Quality ReportPrepared for NHS Greenwich CCG Governing Body

September 2014

Monthly Quality ReportPrepared by Maggie Aiken

Associate Director of Quality & Governance

Presented by Nicola MooreDirector of Integrated Governance

Refers to Q.1 & 2 and data currently available for month of report.

Contents

1. Integrated Quality Dashboard 3

2. Clinical Quality Review Group Update 4

3. Serious Incidents 6

4. Safeguarding Children 12

5. Safeguarding Adults 13

6. Infection Control & Prevention 20

7. Glossary of Terms 20

September 2014 Quality Report 2

Contributions are gratefully acknowledged from: Simon Cheek- Informatics Team, Diane Goodenough – Patient Safety Manager, PaulaHill & Evonne Harding – Children & Adult Safeguarding, NHS GCCG; Ike Philip – SELCSU; LGT & Oxleas NHS FT Governance Leads; DrMohammed Tamim – Health Protection Manager RBG PH.

2014-15

Q1 Q2 Q1 Q2 Q1 Q2 Q1 Q2 Q1 Q2

267 115 84 7 178 71 33

31% 37% 25%

0 0 0 0 11 1 0 0 0 0

35 19 18 7 31

0 1 0 0

0 0 1 0

7 18 24 2

Grade 1

Grade 2 63

Grade 3 0 21

Grade 4 0 0

Harm Free 87.53% #DIV/0! 90.99% 88.18% 95.93% 95.92% 91.33% 90.24% 92.24% 94.84%

Pressure Ulcers 8.36% #DIV/0! 7.51% 9.82% 3.01% 3.44% 6.57% 7.32% 5.38% 3.81%

Falls 1.94% #DIV/0! 0.53% 0.73% 0.30% 0.15% 0.45% 0.67% 0.74% 0.22%

Catheters & UTI 2.62% #DIV/0! 1.23% 1.27% 0.70% 0.29% 1.60% 2.00% 1.53% 1.12%

VTE 1.10% #DIV/0! 0.13% 0.18% 0.17% 0.20% 0.49% 0.44% 0.37% 0.22%

0 0 0 2 0

15.70% 15.85% 10.47% 10.70%

2.90% 2.20%

3.65% 3.10% 3.57% 3.20%

90% 95.54% 96.56% 97.78% 96.05%

<1 0.99

0.040333

RTT 18 Weeks Admitted 90% 92.73% 92.73% 90.63% 96.00% 76.30% 90.19%

Non-admitted 95% 97.96% 100.00% 95.44% 91.50% 95.88% 97.50%

Incomplete 92% 92.01% 100.00% 92.64% 92.90% 92.25% 96.61%

95% 88.28% 89.56% 99.91% 96.80% 96.31% 88.95% 90.81% 95.76% 95.10%

112 115 403 45

PROVISIONAL DATA ONLY

8058

PEAT: Food

Mixed Sex Accommodation

DARTFORD &

GRAVESHAM

Patient Throughput

MEASURE

Tra

jecto

ry OXLEAS - MH

& COMMUNITYGUY'S KINGS

LEWISHAM &

GREENWICH

Staff Retention Rate

Patient Voice Comments

Ombudsman's Rating

5

Contract Value

Safe

ty

Number Incidents Reported

Serious Incidents

Never Events

Medical Errors

MRSA

C.Diff

Pressure Ulcers

Safety

Thermometer

Idicators

Clinical Negligence Scheme Payments

Rule 43 Coroner Reports

PatientExperience

Inpatient Survey

PEAT: Privacy & Dignity

Complaints

PEAT: Environment

Complaint Response Times

Friends & Family Test

Work

forc

e Vacancy Rate

Agency Spend (£'000s)

Sickness Rate

Leaders

hip

&

Govern

ance Monitor Governance Rating

Monitor Financial Rating

Incident Reporting Culture

CQC Outcomes

Clin

ical&

Opera

tional

Effectiveness

VTE (Risk Assessment Compliance)

