PAPER F Performance and Outcomes Report - NHS Sheffield CCG US/CCG... · Performance, Quality and...

Performance, Quality and Outcomes Report: Position Statement

Governing Body meeting

F10 January 2019

Author(s) Jane Howcroft, Programme and Performance Assurance Manager Rachel Clewes, Senior Programme and Performance Analyst

Sponsor Directors Brian Hughes, Director of Commissioning and Performance Mandy Philbin, Chief Nurse

Purpose of Paper

To update Governing Body on key performance, quality and outcomes measures.

Key Issues

1. Areas of concern, which remain under review

A&E 4 hour waits: The proportion of Sheffield CCG’s adult patients admitted, transferred or discharged within 4 hours of arrival at Sheffield Teaching Hospitals NHS Foundation Trust’s (STHFT) A&E, continues to remain below the Constitutional standard of 95% and the interim improvement target of 90% for Quarter 3. The CCG will co-ordinate city wide escalation during the winter months, including pre-agreed actions for times when escalation is needed.

These actions include: an option for care home staff to get direct clinical advice via 111 in order to avoid unnecessary trips to hospital or admissions; a protocol is in place whereby if any if ambulance crews have capacity they are diverted to support discharge processes, and ensuring that all care homes are aware of the YAS Emergency Care Practitioner service to assess and treat the patient in situ.

Delayed Transfers of Care (DTOC):.A ‘delayed transfer of care’ occurs when a patient is ready to leave a hospital or similar care provider but is still occupying a bed. This issue remains a key priority for the CCG and our partners across the city, with additional capacity being created in a number of services, particularly those which enable patients to be transferred back home with support to regain independence.

Closure of the Hadfield Building at STH (Northern General site)

Building work on the Hadfield Building at the Northern General Hospital commenced in mid November. The work is necessary following some exploratory inspection work on the walls of the building, which prompted STH to seek advice from South Yorkshire Fire Service about fire prevention measures inside the walls.

The Fire Service advised that STH need to do further work on prevention measures within the walls and that this work should be undertaken as a priority. This advice is not due to any new sudden increased risk of a fire starting in the building; it is more concerned with fire protection measures inside the walls which would limit the impact of a fire.

The work will inevitably cause a level of disruption which cannot be avoided and following advice from the Fire Service patients and staff have been re-located.

1

During the period it will take to relocate patients, STH are also enhancing fire prevention and protection measures, such as onsite trained fire safety officers, regular checks and they will continue to have support from the fire service.

The beds usually located within the Hadfield Building have been opened in other parts of the STH estate, this means that there is no potential for any further capacity to be created over the winter period. The CCG is liaising closely with the Trust regarding how we manage the potential impact on both elective and unscheduled care.

2. Care Quality Commission (CQC) inspections in Sheffield

Sheffield Teaching Hospitals NHS Foundation Trust

The CQC undertook and inspection of STH this autumn and published their report in November; the Trust was again rated as “good” for the domains of safety, effectiveness, caring and a well-led organisation. STH was seen as “outstanding” in terms of being responsive to patients.

The Northern General hospital was rated as Good overall as both urgent and emergency care and end of life had improved. Responsiveness was outstanding at this site which was an improvement.

Sheffield Special Educational Needs and/or disabilities (SEND) Inspection

A separate briefing paper has been prepared for Governing Body on this topic by the CCG’s head of Commissioning for Children’s Services.

3. Performance and quality highlights

Diagnostics: STH delivered the 6 week waiting time standard for diagnostics in October, ahead of the date they were forecasting, having implemented speciality specific recovery plans, eg in echocardiography.

Elective referral to treatment times (RTT): The CCG again delivered the 18 week standard for the waiting times from referrals to treatment in October, as did both our local providers.

Health care associated infections: there were no MRSA bacteraemia infections in November.

Is your report for Approval / Consideration / Noting

Consideration

Recommendations / Action Required by Governing Body

The Governing Body is asked to discuss and note: Sheffield performance on delivery of the NHS Constitution Rights and Pledges Key issues relating to Quality, Safety and Patient Experience

2

Governing Body Assurance Framework

Which of the CCG’s objectives does this paper support?

