Trust Board - Croydon Health Services NHS Trust

Trust Board
Date: 15 April 2015
Agenda No: 8.4
Date Paper produced:
March 2015
Paper Title: Quality Report
Sponsoring Director
Michael Fanning, Director of Nursing, Midwifery and AHPS
Steve Ebbs, Medical Director
Authors:
Mike Hayward, Deputy Director of Nursing, Midwifery and AHPS
Purpose/Decision
required:
The Trust Board is asked to consider the work being carried out to assure
continuous improvement in patient safety, patient experience and clinical
effectiveness and outcomes for patients.
Impact on Patient
Experience:
The report is the Nursing and Medical Directors reflection of their business
as usual and work plans activity in regard to patient experience. It provides
assurance in regards to activity.
Impact on Financial
Improvement
There are no direct impacts on Financial Improvement. However a
number of areas contain reviews and patient experience activity which
required investment.
History: (which groups
have previously
considered this report)
Quality and Clinical Governance Committee
Executive Summary:
The report provides an overview of work undertaken within Croydon Health Services NHS Trust to
deliver high quality and patient centred care which improves outcomes, patient safety and patient
experience.
Key Messages
1.
Caring
A total of 170 patients were surveyed during January and February across the inpatient areas.
The areas which were identified for improvement were improved compliance were displaying the
named consultant and nurse, 37 patients did not have the name displayed. Care plans were
also identified, as 21 patients did not have a personalised plan to meet their needs. The wards
were within Adult Care Pathways.
The availability of menus at the patient bedside and the choice of food was highlighted as a
concern. Action has been taken to address this with the Inpatient Services Catering Manager,
this includes monitoring the supply of menus and a Housekeeper „Master Class‟ in April.
Patients felt they did not have enough information about the possible side effects of their
medicines and the Chief Pharmacist is currently looking at web based options to produce easy
read information which can be downloaded, printed and given to patients.
Patients reported they were not aware of their discharge date and the newly formed
Implementation Group for Effective Discharge has developed a Standard Operating Procedure
for discharge management and this group will monitor its effectiveness.
1
The Matron Quality Rounds have been reviewed and a new observational tool has been
produced for Matrons to use during March, the tool will be refined as needed and then fully
implemented from April. The expectation is that each Matron will undertake a quality review on
each of their wards once a week.
2.
Well led
The current safe staffing data shows that the average rate of planned staffing levels is 98.25%.
During January and February 2015 a total of 70 red flags were reported on the daily monitoring
staffing data base. This represents an 11% decrease compared to November and December
2014. The red flags were evenly distributed across all clinical areas.
During January and February 2015 a total of 18 Quality Reviews were undertaken and a range
of issues identified including noise at night, staff name badges not visible to patients and the
lack of knowledge of staff about their ward performance indicators. The feedback from the
reviews is provided to the ward and also the directorate teams to drive further improvements for
both patients and staff.
3.
Safe
The Trust continues to perform well in relation to Harm Free Care and the trends in January
2015 were 96.52% and in February 95.94% and this compares favourably to the national score
of 93.72%.
The Trust scores well against the national benchmark for pressure ulcers, the national average
in January 2015 was 4.59% and the Trust score was 3.4%. The national score in February was
4.64% and the Trust score was 3.09%.
The Trust has reported fewer falls, in January 2015 0.23% and February 0.96%. The Trust
remains below the national average of 1.79%. Those patients who fall and result in harm has
also decreased in January and February compared to the national average.
Catheter Associated Infections in January and February are reported below the national
average.
The Trust reported 94.77% of patients in January and 88.3% in February having VTE
assessment completed, compared to the national average of 84.69%.
The total number of Clostridium difficle cases reported at the end of February was 14 against
the annual trajectory of 17.
The Trust remains at 1 MRSA blood stream infection against the annual trajectory of zero.
4.
Responsive
The Friends and Family Test response rate improved for January for both A&E and inpatient
areas. The rates for A&E were 29.7 % which was greatly improved to December 2014.
The percentage of women in January who would recommend the maternity services improved
for their experience at birth and in the post natal period compared to December 2014. The area
which reduced in recommendation was in the postnatal community period.
During this period, we received 39 new formal complaints and 3 cases were reopened for further
attempts at local resolution. A further 11 cases were recorded as informal complaints after
discussion with the complainant. 122 Patient Advice and Liaison Service (PALS) contacts were
recorded and 38 compliments were received and logged.
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5.
Effective
Dr Foster data has not been accessible and this will be resolved for future reporting.
A total of 28 serious incidents were reported between January and February 2015 all were
attributed to the Trust.
During January and February 19 new NICE guidance and 5 Quality Standards were published.
Four National Audits were also published during January and February.
Key Issues for discussion:
Nurse staffing levels
Safety data
FFT
Complaints
Related Corporate Objectives:
To deliver high quality, integrated patient-centred services
To ensure staff are able, empowered and responsible for the delivery of effective and
compassionate care
To achieve best practice performance standards
To secure value for money and ensure the financial sustainability of the Trust
To work with partners to improve the health and wellbeing of the people of Croydon.
Related CQC 5 Key Areas of
Care:
Has an equality impact
assessment form been
completed?
N/A
√
Safe
√
Effective
√
Responsive
√
Caring
√
Well-Led
If not applicable,
N/A
Does this report have any financial implication?
N/A
Has legal advice been taken?
If so, has the report been approved by
the Financial Department?
N/A
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Quality Report - April 2015
1.
CARING
1.1
Nursing Quality Rounds
The following tables show the total results from the January and February Quality Rounds
across general wards and a RAG rated visual summary of compliance against all
indicators which are included in the assessment of the quality round.
A total of 170 patients were surveyed in general wards.
Table 1: All Inpatient Wards
4
Table 2: Listing of indicators for General Wards (RAG rated)
Compliance against indicator
is the named nurse and consultant written above bed
Has the patient got a care plan
is there a menu at the bedside
has the patient been informed of side effects of medicines
is the patient aware of their discharge date
has the patient not been bothered by noise at night
does the patient feel they have had hourly rounds
is the patient aware of discharge arrangements
are call bells being answered in a timely way
Does the patient feel involved with decisions
has the patient been able to discuss worries and fears
does the patient feel their pain has been well managed
are staff following dress code
is the patient's call bell within reach
are the daily staffing numbers displayed correctly
does the patient look well cared for
is the correct sign up for restricted fluids and diet
does the patient feel inf control standards are adhered to
are 2 commodes clean
is fresh water available and within reach
is the patient wearing a correct name band
1.2
Trends
1.2.1
Named Nurse above the Bed
The Francis Report made a number of recommendations on the need for there to be a
named clinician who is accountable for a patient‟s care whilst they are in hospital. In
addition the Secretary of State for Health in England has supported the concept of having
an accountable consultant and nurse with “their name above the bed”.
37 patients included in the Quality Rounds did not have the names correctly written above
their beds.
Wards where this was most evident were Duppas, Purley 2, Wandle 2 & Wandle 3 and
targeted improvement actions will be taken to improve compliance.
1.2.2
Care Plans
The CQC National Standards require that patients should expect to be respected,
involved in their care and support, and told what‟s happening at every stage and the
patient should expect care, treatment and support that meets their needs.
A review of care plans during the Quality Rounds identified that 21 patients did not have a
personalised care plan which was appropriate to their needs. The following wards should
focus on care plans as a result of this finding: Purley 2, Wandle 1, Wandle 3 & Wandle 2.
1.2.3
Availability of Menus
The most recent Inpatient Satisfaction Survey results (2013-4) showed that inpatients at
Croydon Health Services did not feel they had adequate choice of their meals.
5
There is a trend that menus are not always available at the patient‟s bedside. This can be
triangulated with Friends and Family comments, where the unavailability of bedside
menus has led to patients not having the opportunity to choose their meals from the full
range on offer.
During February the Patient Experience Manager compiled a “top 10” of patient‟s
concerns with food and the meal service. This included patient choice and the availability
of menus. Awareness has been raised with the Inpatient Services Catering Manager and
the supply of menus at the bedside is being monitored by the Ward Housekeepers.
