requirement for further information.
7 GP cases await the PIR process.
1 STH inpatient case has been identified as having ‘lapse in care’ by STH themselves following their internal review. Having reviewed the RCA there is some probable environmental/ cross contamination. Learning outcomes and actions will be followed up by Sheffield CCG.
1 STH inpatient case has been identified as having ‘no lapse care’ by STH themselves following their internal review. This has been taken to the Sheffield CCG PIR meeting and discussed with agreement. Rotherham CCG has received this and also is in agreement.
1 STH case has not yet been forwarded to Rotherham following the investigation. Sheffield review cases on a quarterly basis.
3 TRFT cases have been identified as having ‘No lapse in care’, - 1 of these cases was declared as an SI but was subsequently delogged
1 TRFT case has been identified as having a ‘lapse in care’ relating to a delay in sample taking and infection detection.
1 TRFT case has not yet been discussed at the PIR meeting. It will be discussed at the next meeting.
The remaining cases, following completion of reviews, will be discussed at the next PIR meeting to determine any ‘lapse’ or ‘no lapse’ in care, with action taken as relevant and any themes recorded.
Figure comparison of CDI
23 Cases -YTD 16/17 as of the end of August in comparison to YTD 2015/16 as of the end of August there were 40 cases.
1 case in April 16/17 compared to 4 cases in April 15/16.
5 cases in May 16/17 compared to 9 cases in May 2015/16
4 cases in June. 16/17 compared to 9 cases in June 15/16
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7 cases in July 16/17 compared to 12 cases in July 2015/16
cases in August 16/17 compared to 6 cases in August 2015/16
8 Cases in September 16/17 compared to 10 cases in September 2015/16
Early analysis to date identifies
8 GP Surgeries have had more than 1 case of C Diff, some with relapses, this is currently being investigated and will be discussed at the next PIR meeting.
3 Care homes have had residents with C Diff infection. 1 appears to have had more than 1 case, This will be discussed at the forthcoming PIR meeting.
2. MORTALITY RATES
The most recent 12 month rolling HMSR to May 2016 is 98.81 which is within expected range and has been below 100 for the last five months reported. Whilst SHMI is now outside of the normal range it remains above 100 due to the older figures reported in the calculation SHMI is reported again at 105 as it is only recalculated on a quarterly basis. The crude rate of mortality continues to be reported as similar to last month with nearly 6000 admissions and discharges in the month of July.
The diagnosis groups which have triggered are being scrutinised by the TRFT Mortality and Quality Alerts group and work is on-going with these to determine where improvements can be made. Cancer of the colon mortality is still showing statistical significance with a higher than expected HSMR. A verbal assurance has been provided at the Trust’s mortality committee that there are no clinical concerns and a written report will follow.
3. SERIOUS INCIDENTS (SI) AND NEVER EVENTS (NE)
SI Position 23.09.2016 – 17.10.2016 TRFT RDASH
RCCG Out of Area
YAS Care UK
GP CCG *PH
Open at start of period 58 12 2 0 3 1 2
Closed during period 0 0 0 0 0 1 0
De-logged during period 2 0 0 0 0 0 0
New during period 6 2 3 0 0 0 0
Total Open at end of period 62 14 5 0 3 0 2
New Never Events 0 0 0 0 0 0 0
Final Report Status
Final Reports awaiting additional information 2 1 2 0 0 0 0
Investigations on “Hold” 2 2 0 0 1 0 0
CCG approved Investigations above 60 days 29 1 0 0 0 0 0
Investigations above 60 days without approval 0 0 0 0 0 0 0
Final Reports due at next SI Meeting 44 6 1 0 2 0 0
*Public Health related SIs
4. CHILDREN'S SAFEGUARDING
Date Discussion Outcome Follow up/Next Steps
Aug 2014/Jan 2015
Child Sexual Exploitation (CSE) Report published Aug 2014.
Report published August 2014, media interest immense. Negative press received for LA and Police.
Chief Nurse/Officer commitment to high level CSE meetings continue. Deputy Designated Nurse
Significant national publicity September 2016 due to an on-going court case in Sheffield regarding the historical exploitation of young Rotherham females.
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Date Discussion Outcome Follow up/Next Steps
attending operational CSE group and works closely with the Named GP to ensure information is appropriately shared with primary care.