1. To improve patient experience and access to care 2. To improve the quality and equality of healthcare in Sheffield

Specifically the risks:

2.1 Providers delivering poor quality care and not meeting quality targets

2.3 That the CCG fails to achieve Parity of Esteem for its citizens who experience mental health conditions, so reinforcing their health inequality and life expectancy

Are there any Resource Implications (including Financial, Staffing etc)?

Not applicable at this time

Have you carried out an Equality Impact Assessment and is it attached?

Please attach if completed. Please explain if not, why not No - none necessary

Have you involved patients, carers and the public in the preparation of the report?

It does not directly support this but as a public facing document is part of keeping the public informed.

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Performance, Quality & Outcomes Report

2018/19: Position statement using latest information

for the 10 January 2019 meeting of the Governing Body

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Highest Quality Healthcare NHS Constitution Measures Performance Dashboard

Performance Indicator Target

CCG

Quarterly

Q2 18/19

CCG Latest monthly

Position

CCG

Performance

against standard

(latest 6 months)*

Latest Provider Total Monthly Position

Sheffield

Teaching

Hospital

Sheffield

Children's

Hospital

Sheffield

Health &

Social Care

Yorkshire

Ambulance

Service * Mental Health CPA 7 day followup & Cancelled Operations (28 days) trend lines are using latest quarterly (not monthly) data.

Referral To Treatment

waiting times for non-urgent

consultant-led treatment

All patients wait less than 18 weeks for treatment to start 92% 94.25% Oct-18 92.55% 93.39%

No patients wait more than 52 weeks for treatment to start 0 1 Oct-18 0 0

Diagnostic test waiting

times

Patients wait 6 weeks or less from the date they were referred 99% 99.90% Oct-18 99.96% 99.50%

A&E Waits

Patients are admitted, transferred or discharged within 4 hours of arrival

at A&E 95% 90.14% 89.29% Nov-18 86.83% 97.04%

No patients wait more than 12 hours from decision to admit to

admission 0 0 Nov-18 0 0

Cancer Waits: From GP

Referral to First Outpatient

Appointment (YTD)

2 week (14 day) wait from referral with suspicion of cancer 93% 95.46% 95.45% Oct-18 95.64%

2 week (14 day) wait from referral with breast symptoms (cancer not

initially suspected) 93% 93.03% 94.34% Oct-18 94.64%

Cancer Waits: From

Diagnosis to Treatment

(YTD)

1 month (31 day) wait from referral with suspicion of cancer to first

treatment 96% 95.38% 95.78% Oct-18 93.42%

1 month (31 day) wait for second/subsequent treatment, where

treatment is anti-cancer drug regimen 98% 100.00% 100.00% Oct-18 100.00%


treatment is radiotherapy 94% 93.78% 93.62% Oct-18 94.03%


treatment is surgery 94% 93.33% 92.98% Oct-18 87.80%

Cancer Waits: From

Referral to First Treatment

(YTD)

2 month (62 day) wait from urgent GP referral 85% 82.24% 72.03% Oct-18 67.55%

2 month (62 day) wait from referral from an NHS screening service 90% 87.04% 86.67% Oct-18 88.52%

2 month (62 day) wait following a consultant's decision to upgrade the

priority of the patient

(85%

threshold) 86.05% 76.19% Oct-18 71.43%

Ambulance response times

Category 1 (life threatening) calls resulting in an emergency response

arriving within 7 minutes (average response time) 7 mins 7 mins 1 sec Nov-18 7 mins 1 sec

Category 2 (emergency) calls resulting in an emergency response

arriving within 18 minutes (average response time) 18 mins

20 mins 30

secs Nov-18

20 mins 30

secs

Category 3 (urgent) calls resulting in an emergency response arriving

within 120 minutes (90th percentile response time) 120 mins

118 mins 19

secs Nov-18

118 mins 19

secs

Category 4 (less urgent) calls resulting in an emergency response

arriving within 180 minutes (90th percentile response time) 180 mins

226 mins 51

secs Nov-18

226 mins 51

secs

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Information and Intelligence Team, NHS Sheffield CCG Page 1

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Apr

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Highest Quality Healthcare NHS Constitution Measures Performance Dashboard

