AGENDA - NHS Stafford and Surrounds CCG

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Enc 00 Stafford & Surrounds Clinical Commissioning Group Governing Body Meeting in Public Beacon International Centre, Unit 26 Anson Court, Staffs Technology Park, Stafford, ST18 0GB To be held on Tuesday 17 th February 2015 14:00 – 16:30 AGENDA 12:30 – 14:00 Confidential Governing Body Meeting FOLLOWED BY: 14:00 – 16:30 Governing Body Meeting in Public A=Approval R=Ratification D=Discussion I=Information Enc Lead A/R/ D/I 1. Welcome by the Chair Verbal AMH I 2. Apologies for Absence Verbal AMH I 3. Conflicts of Interests Declarations of Interest Register for Stafford & Surrounds Governing Body Enc 01 AMH I 4. Minutes of the last meeting: Minutes of Meeting 20/01/15 Matters Arising/Action List Enc 02 Enc 03 AMH AMH A A 5. Chairs Report Verbal AMH I 6. Chief Officers Report Enc 04 AD I 7. Quality and Safety Report Enc 05 VJ I 8. Performance Report – December 2014 Enc 06 LM I 9. Board Assurance Framework (BAF) Enc 07 SY D 10. Finance Report - December 2014 Enc 08 PS D/I 11. Primary Care Strategy Enc 09 LM A 12. IVF/ICIS Policy 2015 Enc 10 MH A 13. Stafford CCG Q2 Assurance letter Enc 11 AMH I 14. Items for Information Finance, Performance & Contracting Minutes Communications & Engagement Committee Minutes Enc 12 Enc 13 AMH I

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Transcript of AGENDA - NHS Stafford and Surrounds CCG

Stafford & Surrounds Clinical Commissioning Group Governing Body Meeting in Public
Beacon International Centre, Unit 26 Anson Court, Staffs Technology Park, Stafford, ST18 0GB
To be held on Tuesday 17th February 2015
14:00 – 16:30
A=Approval R=Ratification D=Discussion I=Information
Enc Lead A/R/ D/I
2. Apologies for Absence Verbal AMH I
3. Conflicts of Interests Declarations of Interest Register for Stafford & Surrounds Governing Body
Enc 01 AMH I
Minutes of the last meeting: Minutes of Meeting 20/01/15 Matters Arising/Action List
Enc 02 Enc 03
6. Chief Officers Report Enc 04 AD I
7. Quality and Safety Report Enc 05 VJ I
8. Performance Report – December 2014 Enc 06 LM I
9. Board Assurance Framework (BAF) Enc 07 SY D
10. Finance Report - December 2014 Enc 08 PS D/I
11. Primary Care Strategy Enc 09 LM A
12. IVF/ICIS Policy 2015 Enc 10 MH A
13. Stafford CCG Q2 Assurance letter Enc 11 AMH I
Enc 14
Next Meeting – Organisational Development
Date: Tuesday 17th March 2015 Time: 14:00 – 17:00 Venue: Beacon International Centre, Unit 26 Anson Court, Staffordshire
Technology Park, Stafford, ST18 0GB
1. A&E Accident & Emergency 2. ALE Auditors Local Evaluation 3. AED Automated External Defibrillator 4. ADP Accelerated Development Programme 5. AHP Allied Health Professional 6. ALAN Adult Literacy and Numeracy 7. ALOS Average Length of Stay 8. ANNP Advanced Neonatal Nurse Practitioner 9. APMS Alternative Provider Medical Services 10. AQP Any Qualified Provider 11. AVS Acute Visiting Service 12. BCH Birmingham Children’s Hospital 13. BEN Birmingham East and North PCT 14. BNP Brain Natriuretic Peptide 15. CAG Commissioning Advisory Group 16. CAMHS Children and Adolescent Mental Health Service 17. CAS Clinical Assessment Service 18. CB Commissioning Board 19. CBSA Commissioning Business Support Agency 20. CC Cannock Chase 21. CCG Clinical Commissioning Group 22. CDiff Clostridium Difficile Infection 23. CEO Chief Executive Officer 24. CGA Comprehensive Geriatric Assessment 25. CHAI Commission for Health Auditing Inspection 26. CHI Commission for health Improvement 27. CHPP Children’s Health Promotion Programme 28. CIAMs Commissioning Investment Asset Management Strategy 29. CIG Clinical Informatics Group 30. CIP Cost Improvement Programme 31. CNST Clinical Negligence Scheme for Trusts 32. CoE Care of the Elderly 33. COPD Chronic Obstructive Pulmonary Disease 34. CPAG Clinical Policies Advisory Committee 35. CPN Community Psychiatrist Nurse 36. CQC Care Quality Commission 37. CQRM Care Quality Review Meetings 38. CQUIn Commissioning for Quality and Innovation 39. CQINS Cancer Quality Improvement Network System 40. CMT Contract Management Team 41. CRL Capital Resource Limit 42. CRT Crisis Response Team 43. CSIP Clinical Services Implementation Programme 44. CSU Commissioning Support Unit 45. CSW Clinical Support Worker 46. CWG Clinical Working Group 47. DC Day Care 48. DCC Direct Clinical Care 49. DES Direct Enhanced Service 50. DIPC Director of Infection Prevention & Control