Nov 2016 Update
Serious Case Reviews Overview
3 SCR involving Rotherham agencies to greater/lesser extent
4.1 Drivers for Change:
Date Discussion Outcome Follow up
October 2014
Ofsted Inspection of Local Authority completed. Rotherham received an Inadequate Grade.
Feedback –the government have appointed a number of independent commissioners to oversee improvements and a new DCS appointed.
LA has set up an improvement panel to consider implications and drive up changes. NHS RCCG Chief Officer and Chief Nurse attending.
Head of LAC in LA has left the post – interim in place.
Rotherham health economy is fully committed to safeguarding (one of four priorities in the Commissioning Plan)
August 2016 commissioners are starting to withdraw from Rotherham as an area requiring significant improvement. Ofsted continue to visit regularly to monitor progress.
Ofsted due to review LAC in October 2016
Joint LA and CCG Children Commissioner post is taking forward a number of initiatives – joint post holder is moving areas. This will potentially leave a gap.
CQC visiting TRFT in September and RDaSH in October for follow up inspections. No feedback yet but aware that TRFT safeguarding was on the agenda.
Feb 2016 Joint Targeted Area Inspections proposed by Ofsted, CQC and HMIP
Joint inspectorates have published their expectations on joint inspections. Themed deep dives to be undertaken, from September 2016 to consider children living in domestically abusive situations.
Paper to NHS RCCG Operational Executive sent 15 February.
Still no meetings arranged by LSCB therefore health economy have updated communications list.
May 2016 Paper presented to Local Safeguarding Children Board Performance and Quality Sub Group. This was an audit
Data from both systems to be synchronised as a matter of urgency and a full review of the current system needs to happen. Both LA, CCG and TRFT need to actively seek
A short term task and finish group has been set up to consider the data presented by the LA regarding LAC Initial Health Assessments. Nurse Consultant RDaSH to
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Date Discussion Outcome Follow up
of LA LAC records and the timeliness of LAC Initial Health Assessments.
Data presented from the LA system states that only 10.2 % of Initial Health Assessments are held within the 20 working days timeframe. This is totally unacceptable and requires urgent attention.
Designated Dr records state 35% held in timescale.
May and June IHA Audit undertaken by LSCB and Designated Nurse 0% IHA undertaken in timeframe. Unacceptable and challenge raised with LA and TRFT. Report due at LSCB performance sub group
to clarify the position and ensure that Initial Health assessments are being held in a timely fashion.
Raising Aspirations Health and Wellbeing work stream to continue to scrutinise processes and will work alongside the short term Task and Finish group set up by LSCB.
17 children refusing health assessments – all reviewed by TRFT Team and a proposal for a change in the system being highlighted within TRFT and LA. Report due at Corporate Parenting setting out proposed changes.
co-chair with a young person from the LAC Council. Report due to LSCB and Corporate Parenting end September 2016.
September Update: progress continues to be challenging and extremely poor. NHS RCCG has raised these issues as significant challenges to TRFT via Quality and Performance group. TRFT are reviewing the whole system, a watching brief is in place with a report expected back to the LSCB September 2016
Paper on ‘refuses’ presented and well received at Corporate parenting 27 September with changes to process outlined.
Designated Nurse LAC met with Interim Head of LAC to discuss a systematic way of identifying and tracking children in care requiring an initial health assessment.
14.10.16 high level Summit meeting arranged to discuss lack of progress and source solutions.
October RMBC Peer Challenge
LA undertook a bespoke ADCS Peer Challenge in relation to LAC
RMBC welcomed input from partners. Report expected end of October regarding next steps required.
Ofsted visiting RMBC end of October 2016 to review LAC. Will provide a graded response.
4.2 Learning Review
Area Discussion Outcome Output
September 2016
Goddard and Bradbury national inquires self-assessment for health organisations
NHS RCCG has supported provider in undertaking a self-assessment of compliance with the expectation from central government that safeguarding records will be available to the Inquiry Team
Excellent response from provider in Rotherham. Paper to AQUA September 2016
GP roll out has commenced, report due winter 2016.
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5. ADULT SAFEGUARDING
5.1 Headlines
RSAB – Next meeting 14th November
Safeguarding Adult Review ( SAR) Sub group – First meeting held and Terms of Reference agreed. Board manager is to source an independent chair to facilitate the agreed case from Septembers Board. Update to the group on the SAR that NHS England is undertaking. Next meeting 27th October.