Performance Indicator Target

CCG

Quarterly

Q2 18/19

CCG Latest monthly

Position

CCG

Performance

against standard

(latest 6 months)*

Latest Provider Total Monthly Position

Sheffield

Teaching

Hospital

Sheffield

Children's

Hospital

Sheffield

Health &

Social Care

Yorkshire

Ambulance

Service

Ambulance handover / crew

clear times

Ambulance Handover - reduction in the number of delays over 30

minutes in clinical handover of patients to A&E

Local

Reduction 6.93% Oct-18 13.26% 0.00% 6.93%

Ambulance Handover - reduction in the number of delays over 1 hour in

clinical handover of patients to A&E

Local

Reduction 0.87% Oct-18 0.55% 0.00% 0.87%

Crew Clear - reduction in the number of delays over 30 minutes from

clinical handover of patients to A&E to vehicle being ready for next call

Local

Reduction 3.07% Oct-18 3.42% 1.79% 3.07%

Crew Clear - reduction in the number of delays over 1 hour from clinical

handover of patients to A&E to vehicle being ready for next call

Local

Reduction 0.20% Oct-18 0.34% 0.00% 0.20%

Mixed Sex Accommodation

(MSA) breaches

Zero instances of mixed sex accommodation which are not in the

overall best interest of the patient 0 0 Oct-18 0 0 0

Cancelled Operations

Operations cancelled, on or after the day of admission, for non-clinical

reasons to be offered another date within 28 days

Local

Reduction 12

*

12 0

No urgent operation to be cancelled for a 2nd time or more Local

Reduction 2 Oct-18 2 0

Mental Health People under adult mental illness specialties on CPA (Care Plan

Approach) to be followed up within 7 days of discharge (YTD) 95% 88.52%

*

100.00%

Highest Quality Healthcare Mental Health / DTOC Measures Performance Dashboard

Early Intervention in

Psychosis (EIP)

Proportion of EIP patients seen in 2 weeks 53% 78.43% 75.00% Oct-18 100.00% 66.67%

Improved Access to

Psychological Therapies

(IAPT)

Number of patients receiving IAPT as a proportion of estimated need 4.8% (Qtr

target) 4.80% 1.61% Sep-18 1.64%

Proportion of IAPT patients moving to recovery 50.00% 49.47% 49.40% Sep-18 50.00%

Proportion of IAPT patients waiting 6 weeks or less from referral 75.00% 88.74% 89.66% Sep-18 88.76%

Proportion of IAPT patients waiting 18 weeks or less from referral 95.00% 99.01% 98.85% Sep-18 97.75%

Dementia Diagnosis Estimated rate of prevalence of people aged over 65 diagnosed with

dementia 71.5% 79.70% Nov-18

Delayed Transfers of Care

(DTOC)

Total number of delayed days (from acute and non-acute) when a

patient is ready for discharge but is still occupying a bed 4,306 (Qtr

target) 7,419 2,935 Oct-18 2,644 209

No individual provider targer for DTOC bed days

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Highest Quality Health Care NHS Constitution Measures Performance Dashboard: Actions

Area Action being taken Expected timeframe for

improvement

Action requested of

Governing Body

RTT 52 week For October, one patient was showing as waiting over 52 weeks – this is We will continue to monitor None

waits the same patient who was showing as a breach last month at Northern

Lincolnshire and Goole NHSFT (in ‘Other’ speciality). The Trust have

informed us that the patient was due to be treated on 14th November

2018. The treatment had been delayed due to capacity issues.

this patient until they have

been seen.

Diagnostic Diagnostic waits continue to be monitored through monthly Contract STH met the six week To endorse the approach of

Waits - STHFT Management Group (CMG) meetings; as can be seen, the Trust met the

required national standard in September and October, a month ahead of

the forecast trajectory.

There were only 2 patients waiting over 6 weeks at STH during October,

both in Echocardiography, this is in line with the recovery action plans

devised by STH. This success reflects significant effort on behalf of the

Trust.

standard in September and

October. The CCG will

continue to monitor, in order to

ensure that this improvement

is maintained.

monitoring STHFT achievement

of diagnostic waiting times and

any necessary mitigating

actions, through monthly PCMB

meetings with the Trust.

A & E Waits STH's performance in November was 86.8%, a decrease from the reported

October position of 89.4%. The interim target of 90% for Quarter 3 will not

be met, despite concerted efforts and additional staff. A wide range of

actions are being taken by the Trust, as part of their "Action 95" plan and a

series of local actions agreed across the city health and social care system

are being signed off by the Operational Resilience Group (a sub-group of

the UECTDB, chaired by the CCG) to help mitigate the impact of winter

pressures. STH's Trust Executives meet with A&E each month to monitor

progress on the detailed "Action 95" improvement plan, and the CCG

receives an update each week on progress of implementing the actions.

