· web viewexecutive summary (maximum 500 word limit) ... infection p. revention & control...

Title of meeting Governing Body Agenda Item 8

Date of Meeting 24th March 2016 Confirm Part One or Two

Part One

Title of Paper Quality and Safety ReportResponsible Director Cath Byford, Director of Commissioning & QualityAuthor Quality and Safety TeamAction required Approval ☐ Decision ☐ Discussion Information

Purpose of the report: For Governing Body to receive detailed information regarding performance and issues relating to patient safety and quality from providers

Executive Summary (maximum 500 word limit)

This report provides comprehensive information with regard to quality and patient safety performance across providers. Items of particular note are as follows:

James Paget University Hospitals NHS Foundation Trust (page 6) CQC report published on 12 November 2015 judged

JPUH as ‘Good’ overall. Mixed Sex Accommodation breaches continue due to

lack of bed availability. Quality Issue Reports still being received for patient

discharge concerns.

East Coast Community Healthcare (page 12) The Tissue Viability Team continues to work

collaboratively with JPUH and to deliver training and education to care homes regarding pressure ulcers.

CQC report published on 28 September 2015 judged Beccles Hospital to be meeting the required standards following re-assessment.

Staffing continues to be problematic across the organisation due to a combination of staff absence and resignations.

Norfolk and Norwich University Hospitals NHS Foundation Trust (page 16) CQC report published on 16 March 2016 judged the

NNUH as ‘Requires Improvement’ overall. Three Never Events reported since April 2015, one

involving a GYW patient. Delayed responses to Quality Issue Reports raised at

CQRM, new process being implemented as a result.

Norfolk and Suffolk NHS Foundation Trust (page 21)

of 44

CQC report published on 3 February 2015 judged NSFT as ‘Inadequate’ overall.

CQC inspection scheduled for 11th July 2016. Comprehensive improvement plan in place being

managed by Monitor.

Norfolk Community Health & Care (page 23) See full report.

Integrated Care 24 (111 / Out of Hours) (page 24) Call response times being closely monitored.

East of England Ambulance Service NHS Trust(page 24) CQC inspection report published CQC inspection scheduled for 4th April 2016. EEAST performance is below both the national

standards and agreed recovery trajectories.

Infection Prevention & Control Performance (page 26) C. Difficile Infection (CDI) trajectory for 2015/16 is 70

cases. From 1 April 2015 to 15 March 2016 there have been 83

reported cases. Approximately 50% cases continue to be successfully

appealed.

GYW CCG Complaints (page 27) See full report.

Care Provider CQC Overview (page 29) See full report.

Primary Care (page 33) Two GP practices recently rated as “Outstanding” by the

CQC in recognition of the excellence of care being offered to patients - Sole Bay Health Centre and Park Surgery.

The recommendation is to:Links to the CCG strategic objectives:

Effectiveness Quality Improved experience Make a difference for local people Reduce inequalities and delivery ☐Sustainable financing ☐

Links to strategic risk register:

Risk scoring and description:

of 44

Consequence(impact)

Rar

e

Unl

ikel

y

Poss

ible

Like

ly

Alm

ost

Cer

tain

1 2 3 4 51 Negligible 1 2 3 4 52 Minor 2 4 6 8 103 Moderate 3 6 9 12 154 Major 4 8 12 16 205 Catastrophic 5 10 15 20 25

The CCG Quality and Safety Directorate continue to locally monitor performance, challenge issues and report on good practice relating to patient safety and quality. This is achieved by support of the commissioning and contracting teams and through Clinical Quality Review Meetings with providers. Quality schedules are detailed within contracts and providers are required to report on key performance indicators. Where concerns are raised providers are required to provide detail including but not limited to; root-cause analysis, action plans to address poor performance, recovery action plans and information detailing lessons learned and corrective measures following complaints and incidents.This risk has been assessed as follows

1. Without controls - on the basis of failure to effectively monitor providers with regard to Quality and Patient safety

2. With controls - effective monitoring of quality and patient safety to support early identification of performance issues and contractual requirement for remedial action

Without controls4x4 =16(Red)

With controls3x3 = 9(Amber)

Primary Care Conflict of Interest

Conflict of Interest Exists (Y/N) No

Potential Conflict of Interest Exists (Y/N) No

Impact

Quality and Safety Positive Negative ☐ Neutral ☐Enables monitoring and early identification of possible issues allowing a collaborative approach with providers to review, learn lessons and improve services for Great Yarmouth and Waveney patients

Patient Experience Positive Negative ☐ Neutral ☐An effective locally delivered Quality and Patient Safety service will positively impact on patient experience for Great Yarmouth and Waveney residents.

Clinical/Operational Effectiveness

The provision of an effective Quality and Patient Safety service supports effective commissioning of safe, clinical effective services and allows for monitoring of performance against quality outcomes

Financial/Performance (see business case template attached where applicable)

N/A

QIPP/Better Care Fund N/AStatute/Compliance/Governance Issues

Quality and Patient safety monitoring supports effective governance with regard to authority, accountability and decision making.

NHS Constitution

of 44

Equality Impact Positive ☐ Negative ☐ Neutral

Human Resources N/APatient Engagement N/ASystem incl. primary care, NHS providers, local authority, voluntary sector etc.

The Quality and Safety Directorate work collaboratively with providers, local authorities, other commissioning organisations, and the independent sector.

Supporting documents(List all appendices or further attachments)Communications Strategy(How this initiative will be disseminated)Acronyms used in the report(List alphabetically and list in full within the report)

A&E – Accident and EmergencyCCG – Clinical Commissioning GroupC.Diff – Clostridium DifficileCHC – Continuing Health careCQC – Care Quality CommissionCQRM – Clinical Quality Review MeetingCQUIN – Commissioning for Quality and InnovationEEAST - East of England Ambulance Service NHS TrustECCH – East Coast Community HealthcareFFT – Friends and Family TestGYW – Great Yarmouth and WaveneyHCAIs – Healthcare Associated InfectionsHR – Human ResourcesIC24 – Integrated Care 24INR – International Normalised RatioJPUH – James Paget University Hospital NHS Foundation TrustKLOEs – Key Lines of EnquiryLAC – Looked After ChildrenMDT – Multi-disciplinary TeamMRSA – Methicillin Resistant Staphylococcus AureusMSA – Mixed sex AccommodationNCHC – Norfolk Community Health and CareNICE – National Institute for Clinical ExcellenceNNUH – Norfolk and Norwich University Hospital NHS Foundation TrustNSFT – Norfolk and Suffolk Foundation TrustOOH – Out of HoursPIRs – Post Infection ReviewsQIPP – Quality, Innovation, Productivity and PreventionQIR – Quality Incident ReportRCA – Root Cause AnalysisRTT – Referral to Treatment

of 44

SHMI – Standard Hospital Mortality IndexSI – Serious IncidentSSNAP – Sentinel Stroke National Audit ProgrammeWHO – World Health Organisation

Directorate involvement and sign off prior to submission to committee / board. Please state role titles or state N/A if appropriate.