51. DN District Nurse 52. DoH Department of Health 53. DoLs Deprivation of Liberty Standards 54. DPD Dental Practice Division 55. DPP Developing Patient Partnerships 56. DQF Data Quality Facilitator 57. DRS Dental Reference Service 58. DTC Delayed Transfer of Care 59. EAU Emergency Admissions Unit 60. ECDL European Computer Driving Licence 61. ECIST Emergency Care Intensive Support Team 62. EDD Expected Discharge Date 63. EDS Euality Delivery System 64. EL Elective 65. EMS Escalation Management System 66. ENT Ear Nose Throat 67. EPO Emergency Planning Officers 68. ESR Electronic Staff Record 69. EWISS Emotional Well Being in Stafford & Surrounds 70. EWTD European Working Time Directive 71. FE Frail Elderly 72. FIG Financial Improvement Group 73. FIMS Financial Information Management System 74. FIT Funding Individual Treatment – now FET 75. FET Funding Exceptional Treatment 76. FFT Friends and Family Test 77. FNOF Fractured Neck of Femur 78. FOI Freedom of Information 79. F&P Finance and Performance 80. FPC Finance Performance & Contract Committee 81. GAAP Generally Accepted Accounting Principles 82. GDC General Dental Council 83. GDS General Dental Services 84. GMS General Medical Services (Practice) 85. GPWSI GP with special interest 86. GSF Gold Standard Framework 87. HALO Hospital Ambulance Liaison Officer 88. HCC Healthcare Commission 89. HCIA Healthcare Acquired Infection 90. HEFCE Higher Education Funding Council for England 91. HEFT Heart of England Foundation Trust 92. HIS Health Informatics Service 93. HPA Health Protection Agency 94. HPS Health promoting Schools 95. HPSS Health promoting Schools Scheme 96. HRG4 Healthcare Resource Group 4 97. HROD Human Resources Organisational Development 98. HSJ Health Service Journal 99. ICG Infection Control Group 100. IFR Independent Funding Request 101. IFRS International Financial Reporting Systems
102. IG Information Governance 103. IP Inpatients 104. IM&T Information Management and Technology 105. IPC Infection Prevention & Control 106. IPR Individual Performance Review 107. IQT Improving Quality Team 108. ISA Intermediate Support Assistant 109. ITT Invite to Tender 110. IV Intravenous Therapy 111. IWL Improving Working Lives 112. JCI Joint Clinical Investigation 113. JCU Joint Commissioning Unit (SCC) 114. JSNA Joint Strategic Needs Assessment 115. JSP Joint Staff Partnership 116. KPI’S Key Performance Indicators 117. LAA Local Area Agreement 118. LCCB Local Collaborative Commissioning Boards 119. LCP Liverpool Care Pathway 120. LDP Local Delivery Plan 121. LES Local Enhanced Service 122. LETB Local Education and Training Board 123. LH Local Hospital 124. LHE Local Health Economy 125. LIN Local Intelligence Network 126. LINks Local Involvement Networks 127. LMC Local Medical Council 128. LMS Local Medical Services 129. LOC Local ophthalmic Committee 130. LSC Learning Skills Council 131. LSP Local Strategic Partnership 132. LTB Local Transition Board 133. LTC Long Term Conditions 134. LTFM Long Term Financial Model 135. MAU Medical Assessment Unit 136. MAT Maternity 137. MDT Multidisciplinary Team 138. MFCA Multi Factorial Comprehensive Assessment 139. MHRA Medicines & Healthcare products Regulatory Agency 140. MICOT Minor Injuries Community Outreach Team 141. MLU Midwife-led Unit 142. MORI (Market & Opinion Research International) 143. MOI Memorandum of Information 144. MPIG Medical Practice Income Guarantee 145. MRSA Meticillin-Resistant Staphylococcus Aureusis Infection 146. MSFT Mid Staffordshire NHS Foundation Trust 147. MSK Musculoskeletal 148. MUR Medicine Use Review 149. NCAS National Clinical Assessment Service 150. NCB National Commissioning Board 151. NCT National Childbirth Trust 152. NEDs None Executive Directors
153. NEL Non-Elective 154. NES National Enhanced Service 155. NICE National Institute for Clinical Excellence 156. NHSU NHS University 157. NHQAC Nursing Home Quality Assurance Group 158. NRPSI National Register of Public Service Interpreters 159. NTDA NHS Trust Development Authority 160. OBD Occupied Bed Days 161. OOH Out of Hours, also Out of Hospital 162. OP (D) Outpatients (Department) 163. OT Occupational Therapist 164. PA Programmed Activities 165. PAED Paediatrics 166. PALS Patient Advice and Liaison Service 167. PASS Professional Advice and Support Service 168. PAU Paediatric Assessment Unit 169. PBC Practice Based Commissioning 170. PBR Payment By Results 171. PC Planned Care 172. PCR Patient Charge Revenue 173. PCT Primary Care Trust 174. PCTDS PCT Dental Service 175. PEAT Patient Environment Action Team 176. PEC Professional Executive Committee 177. PRF Patient Report Form 178. PiP Partners in Paediatrics 179. PIP Productivity Improvement Programme 180. PIS Prescribing Incentive Scheme 181. PLCV Procedures of Limited Clinical Value 182. PLT Protected Learning Time 183. PMO Programme Management Office 184. PMS Personal Medical Services 185. POPP Partnerships for Older People Projects 186. PPG Patient Participation Group 187. PPI Patient and Public Involvement 188. PPI
(prescribing) Proton Pump Inhibitors
189. PPV Post Payment Verification 190. PQQ Pre Qualifying Questionnaire 191. PRISM Personnel Resource Information System for
Management 192. PROMs Patient Related Outcome Measures 193. PT Physical Therapist 194. PTL Patient Target List 195. PU Pressure Ulcer 196. PWSI Pharmacist with Special Interest 197. QIA Quality Impact Assessment 198. QIF Quality Improvement Framework 199. QIL Quality Improvement Lead 200. QIP Quality Improvement Lead 201. QIPP Quality, innovation, productivity and prevention.