The Trust is implementing its

detailed Action Plan and is

working towards achieving the

interim performance target of

90% in Quarter 3, in line with

the NHS Improvement / NHS

England trajectory. Achieving

the 90% target presents a

challenge in the context of

winter pressures.

To continue to endorse the

CCG's ongoing monitoring of

STHFT's progress towards

achievement of the A&E

standard and the delivery of any

necessary mitigating actions, as

agreed through the Performance

Contract Management Board.

Cancer Waiting STH continues miss the delivery of the 31 and 62 day targets; this is due to The Cancer Alliance is To note the continued work

Times - 62 day the ongoing high volume of patients, particularly in Urology and the addressing the capacity and undertaken locally and across

waits complexity of treatment in Head and Neck cancer sites, and Urology.

As previously outlined, in Head and Neck, there are long term issues

relating to patient choice delays. Patients often need extra time to make

decisions around when considering complex surgery with life changing

consequences.

Increased referrals into Urology for prostate cancer continue and as

patients convert to surgical waiting lists the pressures on robotic capacity

at STHFT increase. Additional funding in the region will support current

planned activity but not address the robotic surgery capacity shortfall fully.

There is no clinical concern identified in regard to these waiting time

breaches.

In addition to the actions outlined in this report previously the Cancer

Alliance are leading an exercise to identify opportunities to increase activity

across all cancer sites to improve overall performance in quarter 4 and

associated funding requirements, STHFT have provided a number of

opportunities.

demand issues which affect

STH and neighbouring

providers' issues through joint

action. Despite concerted work

to manage capacity across the

system and additional support

from NHS England it is

probable that these issues will

not be fully resolved until

quarter 2 2019/20, work is

underway to review the

recovery trajectory based on

latest capacity and demand

information. Potential

initiatives in quarter 4 2018/19

may improve this trajectory

sooner but have yet to be

confirmed.

the Cancer Alliance to address

immediate capacity issues and

also to develop integrated

pathways to sustain service

delivery and performance. To

continue to monitor progress

against internal improvement

plans and escalate to the PCMB

as appropriate.

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improvement

Action requested of

Governing Body

Ambulance Yorkshire Ambulance Service is continuing to participate in NHS England’s Progress continues to be None this month.

Response Ambulance Response Programme (ARP) pilot and has now moved to the closely monitored by the

Times next stage, Phase 3. YAS are reporting on the new standards, which

replaced the previous way of measuring performance.

YAS remains unable to report the performance data at CCG level, so the

Sheffield data is still not available. However, it can be reported that in

comparison with other ambulance trusts nationwide, YAS is the top

performing service for call answer, the second best for early identification

of life threatening calls and third top performing service for hear and treat.

Work is ongoing with regards to training staff, re-designing services,

ensuring that vehicle fleet is modernised to enable YAS to meet all the

targets and an integrated workforce work stream is now established.

Oversight and management of business cases for YAS service

development is being co-ordinated by the Lead Commissioner Wakefield

CCG.

Urgent Care Team, Urgent

and Emergency Care

Transformation Delivery Board

and at the Yorkshire & Humber

999/111 Contract

Management Board meeting.

Ambulance Whilst ambulance handover performance for STH has seen a small The CCG continues to To continue to endorse the

handover / crew improvement, handover times are still too long (some days have had facilitate meetings between approach of monitoring

clear times delays over 1 hour). STHFT is one of the three acute Trusts highlighted as

a continuing concern within Yorkshire and Humber.

There has however been improvement in crew waiting hours - this has

gone down from an average of 10.5 hours a day in August to 7.08 in

November. Even more positively for this month, the rolling 30 day position

(up to the 6th of December) showed this has further reduced to 3.22 lost

hours per day which shows great progress. It is possible that this progress

may not be maintained over the next few months, given the additional

pressures of winter and the closure of the Hadfeld wing at the Northern

General.

The CCG and STH have agreed a new clinical protocol which enables YAS

to convey patients directly to the Walk In Centre, thereby relieving

pressure on A&E.

STH & YAS to discuss

measures to improve

performance moving forward.

ambulance handover

performance, the monitoring of

any necessary mitigating actions

through monthly Contract

Management Group meetings

with the Trust and support the

decision by the UECTDB that

this be an area of significant

system focus moving forward.