An addition, a Housekeeper‟s MasterClass is scheduled for April 2015 where there will be
increased focus on the full scope of the role and the relationship between the
Housekeeper and the patient experience.
1.2.4
Medication Side Effects
Patients report that they are not always informed of possible side effects of their
medication. This was evident across the wards and focus should be given to medication
counselling at the bedside by the ward pharmacist, prescribing doctor and registered
nurse.
The Chief Pharmacist is currently scoping the advantages to purchasing web-based
software which allows the healthcare professional to print off easy-read information about
their medication including side effects.
1.2.5
Discharge Date
Patients report that they are not aware of their expected discharge date. Since February
2015 the Implementation Group for Effective Discharge has developed a Standard
Operating Procedure (SOP) for discharge management including practice guidance for
Handover, MDT meeting and the Ward Round. All elements of the SOP put the patient at
the centre of the process, and the plan of care is communicated at key points including
the ward round.
It is expected that the patient will be made aware of their expected date of discharge
within 48 hrs of their admission.
Improvement metrics have been agreed and the project will be evaluated at the
Performance and Finance Committee.
1.2.6
Noise at Night
A common theme found also in FFT comments is Noise at Night. This will be discussed at
the Housekeeper‟s Masterclass. Initiatives include:
Review of soft closing bins
Stock ordering of ear plugs
Quiet time 1-2pm on each ward
1.2.7
Hourly Rounds
Hourly Rounds aim to put patients at the centre of care and consists of nursing staff
checking on their well-being at regular intervals. The introduction of this structured
approach follows concerns about failures in care highlighted by a number of recent highprofile reports including Francis and the Care Quality Commission.
Ward Sisters are responsible for ensuring all trained and untrained nurses receive training
in the process of Hourly Rounding on local induction to the wards. It is the responsibility of
the ward manager to ensure all Hourly Rounds are undertaken throughout the patient‟s
admission.
6
The Matron has a responsibility to ensure that effective Hourly Rounds are undertaken in
their designated areas. Monitoring of the use of Hourly Rounds is reported on the monthly
matrons scorecard.
1.2.8
Observational Quality Round
The Quality, Experience and Safety Programme was approved at the Turnaround Board
in January 2015. The first meeting of the QSE Operational Group met in early February
and one of the key elements discussed was the re-focus of the Matron Quality Rounds.
As a result the Matrons Quality Round methodology has been reviewed. The tool has
been developed by the Head of Nursing for Patient Experience and Quality to reflect key
and recurring themes from FFT, Picker Survey, complaints, the Quality Implementation
Plan 2014-5 and the safety thermometer. The tool is observational in nature and provides
a deeper dive by the Matron into quality aspects of care. It has been endorsed by the
Head of Nursing for Quality for Clinical Support Unit and in association with Croydon
CCG.
A Master Class was held in March 2015 for Matrons using the tool so that there is a
consistent approach in the style of observation. If during the round there are issues which
need reporting i.e. medicines safety then these will be reported on Datix. The rounds must
be undertaken by Matrons and not delegated, although it would be good practice if they
build in to have a „critical friend‟ or buddy with them from another directorate. The rounds
rotate to incorporate weekdays, evenings and weekends.
The results of quality rounds will be captured and will feed into the Quality Reviews and
into the QSE Operational Group.
2.
WELL LED
2.1
Nurse Staffing Levels
The Trust has an established process for the monitoring of safe nurse staffing levels
throughout the 24/7 period. We continue to collect and publish daily staffing levels as per
the Hard Truths staffing requirements.
Data published since June 2014, shows that nurse and care staffing levels at Croydon
University Hospital met planned levels based on patient need in the months June to
February 2015 and compares favorably with our peers.
The current safe staffing data shows CHS average safe staffing data to be 98.25% of
planned care levels.
2.2
Daily Monitoring of Safe Staffing
The ward nurse staffing data for January and February 2015 showed that across the 2
month period there were 70 red flags around safe staffing compared to 79 episodes
between November and December 2014. This represents an 11% decrease. The red
flags were spread evenly across clinical areas. The January and February 2015 nurse
staffing position is shown in the tables below. The Trust is in the process of reviewing the
categorising of local red flags to ensure compliance with NICE guidance published in
November 2014.
7
January 2015
February
2.3
Publishing Daily Safe Staffing Data
Staffing safety data is collected on a daily basis and staff record the actual numbers on a
shift against the expected nurse staffing levels in the mornings, afternoons and at night.
All in-patient areas of the hospital participate including maternity. Staffing ratios are
divided into qualified and unqualified staff.
8
The Trust is now required to report staffing levels against safer staffing performance
indicators looking specifically at how staffing impacts on staff sickness, mandatory training
and staff and patient views on staffing levels. These indicators are compiled into a league
table of all Trusts. The Trust complies with these requirements through the following
process:
2.3.1
Local reporting - Ward Safe Staffing Data
Planned versus actual staffing levels are displayed at ward level every day at the
nurses‟ station.
Each ward has a performance board where daily staffing numbers are also
displayed with information about the nurse in charge. Each ward also has a clearly
displayed poster with a picture and contact details of the relevant Matron.
Monthly nurse staffing assurance data is displayed via the CHS Trust website @
http://www.croydonhealthservices.nhs.uk/patients-visitors/safe-staffing-levels.htm
2.3.2
National reporting - Ward Safe Staffing Data
The safe staffing data is reported monthly to NHS England via the Unify website. This
process records data for all inpatient areas with the exclusions of CDU and escalation
wards. The data is recorded over the full 24 hour period of each month. It is broken down
and reported as:
Qualified staff planned to be on duty and qualified staff actually on duty
Unqualified staff planned to be on duty and unqualified staff actually on duty
The following table shows the most up to date Unify submissions for amalgamated day
and night shifts for Registered Nurses and Carers for January 2015. These figures
demonstrate a safe level of delivery of actual nurse staffing, against the planned nurse
staffing performance at a Trust level however there were clinical areas where the staffing
fell below that expected and according to guidance from the Chief Nurse would be rag
rated red, the staffing on all clinical areas is now triangulated against quality and patient
safety outcomes each month.
The table below bench marks the current CHS safe staffing position against our local NHS
Trusts for January and is taken from NHS Choices website.
Organisation name
Princess Royal University Hospital
Kingston Hospital
St Helier Hospital
Kings College Hospital
University Hospital Lewisham
Croydon University Hospital
Epsom Hospital
St George‟s Hospital
Safe staffing as % of planned level
114.7%
105.2%
102.2%
102%
100.7%
98.25%
95%
90.75%
The data is uploaded via Unify and is then published on the NHS Choices website
allowing patients to examine key quality and safety indicators between various NHS
Trusts. The current safe staffing data shows CHS average safe staffing data to be
98.25% of planned care levels and all grades of staff in January and 99.3% in February.
The following graph shows that when subdivided into average fill rates for trained nurses
both day and night it is evident that there has been a steady decline in the average fill rate
in all in patient areas since the peak in July 2014 and the increase in fill rates shown
above is explained by an increase in care staff.
9
2.4
Executive Visible Leadership
Following discussion at the executive management meeting these safety walk rounds
have been amended to support the quality improvement programme and prepare the
Trust for the next CQC inspection in 2015, a programme of Quality Reviews for clinical
quality and safety are being launched in January to assist the development of staff at CHS
and will be based on the new CQC Inspector and Inspection Handbooks.
In January 2015 and February, 18 Quality Reviews were undertaken spanning the entire
Trust.
The review teams visited the areas to assess performance against the five CQC questions
using interview questionnaires to provide a framework for the reviews.
Table showing Walk Rounds undertaken:
Activity
July
Sep
12
Au
g
12
Quality Reviews
Medication Walk
Rounds
Falls Walk
Rounds
11
Oc
t
10
No
v
3+3
De
c
3
Ja
n
8
Fe
b
10
3
3
1
2
2
1
2
2
3
2
2
2
2
2
2
2
Ma
r
Ap
r
Ma
y
Jun
e
The evidence is gathered through a variety of methods and includes the following:
Observing clinical and operational practice
Checking the environment, seats not all washable in the community bases.