Mortality Rate (SHMI)

Mortality Rate (HSMR)

Readmissions

A&E Waiting times

Cancelled Operations

2. Clinical Quality Review Group (CQRG)UpdateThe Lewisham & Greenwich NHS TrustCQRG was held on 21ST August 2014

Patient SafetyFalls resulting in major harm: There were 2 falls recorded in May resulting in majorharm – one fractured neck of femur; one fractured neck of femur and patella. Bothoccurred at QEH site. (See SI section for detailed information on Sis and NeverEvents)

Clinical EffectivenessC.Difficile: The CQRG received an update with regards to themes, trends identifiedfrom cases of Trust attributable Clostridium Difficile. As of March 2014 the Trustended the year with a breach of both site targets. Root causes includedinappropriate antibiotics; multiple, factors (prescribing, bowel management,sampling) . The patients who have developed Trust attributable C.diff are in linewith what is nationally recognised as the most significant risk factors (elderly withco-morbidities). The Trust has worked closely with NHS GCCG and RBG PH toensure close working across acute and community and support education andstandardisation of approach to issues such as GP discharge letters and patientinformation. The Trust and NHS GCCG will participate in the SEL C.diff reviewpanel. This is being kept under close scrutiny by the CQRG.NICE Compliance: The bi-annual NICE Annual Report was received.NICE compliance with technology appraisals reported at 91.0% for LGT against thetarget of 100%. The Trust has undertaken a gap analysis of the 7 pieces of NICEtechnology appraisals for both UHL and QEH sites. NICE Interventional ProceduresGuidelines compliance reported at 88.0% for LGT against the target of 100% . Theclinical effectiveness team are working closely with Clinical Divisions to ensurecompliance assessment

Central Alerting System (CAS Alerts) – The CQRG received the Q.1. CAS report. TheTrust Risk Team monitors responses to alerts. These are reviewed and scrutinizedby the appropriate Trust Committee. All deadlines for CAS alerts have been met bythe Trust within this time period.

Patient ExperienceComplaints: The Trust is still facing challenges to meet time scales to resolveissues. The internal sign off process is being reviewed by the Trust. Surgery isparticularly challenged. The Trust has put in extra resources to manage complaints.Divisions have been asked to submit complaint handling action plans and provide atrajectory for achieving the 70% target which will be reviewed at the Sept CQRG.Friends and Family Test: LGT figures have improved since April. On the QEH sitethere is still a continued effort to increase the number of FFT returns beingcompleted on the inpatient wards. 5 / 17 wards achieved the Net Promoter Score(NPS) equal to or above 60. 6/17 wards achieved a return of higher than 30%. Onthe UHL site 6/14 wards achieved the NPS equal to or above 60. 13/14 wardsachieved a return rate above 30%. The QEH Patient Experience Team are workingto increase rates with inpatient wards. The Trust has been asked to present keylearning from feedback on FFT in November ‘14MaternityThe Marketing strategy continues. ‘Call the Midwife’ bus driving around theboroughs with midwives and maternity staff on board discussing service at LGT.Ongoing promotion to encourage direct access for booking.Total Caesarian section rate is reported at 27.6% for LGT against the target set of ator below 24%. The Trust is working to ensure that C-sections are minimised.

September 2014 Quality Report 4

The CQC Action Plan is monitoredthrough a Part 2 of the CQRG andincludes scrutiny from members of theTDA as well as CCG commissioners

• LGT are making good progress against their CQC ActionPlan having already achieved nearly 40% of their actionsby their end date at the end July ‘14.

• The CCG is assured on the governance and process ofescalation

2. Clinical Quality Review Group (CQRG)(continued)

Oxleas NHS FT (Q.1.)Patient Safety:Incident reporting continues to increase albeit at a slower pace thanthe previous year.There has been a slight dip in compliance with Level 3 SpecialistSafeguarding Children training and an action plan has been agreedto improve this 79.17% compliance in Q.1 compared to previousrate of 84.30% against the 80% target.

