KPCT-11-124_NHS_Kirklees_Patient_Safety_and_Quality_Report_V3

Agenda Item 08 Enclosure KPCT/11/124

NHS KIRKLEES Report To:

NHS Kirklees Board

Title:

Quality and Patient Safety Report

FOI Exemption Category

Open

Lead Director:

Sue Cannon – Executive Director of Quality and Governance

Laura Elliott – Head of Quality Improvement

Author:

Key Points to Note:

Penny Woodhead – Deputy Director of Quality and Professional Development

To note the 2010/11 CQUINs performance To note the 2011/12 quarter 1 CQUINs performance To note current quality performance information and actions being taken To receive an update on recent Care Quality Commission activity and current Quality and Safety issues

Budget Implications: Risk Assessment: Legal Implications: Health Benefits: Staffing Implications: Equality Impact:

Environmental Impact: Sub Group/Committee: Recommendation:

To receive the report and note the actions being taken to address quality and safety performance

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1.0

Purpose of the Report To provide the NHS Kirklees Board with an update on key quality and patient safety issues and activity.

2.0

Commissioning for Quality and Improvement Scheme (CQUIN)

2.1

The overview of the development of local CQUIN schemes, including implementation, trajectories setting, improvement plans and recommending these to the relevant Contract Management Boards continues to be managed through the Clinical Quality Board arrangements.

2.2

All 2011/12 CQUIN schemes for Calderdale and Huddersfield Foundation Trust (CHFT), the Mid Yorkshire Hospitals Trust (MYHT), South West Yorkshire Partnership Foundation Trust (SWYPFT), and Yorkshire Ambulance Service (YAS) have been agreed through the respective contract management boards. The CQUIN scheme for Kirklees Community Health Services (KCHS) was signed off by the Contract Management Board in August 2011.

2010/11 Commissioning for Quality and Innovation performance was as follows: CHFT achieved 83.5 %; MYHT achieved 62.5%; SWYPFT achieved 97.2%; YAS achieved 100% (the 2010/11 scheme was a development scheme; largely data collection to support 2011/12 improvement trajectories); KCHS Kirklees community services achieved 75%

2.3

All providers, with the exception of KCHS, submitted Quarter 1 returns by the specified deadline (31 July 2011). NHS Kirklees have agreed that KCHS will report Quarters 1 and 2 in October, in line with agreed contractual reporting timescales.

For Quarter 1, our main providers achieved the following performance:

Provider

Achieved

Not achieved

Comment

CHFT acute

7/8 indicators achieved their set trajectories

1/8

Did not achieve C-section rates for the maternity indicator 6 indicators required data submission only for quarter 1 for baseline measurement and trajectories to be set for quarter 2 onwards

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Provider

Achieved

MYHT – acute

7/7

Not achieved

Comment 4 indicators required data submission only for quarter 1 for baseline measurement and trajectories to be set for quarter 2 onwards Data for 2 further indicators is not required until quarter 2. Data for 1 further indicator is based on the national inpatient survey and will be calculated in quarter 4.

SWYPFT

9/13

4/13

Did not achieve access to assessment for people experiencing acute mental health problems; access to psychological therapies; nutrition screening Partially Achieved improving access to access to assessment and treatment to non-acute mental health services.

YAS

Submitted their provisional data to Bradford and Airedale. All commissioners have reviewed and commented back to YAS. The YAS Clinical Quality Review Group will formally review all the data following YAS response to the feedback on the provisional data submission and make formal recommendations to Contract Management Board in September

2.4

A 2011/12 CQUIN scheme for independent sector providers, Spire Elland, Spire Methley Park and BMI Huddersfield has now been agreed as part of the Standard Acute Contract. The indicators agreed reflect those featured in other local acute schemes and include venous thromboembolism (VTE) risk assessment, Improving Patient Experience, Hip and Knee Best Practice Bundle, Falls, Post-Operative Pain Management, Safeguarding Training and Smoking Cessation

2.5

The first report on these schemes reflecting quarter 2 performance will be submitted by providers at the end of October 2011, in line with NHS providers.