Cancelled There were 12 operations of this type cancelled during Quarter 3, all were Ongoing monitoring. None requested.

Operations - (on at STHFT. The cancellations were caused by capacity issues in critical

day of care over the summer period; these improved in September, and the

admission) number of cancellations reduced.

Cancelled 2 patients had their urgent operations cancelled for a second time in Ongoing monitoring. None requested.

Operations - October, both at STH.

(Urgent These 2 cancellations were orthopaedic patients and surgery was

operations cancelled on both occasions due to lack of theatre time (list overrun /

cancelled for overbooked). Both patients received their surgery in October 2018.

2nd time)

Mental Health The CCG continue to receive regular assurance at the monthly Contract CPA, in line with monthly To continue to receive

CPA 7 day Management Groups from Senior Operational Managers within SHSC and performance reporting, is a monitoring reports on this

follow up the Director of Operations provide regular updates and rationale

surrounding any breaches. The Trust has implemented a daily monitoring

process which alerts senior managers of any breaches. The CCG does still

have concerns over the recording of data in real time; the team have

questioned the reliability of data due to system errors. This is being

reviewed with SHSC in line with the Contract Management processes.

standard agenda item at the

Contract Management Group

(CMG). SHSC continue to

focus on improving their data

collection systems and the

CCG will expect an

improvement in order to

achieve the National target.

national target.

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improvement

Action requested of

Governing Body

Mental Health / DTOC Measures Performance Dashboard: Actions

Improved Sheffield IAPT, remain slightly below the 50% recovery target, at 49.40% An updated position will be Governing Body is asked to

Access to for September, but as previously reported, recovery rate will always be presented to Governing Body continue to receive these

Psychological reduced for this cohort, due to acceptance of people with more complex to monitor whether the service updated position statements,

Therapies needs by Sheffield IAPT, compared to other national IAPT services. We sustains this significant until this standard is delivered

(IAPT) continue to monitor this through Contract Management Group, as the progress against the national consistently.

Recovery Rate service had reported confidence that they would achieve the target by the

end of quarter 3. However the service does overachieve on all other

targets.

target of 50% (monthly as well

as quarterly). Delivery of the

targets are also monitored as

part of the standard CMG

meetings with SHSC.

Delayed Additional actions across the system have resulted in a steady Ongoing None requested

Transfers of improvement in reducing the number of delayed days.

Care (DTOC) This includes:

- Additional assessment capacity is ensuring more patients are discharged

and assessed for longer term needs.

- Prevention and Escalation: The locality pilots are starting to show early

success in identifying and supporting some patients to return home with

support from Primary care. Going forward this will be supported by

additional voluntary sector capacity.

- Increasing the opportunity for patients to return home independently: The

voluntary sector will be commencing a range of additional services in late

December, early January that will support carers and patients to return

home and reduce readmissions.

- Increasing the support available for patients to return home with some if

required immediately or following further assessment: SCC will be

providing an additional 6% independent sector capacity throughout

December to enable more patients to be discharged home with support.

Additional equipment rounds is ensuring faster delivery of equipment.

Medically stable patients are offered the opportunity of a short stay in

offsite bed to continue their recovery until they are ready to return home.

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Highest Quality Health Care Quality Dashboard

Latest data Latest data Latest data Latest data Latest data

Q2 18/19 Target 95% 95.04%

Oct17 - Mar18 Provider Actual

previous year 37.6 40.84

Provider Actual


Provider Actual


Oct17 - Mar18 Provider Actual


Provider Actual


Provider Actual


Provider Actual


Nov-18 Plan 0 0 Plan 0 0 Plan 0 0

Nov-18 Plan 16 22 Plan 7 4 Plan 0 0

Nov-18 YTD Plan 128 140 Plan 57 58 Plan 2 5

Nov-18 4 3 0 1 0

Nov-18 YTD Target 0 2 Target 0 2 Target 0 0 Target 0 0

Patient Reported Outcome

Measures (PROMS)

Health gain (EQ-5D Index) - hip replacement surgery

(primary) Apr17-Mar18

(Aug release) England Average 0.470 0.455

Patient Reported Outcome

Measures (PROMS)