Clinical Effectiveness:Audit on NICE clinical audit on ‘Autism diagnosis in children andyoung people’ highlighted carried out by the Greenwich CommunityPaediatrics Team. The Pressure Ulcer RCA Summary Reportprovided an overview of the Oxleas pressure ulcer preventionstrategy.

Patient Experience:Oxleas NHS FT follow the CQC ‘ new start’ framework which asks ifservices provided are caring. Complaints during Q.1. have reducedin comparison to the same period during 2013/4. 37 complaintswere received in comparison to 57 recorded for 2013/4. 41%related to Adult Acute Mental Health Services; 8% to Older People’sMental Health Services; 41% to Adult Community Services and 10%to Children & Young Peoples Services.Friends & Family Tests (FFT ): All providers of mental health andcommunity health services must implement FFT by 1st Jan 2015.Oxleas aim to rollout FFT to all proposed service teams by 1st Jan2015. Oxleas NHS FT was an early implementer site for FFT.

Embedded Learning Event

NHS Greenwich CCGGovernance Leads attended anEmbedded Learning Event on‘Learning from an adolescentsuicide’ led by Dr Peter Jarrett,Clinical Lead for Patient Safetyat Oxleas NHS FT

This event was awarded aLevel 3 Safeguarding ChildrenStatus

September 2014 Quality Report 5

3. Serious Incidents

September 2014 Quality Report6

Site Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14GrandTotal

LGT - NursingHome 3 2 4 14 6 8 5 3 45LGT - QueenElizabeth 8 19 4 7 6 6 6 3 6 10 75LGT - UniversityHospitalLewisham 10 7 9 7 5 12 1 6 9 5 71

LGT Patient Home 7 4 15 43 12 37 20 8 3 4 153

Grand Total 28 32 32 71 29 63 32 20 18 19 344

Overall reporting trend by Lewisham and Greenwich NHS Trust (LGT)

Reporting trend by Lewisham and Greenwich NHS Trust (LGT) for Greenwich patientsonlySite Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14

GrandTotal

LGT - Nursing Home 4 1 4 2 2 13

LGT - Queen Elizabeth 5 4 3 3 4 4 5 2 1 6 37LGT - University HospitalLewisham 1 1 1 2 1 6

LGT Patient Home 5 13 6 20 9 4 57

Grand Total 6 4 9 21 11 28 16 8 3 7 113

3. Serious Incidents (continued)Reporting rates by Type of Incident by LGT for Greenwich patients

September 2014 Quality Report7

TYPE of SI Oct-13Nov-

13Dec-

13Jan-

14Feb-

14Mar-

14Apr-

14May-

14Jun-

14Jul-14

GrandTotal

Pressure Ulcer 3 (PU3) 1 3 5 1 1 2 0 2 2 17

Pressure Ulcer 4 (PU4) 2 0 0 0 0 0 0 1 3

Mat Services - Unexpected admission toNICU 1 1 1 1 1 5

Mat Services - Intrauterine death 1 1 1 3

Screening Issues 1 1 1 3

Surgical Error 1 1 1 3

Ambulance (General) 1 1 1 3

Unexpected death general 1 1 2

Other 1 1 2

Delayed Diagnosis 1 1 2

Hospital Equipment failure 1 1 2

C. Diff & Healthcare acquired infection(HCAI) 1 1 2

Mat Services - Mat unplanned admission toITU 2 2

Mat Services - Unexpected neonatal death 1 1

Unexpected Death of Inpatient (not inreceipt) 1 1

Hospital Transfer Issue 1 1

Child Death 1 1

Death in Custody 1 1

Communicable Disease and Infection Issue 1 1

3. Serious Incidents (continued)• As previously reported, LGT had reverted to reporting community

acquired pressure ulcers as their own SI’s rather than passing them on toOxleas. This was a transitional issue and now resolved. These incidentshave now been repatriated with Oxleas and the figures adjusted in thetable on Page 7.