Finance N/ACommissioning N/AQIPP and Delivery N/AInformation N/AContracting N/AEngagement N/AGovernance N/AQuality and Safety Rebecca Hulme – Deputy Chief Nurse

of 44

1.0 James Paget University Hospital (JPUH)

1.1 Friends and Family Test (FFT) for Inpatients, A&E and Maternity Services:

December 2015

Area Total Responses

Total Eligible

Response Rate

% Recommended

% Not Recommended

A&E 503 4498 11.2% 91% 2%

Inpatients 1003 5855 17.1% 97% 1%

Maternity –Antenatal Care 42 Not

AvailableNot

Available 100% 0%

Maternity –Birth 60 168 35.7% 100% 0%

Maternity –Postnatal Ward 34 Not

AvailableNot

Available 94% 0%

Maternity –Postnatal Community Provision

23 Not Available

NotAvailable 100% 0%

January 2016


Total Eligible

Response Rate

% Recommended

% Not Recommended

A&E 437 4478 9.8% 92% 3%

Inpatients 889 5707 15.6% 97% 1%

Maternity –Antenatal Care 80 Not

AvailableNot

Available 99% 0%

Maternity –Birth 57 177 32.2% 98% 2%


AvailableNot

Available 93% 2%

Maternity –Postnatal Community Provision

78 NotAvailable

NotAvailable 99% 1%

For further information, the following link shows the full range of results for FFT by region, Trust, Site and Ward: http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/ .

Note: FFT data for February 2016 will be published by NHS England on 7 April 2016 (post report publication) and the FFT data for March 2016 will be published by NHS England on 12 May 2016.

1.2 Care Quality Commission (CQC)

The CQC undertook a planned inspection at JPUH week commencing 10 August ‘15. The inspection report was published on 12 November ‘15 where the CQC overall judged JPUH to be Good.

CQC Inspection Area RatingsSafe? Requires improvementEffective? GoodCaring? GoodResponsive? GoodWell-led? Good

of 44

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

http://www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/

The Trust has developed an action plan to address the improvements identified which is being monitored at the Clinical Quality Review Meetings.

1.3 Patient Safety Indicators Published on NHS Choices

From June 2014, all NHS providers are expected to upload and publish data about their nurse staffing levels on their public website. In addition you can also see how hospitals perform on patient safety on NHS Choices. These include how hospitals recognise and report problems with safety, how well they are fulfilling their nurse staffing requirements or if the staff would recommend the hospital to their own family or friends.

The February 2016 position for JPUH is below. The nurse staffing metrics continue to report that only 91% of planned nursing staff was in place; however this is an improved position and the Trust continues to actively recruit locally, nationally and internationally. It should be noted that the Trust is reporting against their enhanced established levels which surpass NICE guidance.

CQC Rating A&E Performance

Safe Staffing

Recommended by Staff

Infection Control and Cleanliness

Percentage of patients

waiting less than 18 weeks from referral

Patients assessed for blood

clots

Open and honest

reporting

Good

95.7%Patients seen within 4 hours

93%Of planned

levelWithin expected

range with a value of 65%

Among the best

93%of patients

waiting less than 18 weeks

97%Of patients assessed

As expected

1.4 Mixed Sex Accommodation (MSA)

During January the Trust experienced a number of periods of significant operational pressure where it was not possible to comply with mixed sex requirements on two occasions. 12 patients were affected on the Acute Coronary Unit and Hyper Acute Stroke Unit over a period of seven days resulting in 45 breaches.

On two occasions during February the Trust reported MSA breaches due to bed pressures and lack of bed availability to resolve both breaches. This affected 5 patients on the Acute Coronary Unit and Hyper Acute Stroke Unit.

The CCG has received both full investigation reports.

1.5 Serious Incidents (SIs) / Never Events

Serious Incidents reported:

Apr2015

May2015

Jun2015

Jul 2015

Aug 2015

Sept2015

Oct2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

8 5 6 4 4 3 7 5 3 3 3

No new Never Events have been reported by the Trust since July ’14.

of 44

SIs that currently remain open (as at 29.02.16) pending investigation are noted within the following table:

SI number Category Incident Date

Reported Date Current Status

2015/34682 Treatment / Procedure 20/09/15 03/11/15 RCA received for review2015/36021 Breast Screening / Radiology 16/11/15 18/11/15 RCA received for review2015/37324 Breast Screening / Radiology 02/12/15 02/12/15 RCA received for review

2016/167 Obstetric Delay 25/12/15 05/01/15 Currently under investigation2016/195 Business Continuity 04/01/16 05/01/16 Currently under investigation

2016/5097 Fall 20/02/16 23/02/16 Currently under investigation2016/5113 Grade 3 Pressure Ulcer 07/02/16 23/02/16 Currently under investigation2016/5115 Grade 3 Pressure Ulcer 20/02/16 23/02/16 Currently under investigation

The GY&W CCG Patient Safety and Clinical Quality Committee continue to identify SIs to be reviewed in more detail. This focuses on completed RCAs and details behind any delays in submission.

1.6 World Health Organisation (WHO) Surgical Checklist

The Trust continues to audit compliance in operating theatre settings with the WHO Surgical Checklist on a monthly basis and results are received on a 6 monthly basis at the Quality Meetings. As previously reported, the October ‘15 results showed an overall figure of 99.7% compliance.

1.7 Quality Issue Reporting (QIR)

QIRs reported:

Apr2015

May 2015

Jun 2015

Jul2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

15 4 10 7 8 7 2 7 4 6 9

1.7.1 Open / Closed / Void

From 1st October 2014 to 29th February 2016, 16 QIR remain open pending investigation, 149 QIR have been closed, 9 QIR have been voided and 2 are pending closure.

1.7.2 Open QIR reported in 2014/15/16:

QIR Ref Date Source of QIR Description of Concern StatusDate

reminder sent

JPUH/316 20/04/2015 Park Surgery No discharge summary or instruction for care.

Under investigation 15/03/16

JPUH/352 15/09/2015 Beccles Medical Centre Anti-coagulation communication. Under

investigation 15/03/16

JPUH/355 23/09/2015 Alexandra Road Surgery Anti-coagulation issue. Under


JPUH/356 23/09/2015 Alexandra Road Surgery Communication failure. Under


JPUH/360 09/11/2015 Cutlers Hill Surgery Lack of information on discharge summary.


JPUH/368 08/12/2015 Park Surgery Incorrect discharge summary. Under investigation 15/03/16

JPUH/370 31/12/2015 Beccles Medical Centre

Report received for wrong patient.


of 44

QIR Ref Date Source of QIR Description of Concern StatusDate

reminder sent

JPUH/371 04/01/2016 ECCH Inappropriate discharge. Under investigation

JPUH/372 05/01/2016 ECCH Inappropriate discharge. Under investigation

JPUH/373 08/01/2016 Norfolk County Council Inappropriate discharge. Under

investigation

JPUH/375 26/01/2016 ECCH Medicines reconciliation error. Under investigation

JPUH/376 01/02/2016 Andaman Surgery Incorrect patient’s details. Under investigation

JPUH/377 28/01/16 Chet Valley Medical Practice

Inappropriate discharge. Pending Closure

JPUH/378 30/01/2016 IC24 Medicines availability. Under investigation

JPUH/380 19/01/16 ECCH Information Governance Pending Closure

JPUH/381 12/02/2016 EEAST Inappropriate discharge. Under investigation

JPUH/382 12/02/2016 Norfolk County Council Inappropriate discharge. Under

investigation

JPUH/384 24/02/2016 EEAST Ambulance crew delay. Under investigation

The CCG continues to monitor trends and themes arising from reported QIRs at the monthly CQRM. This includes inappropriate discharges, medicines on discharge and equipment concerns.