202. QOF Quality and Outcomes Framework 203. QSG Quality Surveillance Group 204. QSISM Quality and Safeguarding Information Sharing Group 205. RAG Responsible Authorities Group 206. RAG Red Amber Green 207. RCA Root Cause Analysis 208. RIA Risk Impact Assessment 209. RRL Revenue Resource Limit 210. RTT Referral to Treatment 211. RWHT Royal Wolverhampton Hospital Trust 212. SALT Speech & Language Therapist 213. SARC Sexual Assaults Referrals Centre 214. SCC Staffordshire County Council 215. SCG Strategic Commissioning Group 216. SCR Strategic Change Reserve 217. SCIO Staffordshire Consortium of Infrastructure Organisations 218. SCBU Special Care Baby Unit 219. SCWP Social Care Workforce Planning 220. SDB Service Delivery Board 221. SHA Strategic Health Authority 222. SI Serious Incident 223. SIB Service Improvement Board 224. SIC Statement of Internal Control 225. SLAM Service Level Agreement Model 226. SPA Supporting Programmed Activities 227. SPEC Strategic Public Engagement Committee 228. SSHLF South Staffordshire Health Libraries Federation 229. SSOTP Staffordshire & Stoke on Trent Partnership Trust 230. SSPAU Short Stay Paediatric Assessment Unit 231. SSSHCFT South Staffs & Shropshire Healthcare Foundation Trust 232. SUI Serious Untoward Incident 233. SUS Secondary User Services 234. TSA Trust Special Administrator 235. TV Team Tissue Viability Team 236. UCC Urgent Care Centre 237. UDA Units of Dental Activity 238. UHB University Hospital Birmingham 239. UHNS University Hospital North Staffordshire 240. UOA Units of Orthodontic Activity 241. VT Vocational Trainee 242. VFM Value for Money 243. VO Variation Order 244. WIC Walk in Centre 245. WCC World Class Commissioning 246. WMQRS West Midlands Quality Review Service 247. WMSCG West Midlands Strategic Commissioning Group 248. WTE Whole Time Equivalent
Declarations of Interest Register for Stafford & Surrounds Governing Body
January 2015
Name Date of Declaration
Position/Role Designation Potential or actual area where interest could occur
Dr Manu Agrawal 24.11.2014 GP Rising Brook Surgery
Practice member of GP First Director of GPF Rising Brook Limited Membership Board Member
Neil Chambers 13.01.2015 Lay Member for Governance
CC & SaS CCG Working across both CCGs.
Non Exec Board Member Wyre Forest Community Housing Group
Andrew Donald 12.01.2015 Chief Officer CC & SaS CCG Spouse - Chief Operating Officer North division Staffordshire & Stoke on Trent Partnership Trust. Working across both CCGs.
Ruth Goodison 26.01.2015 Lay Member for PPI
Stafford & Surrounds CCG
Nil to declare
Dr Paddy Hannigan 13.01.2015 GP Holmcroft Surgery Partner at Holmcroft Surgery
Salaried sessional post as GP to Weston House Nursing Home owned by MHA Practice is Shareholder in GP First
Spouse - Consultant Neonatologist at UHNM
Jean Harrison 13.01.2015 Lay Member (Non Statutory)
Stafford & Surrounds CCG
Sibling is Director of Stafford Railway Circle Ltd Trustee and Chair of The Proteus Family Network UK Charity
Bank Staff in Finance Department at Katharine House Hospice 'Member of the Proteus Family Network UK Medical Advisory Board at Gt Ormond St Hospital, London
Dr Marianne Holmes
Partner Great Haywood Health Centre Practice Member GP First
Dr Anne-Marie Houlder
Salaried GP Brewood Surgery
Assistant Medical Director Staffordshire & Shropshire Area Team
NED Stafford FM Radio (unpaid)
Spouse is GP Partner & Shareholder in Brewood Medical Services
Brewood Medical Services minority shareholder in GP First
Brewood Surgery are a provider of GMS services, some community surgical procedures and some community dermatology
Declarations of Interest Register for Stafford & Surrounds Governing Body
January 2015
Name Date of Declaration
Position/Role Designation Potential or actual area where interest could occur
Val Jones 12.01.2015 Director Quality & Safety/ Chief Nurse
CC & SaS CCG Working across both CCGs.
Dr Kate Millward 19.12.2014 GP Mansion House Partner Mansion House Surgery
Practice Member GP First
Clinical Advisor in Quality & Safety for CCG
David Pearsall 14.01.2015 Lay Member (Non Statutory)
Stafford & Surrounds CCG
Spouse works for MEDACS, Beaconside Technology Park Spouse is a Governor on the Board at SSSFT
Paul Simpson 06.12.2014 Director of Finance
CC & SaS CCG Working across both CCGs
Diana Smith 13.01.2015 Lay Member (Non Statutory)
Stafford & Surrounds CCG
CC & SaS CCG Working across both CCGs
Lynn Millar 12.01.2015 Head of Strategic Change
CC & SaS CCG Working across both CCGs
Tamsin Parker 12.01.2015 Locality Communications & Engagement Lead
CSU Work for the CSU Work across both CCGs Freelance as a newsreader at Signal Radio
Sally Young 12.01.2015 Head of Governance
CC & SaS CCG Working across both CCGs
AMH that follo AMH AMH duri AMH adv not AMH
Names Dr Ann Andrew Dr Pad Jean H Dr Mar Val Jon Dr Kate David P Paul Si Diana S Dr Man
ce Tamsin Gill Hac Sally Y Lynn M Andrew Dr Jane Lesley
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Page 5 of 9
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17th Februar 4.30 pm ternational
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on Court, ST18 0GB
ng Held 21 Oct
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NDS CCG G n List 20th J
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dd clinical lead to the BAF
ovide update in campaign.
rovide develop nce improveme
OD session on mpleted
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ty and Sal
WMAS to be in spoken to Mark confirmed that h come to GB to everything the doing - Carri April 2015 Bring back in Fe March
Further work to – revised plan to
Page | 1  
as per
B to confirm
nvited. AD had k Docherty and he would like to o take through
ey have been ed forward to
Update (Completed items will remain on the Action List until the following meeting) GB at OD session SY to organise for next available OD session.
– Recommendations from Clinical Priorities Policy Group (CPPG)
9.0 MH to bring the paper to the next GB meeting. Marianne Holmes
To be carried forward to the next OD session in March
Presentation title goes here…
• Better Care Fund 
• Transition of Services
• Pressures at Royal Stoke but being managed
• Strategic Resilience Group – meeting weekly  at Chief Executive/Accountable Officer level
Item: 06 Enc: 04
• Next Steps
• Agreed joint work with CCGs at  Commissioning Congress
Item: 06 Enc: 04
Better Care Fund  • Risks
Item: 06 Enc: 04
• Agreed to move Paediatric transfer to May  2015
• Work to develop community paediatrics  service – this will involve engagement with  families
Item: 06 Enc: 04
• Significant challenges on delivery of  finance/activity 2015/16
• Robust Plans
Item: 06 Enc: 04
TO BE HELD ON: Tuesday 17th FEBRUARY 2015
Subject: Quality Report
To update the Governing Board on the quality and safety issues reported at the Clinical Quality Review Meetings (CQRMs)
1. The level of concern for the County site is AMBER RED due to a period of deteriorating A&E performance which has since recovered. There were no Trolley breaches reported. However, the local economy is under pressure. There is still a concerning level of nurse vacancies although this is being mitigated with bank and agency staff some of whom are now to be offered interim contracts. Ward fill rates are being met. SAS CCG has made two unannounced visits pre and post the transfer of services. The Trust is to provide the CCG with weekly assurance on staffing and the CCG have escalated the issue of the cancellation of three consecutive Internal Quality Committees.