Reviewing documentation where appropriate
Talking to a range of staff
Talking to a selection of patients
In general, the findings from the reviews were very positive and patients were
complimentary about the care they received and staff certainly valued the reviews where
they could showcase their achievements. However early analysis suggests that there are
some issues that need to be addressed. These are summarised below:
10
There was a general impression of disrepair and some failed standards of
cleanliness in community clinics.
Name badges were not visible in all areas
FFT cards were not being used in Community areas
Patient notes were not stored out of sight in community clinics
Patients were disturbed at night in ward areas.
Lack of ward meetings
Nurses not aware of KHWD results
Patient unaware of consultant name, staff levels, behaviour and attitudes
Call bells not answered
2.4.1
Next Steps
It is important to address the findings from the reviews and walkabouts and to ensure that
staff remain engaged in the improvement process. Following the cycle of Quality Reviews,
directorates will be expected to follow up any work outstanding and ensure that patient
safety and experience issues are addressed with ward managers and individuals to
ensure learning. The following actions have been taken:
Directorates receive timely feedback and show improvements to the initial reports.
There will be an inventory checklist sent to Estates and Facilities for confirmation of
actions, and to ADNs in directorates for actions regarding staffing issues. The
expectation is that improvements will be evident by May 2015.
3.
SAFE
3.1
Harm Free Care
The Trust has reached the 2014/15 CQUIN for harm free care based on our prevalence
data.
This report includes Harm Free Care data from January and February 2015 taken from
Safety Thermometer submissions. Locally entered data on the survey days shows that
the Trust continues to outperform the national average for delivery of harm free care with
96.52%% and 95.94% of patients within Croydon Health Services experienced harm free
care from samples of 861 and 937 of patients respectively.
Overall the trends in harm free care within CHS are as follows;
CHS outperformed the delivery of harm free care compared to all organisations in
both January 2015 (96.52%) and February (95.94%) compared to 93.75% and
93.72 % nationally.
CHS performs well against the national benchmark for all pressure ulcers: 4.59%
nationally and 3.4% in CHS in January 2015 and 4.64% nationally and 3.09% in
February in CHS and significantly below the benchmark for Pressure Ulcers new
0.23 % (2 patients) in CHS compared to 1.08% Nationally in January 2015 and
1.02% in February.
CHS has also seen a reduction in the number of falls overall, 0.23% in January
2015 (2 patients) and February 0.96% (9 patients). The Trust remains significantly
below the National average of 1.79%. The number of falls with harm has
decreased in January 2015 from 0.41% in December to 0.11% (1 patient) in
January and 0.11% in February (1 patient) this remains below the average when
compared to all organisations who reported 0.66% for all organisations.
There has been a decrease in injurious falls with 1 reported in February 2015.
11
3.2
Harm Free Care Trends
This data is displayed in graph form below shows the trend in harm free care both
nationally and within Croydon. Data is taken directly from the Health and Social Care
Information Centre website that calculate the harm free percentages overall and for each
subcategory monthly and can be viewed by everyone on www.hscic.gov.uk/thermometer
The data below shows a comparison of Safety Thermometer findings during the period:
January 2015
Harm free
Patients surveyed
Acute
Community
861
421
440
96.52%
95.96%
97.05%
No patients
harm free
831
404
427
Patients with
harm
30
17
13
% Patients
with harm
3.48%
4.04%
2.95%
February 2015
Harm free
Patients surveyed
Acute
Community
937
480
457
95.94%
95.83%
96.06%
No patients
harm free
899
460
439
Patients with
harm
38
20
18
% Patients
with harm
4.06%
4.175
3.94%
Overall the trends in harm free care within CHS are as follows;
Outperformed the delivery of harm free care compared to all organisations in both
January 2015 (96.52%) and February (95.94%) compared to 93.75% and 93.72 %
nationally.
CHS performs well against the national benchmark for All pressure ulcers: 4.59%
nationally and 3.4% in CHS in January 2015 and 4.64% nationally and 3.09% in
February in CHS and significantly below the benchmark for Pressure ulcers new
0.23 %( 2 patients) in CHS compared to 1.08% nationally in January 2015 and 1.02
% in February.
CHS has also seen a reduction in the number of falls overall, 0.23% in January 2015
(2 patients) and February 0.96% (9 patients). The Trust remains significantly below
the national average of 1.79%. The number of falls with harm has decreased in
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January 2015 from 0.41% in December to 0.11% (1 patient) in January and 0.11%
in February (1 patient) this remains below the average when compared to all
organisations who reported 0.66% for all organisations.
3.3
Pressure Ulcers
In January 2015 the total number of pressure ulcers reported as part of the point
prevalence was 27 (3.14%) of which 17 (4.04%) were in the acute setting and 10 (2.27%)
in the community. When subdivided into pressure ulcers acquired under CHS care, there
were a total of 2 (0.23%) compared to 1.08% for all organisations.
In February 2015 a total of 29 pressure ulcers were reported as part of the point
prevalence survey (3.0%) of which 12 (2.51%) were in the acute setting and 17 in the
community (3.72%). When subdivided into pressure ulcers acquired within the Trust this
figure falls to 2 (0.2%) in both January and February.
3.4
Datix-Incidence
3.4.1
During January 2015 2014 a total of 89 pressure ulcers were reported on Datix.
Of these only 28 were validated as acquired within the Trust:
Of the remaining 61: 29 were admitted from patients home and were not known to
the community services prior to admission. These are reported to the relevant
general practice.
18 were admitted from nursing homes
6 were admitted from other locations including other hospital settings and residential
homes
The remaining are validated as subcategories of those above
Following validation during February 2015 a total of 109 pressure ulcers were reported on
Datix:
Of these 23 were validated as acquired within the Trust:
3.4.2
-
Of the remaining 86: 54 were admitted from patients home and were not known
to the community services prior to admission. These are reported to the relevant
general practice
-
8 were admitted from nursing homes
-
9 were admitted from other locations including other hospital settings and
residential homes
Key issues:
There were 2 grade 3 pressure ulcers reported to NHSE in January 2015 from
Purley 1 and Wandle 1 and 1 in February; 2 from AMU, 1 from Queens 1and 2 from
the community.
3.4.3
Key actions:
To improve quality and increase assurance the following actions are being taken:
Since the launch of the LiA project is there has been a 45% reduction in pressure
ulcer incidence overall and 55% reduction in those being acquired in nursing homes
and patients‟ homes.
13
The cross organisational action plan has been shared with the CCG and approved
by them.
A follow up LiA big conversation has been arranged for May 2015 to review
progress and analyse specific reasons for successes.
The Head of Nursing for Patient Safety has been invited to join the CCG Pressure
Ulcer Steering Group looking to developing a shared approach to pressure ulcer
prevention across the entire Croydon health economy.
3.5
Falls
3.5.1
90 falls were reported on Datix in January 2015 and 59 in February. This figure includes in
patient falls, and those that occurred during rehabilitation and falls outside clinical areas.
When triangulated with the Harm Free Care data results 0.23% (2 patients) of the sample
sustained a fall in January 2015 and 0.96% in February (9 patients).
3.5.2
Key Issues
The performance report showed a rate of 6.94/1000 bed days in January 2015.
There was 1 injurious falls in February 2015 reported to NHSE as a serious incident
3.5.3
Key Actions.
A falls summit has been held with members of the CCG to discuss our serious
incidence related to falls and review actions put in place to mitigate against them.
The Trust has signed up to participate in the yearly national falls audit which will be
undertaken in the elderly care wards and AMU in quarter 4.
3.5.4
Falls Walk Rounds
The weekly falls safety multi-disciplinary team review of care for patients who have
experienced more than 1 fall whilst in hospital has continued in January 2015 and
February in an attempt to reduce the upward trend in in patient falls reported via Datix in
November and December. In the past 2 months 4 multi-disciplinary walk rounds have
taken place.