Health gain (EQ-5D Index) - knee replacement

surgery (primary) Apr17-Mar18

(Aug release) England Average 0.340 0.339

Friends and Family Test Response rate - A & E Oct-18 Target 20% 23.0% Children's Trust

average 7.3% 17.5%

Friends and Family Test Response rate - Inpatients Oct-18 Target 30% 26.1% Children's Trust

average 40.3% 97.2%

Friends and Family Test Number of responses - Mental Health Oct-18 Children's Trust

average 46 32

Average for Trust

last 12 montIs 171 311

Friends and Family Test Proportion recommended - A & E Oct-18 England Average 87.1% 85.5% Children's Trust

average 84.7% 79.4%

Friends and Family Test Proportion recommended - Inpatients Oct-18 England Average 95.7% 96.6% Children's Trust

average 94.4% 83.5%

Friends and Family Test Proportion recommended - Mental Health Oct-18 Children's Trust

average 89.2% 93.8%

England

Average 90.1% 99.0%

Staff Friends and Family Test Proportion recommended - as a place of work Q2 18-19 England Average 64.0% 71.7% England

Average 64.0% 62.7%

England

Average 64.0% 58.8%

Staff Friends and Family Test Proportion recommended - as a place of care Q2 18-19 England Average 80.5% 92.4% England

Average 80.5% 89.9%

England

Average 80.5% 67.5%

Patient Complaints Number of complaints responded to within agreed

timescale Various Internal target 85%

92% (Oct18 YTD)

Internal target 85% 75%

(Q4 17/18) Internal target 75%

38% (Q1 18/19)

CQC national patient survey Community Mental Health Survey 2018 - Overall

Experience Score 2018 6.6/10

Mixed Sex Accommodation Number of breaches Oct-18 Target 0 0 Target 0 0 Target 0 0 Target 0 0

Continuing Healthcare (CHC) Proportion of DST's (Decision Support Tool)

completed on patients in an acute hospital setting Q2 18-19 Target 15% 0%

Continuing Healthcare (CHC) Proportion of Referrals completed within 28 days Q2 18-19 Target 80% 96%

Jul17-Jun18 England Average 1.0035 0.9491

Up to Nov 18

YTD Target 20 wks 20wks

PATIENT SAFETY

Patients admitted to hospital who were risk assessed for venous thromboeombolism

(VTE)

Rate of reporting of patient safety incidents per 1000 bed days, using the National

Reporting and Learning System (Trusts which report a higher number of incidents

tend to have a more effective safety culture)

Performance Indicator Reporting

period

Sheffield CCG Sheffield Teaching Hospital Sheffield Children's Hospital Yorkshire Ambulance Service

Target / Average Target / Average Target / Average Target / Average Target / Average

Sheffield Health & Social Care

Proportion of patient safety incidents resulting in severe harm or death

Incidence of Healthcare Associated Infections - MRSA

Summary Hospital-Level Mortality Indicator (SHMI)

Serious Incidents - Number opened in month No target

Incidence of Healthcare Associated Infections - Clostridium Difficile (Cdiff)

HOSPITAL MORTALITY

No target No target No target No target

Serious Incidents - Never Events

PATIENT EXPERIENCE

CHILDREN & YOUNG PEOPLE

Average delivery time for Education Healthcare Plans (EHCP)

Benchmarked against other

Trusts as 'about the same'

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Highest Quality Health Care Quality Dashboard Actions

Area Commentary / Action being taken Expected timeframes Action requested of

Governing Body

Patient Safety

Healthcare Clostridium difficile Weekly monitoring. None requested.

Associated STHFT had 4 cases for November (total 58 to date) which is 1 case over

Infections the national target for November. Root Cause Analysis (RCA) review of

cases for Q1 has been undertaken and STH had 16 cases of which 6 were

assessed as lapses in care: 2 due antibiotic prescribing not within

guidelines, 1 transmission event on a ward, 1 failed audits and 2 due to

wards not completing audits within the specified time frame of 30 days

(note this has been recently changed to 30 days from 60 so may account

for the higher ratio of lapses to non lapses).

Amendment to STH October figures. STH reported 8 cases for October but

following RCA has since reclassified 1 case as carriage rather than

infection (as patient not symptomatic) so in fact they had 7 cases in

October.

SCHFT has had zero cases in November. RCAs have now been received

on all 5 and all agreed as no lapses in care/unavoidable.