2. The level of concern for the RSUH site for this month is rated at RED due to escalating concerns from consistently poor deteriorating A&E performance and the highest number of trolley breaches in the country. A summit meeting was held by NHSE and actions agreed to improve performance and mitigate any risks to patients. The Trust continues to be monitored closely by the lead commissioners and is making every effort to address particular flow issues.
3. The level of concern for SSOTPT is rated at GREEN as there are no major quality or safety
concerns at this time.
4. .The level of concern for SSSFT is rated at GREEN as there are no major quality or safety concerns at this time.
5. The level of concern for BHT is rated at AMBER to reflect that the Trust remain sin special
measures. The Trust has reported a Never event and has exceeded the trajectory for C Diff
Item No: Enc:
cases however only on case was found to be avoidable
6. The level of concern for RWT is rated at AMBER reflecting the issues relating to the problems in meeting referral to treatment times and the waits for cancer treatment which are under close scrutiny by the CCG.
7. The level of concern for WHT is rated at AMBER to reflect the fact that the Trust is struggling to meet its cancer targets and has also reported a Never Event.
Relevance to Key Goals A 10% reduction the levels of obesity against the expected prevalence
Commissioning for quality will enable the CCG to put  in place exemplary systems for commissioning 
intentions and provider performance management   that will deliver its Key Goals
A reduction in the proportion of people with undiagnosed disease from 30 – 10 %. A “levelling up” of health outcomes so that all residents experience the same health care outcomes A reduction in excess winter deaths of 50% A reduction in unplanned admissions to hospital for people with Long Term Conditions of 50%
Legal and/or Risk Enable the CCG to meet its statutory responsibilities for commissioning quality; reduce and mitigate risks to the organisation and to patients.
CQC Enable the CCG to meet commissioner responsibilities for CQC Essential Standards for Health including that providers have up to date registration with the CQC.
Patient Safety Integral element of the Quality Strategy which describes the systems that will be deployed to “keep patients safe.”
Patient Engagement Integral element of the Quality Strategy which describes how the CCG will use patient engagement and experience to form the intelligence essential for effective and safe commissioning
Financial Following the baseline assessment of the CCG structure, systems and processes there maybe implications for additional funding.
Sustainability A three year plan which will be refreshed on an annual basis through the annual Quality Improvement Plan
Workforce / Training Organisational Development Plan for the CCG is in place to develop members, staff and leadership.
Item No: Enc:
The SAS CCG Governing Board is asked to: Note the key quality and safety issues in the report and actions taken to improve quality and reduce risk.
KEY REQUIREMENTS Yes No Not Applicable
Has a quality impact assessment been undertaken?
Has an equality impact assessment been undertaken?
Has a privacy impact assessment been completed?
Have partners / public been involved in design?
Are partners / public involved in implementation?
Are partners / public involved in evaluation?
January  2015  Main Issues/Top Themes For Providers 
1.  Mid Staffordshire Hospital Foundation Trust (MSHFT)   a. Cancellation of UHNM CQRM and County Internal Quality Committee    b. Unannounced visit on 14th January 2015    c. Mortality Review of Backlog 
2.  University Hospital of North Midlands  (UHNM) – County Hospital   a. Cancellation of UHNM CQRM and County Internal Quality Committee    b. Unannounced visit on 14th January 2015    c. Mortality Review – new back log   University Hospital of North Midlands (UHNM) – Royal Stoke 
  a. Cancellation of UHNM CQRM    b. Consecutive Cancellations of County Internal Quality Committee    c. Never Event Update    d. 12 hour trolley breaches    e. Unannounced visit update 
3.  Staffordshire Stoke On Trent Partnership Trust (SSOTPT)      a. No major issues  
4.  South Staffordshire Shropshire Healthcare Foundation Trust (SSSHFT)    a. Delayed Transfers of Care    b. CRHT Four Hourly Responses
5.  Burton Hospital Foundation Trust (BHFT)    a. Monitor Update     b. Never Event    c. Infection Control 
6.  Royal Wolverhampton Hospital Trust (RWHT)     a.  CQC   RTT (Referral to Treat) 
  b.   Cancer waiting times update  7.  Walsall Hospital Trust (WHT) 
  a. Cancer 62 day Referral to Treatment (RTT)    b. Never Event  8.  British Pregnancy Advisory Service (BPAS) 
  a. Reporting timescales  9.  Hospices 
  a. Reporting styles    b. DNAR paperwork 
10.  Safe Guarding Reports      a. Quarterly report to Quality Committee 
12.  Nursing Home Quality Assurance (NHQA) Update    a. Quarterly report to Quality Committee
13.  BADGER (OOH)    a. No issues 
14.  111 Service     a. KPIs 
University Hospital of North Midlands – County Hospital  MAIN ISSUES FOR PROVIDERS 
Cancellation of UHNM CQRM and County Internal Quality Committee  The first UHNM CQRM post transfer was cancelled along with the County Internal Quality Committee which has now  been cancelled on 3 consecutive occasions due to hospital pressures and timetabling. The dates are to be rearranged  and a member of the CCG is to attend. The CCG has raised this as a concern with the lead commissioners. However  this has been mitigated by this CCG having conducted two unannounced visits to County Hospital post transfer of  services to provide additional assurance and have received a separate Quality Assurance Report for County.   