Domestic Homicide Review (DHR) – Multi agency meeting held on the 6th October. All agreed that the case meet the criteria for a Domestic Homicide Review. Steve Parry (chair) Safer Rotherham Partnership is source an independent chair.
Human Trafficking – PC M Bolger SYP gave an overview to safeguarding adult professional on the Human Trafficking Unit at SYP and the work that they are undertaking in addressing the crime with input from the Salvation Army.
5.2 Care Home update
Care Home 1 – Further meeting held on the 30th September with the provider, RMBC contracts and RCCG. A new home manager and area manager are now in place. Improvements continue to be made in terms of environment and care plans. The provider submitted an objection to CQC re their letter for the de registration of nursing beds – awaiting response. Further progress meeting arranged for 6 weeks time.
Care Home 2 – no longer remains in default with RMBC contracts.
6. DELAYED TRANSFER OF CARE (DToC)
6.1 Adult mental Health Services
Although the numbers remain low, housing has been identified as generating lengthy delays for those affected. RCCG are facilitating strategic meetings between colleagues in RDaSH and RBMC to identify opportunities to improve efficiency and information sharing to support earlier discharge for complex individuals.
See below the graph of DTOC for Adult services.
6.2 Older People’s Mental Health Services
Placement availability for complex patients remains an issue affecting some. Whilst numbers are limited, delays can be prolonged. Rotherham CCG is working with clinical services to identify alternative provision.
See graph of DTOC for Older Peoples services over:
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7. LEARNING DISABILITY MORTALITY REVIEW (LEDER) PILOT – YORKSHIRE AND THE HUMBER
See APPENDIX 1 - LD MORTALITY REVIEW PILOT – Y&H regarding Learning Disability Mortality Review being undertaken.
8. DEPRIVATION OF LIBERTY SAFEGUARDS (DOLS)
Provider Applications Figures
Hospitals (Acute)
Requests received in 16/17 132
Number Received This Reporting Month 26
Granted in This Reporting Month 0
Not Granted in This Reporting Month 3
Total Number in the Backlog 64
Hospitals (Psych)
Requests received in 16/17 8
Number Received This Reporting Month 0
Granted in This Reporting Month 0
Not Granted in This Reporting Month 5
Total Number in the Backlog 3
Care Homes (New Requests)
Requests Received in 16/17 510
Number Received This Reporting Month 86
Granted in This Reporting Month 21
Not Granted in This Reporting Month 7
Awaiting reports from BIA/MHA 18
Total Number in the Backlog 418
16/17 102
15/16 268
14/15 48
Awaiting Further Information 63
Total Not Granted in 16/17 167
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9. ADULT CONTINUING HEALTHCARE (CHC)
9.1 Headlines
The PHB advisor has continued to develop information that will be made available to the public on RCCG website. The newly recruited CHC business manager has now commenced in post and following a comprehensive induction, work will commence to progress data reporting which will allow not only the CHC service, but also other services such as D2A to identify areas of service improvement.
The CHC service continues to work with RMBC to progress any individual cases that are in dispute regarding funding eligibility, and a fortnightly dispute panel has commenced and is working through all outstanding cases.
9.2 Reports
Table 1 - The table identifies the total number of patients eligible for funding from NHS Rotherham Continuing Health Care service, including 12 month outstanding reviews
W/C 08/08/16 05/09/16 3/10/16
Total Number Eligible Patients 594 584 579
Total % Outstanding 12mth Reviews 26.26% 26.20% 27.98%
Total Number of 12mth Outstanding Reviews
156 153 162
Number of LD Team patients Eligible 124 124 124
Total % of LD Team outstanding 12mth reviews
29.03% 29.03% 32.26%
Total Number of 12mth outstanding LD Team reviews
36 36 40
Table 2 - The table identifies the total number of referrals received into NHS Rotherham Continuing Health Care service, including the number requiring a full DST.
.
Month July 16 August 16 September 16
Total number of referrals received
Acute 33 33 33
D2A 5 18 7
Community 52 72 48
Total number of referrals screened in
to complete a full DST
Acute 7 8 6
D2A 0 5 2
Community 13 19 8
Total number of referrals screened out
Acute 8 3 7
D2A 1 4 2
Community 5 8 5
Total number of referrals returned for further information
Acute 18 22 20
D2A 4 9 3
Community 34 45 35
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10. CHILDREN’S CONTINUING HEALTHCARE
10.1 Headlines:
A project has been undertaken between the CCG and the local authority to review cases against the national framework, this has provided the CCG with assurance that assessments and decision making are compliant.