1.8 Infection Prevention & Control

The ceiling of maximum c-difficile cases within JPUH for 2015/16 has nationally been determined as no more than 17 avoidable cases.

1.9 Stroke Performance (July – September 2015)

The Sentinel Stroke National Audit Programme (SSNAP) data is the agreed source of data for stroke measures within the Clinical Commissioning Group (CCG) Outcomes Indicators Set and reports against these measures for the population of each CCG in England. Included in SSNAP’s reporting suite are high level summaries of hospitals’ performance across 10 key aspects of stroke care, a more detailed analysis of every hospitals' performance across each of these key indicators, and an overall SSNAP score. The reporting cycle is three months in arrears.

Domain (D): Oct – Dec ‘14 Jan – Mar ‘15 Apr – Jun ‘15 Jul – Sep ‘15D1 Scanning B B B BD2 Stroke Unit B B B BD3 Thrombolysis C C C DD4 Specialist Assessments C B B BD5 Occupational Therapy A B A AD6 Physiotherapy B B C BD7 Speech & Language Therapy D D D CD8 MDT Working D C D DD9 Standards by Discharge D B B BD10 Discharge Process C B B BPatient-Centred SSNAP Level C B B B

of 44

1.10 Cancer Target Performance (January 2015 – December 2015)

Preventing people from dying prematurely:

Breast symptoms urgent referral to first outpatient appointment (Target – 93%)Target is to achieve a 14 day maximum wait from GP referral to first outpatient appointment with patients with any breast

symptoms except suspected cancer.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec100 96.77 100 95.8 96.8 100 93.3 100 91.3 100 92.31 93

Cancer urgent referral to first outpatient appointment (Target – 93%)Target is to maintain a 14 day maximum wait from urgent GP referral to first outpatient appointment for all urgent suspected

cancer referrals.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec97.9 97.9 97.4 96.9 97.2 97.3 96.7 97.46 96.13 97.1 96.31 97.8

Cancer 2 week wait - Monitor combined Breast and urgent referral target (Target – 93%)Performance

Target is to achieve a 14 day maximum wait from GP referral to first outpatient appointment for both patients with any breast symptoms and also urgent suspected cancer referrals.

Q4 (14/15) Q1 (15/16) Q2 (15/16) Q3 (15/16) Q4 (15/16)

Met Met Met Met

Cancer urgent referral to treatment 62 day target (Target – 85%)Performance

Target is to achieve a maximum waiting time of 62 days from urgent referral to treatment for all cancers.Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec85.7 93.42 78.5 80 75 85.29 83.8 83.76 81.89 86.6 88.54 90

Cancer urgent referral to treatment from cancer screening services 62 day target (Target – 90%)Target is to achieve a maximum time of 62 days from screening services referral to treatment.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec90 96.67 90.9 94.7 100 91.3 100 100 85.71 100 94.74 100

Cancer urgent referral to treatment – Consultant upgrade (Target – 85%)Target is to achieve a maximum waiting time of 62 days from Consultant upgrade to treatment.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec80 100 72.7 100 85.7 100 100 57.14 81.82 94.1 96.55 93.3

Cancer urgent referral to treatment all 62 day pathways - Monitor target (Target – 85%)Performance

Target is to achieve a maximum waiting time of 62 days from urgent referral to treatment for all cancers across all 62 day pathways combined.

Q4 (14/15) Q1 (15/16) Q2 (15/16) Q3 (15/16) Q4 (15/16)

Met Failed Failed Met

Cancer diagnosis to treatment waiting times – 31 day target (Target – 96%)Target is to ensure a maximum waiting time of 31 days from diagnosis to treatment for all cancers.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec98.8 100 100 97.1 97.1 100 100 100 100 100 99.14 100

Cancer diagnosis to subsequent treatment waiting times – Surgery (Target – 94%)Target is to ensure a maximum waiting time of 31 days from diagnosis to subsequent surgical treatmenty.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec100 100 100 100 100 100 100 100 100 100 100 100

of 44

Cancer diagnosis to treatment anti-cancer drug regimen (Target – 98%)Target is to ensure a maximum waiting time of 31 days from diagnosis to subsequent treatment or anti-cancer drug regimen.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec100 100 100 100 100 100 100 100 100 100 100 100

Cancer diagnosis to treatment all 31 day pathways - Monitor pathway (Target – 98%)Performance

Target is to achieve a maximum waiting time of 31 days from diagnosis to treatment for cancer across all 31 day pathways combined.

Q4 (14/15) Q1 (15/16) Q2 (15/16) Q3 (15/16) Q4 (15/16)Met Met Met Met

Cancer is a priority quality standard for the CCG and enhanced scrutiny is being placed on the acute providers to ensure delivery of these key safety standards.

1.11 Pressure Ulcers

Both JPUH and ECCH continue their local CQUIN Indicator in 2015/16 which requires both organisations to track patients with pressure ulcers within the Great Yarmouth and Waveney locality. Progress against these CQUIN local indicators is monitored by the CCG and at relevant monthly meetings with both organisations.

The above chart shows the number of Grade 3 Hospital Acquired Pressure Ulcers covering the period from January 2015 to October 2015. More recent data is unavailable due to the timings of the completion of the Root Cause Analysis investigations.

1.12 Slips, Trips and Falls (February 2015 to January 2016)

JPUH and ECCH continue to work collaboratively to identify and intervene where patients are at risk of falling. The graph below shows the number of inpatient falls covering the period from February 2015 to January 2016.

of 44

Throughout 2015/16, the Trust average of falls per 1000 bed days is 5.17 (year to date). This is comparable with the national average for 2013 of 6.63 falls per 1000 bed days, as identified by the National Falls audit data. The average for the Trust during 2015 was 6.51.

1.13 Summary Hospital-level Mortality Indicator (SHMI)

JPUH has been identified, in recently published figures, as having an “as expected” SHMI for the period April 2015 to June 2015 with a SHMI of 109.7.

The SHMI relates to patients who have died in hospital or within 30 days of discharge. The SHMI is the ratio between the actual number of patients who die following hospitalisation and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there.