Unannounced visit on 14th January 2015  An unannounced visit took place due to the deteriorating A&E performance and to scrutinise the arrangements for  surge  beds.  The  visit  focused  on  issues  relating  to  bed management,  staffing,  discharge  arrangements  and  risk  management. There were no serious  issued although there was a concern over the number of vacancies although  this had been mitigated by the use of bank and  long standing agency staff. The staffing  issues are monitored on a  daily basis.      Mortality Review – new back log   
  Total number of overdue (3 months) mortality reviews      2014
  End Apr  End May  End Jun 14/07 05/08 20/08 03/09 23/09  06/10 07/11 Medicine  82  48  36  33  12  4  21  19  33  40 
Surgery  18  15  13  13  9  2  12  12  12  6 
Total  100  63  49  46  21  6  33  31  45  46
  The mortality back log will be monitored through the Internal County Hospital Mortality group which the CCG Clinical  lead attends.  There is to be a meeting scheduled for early January 2015.      Family and Friends Test (FFT)   
Mid Staffordshire Foundation Hospital Trust MAIN ISSUES FOR PROVIDERS 
Final CQRM  In November  a CQRM  took place  to  review  the  final  contractual  submission of data  covering October 2014.   All  actions were either closed or allocated to the new Providers.  The back log of mortality reviews are being addressed  by UHNM who have committed to completing the backlog by end of March and any ongoing Serious incident RCAs  were allocated respectively to Wolverhampton or UHNM.    The dissolution of MSFT occurred on 31st October 2014 and the ownership of the services was transferred to RWT  and UHNM  (previously known as UHNS)  in  line with the TSA plan.   The Stafford site of UHNM  (now known as the  “The  County Hospital”) will  be  reported within  the  ‘County’  section  of  this  report  and  the  Cannock  site will  be  reported within the ‘Cannock’ site section.   
  Eliminating Mixed Sex  No breaches for November 2014    Complaints  A total of 8 complaints were reported for the month of November.  
  Out of a  total of 26 Serious  Incidents  reported  in December at UHNM, 2 Serious  Incidents appertained  to County  Hospital of which were Intrauterine deaths.           
      Intrauterine Deaths  There has been 3 intrauterine deaths over a 2 month (October & November) period at the  County site.  These are being fully investigated via an RCA.  It was identified there was a need to have a consistent  definition for recording an intrauterine death across Staffordshire to be able to make meaningful comparisons. It is  noted that the women concerned would not have met the criteria for delivery at the MLU 
F & F Inpatient Percentage  Recommended  95  96  96  95  92  97  94 
F & F Inpatient Response Rate (%)  31.38  33.53  30.64  25.7  36.17  37.08  46.10  F & F  A & E Percentage  Recommended  91  95  86  92  83  93  94 
F & F A & E Response Rate (%)  22.6  19.6  14.6  21.8  30.0  14.2  7.1 
F & F  Maternity  (Birth) Percentage  Recommended  96  97  97  94  100  98  96 
F & F  Maternity Response Rate (%)  31.4  38.2  10.0  23.9  14.5  42.3  19.1 
University Hospital  of North Midlands (UHNM) – Royal Stoke site  REGULATORS INVOLVEMENT AND ISSUES 
No issues reported this month  
Never Event Update Naso Gastric Tube update  The RCA has been signed off at the December 2014 CQRM.   An action plan  including an ongoing audit programme  which will be shared with Commissioners.    12 Hour Trolley Breaches  During August to November 2014, the pressures on patient  flow within UHNM have resulted  in delays  in patients  being admitted via A&E and in 12 hours breaches. The number of breaches has risen considerably and is a cause for  concern.  
August  2  September  4 
October – 23 (awaiting confirmation)  November – 20 
A previous review of trolley breaches which occurred in September identified that there was a higher than expected  number of admissions which impacted on the availability of cubicles in A&E.    A contract query has been raised in November 2014 against the low performance in A & E.    Root Cause Analysis (RCA's) were undertaken for all events which  identified that there was a high demand for side  rooms due to increased numbers of patients attending with infection control issues and a reduction in the numbers  of beds available due to wards being closed both internally and within the Community, again due to infection control  issues. Actions were identified as follows:    Review of escalation plan  to be undertaken  Infection control processes  to be  reviewed  to  include  side  room 
audits, protocol for the cohorting of patients and infection control presence at daily bed meetings.  The RCA's will be presented to the Trust's Quality & Safety Forum and the Serious Incident Panel.  A Quality summit was held in December with the NTDA, with a further summit is being scheduled for January 15.    CCGs are currently in the process of producing an internal process/flowchart for the management of RCAs following  trolley breaches to provide staff on with clarity around this process. UHNM have provided their internal audit results  on this process to the December CQRM which will be incorporated within the CCG internal process.    Unannounced Visit on 6th January to UHNM   An unannounced visit was made to A&E by the lead commissioners.  Although the A&E was busy, it was evident that  patients The staff felt supported by the Trust in regards solutions following escalation and patients praised the staff  in A & E.    It was  noted  that  staff  sickness  had  increased  over  December  and  January;  however,  this was  anticipated  and  managed.  Patient numbers and acuity are reviewed by the Director of Nursing and Associate Chief Nurses. Staffing  ratios are adjusted accordingly to maintain 96% of planned staffing.   
MRSA/ Clostridium difficile/ Outbreaks and Serious Incidents 
  2014  UHNS  Target  Trend  Apr  May  Jun  Jul  Aug  Sep  Oct  Nov  YTD 
MRSA bacteraemia  There have been no cases of MRSA in November 2014.    Clostridium difficile Infection  There has been 1 Trust apportioned Clostridium difficile cases identified in November 2014. (County Site)    Closures  There were seven ward areas closed in November 2014 due to D&V/Norovirus, 65 patients and 19 staff have been  affected on the Stoke Site and no closures on the County Site   
Family and Friends Test (FFT)   UHNM  Sept  Oct  UHNM  Royal Stoke  RWHT  BHFT  WHT 
F & F Inpatient Percentage Rec.  95  96  96  97  92  97  94  F & F Inpatient Response Rate (%)  31.38  33.53  30.64  31.95  36.17  37.08  46.10  F & F  A & E Percentage Rec.  91  95  86  82  83  93  94  F & F A & E Response Rate (%)  22.6  19.6  14.6  12.4  30.0  14.2  7.1  F & F  Maternity  (Birth) Percentage Rec.  96  97  97  100  100  98  96  F & F  Maternity Response Rate (%)  31.4  38.2  10.0  6.3  14.5  42.3  19.1 
There is a significant increase in the Family and Friends rates.  This is a result of a change to the methodology for reporting in response to National Guidance.  The  impact of this is that there will be an increase in all scores. 