3.0

Elimination of Mixed Sex Accommodation (EMSA)

3.1

The Operating Framework for 2011/12 requires all providers of NHS funded care to confirm whether they are compliant with the national definition ‘to eliminate mixed sex accommodation except where it is in the overall best interests of the patient, or reflects their patient choice’.

Those organisations that either do not make a declaration or declare they are not compliant will face contractual penalties.

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3.2

CHFT, MYHT and SWYPFT completed the required declaration exercise on 31 March 2011, including undertaking a self-assessment, generation of a plan which indicates areas of weakness and describes clear activities and timescales for corrective action and made declarations, clearly visible on their websites.

3.3

Breaches - August 2011

Provider

Q1

July 2011

August 2011

CHFT

0

0

0

MYHT

94

SWYPFT

6

2 NHSWD 4 NHSK

0

19

3 NHSWD 14 NHSK 2 NHSL

0

0

3.4

MYHT’s breaches continue to be on the High Dependency Unit at Dewsbury District Hospital (DDH). The increase in breaches in August 2011 is due to wardable surgical patients being admitted because of bed pressures within MYHT. Work has now been undertaken with the Clinical Site Managers and daily monitoring is in place to ensure that it does not occur again, guidance has also been issued to the HDU.

4.0

Healthcare Associated Infection (HCAI)

4.1

Year to date (YTD), HCAI performance data is presented in the following table. It should be noted that the data for August 2011 is limited to those patients reported by acute Trusts within Yorkshire & Humber.

Meticillin-resistant Clostridium Staphylococcus Aureus difficile (C.diff) (MRSA) Objective Aug YTD Objective Aug YTD

NHS Kirklees

4.2

13

2

5

104

11

51

From January 2011, it became a mandatory requirement for all acute NHS Trusts to report Meticillin Sensitive Staphylococcus Aureus (MSSA) bacteraemia and from 1 June 2011, mandatory surveillance of Escherichia coli (E.coli) bacteraemia.

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The following table shows the cumulative reported bacteraemias reported by the PCT (cumulative since mandated).

NHS Kirklees

MSSA

E. Coli

44

58

5.0

Venous Thromboembolism (VTE)

5.1

VTE risk assessment measures were introduced as part of CQUINs schemes in 2010/11. The performance for CHFT and MYHT against the measure of the % of all adult in patients who have had a VTE risk assessment on admission to hospital using the clinical criteria of the national tool is included in the table below.

Q1 CHFT

90.9%

MYHT

94.2%

6.0

National Patient Safety Agency – Safety Alerts

6.1

The information presented in the following table was published by the National Patient Safety Agency (NPSA) on 16 September 2011, of all alerts where actions are ongoing.

Trust

Alert

CHFT

No open alerts

SWYPFT

No open Alerts

YAS

No open Alerts

MYHT

NPSA/2007/16

NPSA/2009/RRR04

NPSA/2011/PSA002

6.2

Early identification of failure to act on radiological reports Preventing delay to follow-up for patients with glaucoma Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants.

Issue date

Closure date

05-Feb2007

28-Feb2008

11-Jun2009

10-Dec2009

10-Mar11

12-Sep-11

Mid Yorkshire Hospital Trust

6.2.1 Early identification of failure to act on radiological imaging reports (NPSA/2007/16) where the issues with the full implementation of the 6 of 11 Z:\Corporate Services\Meetings\Board\2011\Sept 11\KPCT-11-124 NHS Kirklees Patient Safety and Quality Report V3.docx

electronic system and safety net to ensure all images are reported and all reports are seen and actioned have now been resolved.

Improvement is expected to allow closure of this alert by the end of October 2011.

6.2.2 Preventing delay and follow-up for patients with glaucoma (NPSA/2009/RRR04) has been identified as a risk to MYHT and is captured on their risk register due to capacity issues in Ophthalmology.