The Childrens service will be developing and providing a regular training package for Children’s & Young Peoples Continuing Care for health, social care and education partners.
10.2 Reports
Children’s Continuing Care
Months Aug Sept Oct Nov Dec
Total number of Eligible patients 45 44 46
Total outstanding Reviews 6 0 0
11. PERSONAL HEALTH BUDGETS (PHB) FOR PATIENTS IN RECEIPT OF CONTINUING HEALTHCARE
A personal Health Budget internal group is being developed to build upon the vision of the published local offer, future development outside of continuing care will be reported to governing body through the Patient Safety/Quality Assurance Report.
Date Sept 2015
Oct 2015
Nov 2015
Dec 2015
Jan 2016
Feb 2016
Number RCCG CHC patients eligible for a PHB
589 578
Number of RCCG CHC patients in receipt of a PHB
96 95
12. PREVIOUSLY UNASSESSED PERIODS OF CARE (PUPoC)
Number of requests received
Sept 2015
Oct 2015
Nov 2015
Dec 2015
Jan 2016
Feb 2016
Mar 2016
April 2016
Current number of outstanding cases
83 77
Additional cases as part of the PUPoC collaborative have been outsourced to a provider in order to meet the September 2016 trajectory for completion, there has been a decrease in cases completed this month.
As part of the collaborative the agreed equalised model reflects that all CCGs will complete at the same time, trajectory for completion currently remains at January 2017.
13. FRACTURED NECK OF FEMUR INDICATOR
The year to date (August) position shows that the Trust are achieving the target with actual numbers seen at 107 and subsequently a predicted outturn of 256 against an annual target of 280. Numbers have decreased significantly between July and August 2016.
14. STROKE
Performance across all stroke indicators as at July 2016 shows targets have been achieved for 7 of the 10 stroke indicators.
The metric in relation to the proportion of patients admitted directly to an acute stroke unit within 4 hours of hospital arrival has not been achieved with the August position showing 57% against a target of 90%.
The metric in relation to the % patients receiving thrombolysis following an acute stroke has not been achieved with the July position showing 8% against a target of 11%.
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Work is on-going regarding changes to hyper-acute stroke (HASU) services as part of the Working Together work stream.
15. CQUIN UPDATE
15.1 RDaSH
Quarter 1 has now been signed off. CQUIN guidance has been received for 2017/18 and all CQUINs will be national CQUINs going forward so there will be no flexibility to agree local CQUINs.
15.2 Hospice
The Quarter 1 meeting has taken place and the CQUINs have been signed off.
15.3 TRFT
RCCG has received the Quarter One submission from the Trust. A final position has been agreed showing achievement of 91% for Q1. Areas of non-achievement were the national indicators for Sepsis.
16. COMPLAINTS
16.1 TRFT
The Trust received 30 formal complaints in August 2016, which is an increase from the previous month.
Improvement continues in relation to timely response to complaints and in August 60% of responses were issued within agreed timeframes.
Currently there are six cases under investigation with the Parliamentary Health Service Ombudsman (PHSO). One new request was received and one was closed in August. The latter was not upheld by the PHSO.
16.2 Via RCCG
Dissatisfaction with the CHC decision making process. Under investigation.
A CHC case has been referred to the Parliamentary & Health Service Ombudsman’s Office by a solicitor after their receipt of a PUPoC closedown letter. While the CCG did not receive this case as a complaint, the PHSO have decided to undertake an investigation and requested information relevant to the case.
For information, requests made by solicitors for copies of Checklists, DSTs and decision letters continue to be outstanding several months after receiving the requests.
17. ELIMINATING MIXED SEX ACCOMMODATION
RDaSH/Hospice – There have been no mixed sex accommodation breaches, year to date.
TRFT - There were 0 reported breaches in August 2016.
18. CQC INSPECTIONS
18.1 TRFT
An unannounced visit by the CQC took place in October as a follow up to the earlier announced visit. Formal written feedback awaited.
18.2 RDaSH
The CQC undertook further unannounced visits to RDaSH services in September as follows:-
Older Peoples Mental Health – Inpatient Ward – 28th & 29th September
Adult Mental Health Services – Long stay/Rehab – 28th September.
No official feedback has been received so far.