2.0 East Coast Community Healthcare (ECCH)

2.1 Serious Incidents (SIs)

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

14 4 1 1 4 3 1 2 4 1 5

SIs that currently remain open (as at 29.02.16) are all being investigated within the contractual time-frame. These are noted within the following table:

SI number Category Incident Date


2015/39296 Grade 3 Pressure Ulcer 18/12/15 23/12/15 Currently under investigation due 18th March 2016

2016/2831 Grade 3 Pressure Ulcer 04/01/16 01/02/16 Currently under investigation2016/3212 Grade 4 Pressure Ulcer 11/02/16 03/02/16 Currently under investigation2016/5380 Fall 24/02/16 26/02/16 Currently under investigation2016/5444 Grade 3 Pressure Ulcer 04/02/16 26/02/16 Currently under investigation


QIRs reported against ECCH:Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

1 2 1 1 5 1 2 2 1 5 4

of 44


From 1st October 2014 to 29th February 2016, 2 QIRs remains open, 17 QIRs have been closed, 1 QIR has been voided and 4 QIRs are pending closure.

The following QIR are open:

QIR Ref Date Source of QIR Description of Concern Status

Date reminder

sent

ECCH/030 04/06/2015

Nelson Medical Practice

Poor communication relating to the ECCA service. Under investigation 13/01/16

ECCH/040 30/10/2015 JPUH Failure to take INR. Pending closure N/A

ECCH/041 20/10/2015 JPUH Failure to take INR. Pending closure N/A

ECCH/042 12/11/2015 JPUH Inappropriate transfer. Pending closure N/A

ECCH/043 11/11/2015 JPUH No INR received by district nurse. Pending closure N/A

ECCH/044 04/12/2015

Falklands Surgery

Poor communication relating to the district nursing service. Under investigation

2.3 ECCH Quality Data

2.3.1 Pressure Ulcers

Janu

ary

Februa

ryMarc

hApri

lMay

June Ju

ly

Augus

t

Septem

ber

Octobe

r

Novem

ber

0

20

40

60

80

100

120

Developed Pressure Ulcers

Grade 4Grade 3Grade 2

of 44

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec JanONE 0 4 3 5 6 8 4 0 5 1 1 3District Nurses 0 3 0 5 6 7 3 0 3 1 1 3

Inpatients 0 0 0 0 0 0 1 0 0 0 0 0Out of Hospital Team North 0 0 0 0 0 0 0 0 1 0 0 0

Chiropody/Podiatry 0 0 0 0 0 0 0 0 1 0 0 0

TWO 49 72 78 63 58 58 44 66 55 46 58 79District Nurses 45 62 66 53 48 55 38 55 52 41 56 72


Lowestoft Out of Hospital Team 0 0 0 0 0 0 0 0 1 0 0 0

THREE 16 11 21 15 17 19 15 13 13 8 15 14District Nurses 13 9 18 15 15 14 13 13 13 8 14 12

Inpatients 2 1 3 0 2 3 2 0 0 0 0 2Community Matrons 0 0 0 0 0 0 0 0 0 0 0 0

Out of Hospital Team North 0 0 0 0 0 0 0 0 0 0 0 0

FOUR 3 3 4 0 0 4 3 4 4 0 2 5District Nurses 2 2 2 0 0 3 3 3 2 0 2 4


Lowestoft Out of Hospital Team 0 0 0 0 0 0 0 0 0 0 0 0

Deep Tissue Injury 0 0 0 0 0 0 0 5 7 8 5 7

NB ECCH report detail on the top 4 reporters only. Therefore some totals appear higher than the detailed breakdown relating to each grade of pressure sore

Not all of these pressure ulcers have developed whilst under the care of ECCH, however the Trust continues to report and investigate them. Safeguarding referrals are made to the local authorities, where appropriate. Out of the 14 Grade 3 and the 5 Grade 4 Pressure Ulcers reported in January 2016, 3 have been reported as possibly ‘Avoidable’ to ECCH. Full investigations are being carried out to determine the root cause of the Pressure Ulcer development and whether these are avoidable or unavoidable to ECCH.

Pressure Ulcer meetings are held monthly by ECCH and all services are invited to attend to monitor and discuss how improvements can be made. Joint working with the JPUH is taking place and all Pressure Ulcer RCAs are reviewed and shared for development and joint learning.

ECCH have implemented on-going staff training in relation to pressure ulcer management which is being developed within the new role of the Tissue Viability Nurse Specialist. ECCH has also offered training to staff in local Care Agencies. In addition ECCH continue to lead on the implementation of a pressure ulcer prevention plan across the health care system.

The increase in the pressure ulcers that are occurring within care homes continues to be of concern in relation to patient safety and experience. ECCH are leading on this work across

of 44

the system and the Tissue Viability Team, led by the Tissue Viability Nurse, have developed training sessions for care home staff and have already been into and trained several homes in the North and South of the locality.

ECCH reports pressure ulcers as serious incidents when the defined criteria are met and in accordance with NHS England’s recommendations.

2.3.2 Inpatient Falls

Aug Sept Oct Nov Dec Jan0

1

2

3

4

5

6

2 2

1

4

2

6

3

1

2

3

0 0

1

0

4

0

2

6

Beccles Hospital WardNorthgate Hospital WardPatrick Stead Hospital Ward

2.3.3 Recorded Patient Falls in Inpatient Areas

A number of initiatives continue underway in ECCH in the on-going prevention and management of falls. These include:

Development of a falls training pack for use with staff, Exploring the potential benefit of additional assistive technology, Purchase of two new low-rise beds for Northgate Hospital.

2.4 Care Quality Commission (CQC)

Beccles Hospital

The CQC re-inspected the hospital on 27 August ’15 to ensure that actions had been taken and published the inspection report on 28 September ‘15. It was found that the hospital had completed the action plan and improvements had been made. It was therefore judged that Beccles Hospital is now meeting required standards.

2.5 StaffingStaffing continues to be problematic across the organisation due to a combination of staff absence and resignation. Although the district nursing vacancy position has reduced over the past 12 months, the outcome of the Shape of the System consultation has impacted ECCHs recruitment processes and abilities, and has resulted in the implementation of a formal internal consultation which is ongoing with the staff that are likely to be affected by the changes. This is being coordinated by the HR department with the support of Senior Managers and the Joint Staff Forum.

of 44

2.6 Infection Prevention & Control

The ceiling of maximum c-difficile cases with ECCH for 2015/16 has been locally agreed as no more than 4 avoidable cases.

3.0 Norfolk & Norwich University Hospital (NNUH)

3.1 Serious Incidents (SIs) for GYW patients

Apr2015

May2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

0 0 0 0 0 0 0 2 0 0 0

Two Serious Incidents involving GYW patients have been reported since April 2015: 1 Treatment Delay and 1 Unexpected Death (Perinatal).

3.2 Never Events

Three Never Events have been reported by the Trust since April ’15:

One was reported in June ’15 within the ophthalmology department, not a GYW patient.

Two were reported in November ’15:- One within the dermatology department, not a GYW patient.- One within the high dependency unit, a GYW patient.

3.3 Quality Issue Reporting (QIR) for GYW patients

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

1 2 0 0 1 3 1 1 0 0 0

Open / Closed / Void

From 1st October 2014 to 29th February 2016, 18 QIRs remain open under investigation, 1 QIR has been voided and 1 QIR has been closed.