3.5.5
Areas of Good Practice Include:
All patients had been reviewed by medical staff within 2 hours of the fall occurring
Falls risk assessment on admission had been undertaken on 80% of patients
65% had been reassessed for their risk of repeat falls after the initial fall.
3.5.5
Areas for improvement include:
Only 40% had a falls care plan in place
Repeat falls assessments had only been completed for 25% of patients on a weekly
basis
3.6
Catheter Associated Urinary Tract Infections (CAUTI)
3.6.1
The Trust is well below the national average of 0.71% for patients having a catheter
associated infection with 0.23% (2 patients) in January 2015 and 0.21% in February (2
patients)
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3.7
Venous Thromboembolism (VTE)
3.7.1
According to Safety Thermometer data:
94.77% of patients in the acute Trust had a VTE risk assessment completed in January
2015; this fell to 88.3% in February 2015. The national figure was 84.69%.
3.7.2
Key Issues
It is important to recognise that Harm Free Care data represents point prevalence
and information is gathered on one designated day therefore the information
gathered will differ from the mean averages reported as the monthly Trust
compliance
3.8
Deteriorating Patient
3.8.1
Weekly monitoring of deteriorating patients continues via the deteriorating patient care
bundle. Weekly data has been collected related to observations at night, lateness of
observations and escalation of ViEWS scores. Analysis of result shows there has been a
steady increase in compliance with the bundle. During January 2015 and February 2015
there were 0 patients admitted to ITU who had not been escalated via the ViEWS system.
98.4% of patients were escalated via the ViEWS system.
3.8.2
Key actions:
A deteriorating patient care plan has now been developed and uploaded onto
Cerner.
The Trust has been approached by the Nursing Times who would like to showcase
the success of the bundle in a forthcoming publication on the use of information
technology to improve patient outcomes.
3.9
Infection Prevention and Control
3.9.1
Clostridium difficile infection
At the end of February there had been 14 cases of hospital acquired C. difficile infection,
against the annual trajectory of 17 cases.
The following measures continue:
All C. difficile infected and colonised in-patients are reviewed at least weekly by the
Infection Control Team including the antimicrobial pharmacist and microbiologists.
Colonised and infected cases are isolated with “step-up” cleaning of their side
rooms.
A system of Special Measures is in place for wards with two cases of C. difficile or
more within a six month period. For the first time since the system was introduced
in April 2013, there are no wards on Special Measures.
3.9.2
MRSA Bloodstream Infections (Bacteraemia)
The Trust remains at one healthcare associated case against a zero trajectory.
Interventions are currently targeted at ensuring timely screening of emergency
admissions, weekly screening of patients on the elderly care wards and decolonisation of
MRSA positive patients. Other interventions include:
Weekly review by the ICT and antimicrobial pharmacist of all in-patients colonised
and/or infected with MRSA.
15
Reminders by the ICT (verbal and written) to ward teams about screening,
decolonisation regimens and inclusion of information regarding MRSA status in
Discharge Letters.
Chlorhexidine body wash prescribed for previous MRSA positive patients on
admission.
Quarterly audit by the ICT of adherence with the above requirements.
Weekly checks of peripheral cannulas and appropriate documentation of these.
Weekly hand hygiene audits by wards and monthly within outpatient departments.
3.9.3
Viral Haemorrhagic Fever (VHF) Preparedness
The Trust remains alert to the possibility of seeing suspected cases of VHF, including
Ebola Virus. Interventions to ensure that we remain prepared and vigilant have included:
(i)
Updating of Interim VHF guidance for staff each time new national guidance is
published. This guidance is accessible to all staff on the Intranet.
(ii)
Guidance for managers of staff returning from affected areas (led by Occupational
Health).
(iii)
Face-mask Fit Test Training of staff in key areas.
(iv)
The ICT ran refresher training sessions for all VHF (Ebola) leads in February. This
included revision of all local Action Cards and reassessment of the Leads‟
competence in the correct donning and doffing of personal protective equipment.
Leads are then responsible for reassessing staff in their areas.
4.
RESPONSIVE
4.1
Friends and Family Test (FFT) score
The FFT score is reported up to the period of January 2015 and includes progress
towards the Trust wide implementation of the national FFT programme.
4.1.2
Headline Metric for the Friends and Family Test
The headline metric is the percentage of respondents who would/would not recommend a
service to their friends and family. The Net Promoter Score is no longer used to report
FFT results by NHS England. From October 2014 the new headline metric will be used to
report results to staff, patients and members of the public.
4.1.3
A&E and Inpatients FFT Performance
The chart below shows the performance of A&E and Inpatients FFT response rates 201415. The Trust internal response rate targets were set at 20% for A&E and 25% for adult
inpatients for Q 1 – 3. The response rate for Quarter 4 is at least 20% for A&E services
and at least 30% for inpatient services.
16
Chart 1: Response rates in 2014
Chart 2: FFT Percentage „who recommend‟ A&E and Inpatients November –
January 2015
4.1.4
National FFT CQUIN results
The FFT CQUIN framework prioritises indicators to increase response rates, as well as to
ensure the implementation of the national FFT to service areas according to the national
implementation programme.
Following the implementation of the national FFT to Adult Outpatients, Adult Day Cases
and Community Services, the implementation element of the FFT CQUIN is complete, as
per national guidance (The table of results for Community Services FFT results in January
is not available at the time of this report).
The Trust has achieved the response rate element on FFT in the first three quarters of the
year, and the current response rates that are being achieved have been increased in Q4,
to meet the higher requirements.
17
Table 1: FFT CQUIN results 2014 – 15
Q1 CQUIN
response
rate target
Q1
Q2 CQUIN
response
rate target
Q2
A&E
response
rates
15% (rising
to 20%) in
Q4
27.6%
15% (rising
to 20%) in
Q4
Adult
inpatient
response
rates
25% (rising
to 30%) in
Q4
45%
25% (rising
to 30%) in
Q4
achieved
Q3 CQUIN
response
rate target
Q3
22.4%
15% (rising
to 20%) in
Q4
17.7%
41.9%
25% (rising
to 30%) in
Q4
34.0%
achieved
achieved
18
4.1.5
Maternity FFT Performance
The Maternity FFT captures feedback from women at four „touch points‟ 1 - Antenatal 36 week appointment; 2 – Birth, including hospital and home birth; 3 Postnatal ward experience on discharge from the postnatal ward; and 4 - Postnatal Community (capturing experience on discharge from the postnatal
community service (normally at 10 days of home based visits).
The national target for maternity is to achieve a 15% combined response rate. 27.49 % was achieved in January 2015 (Table 3)
Table 3 - January 2015 - FFT Maternity results
19
Chart 3: FFT Percentage of women „who recommend‟ November – January 2015
4.1.6
Comparative adult A&E, adult Inpatients and maternity FFT data
The data for A&E, Inpatients and Maternity Services is taken from the NHS England Analysis
Site and the most recent data available is from December 2014. The Trust‟s performance on
the FFT response rate and the new „would recommend‟ headline metric shows comparable
performance when benchmarked against South West London (SWL) Sector.
Chart 4: A&E FFT results SWL
Chart 5: Inpatient FFT results SWL
20
Chart 6: Maternity FFT results SWL
.
4.1.7
Responding to FFT comments
The overall the percentage of patients who would recommend the following services are as
follows:
A&E 94.9%
Inpatients 93.7%
Maternity 94.3%
OPD 93.2%
Patients are asked “what is the reason for your score?” and “How can we improve?” By
reviewing comments written by patients, it is possible to identify how patients have had a
positive experience and their recommended ways to improve. A sample of comments is
highlighted below.
“What is the reason for your score?”
“Very good ward and the nurses are professional”
“Very nice staff, they always made me feel welcome and always tried to keep a smile on my face when
I felt ill”
“My reception at the clinic was very pleasing and kind. It’s nice to be greeted so well when you are
feeling unwell”
“Explained by the doctor very well and the timing was excellent”
“I have come to this clinic for many years and I have always experienced a very good service”
“How can we improve?”