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18.3 Hospice
The Hospice was visited by CQC during w/c 11th August. Initial feedback showed some areas of concern. The CQC published a report but then withdrew it following the raising of some issues by the Hospice relating to the scope of the inspection.
CQC inspections cover five main areas of: Safe, Effective, Caring, Responsive and Well-led.
Rotherham Hospice
Run by – Rotherham Hospice Trust. CQC inspection published 12th October 2016. Accommodation for individuals who require nursing or personal care, Diagnostic and screening procedures, Transport services, triage and medical advice provided remotely, Treatment of disease, disorder or injury.
Overall outcome:
Requires Improvement
Safe Requires
Improvement
CQC found that safe practice around medicines was not consistently followed and individual risk assessments were incomplete.
Effective Good Staff informed CQC that they were supported through induction, had regular on-going training, supervision and appraisal.
Caring Good It was identified by CQC that all individuals were supported at the end of their life to have a comfortable, dignified and pain-free death.
Responsive Requires
Improvement CQC found that not all care plans reflected individual need and contained enough detail to meet need.
Well-led Requires
Improvement
CQC saw evidence of quality assurance systems and audits in place. However it was noted that these were not always effective in monitoring performance.
18.4 Care Homes
CQC inspections cover five main areas of: Safe, Effective, Caring, Responsive and Well-led.
Sevacare – Rotherham
Run by – Sevacare (UK) Limited. CQC inspection published 19th August 2016. Dementia, Learning disabilities, Mental health conditions, Personal care, Physical disabilities, Sensory impairments, Caring for adults over the age of 65 years.
Overall outcome:
Good
Safe Good
CQC saw systems in place to reduce the risk of abuse and to assess and monitor potential risks to individuals. Risk assessments were up to date and detailed.
Effective Good CQC found evidence that staff had completed a comprehensive induction and training programme before commencing work.
Caring Good Individuals informed CQC that they experienced a good standard of care and that they found staff to be polite and knowledgeable.
Responsive Good CQC saw that individuals were involved in planning their care, and their views about their care and support was included.
Well-led Requires
Improvement CQC found that care plans had not been formally audited for two years.
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Housing & Care 21 Rotherham
Run by – Housing & Care 21 Rotherham. CQC inspection published 21st September 2016. Dementia, Learning disabilities, Mental health conditions, Personal care, Physical disabilities, Sensory impairments, Substance misuse problems, Caring for adults under and over 65 years of age.
Overall outcome:
Requires Improvement
Safe Requires
Improvement
CQC noted that medication systems were in place however medications were not always administered safely.
Effective Good CQC found that staff had an understanding of the legal requirements as required under the Mental Capacity Act (2005).
Caring Good Individuals informed CQC that they were involved in their care planning.
Responsive Good CQC identified a complaints system with evidence that complaints were investigated by the provider.
Well-led Requires
Improvement
A system for monitoring the quality of the service provided was used however the provider had identified to CQC that these were not always effective.
19. ASSURANCE REPORTS
19.1 TRFT Update
A&E
The current month position as at 17th October was 85.00%, Q2 is at 92.31% and YTD is 91.19%. The September position ended at 92.76% and Q2 position ended at 92.2%. The contractual target was not achieved. The Sustainability and Transformation Plan target is to achieve 95% in March.
Contract performance meetings were held on 4 August and 26th September:
The key challenges are:
Demand
Manpower - Medical workforce
Discharge
System wide issues
A highlight report/action plan has been received which will be monitored through the contract and will be a monthly agenda item for the TRFT/RCCG Contract Performance Meeting. The highlight report has been shared with the A&E delivery board alongside actions to address increases in A&E attendances at GP practice level and children’s attendances.
Joint analysis of A&E attendances during the first 2 months of the year has shown that the majority (85%) of the increase in attendances can be accounted for by an increase in ambulance arrivals. Over 50% of these are the over 75s. The analysis was presented at the A&E delivery board on the 14 September, 2016. An update against the action plan was presented on 12 October.
Further work is being undertaken to understand the increase in ambulance arrivals and an A&E analysis action plan is being managed through the contract.
Cancer Standards
In July, all of the 7 cancer standards met the national targets.
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18 Weeks RTT and 52 Week Waits
Current performance as at August showed achievement of 93.44% against a target of the 92%. All specialties with the exception of Cardiology and Dermatology achieved the 92% target.