Complaints  During November 2014, there has been 70 formal complaints, which is a slight decrease from 73 in October 2014.    Eliminating Mixed Sex Accommodation  No breaches for November 2014 
Serious Incidents  UHNM’s SI’s have been split by site, Royal Stoke reported 24 and County Hospital reported 2.   
  Delayed Diagnosis  UHNM have reported a serious  incident of a delayed diagnosis where the patient died. This  is  subject to an RCA and it is not known yet whether the delay in diagnosis was a significant factor.    
November 2014  December 2014  Maternity Services  Unexpected admission to NICU (neonatal intensive 
care unit) x 2  Delayed Diagnosis x 1 
Other – Potential media attention x 1  Maternity Services  Intrapartum death x 1 
Slips/Trips/Falls x 7  Maternity Services  Unexpected admission to NICU (neonatal  intensive care unit) x 2 
Ward/Unit Closure x 1  Pressure Ulcer Grade 3 x 14 
C’Diff x 1  Slips/Trips/Falls x 5 
Pressure Ulcers grade 3 x 2  Ward Closure 1 
Awaiting CQC formal report on unannounced visit reported in October.  
District Nursing Update.  Awaiting outcome of the meeting of CCG and Trust operational group.  
      2014  SSOTP  Target  Trend  Apr  May  Jun  Jul  Aug  Sep  Oct  Nov  YTD  MRSA 
Bacteraemia  0  =  0  0 0 0 0 0 1    1
C Difficile  8    0  1  0  3  1  2  0    7   
PATIENT EXPERIENCE  No further information available for October/November 2014 
  Complaints   No further information available for October/November 2014  In total:  The Trust received 31 complaints in October 2014, a slight decrease from 37 reported in September 2014.   
2014  A  M  J  Q1  J  A  S  Q2   
Trust Overall  Feb  Mar  Apr  May  June  July  Aug  Sept     
No  Data 
F & F Score  72.12 70.61 70.32 69.79 73.57 68.31 68.66  71.31  Number of surveys received  2915 2419 2092 2189 2417 2977 1768  1969  Neighbourhood Area FFT Score  Feb Mar Apr May June July Aug  Sept  Stafford (27 users)*  66.66 81.40 59.26 76.47 82.26 78.87     Cannock (28) *  88.99 100  75  87.50 70.00 92.86     *Data extracted from South Community Teams Dashboard  
November 2014  December 2014  Pressure Ulcer Grade 3 x 11  7 South 
1 Burton  3 North 
Child Serious Injury   Unknown 
Attempted Suicide by Inpatient (not in receipt) x 1   1 South Pressure Ulcer Grade 3 13 North 2 South 
Ward Closure x 3  3 North  Pressure Ulcer Grade 4  2 North 
Death in Custody x 1  1 South  Slips/Trips/Falls x 2   1 South  1 North 
Suicide x 1  1 South Unexpected Death of Inpatient (not in receipt  1 North
Slips/Trips/Falls x 4  4 North     
No issues reported  this month 
Delayed Transfer of Care – Total of 18 delayed discharges of which 2  related  to East Staffordshire CCG and 6  to  South East Staffordshire and Seisdon CCG. The  last CQRM held  in December agreed  to  formulate a  sub Task and  Finish Group to undertake a focused piece of work. Meeting has been arranged for the end of January 2015.     Crisis Resolution Home Team  Four Hourly Responses:  
East  5 breaches for relating to service users not being available, all contacted by phone, 3 cold calls to addresses.   Of which, 2 declined  input, 1 continually cancelled appointments, 2 had police safe and well check carried out, of  which 1 has now declined to engage with the service.       West    3  breaches  relating  to  service  user  requested  appointment  the  following morning  following  discharge.  1  service user failed to keep assessment appointment and CRHT did a spot check to the home, but service user was  discharged  following  lack of engagement with  team. 1 service user discharged  from A & E prior  to being  seen by  CRHT and was later returned to A & E by Police and the service user requested to see CRHT later.    
    2014  SSSFT  Target  Trend  Apr  May  Jun  Jul  Aug  Sep  Oct  Nov  YTD 
MRSA Bacteraemia  0  =  0 0 0 0 0 0 0  0 0 C Difficile  8    0 1 0 3 0 0 0  0 4
  MRSA/ Clostridium difficile/ Outbreaks and Serious Incidents  Darwin Centre (Children’s and Adolescent Mental Health) which was closed for 4 days.  CCG Head of Infection  Prevention traced the index case back to a member of staff who returned to work within the 48 hours of being  symptomatic.  Action Plan and reminder to staff on return to work Policy in place.   
Complaints  Complaints for Q1 were 28.  Q2 report has not been published. The top three categories were: 
1. Clinical Treatment   2. Communication and information for patients   3. Attitude of staff  
  Eliminating Mixed Sex Accommodation   The Trust reported no breaches in November 2014.   
Serious Incidents (SIs)  The number of SIs reported to commissioners for December 2014 was 7, a slight increase from November of 6.   
November 2014  December 2014  Suspected Suicide x 3  Unexpected Death (general) x 4  Safeguarding Vulnerable  Adult x 1  Suspected suicide x 3  Serious Self Inflected Injury Outpatient x 1    
Monitor Regulatory Updates – confirmed that the Trust were still subject to Enforcement Action and subject to  Special Measures from the Keogh review. They have been rated as having an elevated risk for Patient safety  incidents, Mortality, Audit and Partner Sections.    
Never Event – Retained foreign object  This was a retained foreign object relating to maternity patient, which is being investigated     
  MRSA  There were 0 reports of Trust apportioned MRSA Bacteraemia during November 2014.  