• LGT have commenced a weekly pressure ulcer panel meeting to reviewcases from both sites to ensure learning and actions are implemented in atimely manner. The protocol was finalised at the end of May and was fullyimplemented in June.

• The Patient Safety Manager is working closely with the Patient Safety Leadat the QEH site to close outstanding serious incident reports. Report thatafter investigation do not constitute an serious incident are being checkedwith NHS England to ensure that the StEIS database reflects the mostupdated status.

• There were two falls resulting in fractures reported in May (both patientshave since recovered). These have been fully investigated but were notreported as a formal Serious Incidents. This raised questions as towhether falls resulting in fractures should constitute a formal SeriousIncident reportable to NHSE. Discussions are being held with NHSE as weconsult on their SI Policy.

September 2014 Quality Report8

3. Serious Incidents (continued)Overall reporting trend by Oxleas NHS Foundation Trust

September 2014 Quality Report9

Site Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Grand TotalOxleas NHS FoundationTrust 5 4 7 3 4 5 9 3 6 5 51

Oxleas Patient Home 9 5 5 13 10 10 6 12 8 8 86

Grand Total 14 9 12 16 14 15 15 15 14 13 137

Site Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14GrandTotal

Oxleas NHS FoundationTrust 5 4 7 3 4 5 9 3 6 5 51

Oxleas Patient Home 9 5 5 13 10 10 6 12 8 8 86

Grand Total 14 9 12 16 14 15 15 15 14 13 137

Reporting trend by Oxleas NHS Foundation Trust for Greenwich patients only

3. Serious Incidents (continued)Reporting rates by Type of incidents reported by Oxleas NHS Foundation Trust for Greenwich patients

September 2014 Quality Report10

TYPE of SI Oct-13Nov-

13Dec-

13Jan-

14Feb-

14Mar-

14Apr-

14May-

14Jun-

14Jul-14

GrandTotal

Pressure Ulcer 3 (PU3) 7 1 2 7 7 3 4 4 4 3 42

Unexpected Death of Inpatient (in receipt) 1 1 1 1 4

Attempted Suicide by Outpatient (in receipt) 1 1 2 4

Slip/Trip/Fall 1 1 1 3

Unexpected Death of Community patient (inreceipt) 1 1 2

Suicide by Outpatient (in receipt) 1 1 2

Unexpected Death of Outpatient (not inreceipt) 1 1 2

Suicide by Outpatient (not in receipt) 1 1

Unexpected Death of Outpatient (in receipt) 1 1

Attempted Homicide by Inpatient (in receipt) 1 1

Assault by Outpatient (in receipt) 1 1

Assault by Inpatient (in receipt) 1 1

Child Death 1 1

Pressure Ulcer 4 (PU4) 1 1

Serious Incident by Outpatient (in receipt) 1 1

Grand Total 10 3 6 9 9 6 7 7 5 5 67

3. Serious Incidents (continued)• Oxleas reported a total of 43 pressure ulcers from October 2013 to July 2014.

There were 42 reported Grade 3 pressure ulcers and 1 reported Grade 4pressure ulcer from the community for this time frame. It is thought thatthese figures may be lower than what it should be due to the change ofreporting from the QEH site as reported above.

• The Patient Safety Manager has worked closely with Oxleas to create a robustprotocol for reviewing all received CAPUs from LGT. This not only included theweekly CAPUs currently sent by LGT but CAPUs going back up to October 2013when LGT was formed. A protocol was finalised at the end of August. Thereview work for data back dated to October 2013 is due for completion bymid-September.

• Never Events

There were no never events reported for Greenwich patients from Q12014/15 to date. The never event on the Integrated Dashboard relates toanother CCG.