NHS Sheffield CCG had 22 cases of C. difficile in November and RCAs

continue. An annual report has been presented at SMT in December and

will be presented to CCC in January (deferred by CCC from November &

December) which includes analysis of the risk factors associated with

community cases, identification of any cases where there is a lapse in

care, comparison with the previous year, as well as providing

recommendations that can be included in the CCG C.difficile Action Plan,

which is monitored by the Antimicrobial Stewardship Group on a 6 monthly

basis.

MRSA Bacteraemia

In November there were zero cases.

Never Events Never Events are defined as Serious Incidents that are wholly preventable, Weekly monitoring. None requested.

and Serious because guidance or safety recommendations that provide strong

Incidents systemic protective barriers are available at a national level and should

have been implemented by all healthcare providers.

There were no new never events in November. The other 4 Never Events

reported in the dashboard relate to 2 that occurred in June, 1 in August

and 1 in October, the detail of which has already been reported.

Patient Experience

Friends and STHFT: STH triangulates and analyses a wide range of patient experience Ongoing. None required.

Family Test data and takes action in response to trends identified. Response rates for

FFT are good. STH closely monitors FFT response and recommendation

rates and takes action when rates drop. This includes ward level

improvement plans for inpatient areas where the proportion of people who

would not recommend the service is higher than the national average.

SCHFT: FFT response rate for A&E and inpatients has improved.

Response rate for outpatients continue to be very low. There has been an

improvement in the proportion of inpatients that would recommend the

Trust over the last two years, 83% in October 2018. The recommend rate

for A&E rate has seen a gradual reduction, dropping to 79% in October

2018

SHSCFT: The Trust continues to receive low numbers of responses to

FFT, but there has been a slight improvement over recent months with 311

responses received in October 2018.

CQC Community The CQC Survey of community mental health 2018 was published in Ongoing None

Mental Health November 2018. The survey was divided into 11 sections, focussing on

Survey 2018 different aspects of patients’ experiences. When comparing SHSC’s 2018

and 2017 results, there was no significant difference on any question.

However, in 2018 SHSC benchmarked as ‘about the same’ as other trusts

on all questions, whereas in 2017 SHSC was benchmarked as ‘worse than

other trusts’ on questions relating to organising care and reviewing care.

Therefore there has been an improvement in the benchmarked position of

the trust.

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Highest Quality Health Care Quality Dashboard Actions

Area Commentary / Action being taken Expected timeframes Action requested of

Governing Body

Patient The number of complaints responded to within agreed timescale at Ongoing. None required.

Complaints Sheffield Health and Social Care Foundation Trust is below the internal

target of 75%. The response rate has improved from 23% in Q4 to 38% in

Q1 18/19. The CCG is continuing to gain assurance that the Trust is

striving to improve this situation.

Children and Young People

Education Education Health Care (EHC) plans have been established to replace The CYP portfolio is working None requested.

Healthcare Statements of Special Educational Needs for children and young people closely with the SENDSAR

Plans (EHCP) with special educational needs.

Currently the LA maintains 3,155 Education Health Care Plans, of which

there is an education and health element of 52%, this total has remained

consistent since last year. In the last 12 months 552 new requests for

EHCP have been received, compared with 441 on the previous year – an

increase of 111 requests.

In October and November there were 96 requests for EHCP assessment;

in October 48.3% of cases were completed in 20 weeks, in November

44.3% were completed within 20 weeks. The average timescale for

EHCP completion for 2018 is now 20 weeks, this has been a gradual

improvement year on year from 2018 of 48 weeks, 2015 of 34 weeks to

2017 of 29 weeks. 29 new EHCP’s were issued in October, 37 new EHCP

were issued in November.

For November 11 cases were issued within 20 weeks, 25 cases had taken

between 20 and 40 weeks and 1 had taken 40-60 weeks. There are

currently 114 cases to be finalised (29 cases have draft plans issued with

families, 66 await agree to assess decision), 85 are within 0-20 weeks, 27

within 20-40 weeks and 2 are above 40 weeks.

1 new tribunal request was lodged in November, 0 tribunals relate to

health.

Service (previously named the

SEND team) in Sheffield LA to

support EHCP delivery and

track the overall impact of

SEND to better inform our

commission.