Clostridium difficile   There were 2 reports of Clostridium difficile from Burton Hospitals NHS Foundation Trust during November 2014.  Therefore, the Trust had 16 cases against an annual objective of 15. Only 1 of these cases was avoidable.  A quality  summit took place, with attendance from Public Health England and the Area Team; BHFT presented all of the  actions they had taken to reduce C.diff level, which included enlisting the support of the Area Team to address  inappropriate prescribing in Primary Care.    Outbreaks and Serious Incidents  There have been a number of outbreaks due to diarrhoea and vomiting and to norovirus which has resulted in the  closure of bed bays, 16 patients and 1 member of staff have been affected.   
            F & F Inpatient Score  95 96 97 96  92  94 F & F Inpatient Response Rate (%)  31.38  33.53  37.08  30.64  36.17  46.10  F & F Score  A & E  91  95  93  86  83  94  F & F  A & E Response Rate (%)  22.6 19.6 14.2 14.6  30.0 7.1 F & F Score – maternity  96  97  98  97  100  96  F & F  Maternity Response Rate (%)  31.4  38.2  42.3  10.0  14.5  19.1 
The number of formal complaint received in November 2014 reduced to 20. This is a 58% (48) reduction from  2013/14 and 57% (47) reduction from 2012/13.     Medicine and Surgery both received 9 complaints each and Community Medicine received 2 formal complaints.   The highest complaint theme for November is medical care & treatment within the surgical division, communication  & information is the highest complaint theme for medicine.     The Trust has selfreferred 1 case to the Parliamentary & Health Service Ombudsman (PHSO). Top 5 themes are: 
1. Communication/Information   2. Medical Care and Treatment   3. Nursing Care & Treatment   4. Attitude of Staff   5. Medication  
    2014  Burton  Target  Trend  Apr May Jun Jul Aug Sep Oct  Nov  YTD
MRSA Bacteraemia  0  =  1  0  0  1  0  0  0  0    2  C Difficile  15   2 1 6 4 0 0 1  2  16
Serious Incidents (SIs)   The number of SIs reported for December 2014 was 7, a slight decrease from 10 reported in November 2014.  There  have been 3 falls reported as serious incidents and any trends or issues arising from these will be monitored and  reported through the BHT CQRM.    
November 2014  December 2014  Premature Discharge x 1  Communication Issue x 1 
Royal Wolverhampton Hospital Trust (RWT)  REGULATORS INVOLVMENT AND ISSUES 
NHS England and Trust Development Authority (TDA) are commencing a process to validate all Trusts Nationally  in  relation to RTT data. This will commence within RWT the first week in January 2015 and will take approximately 4/5  weeks. RWT have  reported  they  are  confident  that  systems  are  in place  regarding governance and  feel  they  are  ahead of trajectory in terms of the improvement plan agreed with the TDA.   
Cancer Waiting Times – Update   The Trust has been experiencing problems in compliance against the national cancer waiting Times Targets. The  particular areas of concern are the 31 day subsequent surgery target (94%) and the 62 day referral to treatment  compliance against the national target (85%). The Trust has submitted a Cancer Recovery Plan and an RTT Remedial  Action Plan.     RTT: The Admitted target was not achieved and Specialty level for the targets has not been achieved this is a  deliberate move in order to treat as many breach patients as possible and to reduce the overall backlog for the Trust  (this has been agreed with the Commissioners and the TDA).    Emergency Department: A&E continues to see increasing numbers with attendances in November 8.92% higher  than the same period last year this equates to an additional 851 attendances.   There were no patients who breached the 12 hour target during the month.    Cancelled Elective Operations   70 operations were cancelled during November. A root cause analysis continues to be undertaken for every  cancelled operation for nonmedical reasons and continues to be reviewed weekly at the Divisional Managers  meeting. 78.6% of the cancellations in month were due to bed pressures. There was 1 cancelled operation at  Cannock Chase Hospital (CCH) in November. – All readmitted within 28 days.       
      2014  RWT  Target  Trend  Apr  May  Jun  Jul  Aug  Sep  Oct  Nov  YTD 
Clostridium Difficile (C Diff) – Target 39 
C.diff rates have remained stable at 4 for October and November 2014, however this still exceeds the trajectory of 3.   
Family and Friend Test (FFT)    
  There  is a significant  increase  in the Family and Friends rates.   This  is a result of a change to the methodology for  reporting in response to National Guidance.  The impact of this is that there will be an increase in all scores.    Complaints  There have been 30 complaints received in November 2014.  Complaints audit action plan has now been  implemented.    Eliminating Mixed Sex Accommodation  No breaches reported in November 2014. 
Serious Incidents   The number of incidents in November is 25. Eight were pressure ulcers all of which were hospital acquired.     
October 2014  November 2014  Pressure ulcer Grade 3 Hospital acquired   x 1  Pressure ulcer Grade 3 Hospital Acquired x 8  Unexpected death x 2  Ward closure x1 Attempted suicide of inpatient (not in receipt) x 1 Slip, Trip, Fall x 5 Slip, trip, fall x 9  Pressure Ulcer Grade 3 Community x 6  Surgical Error x 1  Pressure Ulcer Grade 4 Community x 1  Pressure ulcers Grade 3 community acquired x 3 Confidentiality Incidents x 4 Pressure ulcers Grade 4 community acquired x 1    VTE death x 1   
Health Acquired infection x 1    Confidentiality incidents x 1 
New  Cross 
Care Quality Commission (CQC) Intelligent Monitoring Report (DRAFT) July 2014   CQC have highlighted a high risk in relation to Referral to Treatment (RTT) targets and Walsall Healthcare NHS Trust  (WHT) has submitted a detailed  improvement plan  relating  to Outpatients, Diagnostic Waits and RTT.  It has been  recognised  that  the  impact  of  the  new  patient  administration  system  and  data  quality  issues  are  affecting  the  accurate reporting  in relation to RTT.   However, the Commissioners are being vigilant with their monitoring of the  Providers progress against action plan to reduce the RTT.  Monitor Framework  Automatic override to red due to A&E, 18 Weeks RTT and Cancer.  NTDA Performance Monitoring – indicates the Trust is rated as having concerns regarding performance as requiring  investigation   
MAIN ISSUES FOR PROVIDER  As a result of the impact of emergency pressures, increases in elective demand and difficulties following the launch  of  the new Patient Administration System,  the Trust  faces significant difficulties  in delivering  the national elective  access standards, especially the 18 week standards.  As a result of the implementation of the new Patient Administration System, the Trust has identified significant data  quality issues and they are working with the Trust Development Authority (TDA) and Walsall CCG to validate the data  available.    Contractual Notices  remain open  for  18 weeks RTT, Cancer  Services, A&E  4 hour wait,  Emergency  readmissions.  Walsall CCG issued a Contract Query Notice in October 2014, and requested a Remedial Action Plan for not achieving  the 6 week diagnostic target in July and August.     Never Event  1 Never Event has been reported  in October 2014. This  is the first never event reported since November 2013 and  relates to a patient who had a retained swab which was not  identified until some months  later where the patient  required extensive surgery to address the affects. RCA completed and action plan devised.    18 Weeks  The  Trust  is working with Walsall  CCG  (WCCG)  and  the  Trust  Development  Authority  to  recover  the  18 weeks  position. Collaborative working is promoted. 