• Levels of reporting

While we have not seen a particular dip in the levels of reporting in the lastquarter, it is imperative we continue to encourage and promote a robust andopen reporting culture within our providers.

September 2014 Quality Report11

4. Safeguarding ChildrenGCCG Safeguarding Team Capacity UpdateThe CCG currently has two Designated Doctor posts; one for LookedAfter Children and one for Safeguarding Children (to be hosted byOxleas) following an unsuccessful recruitment process.Currently, we are being covered on an ad hoc basis by theDesignated Dr in Bromley who is providing supervision for the QENamed Doctors and supervision is being provided by theDesignated Doctor at Bexley for Oxleas Named Doctors.

One of our Designated Nurses for Safeguarding Children (0.5 wte)has recently retired and the remaining Designated Nurse is due toretire in October. After an unsuccessful recruitment process, theCCG will be contracting an interim Designate Nurse and seconding aNamed Nurse as a developmental opportunity towards a futureDesignate Nurse post.

Immunisations and information sharing and SafeguardingThe outcome of the recent immunisation survey was discussed atthe July Practice Managers meeting. In addition the Oxleas healthvisiting service are undertaking an audit of the Health VisitingService and whether they are receiving communication form GPs.The results of this audit will be shared at the next practicemanagers meeting. NHSE have agreed to include the need forinformation sharing between GP’s and Health Visitors in the new GPContract.

Domestic Violence and Early InterventionTo address the issue of DV the Barnardos, Amber pilot projectcontinues to offer early help to women. The project has beenhighly successful with over a 20% increase in the number ofreferrals made to the service in April to June. Barnardos haveappointed three new workers so that there will be a complete teamin place. The Team Leader has been visiting several practices acrossGreenwich to build relationships and promote the service. Abusiness case is currently being prepared with a view to upscalingthis to a full service across all GP practices, A&E and Maternityahead of formal procurement.

Multi Agency Safeguarding Hub (MASH)The Greenwich MASH became fully operational on 6th May 2014after a slow start it is reported to be working very well. The twohealth workers are now an integral part of the MASH team. TheAmber project visit the MASH weekly to share information.

Lewisham and Greenwich NHS Healthcare Trust (LGT)Due to promotion across LGT there was a vacancy for the full-timeBand 8a, Named Nurse for Safeguarding Children at QEH. This hasbeen successfully appointed to by the current full-time Band 7 whowill start in this role on the 8th September. The Band 7 has alsobeen recruited to and commences in September.All members of staff are now in receipt of safeguarding supervisionThe named doctor for safeguarding children is receiving hers fromthe Designated Doctor in Bromley until a Designated Doctor isappointed.Family Nurse Partnership are fully established and issues overaccess to records from the health visiting provider organisation(Oxleas) and their access to the FNP records have been resolved.

Oxleas NHS Foundation TrustThe safeguarding team now have a full establishment forsafeguarding children.The preparations for an impending CQC continue to be reviewed,updated and the staff briefed accordingly.

Looked after childrenA Band 6 has been appointed for the early years children on a oneyear fixed term appointment.A re audit of patient experience has been undertaken up to 31st

August t 2014. There has been an improvement in the numbers ofchildren placed by the Local Authority within 20 miles ofGreenwich. The Designated Nurse for LAC is leaving her post inOctober and plans are in place for her replacement.

Sept 2014 Quality Report12

NH6

Slide 12

NH6 What was the outcome - please include analysis.Nicola Havutcu, 16/09/2014

5. Safeguarding Adults

Joint Safeguarding ExecutiveMeeting held on 4th Sept 2014

• The Joint Safeguarding Children andAdults Executive Meeting was held on 4th

September 2014.

• There is a lot of movement in thesafeguarding workforce across the healtheconomy and this is being risk assessed bythe CCG with mitigating actions being putin place. This effects Oxleas as well as NHSGreenwich CCG.

• A new appointment has been made ofInterim Head of Adult Safeguarding; thepost covers both NHS Bexley and NHSGreenwich CCGs.