The following QIR are open and relate to GYW patients:

QIR Ref Date Source of QIR Description of Concern Status Date reminder

sent

NNUFT/378 18/11/14 High Street Surgery

No notification of procedure to GP.


NNUFT/379 20/11/14 ECCH Poor referral details. Under investigation 18/08/2015

NNUFT/380 24/12/14 ECCH Poor discharge. Under investigation 18/08/2015

NNUFT/381 24/12/14 ECCH Failure to receive test results.


NNUFT/382 06/01/15 ECCH Inappropriate discharge.


of 44

QIR Ref Date Source of QIR Description of Concern Status Date reminder

sent

NNUFT/383 12/02/15 Cutlers Hill Surgery

Medication prescription delay.


NNUFT/384 16/03/15 ECCH Inadequate issuing of disposal equipment.


NNUFT/385 10/04/15 Park Surgery Medication issues. Under investigation 18/08/2015


Incorrect advice given regarding GP responsibilities.



No discharge summary.


NNUFT/388 11/08/15 ECCH No drug chart was sent with medication.



No discharge summary.


NNUFT/390 28/09/15 Park Surgery Out of date medicine provided on discharge.


NNUFT/391 29/09/15 Park Surgery Alleged patient care concerns.


NNUFT/392 23/10/15 Beccles Medical Centre

Discharge summary unclear.


NNUFT/393 02/11/15 NCHC Inappropriate discharge summary.


NNUFT/394 02/06/15 ECCH Information governance issue.


NNUFT/395 24/11/15 Beccles Medical Centre Poor communication. Under

investigation

Delays in responding to QIRs by the Trust has been raised by the CCG’s Director of Commissioning and Quality at the NNUH CQRM. The NNUH has responded by putting a revised process in place for reviewing and responding to QIRs.

3.4 Patient Safety Indicators published on NHS Choices

The February 2016 position for NNUH published on NHS Choices is below. To note, the CQC standards are not met as a result of previously reported non-compliance. The nurse staffing metrics report that 99% of planned nursing staff were in place.

CQC Rating A&E Performance

Safe Staffing

Recommended by Staff

Infection Control and Cleanliness

Percentage of patients waiting less than 18 weeks from referral

Patients assessed for blood clots

Open and honest reporting

No rating

89.7%Patients seen within 4 hours

101%Of planned

levelWithin expected

range with a value of 68%

Among the best 86%of patients

waiting less than 18 weeks

93%Of patients assessed

Among the worst

3.5 Friends and Family Test

of 44

December 2015


Total Eligible

Response Rate

% Recommended

% Not Recommended

A&E 464 6677 6.9% 89% 6%

Inpatients 756 11989 6.3% 97% 1%Maternity –Antenatal Care 761 38363 1.98% 93% 3%

Maternity – Birth 1 * * * *Maternity –Postnatal Ward 24 481 5% 100% 0%

Maternity – Postnatal Community Provision 26 Not

AvailableNot

Available 92% 8%

January 2016


Total Eligible

Response Rate

% Recommended

% Not Recommended

A&E 174 6720 2.6% 94% 3%

Inpatients 536 11762 4.6% 96% 2%

Maternity –Antenatal Care 3 * * * *

Maternity – Birth 26 479 5.4% 96% 4%


AvailableNot Available 93% 4%

Maternity – Postnatal Community Provision 12 Not

AvailableNot Available 100% 0%

If an organisation or one of its sub-units has less than five responses the data will be supressed with an asterisk (*) to protect against the possible risk of disclosure.

Note: FFT data for February 2016 will be published by NHS England on 07 April 2016 (post report publication) and the FFT data for March 2016 will be published by NHS England on 12 May 2016.

3.6 Stroke Performance

Domain (D): Oct – Dec ‘14 Jan – Mar ‘15 Apr – Jun ‘15 Jul – Sep ‘15D1 Scanning B C C CD2 Stroke Unit C C C CD3 Thrombolysis B C B CD4 Specialist Assessments A A B BD5 Occupational Therapy B A C CD6 Physiotherapy B B B BD7 Speech & Language Therapy C C D CD8 MDT Working B B C CD9 Standards by Discharge B B B BD10 Discharge Process A A A APatient-Centred SSNAP Level B B B C

3.7 Cancer Target Performance

of 44

Maximum waiting time of 31 days for subsequent treatments for all cancers –Surgery (Target – 94%)

Q1 Q2 Q3 Q488.7% 90.2% 84.6%

Maximum waiting time of 31 days for subsequent treatments for all cancers –Anti-Cancer Drugs (Target – 98%)

Q1 Q2 Q3 Q499.0% 99.2% 99.4%

Maximum waiting time of 31 days for subsequent treatments for all cancers –Radiotherapy (Target – 94%)

Q1 Q2 Q3 Q498.5% 97.1% 97.8%

Maximum waiting time of 62 days for first treatments for all cancers –GP Referral (Target – 85%)

Q1 Q2 Q3 Q4

76.37% 77.1% 76.2%

Maximum waiting time of 62 days for first treatments for all cancers –Consultant Screening Service (Target – 90%)

Q1 Q2 Q3 Q4

93.8% 91.4% 94.2%

2 week wait from referral to date first seen –All Cancers (Target – 93%)

Q1 Q2 Q3 Q4

94% 95.6% 98.2%

2 week wait from referral to date first seen –Symptomatic Breast Cancers (Target – 93%)

Q1 Q2 Q3 Q4

97.9% 99.4% 98.6%

The CCG has raised concerns about cancer performance and monitors GYW patient pathways on a weekly basis with intervention as required.

The CCG continues to attend the Cancer PTL meetings and bi-weekly outcomes review meeting led by the lead commissioner.

The CCG continues to be clear in our dissatisfaction with poor cancer performance.

Backlog clearance remains a priority for the 62 day target and continues and cancer cases are being prioritised in theatre for a number of specialities.

of 44

3.8 Monitor Investigation

Monitor commenced a formal review of NNUH, with particular attention on breaches in C. Difficile, A&E 4 hour standard, Referral To Treatment and some cancer standards. The Trust has been found to be in Breach of their Licence.

Monitor published the outcomes of their investigation and particularly noted the need for improvements in A&E performance, cancer standards, RTT, leadership and governance. The formal notifications are published and can be found within the following hyperlinks:

Enforcement undertakings issued 24th April 2015https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425078/Norfolk_and_Norwich_Enforcement_Undertakings.pdf

Additional Licence condition issued 29th April 2015https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425073/Norfolk_and_Norwich_Additional_Licence_Condition.pdf

Monitor is continuing to work with the Trust in making sustainable improvements towards both performance and financial recovery.

3.9 CQC

The CQC undertook a planned inspection at NNUH week commencing 10 November ‘15. The inspection report was published on 16 March ’16 where the CQC overall judged the NNUH as Requires Improvement.

