Quality and Assurance Dashboard - westnorfolkccg.nhs.uk Body/2018... · Executive summary and...

Quality and Assurance Dashboard

Executive summary and Provider Indicator report

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Agenda Item 18.13aii

The Information in the report is based on the October and November data available as of 21st December 2017

Key Messages • QEH Clostridium Difficile outbreak closed.

• NCHC have remain below target for appraisals.

• NSFT sickness and absence has increased in October and November.

• EEAST Stroke 60 performance has decreased

• Courtenay House closed 4th December 2017.

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In summary, assurance ratings have been assessed by the NHS West Norfolk CCG Patient Safety and Clinical Quality Committee as defined in the indicators below.

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Rating increased due to C. Diff

outbreak closed

No change to assurance rating






THE QUEEN ELIZABETH HOSPITAL

Quality Assurance Dashboard Executive Summary

Never Events, Serious Incidents and Quality Issue Reporting

October

• There were 3 serious incidents declared in October 2017. Two related to avoidable harm in Maternity services and one related to Unexpected/potentially avoidable death in Maternity Services.

• There were 6 QIR’s submitted in October 2017.

November

• There were 4 serious incidents in November 2017. One related to a fall with Catastrophic harm, one related to avoidable harm in Maternity services, one related to a treatment delay in Accident and Emergency and one related to an unexpected death.

• There were 9 QIR’s submitted in November 2017. Discharge continues to be the biggest reason for reporting.

There have been no Never events declared in October or November 2017.

CCG Actions

To be involved in a collaborative SI review of Maternity services at the end of January 2018.

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THE QUEEN ELIZABETH HOSPITALQuality Assurance Dashboard Executive Summary

Pressure Ulcers:

None of the Pressure Ulcers met the SI threshold.

Falls

October

There were no falls of Catastrophic, major or moderate harm

declared in October.

November

The Trust declared one Catastrophic fall in November.

There were no falls of major or moderate harm declared in

November.

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Clostridium Difficile

• 33 cases of Hospital Acquired infection (April 17-November 17) have been declared. The trajectory set by NHSi for the year is no more than 53 cases. In the previous year the Trust reported 31 cases and this time last year 15 cases were recorded.

Outbreak

• The recent outbreak has now been closed. The three wards across the Trust which triggered outbreaks- Stanhoe, Windsor and Gayton have all had cases of C diff toxin linked to the ward(s) during September and October.

• A cleaning and HPV programme was undertaken to decontaminate these areas.

• Outbreak meetings were undertaken with NHSi, PHE and CCG representation.

• A Hand Hygiene awareness campaign has been implemented with challenges encouraged from all levels of staff. A new policy regarding bare below elbows in any clinical area has been launched.

CCG Actions

An internal meeting with CCG Infection Control Lead and Medicines Management team to complete CCG action plan

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Mixed Sex Accommodation

October November

CCG Actions

Work with the Trust to explore if ‘pods’ can be used within

Critical Care.

Support the Trust in completing patient experience report on

EMSA breaches.

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Cancer 62 Day Performance

(data based on validated performance for September and October 2017)

September

October

CCG Actions

Continue to attend monthly Cancer Delivery Board & bring highlight reports to PSQC

From Feb 2018

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Patient Experience

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Workforce

Please note that November data was not available at time of writing the report.

CCG Actions

To support the Trust with their workforce review including skill mix and staff ratio.

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NORFOLK COMMUNITY HEALTH & CARE NHS TRUST (NCH&C)


Please note: October data available only due to NCH&C not having board meeting in December 2017.


• The Trust did not declare any Never Events in October 2017.

• The Trust declared 4 Serious incidents in October 2017 which all related to pressure care.

• The Trust received 1 QIR during October which related to a failure to monitor VAC dressings.

Medication Incidents

There were 11 recorded medication incidents during October 2017 with no obvious themes.

Complaints

The Trust reported one complaint during October which related to communication.

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Family and Friends Test

FFT Score FF T Responses

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• Family and friends test scores continue to show a high level of either likely or extremely likely to recommend.• Response rates decreased over the last month which appears in trend with Quarter 3 of the previous year.



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2.00%

7.00%

12.00%

17.00%

22.00%Turnover

Turnover

Target +/- 5%

30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

Mandatory Training & PDPs

Mandatorytraining

ProfessionalDevelopmentPlans (PDPs)

• Turnover has reduced from the previous month but remain slightly above the Trust target.

• Mandatory training continues to remain above target.

• PDP compliance has reduced from the previous month and remain below target. Ongoing initiatives are still in place to assist and support managers in completing PDPs including the distribution of weekly compliance dashboards to the senior management team and monthly compliance listings sent to all Localities.



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The in month value has increased to 5.20% and matches the rolling 12 month average of 5.20%. The Trust advise that the Trust Human Resource department continues to produce monthly Managers Packs highlighting employees who hit absence triggers and offer ongoing support to managers in dealing with these cases.

NORFOLK AND SUFFOLK NHS FOUNDATION TRUST (NSFT)



• The Trust did not declare any Never Events or Serious Incidents for October or November.

• The Trust received 1 QIR in October and 1 QIR in November. One related to delay in communication and one related to shared care arrangements for ongoing GP prescribing.