Infection Control 
WHT  Target Trend  Apr May Jun Jul Aug Sep  Oct  Nov YTD MRSA Bacteraemia  0  =  0  0  0  0  0  0  0  0  0 
There have been no reported cases of MRSA Bacteraemia in the last 2 Quarters. There has been no case of C.difficile  reported in November.  Year to date total is 12 against a target of 28.   
There  is a significant  increase  in the Family and Friends rates.   This  is a result of a change to the methodology  for  reporting in response to National Guidance.  The impact of this is that there will be an increase in all scores.    Complaints     There  has been  an  increase  in  formal  complaints  received  during November, which were  37  compared  to  32  in  October. Clinical care/treatment/assessment is again the main theme (22) for November 2014.  Appointments were  the second highest category (6).  There are also 5 complaints relating to staffing     Eliminating Mixed Sex Accommodation  Nil reported in November 2014.   
PATIENT SAFETY    Serious Incidents   There were 3 SI’s reported to Walsall CCG in November, which is a significant decrease compared to the 13 reported  in October.                           
Walsall Hospital Trust  Sept Oct Nov BHFT  
      November  F & F Inpatient Score  87  92  94  97  96  92  F & F Inpatient Response Rate (%)  46.18 58.93 46.10 37.08 30.64  36.17 F & F Score  A & E  92  90  94  93  86  83  F & F  A & E Response Rate (%)  5.1  4.2  7.1  14.2  14.6  30.0  F & F Score – Maternity  97  87  96  98  97  100  F & F  Maternity Response Rate (%)  8.7 10.9 19.1  42.3  10.0  14.5 
October 2014  November 2014  Grade 4 Community Acquired Pressure Ulcers x 1 Grade 4 Community Acquired Pressure Ulcers x 1  Grade 3 Community Acquired Pressure Ulcers x 3  Grade 3 Community Acquired Pressure Ulcers x 1  Never Event x 1  Pressure Ulcer Grade 3 (Hospital) x 1  Safeguarding Children x 2  Intrauterine death x 1    Abscond x 1    Suboptimal care x 1    Patient Fall x 1 
Nil reported for this month 
Timescale  for  reporting  information  to  the CCG  is not  in  line with National Contract and a Contract Variation has  been agreed for BPAS to provide their reports and information requirements on a 4 monthly basis during 2014/2015. This issue has been discussed at CQRM due to the impact it has on the contractual and finance processes. However,  BPAS confirmed in November CQRM that it will not be possible to change this as they have a requirement to report  to 160 CCGs at present.  Quality Dashboard 
  A Hospice CQRM was held in December 2014. Our Hospices provide interesting and useful reports however the style  and approach varies considerable. Commissioners have provided hospices with a suggested dashboard and report  summary framework. Hospices will be piloting these in Q3 14/15 and using for Q4 onwards.  Hospices have been given a simple template to use to report clinical incidents that arise in other providers.    Medication supplier changes  Hospices remain concerned that the changes to the wholesale supplier licencing system for controlled drugs will  have an adverse impact on quality. Examples given were that out of hours urgently needed pain relief medication  might take several hours to be delivered for example from Birmingham. Hospices were concerned that once existing  contracts with supplier expire there may be a cost pressure. This has been escalated to Area Team previously and  one of the hospices has noted that it is a national issue.    DNAR (Do Not Attempt Resuscitation)  Katherine House Hospice commented that it experiences difficulties with sharing Do Not Attempt Resuscitation  (DNAR) Orders with GPs in the Stafford Area. This Hospice uses its own paperwork which complies with national  guidelines. Other hospices are not reporting similar problems.  All hospices confirmed that they had completed nationally recommended medicines security audits (developed in  response to serious incidents in Stockport) and there were no outstanding shortfalls.  St Giles Hospice raised the issue that District nurses are the key workers for end of life services but they receive a  significant number of referrals for patients who ae not on a district nursing case load. The CCG has requested further  information around this.    The next Hospice CQRM meeting will focus on Children’s hospice services and on end of life care plans.   
BADGER (Birmingham and District General Emergency Rooms)  REGULATORS INVOLVEMENT AND ISSUES 
Nil reported for this month   
MAIN ISSUES FOR PROVIDER  No major issues to report 
Friends & Family Test (FFT)  
  Complaints  1 complaint received – UTI Diabetes – not referred, this is currently under investigation.   
BADGER  July/Aug/Sept  F & F Would you recommend this service  873 responded yes out of 977 feedback cards 
Significant Events and Untoward Incidents  No SI’s reported for October 2014.  Two incidents were raised in relation to the Prison Service. 
Head laceration no  visit undertaken  
Under  investigation 
Prison  security  informed  clinician  the nurse had gone home &  no information available    
Call  handler  followed  protocol  for  new  healthcare  professional line instead of prison protocol.  
closed Training  for  call&