CQC Inspection Area RatingsSafe? Requires improvementEffective? Requires improvementCaring? GoodResponsive? Requires improvementWell-led? Requires improvement

The key findings were as follows:

• Staff were overwhelmingly caring in delivering care to patients. We witnessed some outstanding examples of care being given to patients and their relatives.

of 44

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425073/Norfolk_and_Norwich_Additional_Licence_Condition.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425073/Norfolk_and_Norwich_Additional_Licence_Condition.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425078/Norfolk_and_Norwich_Enforcement_Undertakings.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/425078/Norfolk_and_Norwich_Enforcement_Undertakings.pdf

• There were shortages of nursing staff that impacted on care provided throughout the hospital.• There were some areas where there were medical vacancies which impacted on care. Most notably in the palliative care team and in the critical care complex.• Incident investigation and root cause analysis was not always completed by those with extended training.• The security on the children’s ward needed to be improved to ensure their safety.• There was a lack of understanding by staff around patients’ ability to consent to care and treatment.• The consultant body was cohesive, loyal to the hospital and proud to be working at the trust.• The service to patients having a heart attack was extremely good.• The communication with parents in the neonatal unit was very good. These included well written booklets.• The number of one stop clinics within the out patients department was responsive to the needs of patients.

3.10 Referral To Treatment (RTT)

The CCG is concerned about Referral to Treatment (RTT) waiting times at the NNUH and continues to work closely with the lead commissioner, North Norfolk CCG, and the Trust to gain assurance regarding GY&W patients.

4.0 Norfolk and Suffolk NHS Foundation Trust (NSFT)

4.1 Care Quality Commission (CQC) and Monitor

The Care Quality Commission (CQC) undertook an inspection of the Trust and overall judged NSFT to be Inadequate.

CQC Inspection Area RatingsSafe InadequateEffective Requires ImprovementCaring GoodResponsive Requires ImprovementWell-led Inadequate

This has resulted in the Trust being placed in Special Measures.

NSFT has developed a comprehensive improvement plan and is being managed by Monitor who has appointed an Improvement Director within the organisation. Monthly Stakeholder Meetings continue with the Trust, which the CCG attends, where the Trust is required to present an updated position against the agreed improvement plan.

NSFT has placed the improvement plan within the Trust’s Project Management Office structure, mapped against the CQC’s five domains.

NSFT has developed a dashboard cross referenced to the whole of the improvement plan which is reviewed at the monthly CQRMs.

The CQC is due to undertake an inspection during the week commencing 11th July ’16.

of 44

4.2 Serious Incidents / Never Events for GYW patients

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

4 2 2 2 0 5 2 2 1 6 2

4.2.1 Current Open Serious Incidents (SIs) reported for GY&W CCG patients:

SIs that currently remain open (as at 29.02.16) are all being investigated within the contractual time-frame. They are noted within the following table:

SI Number Category Incident Date


2015/29267

Unexpected Death - Outpatient

080/9/15

08/09/15 Currently under investigation

2015/29727

Unexpected Death - Outpatient

08/09/15


2015/31697

Unexpected Death of Community Patient (in receipt)

02/10/15


2015/33583

Unexpected Death of Community Patient (in receipt)

20/10/15


2015/34710

Unexpected Death of Community Patient (not in receipt)

15/09/15


2016/66 Serious Incident by Outpatient (in receipt)

15/12/15


2016/228Unexpected Death of Community Patient (not in receipt)

14/11/15 05/01/16 Currently under investigation

2016/1275 Actual / Alleged Abuse 08/01/16 15/01/16 Currently under investigation

2016/1740 Unexpected Death - Outpatient


2016/1990 Allegation against HC Professional


2016/2430 Assault by Inpatient 26/01/16 27/01/16 Currently under investigation

2016/2511 Serious Incident by Outpatient (in receipt)


2016/2925 Fall 29/01/16 01/02/16 Currently under investigation

2016/5666 Unexpected Death - Outpatient


4.3 Unexpected Deaths

The CCG has received assurance regarding the planned independent investigation into unexpected deaths across the Trust for which the report will be received at CQRM in due course.


Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

1 0 0 0 2 3 2 0 1 2 3

of 44


From 1st October 2014 to 29th February 2016, 1 QIR remains open under investigation, 2 are pending closure, 2 QIRs have been voided and 17 QIRs have been closed.

The following QIR are open and relate to GYW patients:


NSFT/217 21/12/15 Greyfriars Health Centre Inconsistent referral process. Pending Closure

NSFT/219 01/01/16 Norfolk Constabulary Patient welfare. Open

NSFT/222 31/01/16 EEAST Patient welfare. Pending Closure

4.5 GYW Patients Placed Out of Area by NSFT

As at 10th March ‘16, there were 11 patients placed outside of the NSFT geographical area, none of these were GYW patients.

5.0 Norfolk Community Health & Care (NCH&C)

5.1 Serious Incidents

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

0 0 0 0 0 0 0 0 0 0 0

5.2 Quality Issue Reporting (QIR) for GYW patients

Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

0 0 0 0 0 0 0 0 0 0 0

5.3 Specialist Amputee Rehabilitation Service

A Specialist Amputee Rehabilitation Service providing treatment and care for people who have lost a limb and who need further support before returning home from hospital is based at Pine Cottage on the Colman Hospital Site. The service aims to help patients recover quickly and enable them to get back to a life which is as normal as possible.

A team of health and social care professionals works together to provide care, including: physiotherapists, occupational therapists, nurses and doctors and social workers.

The amputee service in-reaches into the acute hospital to enable patients to meet a key member from the Pine Cottage MDT prior to being discharged from the Acute Hospital. This provides patients with reassurance and information prior to admission into Pine Cottage. It also give patients the opportunity to ask questions and empower them to take part in decision making around their rehabilitation at a much earlier stage.

Evidence has been received from NCH&C that the in-reach function of the amputee service is working well and benefiting patients and their families.

of 44

6.0 Integrated Care 24

6.1 Serious Incidents

There has been 1 SI reported by IC24 in June ’15, which has been closed.


Apr2015

May 2015

Jun 2015

Jul 2015

Aug 2015

Sept 2015

Oct 2015

Nov 2015

Dec 2015

Jan 2016

Feb 2016

1 0 2 2 0 2 1 0 0 0 0


From 1st October 2014 to 29th February 2016, 3 QIRs remain open under investigation, 15 QIRs have been closed and 1 QIR voided.


Date reminder

sent

IC24/038 29/06/15 EEAST Inappropriate call transferring Under investigation 13/11/2015

IC24/041 04/09/15 EEAST Patient refused ambulance transfer Under investigation 04/01/2016

IC24/043 20/10/15 JPUH INR results delay Under investigation 06/01/2016

6.3 Clinical Quality and Patient Safety Report

IC24 has agreed the format and content of the quarterly Clinical Quality and Safety Report with the CCG to ensure that sufficient assurance is provided regarding trends and theme analysis, lessons learned and shared, and to present an equitable approach between OOH and 111 issues.

6.4 Annual Quality Assessment

The Annual Quality Assessment is a Statutory Requirement for which IC24 provides an annual report. This report is conjoined with a Work / Audit Plan which is monitored at the monthly Quality Meetings.