Out of Area Placements

There were 6 OOA placement in October, all of which were working age patients. 4 of these were placed out of locality but remained within Norfolk but the other two were placed out of County (West Sussex and East Sussex).

There was 1 OOA placement in November which was a working age patient. This patient was placed in Hertfordshire.

CQC

The Trust have developed an improvement plan to address the actions required by CQC which has been shared with CQC and the CCG’s

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NORFOLK AND SUFFOLK NHS FOUNDATION TRUST (NSFT)


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Workforce Performance Dashboard 2017/18November 2017 West Norfolk Version: 1

Engaged Workforce KPI Mar-17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Annualised Sickness absence % 4.63% 3.94% 4.82% 4.95% 4.81% 4.58% 4.37% 4.40% 4.00% 4.71% 3.94% - - - - 4.5%

Monthly Sickness absence % 4.63% 5.48% 4.10% 2.96% 4.11% 3.65% 4.25% 5.36% 2.20% 4.22% 5.48% - - - - 4.5%

% of anxiety/stress/depression 22.5% 33.7% 29.4% 25.1% 22.7% 21.9% 20.7% 22.7% 24.4% 28.8% 33.7% - - - - 18.0%

Staff recommending as place to work 56.0% - n/a - - 43.0% - - - - - - - - - 65.0%

Survey Response Rate 52.0% - 18.2% - - 45.7% - - - - - - - - - 60.0%

Skilled Workforce KPI Mar-17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Vacancy Rate - All Staff 13.7% 15.8% 20.1% 24.4% 22.5% 21.6% 21.3% 21.5% 19.2% 17.8% 15.8% - - - - 8.0%

All Turnover 13.0% 20.8% 18.9% 24.7% 25.9% 21.6% 20.5% 20.3% 18.7% 22.3% 20.8% - - - - 10.0%

Voluntary Turnover 10.0% 7.3% 11.7% 13.6% 15.4% 10.2% 9.4% 7.9% 7.1% 8.6% 7.3% - - - - 8.0%

Stability Index 87.0% 85.3% 82.5% 78.1% 80.4% 84.2% 85.2% 85.8% 84.7% 84.8% 85.3% - - - - 90.0%

Time to Hire (Days) 75.0 64.0 121.6 91.3 94.0 65.5 78.2 81.3 88.0 104.0 64.0 - - - - 56

Appraisal % - Non Medical 89.0% 82.9% 82.0% 88.4% 64.0% 82.6% 78.3% 74.0% 72.7% 74.0% 82.9% - - - - 90.0%

Appraisal % - Medical 89.0% 100.0% 100% 100% 83.3% 83.3% 100.0% 100.0% 100.0% 100.0% 100.0% - - - - 90.0%

Mandatory Training % 90.0% 88.5% 87.7% 88.1% 84.9% 89.7% 89.5% 90.0% 87.8% 87.1% 88.5% - - - - 90.0%

Strategic Target

Quarter IndicatorTrend*

Performance

Tracker*Trend*

Performance

Tracker*

Strategic

Target

Strategic

Target

Strategic Target

Quarter Indicator

Strategic

Target

Strategic

Target

Benchmark Target

Current Performance

Benchmark Target

Current Performance

Trend data not available

• Monthly sickness absence has increased in October and November

• % of anxiety/stress/depression has also increased in October and November.

• Vacancy rate has reduced in October and November.

EAST OF ENGLAND AMBULANCE SERVICES NHS TRUST (EEAST)


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• The Improvement in ROSC seen in Quarter 2 has been maintained.

• Survival rate to discharge has improved for September.

http://www.eastamb.nhs.uk/performance/ACQIs-by-CCG-2017-18.pdf

West Norfolk CCG Data only

EAST OF ENGLAND AMBULANCE SERVICES NHS TRUST (EEAST)


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West Norfolk CCG Data only

• The improvement in the STEMI

care bundle has been

maintained.

• Stroke 60 performance

decreased in September.

http://www.eastamb.nhs.uk/performance/ACQIs-by-CCG-2017-18.pdf

NURSING CARE HOMES


Amberley Hall Nursing Home (Athena Care Homes UK Ltd):

(CQC inspection January 2017 – Good)

Meadow House Nursing Home (Healthcare Homes Group Ltd):

(CQC inspection May 2016 – Outstanding)

Lower Farm Care Home (Imalgo Ltd):

(CQC inspection August 2016 – Inadequate. New owner in place as of end of April 2017 so previous rating no longer

applies.)

(CQC inspection September 2017 – awaiting publication of report)

The Paddocks Care Home (Castlemeadow Care):

(CQC inspection 13th June 2017 – Overall rating – Good)

Goodwins Hall Nursing Home (Athena Care Homes UK Ltd):

(CQC inspection July 2016, report published October 2016 – Good)

Downham Grange (Kingsley Care Homes Ltd):

(CQC inspection January 2017 - Good)

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NURSING CARE HOMES


Holmwood House (Integrated Nursing Homes Ltd):

(CQC inspection December 2015- Good)

Park House Hotel (Leonard Cheshire Disability Group):

(CQC inspection October 2014, report published April 2015 – Good)

Courtenay House (Four Seasons Health Care Ltd):

Courtenay House closed on the 4th December 2017. All residents have been safely moved into alternative accommodation.

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