A remedial action plan is in progress for Cardiology and Dermatology to secure future delivery and improve the overall Trust position. Ophthalmology and Rheumatology are specialties under close watch by RCCG at there has been a >10% increase in +18 week waits.
The incomplete performance continues to deteriorate with the core issue being the deficit in capacity in a number of specialties. This deficit is also driving the challenges being experienced in waiting list increases for both new referrals and review patients who require a follow up. All of these issues are in turn largely driven be workforce challenges of both a short and medium/long term nature.
6ww Diagnostics
Current performance as at August showed achievement of 3.4% against a <1% target. Respiratory physiology - sleep studies, Flexi Sigmoidoscopy, Colonoscopy, Cystoscopy and Gastroscopy are not achieving the 1% target and the position in these areas has deteriorated since over the past few months.
Short and long term capacity solutions are being reviewed to recover performance.
19.2 Associate Contracts
Current performance against key indicators:
Sheffield Teaching Hospitals NHS Foundation Trust
RTT 18ww Incomplete Pathways – August – 93.00% against a 92% target. Clinical Psychology, Hepatology, Cardiology, Gastroenterology, Clinical Neurophysiology, Neurology, Ophthalmology, Gynaecology, Colorectal Surgery, Upper GI Surgery and Trauma and Orthopaedics did not achieve target. A Remedial Action Plan has been developed and shared with associates. This is being monitored and managed by Sheffield CCG as the lead commissioner for this contract.
A&E – Four Hour Access Standard – August – 94.33% against a 95% target. Sheffield Walk in Centre figures are included in this percentage. A Remedial Action Plan has been developed and shared with associates. This is being monitored and managed by Sheffield CCG as the lead commissioner for this contract.
Cancer 62 day waits from urgent GP referral to first definitive treatment – July – 82.3% against an 85% target. A Performance Notice has been issued by Sheffield CCG and the Remedial Action Plan will be monitored and managed by Sheffield CCG as the lead commissioner for this contract.
Doncaster and Bassetlaw Hospitals NHS Foundation Trust
A&E – Four Hour Access Standard – July – 92.78% against a 95% target.
RTT 18ww Incomplete Pathways – July – 92.5% against a 92% target. All specialties with the exception of General Surgery, Urology, General Medicine and Trauma and Orthopaedics achieved the 92% target.
July data has not been received by RCCG in time for this report.
Barnsley Hospitals NHS Foundation Trust
A&E – Four Hour Access Standard – August 95.3% against a 95% target.
RTT 18ww Incomplete Pathways – August - 93.9% and all specialties achieved the 92% target.
Sheffield Children’s Hospitals NHS Foundation Trust
RTT 18ww Incomplete Pathways – August - 92.3% a number of specialties did not achieve the 92% target however these are small volume services due to the nature of provision at this hospital.
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A&E – Four Hour Access Standard – August - 98.3% against a 95% target.
20. CARE AND TREATMENT REVIEWS
No care and treatment reviews have been completed in the period.
21. WINTERBOURNE SUBMISSION
The CCG is now required to provide a weekly update on admission or discharge of Rotherham patients into an Assessment and Treatment Unit.
Week commencing
Admission Discharge Number in ATU Total number currently
subject to Winterbourne
29th August 0 0 0 4
5th September 0 0 0 4
12th September 0 0 0 4
19th September 0 0 0 4
26th September 0 0 0 4
RCCG continue to work with partners in RMBC to expedite discharges for two of the patients. Placements have been identified and funding decisions are being finalised.