6.5 Contract

IC24 continues to provide a good service overall to GYW CCG.

7.0 East of England Ambulance Service NHS Trust (EEAST)

7.1 SIs for GY&W Patients

There have been seven SIs for GYW CCG in 2015/16 to date (29.02.16).

of 44

The SIs that currently remain open are as below:

The CCG is dependent upon the lead commissioner, Suffolk CG, to confirm closure of all Sis regarding GYW patients.

There have been no Never Events from 1st April 2015 to 29th February 2016.

7.2 Performance

Indicator Name Item Apr-15 May -15 Jun-15 Jul 15 Aug -15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16

Category ARed 1

responses≤ 8 minutes

Actual 84.5% 83.3% 72.4% 73.2% 75.3% 77.0% 76.2% 79.1% 78.9% 72.2%

Plan 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0%

>8 min 11 10 16 22 22 20 20 19 20 25

<8 min 60 50 42 60 67 67 64 72 75 65

Total 71 60 58 82 89 87 84 91 95 90

Category ARed 2

responses> 8 minutes

Actual 78.3% 75.7% 70.4% 70.2% 67.7% 66.1% 66.9% 68.4% 65.4% 60.5%

Plan 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0% 75.0%

>8 min 247 277 341 340 412 393 406 362 477 545

<8 min 892 861 810 802 863 766 821 785 901 836

Total 1139 1138 1151 1142 1275 1159 1227 1147 1378 1381

Category A19

responses≤ 19

minutes

Actual 96.1% 96.7% 93.9% 93.5% 91.2% 92.3% 92.4% 94.4% 92.6% 90.1%

Plan 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%

>19 min 46 39 73 79 120 96 99 69 109 145

<19 min 1161 1156 1129 1135 1238 1143 1210 1167 1363 1325

Total 1207 1195 1202 1214 1358 1239 1309 1236 1472 1470

Within the CCG boundaries, the Trust has failed to achieve the Category A Red 1, A Red 2 and A19 response time targets in January 2016. EEAST performance across the Trust is also below both the national standards and agreed recovery trajectories.

of 44

SI Number Category Incident Date


2015/26269 Non conveyance 05/08/15 12/08/15 EEAST to confirm closure

2015/37294 Delay 18/10/15 02/12/15 EEAST to confirm closure

2015/38245 Non conveyance 30/10/15 14/12/15 EEAST to confirm closure

2015/31948 Sub-Optimal Care of Deteriorating Patient 10/12/15 22/12/15 EEAST to confirm closure

7.3 CQC position

EEAST were inspected by the CQC in December ’13, the outcomes of this inspection were:

Non-Compliant for Outcome 4 – Care and welfare of people who use services (Moderate Impact).

Compliant for Outcome 11 – Safety, availability and suitability of equipment. Compliant for Outcome 12 – Requirements relating to workers. Non-Compliant for Outcome 13 – Staffing (Moderate Impact). Compliant for Outcome 14 – Supporting staff. Compliant for Outcome 16 – Assessing and monitoring the quality of service provision. Compliant for Outcome 17 – Complaints.

EEAST has formed a focus group for Key lines of Enquiry (KLOE) compliance; the ambitious plan, including support by Non-Executive Directors is to visit every station throughout the year by the beginning of 2016 to engage with staff, support any clinical ideas or suggestions and review for compliance against the KLOE’s in as many areas as possible.

The CQC is due to undertake an inspection during the week commencing 4th April ’16.

7.4 Quality and Patient Safety

EEAST has developed a Quality and Patient Safety Strategy which was launched in July ‘15. This is centred upon the five pledges set out in the Sign up to Safety Initiative.

8.0 Healthcare Associated Infections (HCAI)

In the event of C-diff cases being assessed following Root Cause Analysis that they are either unavoidable (with evidence of excellent practice) or a recurrence, cases can be reviewed and, if appropriate, can be considered to not count within the local trajectory. The case reviews that are successful will still be included in the national numbers, however not for the purposes of performance management.

Root cause analysis is undertaken on every single case and opportunities for learning are shared, reviewed within the local CDI case review team and learning incorporated within the local system wide CDI improvement plan. This provides an over-arching forum to ensure best practice is shared across the local GYW CCG health system. 8.1 Clostridium Difficile 2015/16

The GYW CCG C. Difficile Infection (CDI) trajectory for 2015/16 is 70 cases.

From 1 April 2015 to 15th March 2016, there have been 83 reported cases. Accountability for these cases are as follows:

29 cases James Paget University Hospital (including 2 North Norfolk CCG cases) – 25 cases have been reviewed, of which 13 are non-trajectory and 4 cases are still to be reviewed.

47 cases GYW Primary Care – 42 cases have been reviewed, of which 27 are non-trajectory and 5 are still to be reviewed.

1 case Norfolk & Suffolk Foundation Trust – non-trajectory.

of 44

2 cases East Coast Community Healthcare –1 case is trajectory and 1 case is non-trajectory.

1 case Cambridge University Hospitals Foundation Trust – non trajectory.

3 cases Norfolk and Norwich University Hospital – trajectory.

8.2 MRSA

There have been 3 cases of MRSA bacteraemia identified in the JPUH this year. On Post Infection Review (PIR) one case was determined to be a ‘contaminant’ and not a MRSA bacteraemia. The two other cases were determined to be a MRSA bacteraemia but assigned to third parties. Therefore, no cases count as being attributable to JPUH.

9.0 GYW Complaints

The CCG has received 47 complaints for the period 1 April 2015 to 29 February 2016 as follows:

Quarter 1 (1 April to 30 June ’15): 13 complaints received, all of which have been closed.

Quarter 2 (1 July to 30 September ’15): 12 Complaints received, all of which have been closed.

Quarter 3 (1 October to 31 December ’15): 18 complaints received, all of which have been closed.

of 44

Received Response Date Working Days Primary Complaint Upheld / Not Upheld / Partially Upheld

05/10/15 25/11/15 37 CHC Assessment Partially upheld

08/10/15 30/10/15 8 CHC Assessment Partially upheld

09/10/15 22/10/15 10 Commissioning Not upheld

12/10/15 11/12/15 41 James Paget University Hospitals NHS Foundation Trust Partially upheld

15/10/15 Closed N/A James Paget University Hospitals NHS Foundation Trust Consent not received

16/10/15 03/11/15 12 CHC Funding Partially upheld

21/10/15 18/11/15 20 Commissioning Upheld

26/10/15 08/02/16 72 BMI Sandringham, JPUH & NNUH

Not upheld

30/10/15 26/11/15 19 JPUH & CHC Assessment Not upheld

09/11/15 23/12/15 31 JPUH & NSFT Partially upheld

22/12/15 01/02/16 27 Commissioning & JPUH Partially

15/12/15 29/12/15 8 ECCH Not upheld

11/12/15 24/12/15 10 CHC Assessment Not upheld

16/12/15 24/12/15 7 CHC Process Not upheld

21/12/15 24/12/15 4 CHC Process Not upheld

21/12/15 24/12/15 4 Commissioning Not upheld

23/12/15 29/12/15 2 Commissioning n/a MP enquiry

29/12/15 01/02/16 27 Commissioning n/a MP enquiry

Quarter 4 (1 January to 29 February ’16): 4 Complaints received, one of which remains open.