“I like the toast for breakfast but the toast was a bit soggy”
“Food could be improved, more choice”
“Food is boring more variety would be great”
“TV or radio for long term patients to keep minds active”
“Put some TVs on the ward”
“TV facilities have been removed”
“Less noise, your bins are extremely squeaky”
“A less noisy night, it wakes up everyone”
“At night keep the telephones off loud speakers”
21
4.1.8
Responding to comments
The feedback from patients and in particular their comments is a rich source of information for
the Trust and individual services. In response to the comments a range of actions will be taken
and these are summarised as follows;
Targeted support from the Patient Experience Team to areas where the percentage of
recommendation is less than 90%. To include a review of comments with the
ward/department leads, suggest new ways of working and improvement actions. New
public facing posters of results and improvement actions on ward/department boards
which will be launched (March 2015).
A “Housekeepers‟ Masterclass” scheduled for April 2015 to refocus the role and the
relationship between housekeeper and the patient experience (environment, privacy and
dignity, patient mealtimes and seeking patient feedback).
A further scope of the Trust strategy to provide patients with IT devices so they can
stream movies, radio and TV (March – April 2015).
The Patient Experience Manager has compiled a top 10 of most commonly raised
concerns and actions have been agreed with the Patient Services Catering Manager in
order to respond to patients‟ concerns. This will be monitored by the Patient Experience
Manager.
Weekly management reviews are undertaken in OPD, where processes are reviewed
and corrective actions taken.
Standardise ward stock orders for ear plugs and eye visors by Housekeepers
4.1.9
Implementation of the FFT 2014 – 2015
The National requirement for the FFT in 2014 - 2015 is to implement the system in adult
Outpatients and Adult Day Cases to national standards by October 2014, which was achieved.
Additionally, the national system must be implemented in Adult Community Services by 1
January 2015, and this is also achieved. The FFT implementation to national standards in
children and young people‟s services is on track for implementation by April 2015.
4.2
Complaints and PALs
4.2.1
Purpose of Report
The purpose of this report is to provide assurance that complaints and concerns raised with
the Trust during February 2015 were dealt with in accordance with the Trust‟s policy of
openness. The report reviews the level of complaints, concerns and compliments received,
provides assurance that complaints and concerns have been recorded and investigated
appropriately and within agreed timescales; the report also considers any trends or themes in
complaints received and provides information on the actions or learnings implemented. Where
appropriate, figures have been benchmarked against the previous report (covering January
2015) or 2013/14 (previous year).
4.2.2
Number of Complaints
During the period under review, we received 39 new formal complaints. 3 cases were
reopened for further attempts at local resolution. A further 11 cases were recorded as informal
complaints after discussion with the complainant.
The chart below shows complaints received each month during the 2014/15 year with
comparison to figures for 2013/14. Complaints fell during September and October 2014, saw a
marked increase during November before falling again during December 2014 and January
2015. It should be noted that complaints for October and November 2013 reflect the
introduction of Cerner at the main CUH site.
22
Formal complaints received by month 2013/14 vs 2014/15
Year to date - 1 April to 28 February
100
80
60
40
20
0
69
56
Apr
4.2.3
47
41
May
48
48
31
32
Jun
Jul
55
51
Aug
58
63
42
36
Sep
Oct
2014/15
Apr May Jun
56
41
32
Jul
48
Aug
51
Sep
42
Oct
36
2013/14
69
48
55
58
63
47
31
60
53
Nov
85
47
41
Dec
Nov Dec
53
41
60
47
33
Jan
68
39
Feb
Jan
33
Feb
39
85
68
Formal Complaints by Directorate
The table below shows the number of complaints received by individual directorates in
February 2015 and includes figures for January 2015 to show the range of movement. For the
clinical directorates, all showed a small increase in the number of complaints received, with
the exception of Family Services, which recorded a small fall.
Complaints received by Directorate 2014/15
Directorate
Adult Care Pathways
Directorate
Cancer and Core Functions
Directorate
Corporate
Jan
14
Feb
15
4
5
0
0
Estates and Facilities
Directorate
Family Services Directorate
Surgery Directorate
Totals:
1
2
5
9
33
4
13
39
Colour code reflects
fall since previous
month
no change
increase on previous
month
23
4.2.4
Complaints by Patient Episode – January 2015
The tables below show the Trust average across directorates for January 2015 is 1.0
complaint per 1,000 patient episodes of care, against the year to date average of 1.4 per 1000.
January 2015
Directorate
Patient Episodes
Percentage Jan 2015
Adult Care Pathways Directorate
Cancer and Core Functions
Directorate
Family Services Directorate
14
9077
0.15%
4
5980
0.07%
5
6159
0.08%
Surgery Directorate
9
9620
0.09%
Totals:
32
30836
0.10%
2014/15 Year to date
Directorate
Adult Care Pathways Directorate
Cancer and Core Functions
Directorate
Family Services Directorate
4.2.5
Complaints
Complaints
162
Patient Episodes
94710
Percentage
0.17%
59
54959
0.11%
74
57700
0.13%
Surgery Directorate
123
96000
0.13%
Totals:
418
303369
0.14%
Compliance with Complaint Response Targets
The Trust is required to acknowledge formal complaints within 3 working days of receipt. For
February 2015, 100% of complaints received were acknowledged within time. Complainants
were contacted, where possible the same day, to discuss their concerns and how best to
resolve them. The benefits of this contact are reflected in the number of informal complaints
received during this period.
The Trust is committed to responding to formal complaints within 25 working days, unless a
different timescale is appropriate and has been agreed with the complainant. The Trust has an
objective that at least 80% of responses should be completed within agreed timescales.
The chart below shows year to date performance against this target, based on all complaint
responses due, and a comparison with the cumulative response rate achieved for 2013/14.
24
At a meeting with the TDA in October 2014, it was agreed jointly with complaints team and the
directorates to work on a recovery trajectory for complaints responses, with the aim of
achieving a rate of 60% by January 2015 and 75% by end of March 2015.
Since October 2014, the clinical directorates have consistently improved the number of
responses prepared within timescales and this is reflected in the increase in the Trust‟s
average response rate. The response rate for individual months has increased from 42%
recorded for September 2014 to 75% in November 2014 and to 77% for February 2015, which
is in excess of the improvement looked for. This improvement in the monthly response rate
has been reflected in a steady increase in the Trust‟s year to date figures and, looking forward
to 2015/16, suggests that foundations are in place to ensure that the Trust‟s objective is
achieved.
To maintain this level of performance, complaints department coordinators now send a
reminder to the service two days before the draft response is due and then a reminder on a
daily basis. This is escalated to the complaints manager if the response has not been received
by the third day, who will in turn contact the ADN/ADO for an update, after which noncompliance is escalated to the DDN of Nursing.
The directorates also receive a weekly report which shows all open complaints where a draft
response is required, with those approaching the due date highlighted. Complaints
coordinators have regular weekly meetings with the directorate leads for complaints to discuss
any issues or causes of potential delays.
Position at time of report
52 open complaints, an reduction from 68 open at the end of January;
8 cases had breached the target response date, compared to 12 cases at end January;
For breached cases, 4 draft responses have since been received and holding letters are
sent to complainants to explain the reason for delay;
44 cases were in time, of which 12 have a draft response prepared and awaiting review;
Weekly updates on this position are provided for oversight at Exec Review;
The complaints department held 16 draft responses awaiting quality review and
signature, a reduction from 21 held at end January.
4.2.6
Trends and Themes – Subjects Raised
All complaints and concerns raised via the PALS office are recorded by the Trust and
investigated. Complaints are allocated initially to an Associate Director for oversight, who will
then appoint an investigator, usually a senior manager, to look into the concerns raised and
prepare a written response.
PALS concerns are primarily current issues which may be resolved quickly and are therefore
passed to service managers for immediate resolution where possible.