Sue Cassin – Chief Nurse November 2016
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APPENDIX 1 - LD MORTALITY REVIEW PILOT – Y&H
Dear Director of Nursing (Commissioning) Learning Disability Mortality Review (LeDeR) Pilot – Yorkshire and the Humber. I am writing to request your support in meeting the requirements of the national Learning Disability Mortality Review (LeDeR). The remit of the LeDeR Programme is primarily to support local areas to review the deaths of people with learning disabilities The LeDeR Programme has been established as a result of one of the key recommendations of the Confidential Enquiry into the premature deaths of people with learning disabilities (CIPOLD). Commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England the LeDeR Programme supports local reviews of deaths of people with learning disabilities aged 4 to 74 across England. Where there are concerns about the sequence of events leading to their death, or it is felt that further learning could come from a review of a death, a full multi-agency review of the death is recommended. This is likely to be after discussion with other agencies (e.g. safeguarding boards, coroner’s officers, child death review process) to ensure that a coordinated approach is being taken. In reviewing these deaths, circumstances leading to a death could be identified and avoided in the future through improvements to health and care services. The LeDeR Programme also aims to capture best practice in the care and treatment of people with learning disabilities. To-date, following a wide consultation exercise we have agreed the process for local reviews of deaths of people with learning disabilities and the core data to be collected. A secure, web-based platform has been built to handle notifications of deaths and the local review process. All deaths of people with learning disabilities aged 4-74 will have an initial review of their death. It is important to stress that this review applies to all people with learning disabilities, not just those currently known to health and care services. Work is also taking place with community organisations and family / carer forums to notify them of the LeDeR Programme. This work forms part of the wider Transforming Care agenda and NHS England’s commitment to address health inequalities experienced by people with learning disabilities. The Transforming Care Programme focusses on addressing long-standing issues to ensure sustainable change that will see: more choice for people and their families, and more say in their care; providing more care in the community, with personalised support provided by multi-disciplinary
health and care teams ; more innovative services to give people a range of care options, with personal budgets, so that
care meets individuals’ needs; providing early more intensive support for those who need it, so that people can stay in the
community, close to home; but for those that do need in-patient care, ensuring it is only for as long as they need it. There is no funding available for this programme and expectation is that long term this will be embedded in day to day business.
Learning Disability Local Team Yorkshire and the Humber
NHS England Unit 3, Alpha Court
Monks Cross York
YO32 9WN
2nd October 2016
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In order to support the Yorkshire and the Humber Learning Disability Mortality Review Pilot, it is vital that the LeDeR team are notified of any deaths of people with learning disabilities in your organisation. Anyone is able to notify the LeDeR Programme of a death. We expect CCGs ensure that both they and their commissioned services start making notifications from the 1st November 2016. This can be done by telephone or via the LeDeR online portal. Telephone : 0300 777 4774 http://www.bristol.ac.uk/sps/leder/notify-a-death/ There is a data sharing agreement in place, approved by the Secretary of State to allow this to happen. We will send further details of this to your Caldicott Guardian and SiRO. Once a notification is made the LeDeR team will inform the local officer covering Yorkshire and Humber who will be responsible for liaising with your organisation to review the individual’s death and capturing the learning. Following discussion with Director of Nursing Colleagues across the Yorkshire and Humber footprint, Tom Raines, Learning Disability Project Manager, Yorkshire & Humber will be the Local Area Contact ([email protected]; 07918 368594). It is anticipated that as the Transforming Care Partnership Boards mature across all areas, each Board will soon nominate a Local Area Contact for you locally. The role of the Local Area Contact is to: • Receive notification of a death from LeDeR. • Allocate the case to a local reviewer and monitor the progress of the review. • Provide advice for the local reviewer if relevant. • Liaise with the Local Steering Group about any issues as appropriate. • Receive completed review documents and action plans once the review has been finished. • In conjunction with the Local Steering Group, take appropriate action to help improve the care of
people with learning disabilities (and their families) and reduce premature mortality in this population.
Additional materials on the LeDeR Programme are available on the University of Bristol website: http://www.bristol.ac.uk/sps/leder/. The local reviewer can be a health, social care or allied health professional. The role involves:
Attending a day’s training. Receiving notification of a death of a person with learning disabilities from their Local Area
Contact. Completing an initial review of this death using the web based LeDeR review system. Completing a further multiagency review of this death if required. Maintaining communication with the Local Area Contact and LeDeR Programme as appropriate
during the course of the review to update on progress and highlight any problems. Writing a report of the review and complete any associated action plan. Submitting the completed paperwork of the review to the Local Area Contact and the LeDeR
Programme In summary we request four things from you: 1) From the 1st of November your CCG and your commissioned services notifies the LeDeR
Programme should any patient with learning disabilities die whilst in your care. You will need to seek assurance, that your providers commit to this; via your contractual mechanisms.
2) Provide us with details of who will be your organisational contact for this programme. 3) Identify individuals who you would like to be trained as reviewers. 4) Ensure your Board/ Governing Body is sighted on the LeDerRP. We will be happy to lead the
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presentation on your behalf. Please contact [email protected] who will co-ordinate our calendars’ to ensure attendance.
Thanking you all in anticipation of your help Yours Sincerely,
Deborah Turner Deputy Director of Nursing- NHS England (Yorkshire and Humber) Pin No: 88H0975E