The capacity issues are being addressed and monitored through the Executive Contract Board with discussions taking place with an alternate provider to review 400 patients identified as needing glaucoma follow-up. In the longer term NHSWD is delivering an Ophthalmology Transformation Programme as part of its commissioning intentions to increase the capacity for Ophthalmology across the district.

6.2.3 Closure of NPSA/2011/PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants will be followed up at the Quality Review Group (MYHT) in October 2011.

6.2.4 Implementation of the National Patient safety Agency alerts is monitored through clinical quality board arrangements.

7.0

Care Quality Commission (CQC) Activity

7.1

Dignity and Nutrition for Older People - CQC Review

7.1.1 The CQC has recently undertaken a targeted inspection programme of acute NHS Trusts to assess how well older people are treated when in hospital. In particular, whether they are treated with dignity and respect and whether their nutritional needs are met. CHFT received a positive report, which was discussed at the Clinical Quality Board in July 2011.

7.2

CQC unannounced inspection SWYPFT

7.2.1 In June 2011, the CQC carried out an unannounced inspection at the Fieldhead site after receiving non-specific concerns about Appleton and Chippendale wards. These are forensic medium secure facilities within Newton Lodge for people who have a learning disability commissioned through Specialist Commissioning Group (SCG). The CQC assessed compliance with the following outcomes: Outcome 04 - Care and welfare of people who use services Outcome 07 - Safeguarding people who use services from abuse Outcome 10 - Safety and suitability of premises Outcome 13 - Staffing Outcome 14 - Supporting staff Outcome 16 - Assessing and monitoring the quality of service provision 7 of 11 Z:\Corporate Services\Meetings\Board\2011\Sept 11\KPCT-11-124 NHS Kirklees Patient Safety and Quality Report V3.docx

7.2.2 The report from the review was published in July 2011 and showed compliance with two outcomes (4 and 16). There were moderate concerns about compliance with outcome 7 and a compliance action identified to ensure that staff follow safeguarding procedures and safety of patients is not at risk.

7.2.3 There were minor concerns with the other three outcomes and a number of improvement actions identified to ensure the provider maintains compliance including completing work on the external perimeter fence, addressing staffing shortfalls as staff are asked to work on other wards at short notice and providing staff training that is more specific to the needs of patients on these wards to improve their outcomes.

7.2.4 The CQC have asked the provider to submit a report within 28 days of receipt of report, setting out the action being taken to address the compliance and improvement actions. The report and subsequent actions have been discussed at the Mental Health Quality Board in September 2011. The action plan will be supplied once agreed with CQC, SWYPFT have confirmed that they have began the implementation of the proposed actions.

7.3

CQC follow-up inspection at MYHT

7.3.1 On 6 June 2011, the CQC conducted an unannounced inspection at the Trust. The inspection followed the full compliance inspection in October 2010 and was to follow-up on the five outcomes subject to compliance actions. The outcomes were: Outcome 02 - Consent to Care and Treatment; Outcome 08 - Cleanliness and Infection Control; Outcome 09 - Management of Medicines; Outcome 10 - Safety and Suitability of Premises and; Outcome 21 - Records.

7.3.2 Normally, the CQC re-visit organisation within three months of the original review but the follow-up visit was postponed to allow for the Trust’s move to the new hospital. The final report was published in late July 2011 and confirms that the Trust is now compliant with these five outcomes.

8.0

Current quality and safety issues

8.1

Fractured Neck of Femur (MYHT)

8.1.1 MYHT has a significantly higher proportion of patients undergoing surgery after 48 hours than the national average. Following a letter from the SHA in May 2011, written assurance was provided by the Trust about the improvements made to increase the number of patients undergoing surgery within 48 hours and how the impact of the changes will be monitored including:8 of 11 Z:\Corporate Services\Meetings\Board\2011\Sept 11\KPCT-11-124 NHS Kirklees Patient Safety and Quality Report V3.docx