When a complaint or concern is received by the Trust, the complaint department or PALS office
notes the subject areas, which are then further broken down by sub-subjects. This allows the
Trust to identify trends in complaints and concerns received regarding subjects or service areas.
The table below shows the top subjects, broken down by directorate, for February 2015. The
top subjects remain largely unchanged each month, with small changes in the numbers
recorded from month to month. The number of complaints received for February 2015 is in line
with the average for the year to date, approximately 10 complaints a week across all
directorates; the present analysis of subjects does not highlight any particular themes or trends
requiring attention.
25
Complaints by Directorate & Subject (Primary)
Directorate
Diagnosis
Nursing
and
Midwifery
care
Privacy,
dignity
and
consent
1
1
4
2
0
0
0
0
0
1
0
1
1
0
0
1
3
5
10
3
5
1
3
1
5
1
3
Administration
Attitude
of staff
Clinical Care
and
treatment
Communi
-cation
1
0
5
3
1
1
0
5
Adult Care
Pathways
Directorate
Cancer and
Core
Functions
Directorate
Family
Services
Directorate
Critical Care
and Surgery
Directorate
Totals:
Colour Code
Reflects
Fall since previous month
No change
Increase on previous
month
The complaints department also prepare reports for individual directorates and services to
assist in highlighting any areas where a review of performance is indicated.
4.3
PALS Activity
4.3.1
The PALS office recorded 122 patient contacts during February 2015. The chart below shows
the breakdown of directorates involved and the major share of enquiries or concerns received
continue to relate to Adult Care Pathways Cancer and Core Functions and Corporate
directorates.
PALS contacts by Directorate February 2015
49
28
24
14
1
6
Adult Care Cancer and Corporate Estates and
Family
Surgery
Pathways
Core
Directorates Facilities
Services
Directorate
Directorate Functions
Directorate Directorate
Directorate
The contacts have been broken down by subject and the top five subjects remain unchanged
from January 2015.
26
PALS - Top Subjects February 2015
Customer Service
35
Delays and cancellation
24
Administration
23
Clinical Care and treatment
8
Discharge Planning and…
7
Patients Property
5
Communication
5
Attitude of staff
Nursing and midwifery care
4
2
Transport
1
Privacy, dignity and consent
1
Although the subjects remain unchanged, the level of contacts in February 2015 has changed
by comparison to the previous month for some areas.
Concerns about delays and cancellations have risen by 72%, from 14 in January to 24 in
February 2015 and almost 50% of these relate to cancelled and rescheduled outpatient
appointments. Customer Service enquiries, which relate to requests for information or
assistance about our services, access to medical records or questions about our complaint
process, have increased by 35%.
Administration has seen a fall of 51% in concerns raised, whilst Clinical Care and Treatment
has seen a reduction of 65%. Discharge planning concerns are virtually unchanged in number.
Concerns relating to the loss of patient property increased this month but concerns about the
attitude of staff have halved compared to January.
4.4
Compliments
38 compliments were received and logged during the period.
A selection of comments received is attached below:
We write to say how impressed we were with the excellent service provided to my
wife on her recent appointment in the Gastroenterology Department and her
subsequent test in the Endoscopy Unit. The efficiency and courtesy afforded her were
of the highest standard and comparable with the expectations of any private
hospital. We felt that the level of cleanliness was also of a very high standard, both in
these departments and around the hospital in general.
We are very grateful for your service, which over the years we have always found
excellent at the Hospital.
I had an operation on Monday 16 February and was under the care of Zozo in the women's
day care ward after I came out of the recovery room. I have to say the aftercare I received
from Zozo after my op was amazing. Zozo was very caring and went out of her way to make
sure I was as comfortable as possible and nothing was any trouble for her. She was lovely to
talk to and allayed my fears. Please can you pass on my compliments to her. I ended up
spending the night on the Queens 1 ward after where the care was ok but nothing compared
to the outstanding care I received from Zozo. Thank you Zozo.
27
I am writing to express my thanks to Liz who took my blood today (2 Feb), for her assistance and for
going beyond her duty to sort out some problems created by my doctors surgery regarding
paperwork.
It was crucial to have these tests as I am due for heart procedure next week. Had Liz not put herself
out, it is possible the procedure may have been cancelled next week.
I must emphasise that the treatment I received from the ambulance crew, A&E and
subsequently on the Acute Medical Unit & the Cardiac Care Unit at CUH was exceptionally
good.
Really good experience today at the phlebotomy department, a lot of people but I did not wait
too long for my turn, efficient computerised system for labelling my blood samples,
welcoming, knowledgeable and friendly staff especially Jane, thank you.
I have recently been for day surgery twice.
The hospital is so welcoming - reception brilliant - and signposting simple to understand. Staff in day
surgery friendly, efficient and very helpful (I have ear disease that affects ability to balance and they
understood the problem). Theatre staff reassuring, making sure that I was comfortable and the
correct procedure was done. In recovery unit, staff knew who I was/what had been done
and immediately supplied cup of tea and sandwich when time was up. At all times, I was treated as
an individual and with respect. There were glitches (e.g. IT crash meant discharge delayed) but I was
told the reason.
Croydon clearly well-managed with happy, motivated staff - despite all the interference from
politicians. Thank you
Exemplary care throughout my time in C U H in December.
Professional, courteous, friendly all the time. I must mention some
of the brilliant staff at Queens 1; Celia, Cynthia,Gina, Izabella,
Ayeesha, Imm, Nicky, Annette and many more.
The Doctors patiently explained procedures etc to my husband and I,
including Mr N and Dr A. Not forgetting Mr O (anaesthetist?) and
another anaesthetist (Mr M). I am sure I have not named everyone,
but the staff were absolutely ace.
28
Just had an amazing experience of giving birth to my child in
birthing centre and would love to say the biggest ever thank you for
all the time and help we got it from midwife there surely couldn't
do it without you ladies now we in postnatal ward and all the care
is also excellent thank you so much
4.5
Patient Demographics
Ethnicity is recorded to indicate where specific action may be needed to ensure that the
complaint process is accessible to all service users. However, whilst ethnicity is often recorded
within our patient records, this information is not available where a complaint is made by a
family member. Actions have been agreed to improve the recording of cases currently shown
as „not stated‟ where this relates to patients.
For comparison purposes, the chart below shows the ethnicity in percentage terms of the local
area, taken from the 2011 Census and the ethnicity of complainants, where this has been
recorded. Given the broad range of ethnicities within the local area, a number of groups are
small minorities of less than 2%.
29
30
4.6
PHSO cases
Cases under investigation or review by Parliamentary and Health Service Ombudsman
There are 12 cases where the PHSO have advised they plan to investigate; as a first stage the PHSO has asked us to provide copies of
our records, pending the appointment of an investigator by the PHSO, which we have done in all cases. The PHSO have advised that
there are currently long delays between requesting copies of our records and appointing an investigator. We have received draft
reports in three cases - one was not upheld, one was partially upheld and one was upheld.
Opened
30/07/2012
Current Stage
Ombudsman formal
investigation
ID
Directorate
11628 Adult Care Pathw ays
Directorate
23/11/2012
Ombudsman formal
investigation
11837 Adult Care Pathw ays
Directorate
27/02/2014
Ombudsman formal
investigation
12972 Family Services
Directorate
10/04/2014
Ombudsman formal
investigation
13103 Adult Care Pathw ays
Directorate
13/06/2014
Ombudsman formal
investigation
13424 Adult Care Pathw ays
Directorate
09/07/2014
Ombudsman formal
investigation
12528 Adult Care Pathw ays
Directorate
05/06/2014
Ombudsman formal
investigation
13398 Adult Care Pathw ays
Directorate
21/07/2014
Ombudsman formal
investigation
13549 Surgery Directorate
07/08/2014
Ombudsman formal
investigation
13625 Family Services
Directorate
28/10/2014
Ombudsman formal
investigation
13825 Critical Care and Surgery
24/07/2014
Ombudsman formal
investigation
28/10/2013
Ombudsman formal
investigation
13806
Adult Care Pathw ays
Directorate
Adult Care Pathw ays
Directorate
Description
Updated position
Patient's w ife has concerns regarding her
husband treatment and care w hile he w as in
hospital, She says the nurses on MAU w ere
arrogant and patronising. Her husband w as told
he w ould be in for a least 2 days but he w as
discharged the next day. He then came back to
hospital w ith the same problem about a w eek
later he then w as put on F2.During her husbands
stay he lost his slippers and dressing gow n and
many times she found him cold w ith only a sheet
over him. She feels that her husband w as not
looked after very w ell. She feels her husbands
death has been hastened by the cold, lack of
treatment and lack of antibiotics for a persistent
urine infection.