In November 2018, Sheffield

had its local area SEND

inspection. The joint CQC and

Ofsted report is expected

within the next 4 weeks. Work

is already being undertaken in

anticipation of the letter. More

feedback will be provided in

January’s update.

Health’s involvement into the

EHCP process requires

improvement to support

delivery of the EHCP review

process for EHCP, monitor

provision delivery and review

health reports going into

EHCP’s. The CYP&M

commissioning manager is

scoping this with the head of

SEND and a recent business

case to support this has been

approved to recruit additional

admin staff an a therapist into

the SENDSAR service at the

LA.

Safeguarding

Safeguarding Following the 2 citywide inspections re Children Looked after & SEND we

are awaiting final reports in order to formulate any required action plans

which the safeguarding team will contribute to where necessary.

Ongoing Governing Body to note

Produced by


Highest Quality Health Care - Provider CQC Ratings

The following table provides an overview of CQC (Care Quality Commission) inspection ratings for providers within Sheffield CCG locality. The CQC monitors, inspects and regulates health and social care services. Only providers that are

rated as either 'Requires Improvement' or 'Inadequate' in the month or have had a 'focussed inspection' will be displayed for information in the table below.

Organisation Name Provider

Name

Organisation

Inspection

Directorate

Specialism / Services

Date of

Inspection

report

Overall CQC

Rating CQC Rating Report

Alpine Lodge Alpine Health

Care Limited

Adult Social

care

Accommodation for persons who require

nursing or personal care, Dementia, Mental

health conditions, Physical disabilities,

Treatment of disease, disorder or injury, Caring

for adults over 65 yrs

25/09/2018 Requires

Improvement

Is the service safe? – Requires improvement

Is the service effective? – Requires improvement

Is the service caring? – Requires improvement

Is the service responsive? – Requires improvement

Is the service well-led? – Requires improvement

http://www.cqc.org.uk/location/1-

114994765

Diagnostic and screening procedures, Physical

Sloan Medical Centre The Sheffield

Clinic Ltd

Primary Medical

services

disabilities, Sensory impairments, Surgical

procedures, Treatment of disease, disorder or

injury, Caring for adults under 65 yrs

11/10/2018 Focussed Inspection http://www.cqc.org.uk/location/1-

274994960

Hallam Homecare Services

Ltd

Hallam

Homecare

Services Ltd

Adult Social

Care

Dementia, Learning disabilities, Mental health

conditions, Personal care, Physical disabilities,

Caring for adults under 65 yrs, Caring for adults

over 65 yrs

09/10/2018 Requires

Improvement



Is the service caring? – Good

Is the service responsive? – Good



4151895832

Nuffield Health - Sheffield

Fitness and Wellbeing

Centre

Nuffield Health Primary Medical

Services

Diagnostic and screening procedures,

Treatment of disease, disorder or injury, Caring

for adults under 65 yrs, Caring for adults over

65 yrs

16/10/2018 Focussed Inspection http://www.cqc.org.uk/location/1-

4151895832

Four Seasons Health Care

(England) Limited

Balmoral Care

Home Adult social care


nursing or personal care, Dementia, Treatment

of disease, disorder or injury, Caring for adults

over 65 yrs

23/10/2018 Requires

Improvement







135674276


Ash House (Yorkshire)

Limited

Ash House

Residential

Home

Adult social care


nursing or personal care, Dementia, Mental

health conditions, Caring for adults over 65 yrs

31/10/2018 Requires

Improvement





115440705


The following table provides an overview of CQC (Care Quality Commission) inspection ratings for all GP The following table provides an overview of CQC (Care Quality Commission) inspection ratings for all GP practices within practices within Sheffield CCG locality. The table shows the number of Sheffield practices rated under the Sheffield CCG locality. The table shows the number of Sheffield practices rated under the 4 current CQC ratings. 4 current CQC ratings.

Practice Overall Rating

Number of

Sheffield GP

Practices

Proportion of GP Practices

Outstanding 0 0%

Good 85 98%

Requires Improvement 2 2%

Inadequate 0 0%

TOTAL 87 100%

Practice Overall Rating Number of Sheffield Care Homes Proportion of Care Homes

Outstanding 1 1%

Good 85 76%

Requires Improvement 22 20%

Inadequate 4 4%

TOTAL 112 100%

Data as at Quarter 2 2018-19 Data as at Quarter 2 2018-19

Produced by


http://www.cqc.org.uk/location/1-114994765












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