• The Interim Head of Adult Safeguarding isintroducing tools to determine whetherpressure ulcers are classified as asafeguarding incident (The Kensington &Chelsea Pressure Ulcer Tool)

• Arrangements are currently beingexplored in regard to support for theprovision of safeguarding training tomember practices.

September 2014 Quality Report 13

6. Quality Committee Infection control and HCAI briefing-September 2014

C.Difficile

Trajectory for 2014/15Trajectory for 2014/15

2014/15Total

April May June July August September October November

December January February March Total

No morethan 4 5 4 5 7 6 4 7 5 5 5 6 63

Actualnumber ofcases

2 5 8 5 6 26

Other HCAIMRSA- 1, MSSA 3 , E.coli 9

C diff –26 cases to date against trajectory of 25 of which 18 cases are community acquired

• Six cases in August of which 4 were Community acquired and two hospital acquired.• A reduction seen following the high numbers in June• In July all 5 cases were aged 65+, female , one case was a repeat infection,• Risk factors-80% had repeated antibiotic usage in the period preceding the C diff

infection 40% were on PPI

Main issues identified from C Diff RCAs to date :

• Over 90% of Royal Greenwich cases werecommunity acquired and between April to July66% were in QEH

• All cases appear to be single isolated cases.• Several cases have followed a month or two

behind a significant hospital infection• Significant prescribing of PPIs, usually long

term and often unable to confirm theindication

• Often associated with long term indwellingcatheter use – again where leg bags andovernight drainage bags are being used (meansbreaking the circuit more often) and inpatients with urinary tract infections.

• Antidiarrheal drug was used in one case• Antibiotic use – we have one case linked to

clindamycin – an antibiotic that is not one ofthose in the antibiotic guidelines –– very highrisk C.diff.

• Suggestions of Vancomycin resistance - willneed Medicines Management to review

Outstanding areas requiring attention:• Audit of Practice antibiotic formulary

compliance by Medicines Management froma quality perspective

• Understanding reasons for antibioticprescribing outliers

• Examination of increased usage of PPI

The Governing body is asked to:• Note the recommendation for CCG Clinical

lead to attend the IPPC meeting on arotating basis

• Support the delivery of a MedicinesManagement Action Plan

• Note that the CCG Infection ControlCommissioning Incentive schemecommenced in July

it is expected that this will provide anopportunity to discuss C Diff prevention andcontrol with each practice.

7. Glossary Of Terms

• BBGL – Bromley, Bexley, Greenwich & Lewisham• CAS – Central Alerting System• CAPU – Community Acquired Pressure Ulcer• CCG – Clinical Commissioning Group• C.diff – Clostridium Difficile• CIP – Cost Improvement Programme• CIS – Commissioning Incentive Scheme• CQC – Care Quality Commission• CQRG - Clinical Quality Review Group• CQUIN – Commissioning for quality and innovation• DoLS – Deprivation of Liberty Safeguards• FT – Foundation Trust• FFT – Friends & Family Test• HAPU – Hospital Acquired Pressure Ulcer• HCAI – Healthcare Acquired Infection• SHMI – Summary Hospital Level Mortality Indicator• HSCIC – Health & Social Care Information Centre

• LGT – Lewisham & Greenwich NHS Trust• SIs – Serious Incidents• MASH – Multi Agency Safeguarding Hub• MCA – Mental Capacity Act• PREVENT – part of CONTEST, the Governments

counter terrorism strategy . (Eliminating the risk ofindividuals becoming involved in terrorism)

• QIA – Quality Impact Assessment• MECC – Making Every Contact Count• NICE – National Institute for Health and Care

Excellence• QEH – Queen Elizabeth Hospital• PPI – Proton Pump Inhibitors (in C.diff

management)• RBG – Royal Borough of Greenwich• RCA – Root Cause Analysis

September 2014 Quality Report 22