Patients husband came into hospital complaining
he had pains in his stomach and vomiting. It took
2 days to call an on call surgeon w ho suspected
a blocked intestine. Patients w ife thought that the
delay caused unnecessary strain on the heart.
Patient w ants to know w hy her husband died
due to severe coronary artery disease. She says
he had number of ECG's so w hy w as this not
picked also the anaesthetist identified a minor
heart attack on the ECG of w hich he w as not
aw are.
Complainant is unhappy w ith the report that had
been sent to them w ith regards to their formal
complaint Ref:12805
Complainant fad an appointment at the Crystal
Medical Centre to discuss the failings of another
doctor but feels that this w as not addressed in
the report that they received.
Complainant is unhappy w ith the response that
they received dated 05/11/2013.
17/02/2015 - Draft report received from PHSO.
Com plaint partially upheld: Failings identified in
nutritional support provided to patient; no failing found in
access to blankets or in materials used in red food tray.
Action
required by:
Action required: Within one month of final report an
action plan to address failing identified
Final report aw aited
PHSO advised they w ill investigate and copy complaints
file requested. Papers sent 24/12/2014
PHSO have issued draft report advising that they have
decided not to uphold this complaint
Final report aw aited
12/12/14 PHSO advised they w ill investigate and copy
complaints file requested
05.01.2015 aw aiting health records - contacted the
Ombudsman - voicemail to leave contact details and
case number and they w ill call back.
12/01/15 - HR received from HRL - sent to PHSO
reopened complaint as it has since transpired
3.9.14 - Call from Christopher Anjori at Ombudsman,
that child has suffered permanent injury to his
requested information as to status of complaint.
hand as a result of incident in A&E. Pt unable to Advised w e referred complainant to ombudsman as the
use hand and has needed an operation and
service felt the complaint w as investigated in depth
intensive therapy to improve dexterity.
previously 3 years ago, and staff involved in the original
Complainant is a nurse and is concerned that this complaint have since left the Trust. Requested Trust's
is a safeguarding issue.
response by email, sent and attached to datix
8/12/2014 PHSO advised they w ill investigate and copy
complaints file requested
12/01/15 - HR received from HRL and sent to PHSO.
Patient's family unhappy w ith the treatment
patietn recieved. they believe patient w as given
an verdose of fluids w hich contributed to his
death.
15/10/14 PHSO advised they w ill investigate and copy
complaints file requested
06/11/14 medical records and complaints file sent by
recorded delivery. KB
29/01/2015 - PHSO w rote to confirm investigation has
started
Complainant w ould like independent review of the 8/01/15 PHSO advised they w ill investigate and copy
case as he is unhappy w ith the previous
complaints file requested. Papers sent 22/01/15
response and does not feel that a meeting w ould
benefit him at present
Patient has complained that she w as marked
9/01/15 PHSO advised they w ill investigate and copy
DNAR w hen admitted to HDU and that this w as
complaints file requested. Papers sent 22/01/15.
done w ithout consent or discussion w ith her or
her husband.
Patient is not happy w ith the previous response 17/02/15 - Draft report issed. Com plaint upheld and
and w ould like her questions answ ered and
Trust required to issue apology, arrange financial
explained regarding failure to diagnose ovarian
payment of £6,000 and complete action plan to remedy
cancer
failings. Agreement to draft report required by 27/02/15.
Agreement sent 27/02/15 - Final Report is likel;y to follow
w ithin 7 days
Patient has complained that procedure on his
29/01/2015 - PHSO have advised they propose to
knee made his situation w orse and a replacement investigate. Papers requested by 16/02/15
w as unfairly denied. He has paid for surgery
Patient has met DoN and HoN for Patient Experience
privately and w ants an apology and
Meeting held w ith CEO and MD on 11/2/15. Papers sent
compensation. Patient has also complained about to PHSO 13/02/15 w ith note that meeting held and patient
attitude of staff in complaints department and
intending to pursue legal action.
delays in processing complaint.
Complaint about decision to fit pacemaker and
16/02/15 - PHSO have advised they propose to
care and treatment given follow ing procedure.
investigate and have requested comments and
Patient is seeking financial compensation, justice supporting papers.
and to avoid reoccurence
Complaint is that the Trust misdiagnosed a stroke 23/02/2015 - PHSO have advised they propse to
as a chest infection and although this w as picked investigate this complaint and have requested papers
up at a neighbouring Trust, it w as too late to
and comments.
administer appropriate medication. Complaint
included concerns about nursing care w ith
issues about pain medication, bags of faeces left
out, incontinence care, mobilisation, and
infections.
31
5.
Effective
5.1
Mortality Report
As reported previously the Dr Foster data has not been accessible to provide an update and
this will be resolved for future reporting.
5.2
Venous Thrombo-embolism (VTE)
The last available month result shows the Trust to have achieved a satisfactory 96.72%
(December 2014).
5.3
Serious Incidents
28 incidents were reported this period (01/01/2015–28/02/2015), of which all were attributed to
CHS for this period. 1 Never Event was reported during this period. A breakdown of the
incidents reported by month is shown in the table below.
Incidents declared
Total number of CHS incidents reported
+
Total number of incidents de-escalated
=
Total number of SI reported
Number of Never events
2015 01
11
+
0
=
11
2015 02
14
+
0
=
14
0
1
The categories of the reported SI‟s (excluding the de-escalated incidents) are as follows:
Categories of incidents reported to STEIS
2015 01
2015 02
1
0
C.Diff & Health care acquired infections
1
3
Delayed diagnosis
Maternity services - unexpected admission to
0
1
NICU
1
1
Other
0
1
Pressure ulcer - grade 3 (community acquired)
1
3
Pressure ulcer - grade 3 (hospital acquired)
0
1
Pressure ulcer - grade 4 (hospital acquired)
Slips, trips, falls
2
0
3
1
Sub-optimal care of the deteriorating patient
1
1
Surgical error
1
1
Unexpected death (general)
0
1
Wrong site surgery
Total
11
14
*Please note that the above table only represents those incidents that have been reported and
does not include those that have since been de-escalated.
19 Serious Incident reports submitted in this period of which 5 were submitted within
the timescale
Investigations concluded
2015 01
2015 02
Number of reports signed off in month
7
12
Number submitted within timeline
3
2
Number of breached reports
4
10
Of which < 1 week
1
2
Of which < 1 month
2
4
Of which > 1 month
1
4
32
Duty of Candour - Being open
Total number of CHS incidents
reported
Being Open Stage 1 Completed
Being Open Stage 1 Not
completed
Total number of CHS incidents
submitted
Being Open Stage 2 Completed
Being Open Stage 2 Not
completed
5.4
2014 10
10
2014 11
11
6
4
9
2
2
5
2014 12
8
2015 01
11
2015 02
13
4
4
7
4
0
13
4
7
12
1
3
3
6
Duty of Candour - Being Open Stage 2 Monitoring
The Board should note that for the period of Oct and November the Stage 2 monitoring was
not captured as the criteria was not agreed with the CCG. Going forward this will be reflected
and work will commence on a look back exercise to be included in future reports.
For December 2014 there are 3 stage 2 notifications that have not been completed and this
can be attributed to the following:
1
1
1
5.5
= non clinical incident
= not due until January 2015
= no evidence provided
NICE Guidance
During January and February 2015, 19 new NICE guidance and 5 Quality Standards were
published.