The new pathway of care for fractured neck of femur focuses on increasing ortho-geriatric involvement earlier and ensuring patients get to theatre as quickly as possible; Since March 2011 there has been 7 day a week availability of a geriatrician to the orthopaedic service; Theatre availability improved with the move to new Pinderfields and since May 2011, trauma theatre lists are available 7 days a week; 8.1.2 Weekly data shared with the Quality Review Group and Executive Contract Board in July shows a significant increase in the number of patients seen by a geriatrician within 48 hours; and an improving trend for the % of patients undergoing surgery within 48 hours. The Trust is predicting that the improving trend for patients undergoing surgery within 48 hours will continue, reaching 95% between November and December 2011.

8.1.3 Progress will continue to be monitored at the Executive Contract Board on a monthly basis. Commissioners have also requested an improvement action plan and the data split by weekday and weekend.

This will be discussed at ECB on 22 September 2011.

8.2

CQC Review of Castlebeck Group Services

8.2.1 In May 2011, the BBC’s Panorama programme highlighted serious abuse and appalling standards of care at Winterbourne View, a private hospital for people with learning disabilities in Bristol. In response to the issues raised by the investigation, the CQC carried out four inspections at Winterbourne View, suspended admissions to the hospital and started regulatory action against its owner, Castlebeck Care (Teesdale) Ltd. The company did not challenge the action and the hospital closed in June 2011.

8.2.2 Following the closure of Winterbourne View, the CQC has completed an inspection of all facilities provided by Castlebeck Care Group. The inspectors made unannounced visits to each service and were supported by relevant specialist expertise.

8.2.3 Of Castlebeck’s 23 other services, inspectors found: four services with serious concerns; seven services that were not compliant with one or more of the CQC’s essential standards of quality and safety; twelve services were compliant with the standards.

8.2.4 As well as service-specific examples of poor practice, they found a number of company-wide themes including: lack of staff training; inadequate staffing levels and poor supervision of staff; poor care planning; failure to respond to and learn from serious incidents; failure to notify relevant authorities of safeguarding incidents; 9 of 11 Z:\Corporate Services\Meetings\Board\2011\Sept 11\KPCT-11-124 NHS Kirklees Patient Safety and Quality Report V3.docx

failure to involve people in decisions about their own care.

8.2.5 The CQC have taken a range of actions to address these issues and will continue to work with Castlebeck and commissioners to make sure that the safety and welfare of people using these services are met.

8.2.6 In the August 2011 Castlebeck announced that Arden Vale in Meriden, Solihull and Rose Villa, Bristol, two of the services where the CQC had serious concerns, are now to close ahead of the conclusion of legal action by the CQC. 8.2.7 NHS Kirklees has 3 patients placed in Castlebeck facilities all patients have been reviewed and appropriate plans are in plan for these individuals. There is a regional meeting (29/09/11) for commissioners that has been convened by the Chief executive of Castle Beck to review the recommendations from an independent review of all of their services and proposals for improvements across the company.

9.0

CQC unannounced inspections of Learning disability services

9.1

In June 2011, the CQC announced plans to undertake a review of 150 registered providers of services for people with learning disabilities.

The inspections will focus on: Care and welfare of service users.

Safeguarding service users from abuse

9.2

CQC compliance inspectors will be supported by an expert by experience and a professional advisor on each inspection. Currently practising clinical and professional staff will attend each inspection and may lead, during the inspection, on the observation of the quality and level of care. All inspections will be unannounced and wherever we find major or immediate concerns, the CQC will take swift regulatory action.

9.3

Details on these inspections are emerging from CQC and expected to commence shortly. At this stage we do not know whether any facilities NHS Kirklees commission services from will be subject to inspection.

9.4

NHS Commissioners are participating in the annual regional health self-assessment and performance framework, assurance process September 2011 – December 201. Included in this year’s assessment process is Top Target 5 which relates to how progress is being made in implementing the service reforms and developments described in Valuing People Now - a strategy for people with learning disabilities 2009 -12.

10.0

Recommendations i.

Receive and note the contents of the report.

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