5.6
National Audit
Four National Audits were published in January and February 2015
College of Emergency Medicine – Asthma in Children
College of Emergency Medicine – Paracetamol Overdose
National Diabetes Audit Report 2 – Complications and Mortality
National Chronic Obstructive Pulmonary Disease Audit Programme
5.7
National Audit Update
Three National Audit Action Plans were received in January and February. These have been
circulated through the Clinical Directorate Quality Boards for comment
National Prostate Cancer Organisational audit
Falls and Fragility Fracture Audit Programme - National Hip Fracture Database
National Pregnancy in Diabetes Audit Programme
33
5.8
Local Clinical Audit
Audits on Trust Audit Plan (high priority)
Audit title
Compliant
to
standards
Compliant
Reasons for partial or
non-compliance
Actions
N/A
Audit to monitor
compliance with
the implementation
of Best Practice
Policy - National
Institute for Clinical
Excellence (NICE)
Guidance
Trust-wide
Recordkeeping
audit
Compliant
N/A
1. Review and rewrite the Clinical
audit policy which is due for review
in March 2015.
2. Amend Appendix E – Audit
Proforma of the policy
3. Continue to promote awareness of
clinical audit through Quality
Boards, Departmental Meetings,
Clinical Governance etc.
4. Continue to follow-up on updates
on the progress of action plan and
update the monitoring log.
1. Disseminate audit results to
appropriate DPQB/ committees.
2. Continue to follow policy and
escalate accordingly
3. Re-audit in 12mths
Partial
Following the
implementation of the
new Cerner system
compliance in most
areas has improved for
all electronic records.
The paper records that
have been audited in
the community areas
are still non-compliant
in several areas.
DNACPR Q3
Partial
Audit results have
shown that practice has
improved from quarter 1
in the following areas:
Nurses being aware
which patients are not
for resuscitation,
Documented
discussions with
patients who have been
made DNACPR has
increased, Documented
discussions with
patients families has
increased, Patient
demographics being
documented on
DNACPR forms has
increased, Improved
compliance to Trust
policy on the completion
of DNACPR forms
This audit was carried
Audit of clinical
audit process
1. Findings of the audit to be
reported through DPQB and
disseminated to individual teams –
to improve practice through
staff/team/depart mental meetings
and clinical governance sessions.
2. Update on Cerner rollout for
Maternity and Community
Services.
3. Agree audit responsibilities and
arrangements for 2015 with the
new IG manager.
4. Commence re-audit in July 2015
Quarterly DNACPR audit report
1 Re-audit using Cerner to be
completed at the end of quarter 4
2 Formal nursing ward handovers to
be standardised to include the
resuscitation status of each
patient.
3. Consultants to ensure full
adherence to current
Resuscitation Policy regarding
counter signing DNACPR forms
within 48 hours of the original
decision-this to be addressed by
Cerner migration.
4. All medical staff to document
discussions had with patients
regarding the decision to make a
patient not for active resuscitation
5. Where possible and/or
appropriate, medical staff to
document any discussion had with
patients‟ relatives/Welfare
Attorney-if a conversation with the
34
Audit title
In hospital
resuscitation trolley
audit (Q3)
Compliant
to
standards
Partial
Reasons for partial or
non-compliance
Actions
out at the same time
that the Trust was in the
process of migrating
from paper based
DNACPR forms to an
electronic version. It
should be noted that n
in this audit was fairly
low compared to
quarter one. The
difference in part was
due to this migration
period and as such may
not give a true and
accurate reflection of
the Trusts DNACPR
challenges at this time.
It should however be
remembered that any
paper based
documentation should
be compliant with Trust
recommendations, and
as such the data above
is of significance.
relatives/Welfare Attorney is not
appropriate and/or not possible
this should also be documentedthis to be addressed by Cerner
migration.
6. Quarterly DNACPR documentation
review to be presented at the
Trusts Resuscitation and
Deteriorating Patient Committee.
The audit revealed that
overall, 92% of
ward/departmental
resuscitation trolleys
were compliant to the
Trusts Resuscitation
Policy. This is a
significant improvement
from quarter 1 which
showed only 64% of
trolleys were compliant.
Reason for noncompliance :
Rupert Bear Defibrillator pads out of
date and trolley not
checked for four days
Labour Ward- Oxygen
on resuscitation trolley
was completely empty
1. Quarterly audits and reports on
resuscitation trolley compliance
following the above templateResuscitation Service to action
and report produced by the end of
Q4.
2. Increased ward based teaching to
departments/areas that have
challenges-Resuscitation Service
to action by the start of quarter
four.
3. New ward based resuscitation
resource folder to be implemented
in quarter three and evaluatedResuscitation Service to action by
the end of quarter four
4. Ward based simulations to test
local response to emergency
situations exploring any organic
issues- Resuscitation Service to
action by the end of quarter four
35
Audits not on Trust Audit Plan (i.e. categorised as medium or low priority audits)
Audit title
Trichomonas
Vaginalis – Audit
of Services at
Croydon Hospital
Acute Testicular
Pain
Compliant
to
standards
Compliant
Partial
GP Referrals for
Pregnancy
Booking Audit
Partial
RCR Audit of the
Accuracy of
Interpretation of
Emergency
Abdominal CT in
Non-Traumatic
Abdominal Pain
Partial
Severe Sepsis
and Septic shock
in adults
Partial
Reasons for partial
or non-compliance
Actions
N/A as currently
meeting / exceeding
most British
Association for
Sexual Health and
HIV (BASHH)
auditable outcome
targets.
Partially complaint
against gold
standard, but need
improved initial
assessment times
and prompter
referrals.
Pregnancy referral
and yet only 83% had
an obstetric history
documented.
GP surgeries are
using a myriad of
different referral
forms.
Gestation calculation
and documentation –
only 36% of referral
forms had gestation
documented. This is a
problem as the
gestation at referral
determines how
quickly the woman
receives her first
appointment.
In nearly all areas of
the RCR audit, the
department was
compliant to the RCR
standard.
In only one standard
(minor discrepancy
rate) was the
department noncompliant (15% rather
than 10%).
Continue with the current
pathway of receiving treatment
as it is working -Either from
Health Advisor following
diagnosis on microscopy, or from
nurse following positive culture
after seeing HA / Doctor.
There was a general
improvement from
previous audits with
the measurement of
lactate and antibiotics
Apply acute testicular pain
guideline accurately
Re-audit
Present Audit findings at GP
evening to disseminate findings.
Standardisation of referral forms
used.
No particular steps need to be
taken in this case, as the slightly
increased minor discrepancy
rate (in the surgical group) can
be attributed to a difference in
opinion between 2 reporting
radiologists upon reviewing a
scan. Correlation between the
scan report finding and the
subsequent laparotomy found no
significant discrepancy
suggesting the original CT report
was satisfactory.
Ensure current MDT awareness
via email, teaching.
Ensure on-going/future MDT
awareness
36
Audit title
Quality of
Intraoperative
cerebral
protection
Compliant
to
standards
Non compliant
Reasons for partial
or non-compliance
given in ED only
down by a few
percent. All
standards were met
better than the
national average as
found by the CEM
audit 2013/14. This
was likely due to
improved awareness
via methods from
earlier audits such as
posters and also a
new resus team
containing
paramedics and
senior nurses.
However, national
targets still not
reached. There are
further improvements
to be made.
This pan-London
Audit aimed to look at
peri-operative
haemodynamic
instability, end-tidal
carbon dioxide, and
use of depth of
anaesthesia (DOA)
monitoring in the
elderly patients
undergoing surgery.
This high risk group
are known to suffer
morbidity if these
areas are managed
poorly. Our results
show significant
levels of
haemodynamic
instability, 10% of
patients had periods
of hypocapnoea and
there was limited use
of DOA monitoring
Actions
1. Teaching – regular slot in
junior doctor timetable
2. Posters – RATT and Resus
points of likely successful
intervention
To increase awareness of
implications of hypotension,
hypocapnoea in this patient
population, and benefits of DOA
monitoring.
37