Received Response Date Working Days Primary Complaint Upheld / Not Upheld / Partially Upheld

13/01/16 01/02/16 14 CHC Process n/a MP enquiry

15/01/16 Closed JPUH Complaint passed to JPUH to investigate

20/01/16 15/03/16 40 Commissioning Partially upheld

25/02/16 Ongoing CHC Funding

9.1 Common Themes

of 44

Complaints associated with Continuing Healthcare (CHC) continue to be the main theme in particular regarding the assessment process, care provision and funding. There have been no complaints received regarding retrospective claims in Quarters 2 and 3.

Quarter 3 saw an increase in complaints regarding Commissioning. Complaints in this category relate to the CCG’s decisions, in particular regarding funding of current and future services. CCG funding policies are reviewed regularly both internally and with other Norfolk CCG’s to ensure equity of access to service and consistent allocation of resource.

The complaints relating to other providers are around appointments, waiting times, care and treatment provided. These issues are raised as appropriate with Providers at Clinical Quality Review Meetings (CQRM). Providers have action plans describing the measures they intend to utilise to increase capacity.

9.1.1 CHC

All complaints associated with CHC are investigated and overseen by the Head of Quality in Care. The Director of Commissioning and Quality and Chief Nurse also reviews all complaints and responses to ensure optimal opportunities for learning and improvement.

9.1.2 James Paget University Hospitals NHS Foundation Trust

Complaints received regarding the James Paget University Hospitals NHS Foundation Trust relate to the care and treatment provided and discharge. The need to work collaboratively with other agencies has been highlighted and actions taken.

9.1.3 Commissioning

Of the complaints received in Quarter 3, two were enquiries from MPs regarding services which are commissioned by organisations other than the CCG. The MPs concerned were advised of the correct organisation to contact.

Two were for services commissioned from the JPUH, one for an internal administrative process delay and one from an MP regarding CCG services.

10.0 Care Provider CQC Overview

The CQC publish the compliance status of all registered providers on their website; however this is not available in a dashboard in order to be able to review the position across all of the providers. The full table of all care homes and domiciliary care providers in Great Yarmouth and Waveney is presented.

The following provides explanation of the symbols used by the CQC found within the Appendix tables:

This means that the standard was being met in that the provider was compliant with the regulation.

of 44

Min

This means that the standard was not being met in that the provider was non-compliant with the regulation. People who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed of resolved quickly.

Mod

This means that the standard was not being met in that the provider was non-compliant with the regulation. People who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be managed of resolved quickly.

Maj

This means that the standard was not being met in that the provider was non-compliant with the regulation. People who use the service experienced poor care that had a serious current or long term impact on their health, safety or welfare or there was a risk of this happening. The matter needs to be resolved quickly.

En

If the breach of the regulation was more serious, or there have been several or continual breaches, the CQC have a range of actions that they take using the criminal and/or civil procedures in the Health and Social Care Act (2008) and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager of provider. These enforcement powers are set out in law and mean that they can take swift, targeted action where services are failing people.

The CQC has changed the methodology used when inspecting services. The CQC inspectors use professional judgement, supported by objective measures and evidence, to assess services against five key questions:

Are they safe? You are protected from abuse and avoidable harm.Are they effective? Your care, treatment and support achieves good outcomes, helps you to

maintain quality of life and is based on the best available evidence.Are they caring? Staff involve and treat you with compassion, kindness, dignity and respect.Are they responsive to people’s needs?

Services are organised so that they meet your needs.

Are they well-led? The leadership, management and governance of the organisation make sure it's providing high-quality care that's based around your individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.

The CQC also rate services to help people to compare services and to highlight where care is outstanding, good, requires improvement or inadequate. This approach has been developed by the CQC over time and through consultation with providers, stakeholders, care professionals, the public, and people who use services.

The tables to display the results have been separated to distinguish between the services which have been inspected using the new methodology and the services which are yet to be inspected using the new methodology.

Care and Residential Homes (New Methodology) – Page 32Care and Residential Homes (Pre-existing Methodology) – Page 36

GP Practices, Acute Hospitals, Mental Health & Community Services (New Methodology) – Page 39GP Practices, Acute Hospitals, Mental Health & Community Services (Pre-existing Methodology) – Page 41

Key:

of 44

O OutstandingG Good (No action required)R.I Requires ImprovementI Inadequate

10.1 Current Significant Concerns about Care Providers

The Dell, Oulton Broad, Lowestoft (run by Wellbeing Care Limited):

The CQC have undertaken a number of inspections in the past year which have resulted in a number of concerns. The inspection and subsequent inspection report published 08 October 2015, determined that the provider ‘Requires Improvement’. The most recent inspection took place unannounced on 19 January 2016 and determined that the Dell Residential Home was ‘Good’.

Highfield Residential Home, Halesworth (run by Bupa Care Homes Limited):

Highfield Residential Home is a care home providing care and support to a maximum on 40 older people. The CQC undertook an unannounced inspection at Highfield Residential Home over two days, on 16 and 23 October 2015 and determined that the provider was ‘Inadequate’. This means that it has been placed in to ‘Special Measures’ by CQC. The inspection findings are summarised below:

Domain Rating NotesSafe Inadequate The service was not consistently safe and medicines

management issues were identified.All of the risks to people were not clearly planned for and actions put into place to minimise the risks. Appropriate checks were carried out on new staff before they began work.

Effective Requires Improvement

The service was not consistently effective and was not complying with legislation around the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). People had a choice of food and drink that met their needs, and were supported to maintain good nutrition.Staff received appropriate training, supervision and appraisal for the role.

Caring Requires Improvement

The service was caring. Staff interacted with people in a kind and caring way and positive relationships were formed between staff and people using the service.

Responsive Requires Improvement

The service was not consistently responsive.People did not always have access to appropriate stimulation and activity. Improvements are required with regard to the involvement people or their representatives have in the planning of care. Improvements are required to ensure that people’s care records are person centred, and reflect their preferences. People had the opportunity to feedback their views and knew how to complain about the service.

Well-led Inadequate The service was not consistently well-led. A quality assurance system was in place; however this did not always identify shortfalls.Prompt action was not always taken where areas of risk were identified by the quality assurance system.

Wainford House, Beccles (run by Farrington Care Homes Limited):

of 44

http://www.cqc.org.uk/provider/1-137861712

Wainford House is a care home providing care and support to a maximum on 28 older people. At the time of the CQC visit, there were 28 people using the service. The CQC undertook an unannounced inspection at Wainford House on 12 October 2015 and determined that the provider was ‘Inadequate’. This means that it has been placed in to ‘Special Measures’ by CQC. The inspection findings are summarised below:

Domain Rating NotesSafe Inadequate The service was not safe. Medicines were not managed or

administered safely. There were not enough staff available to meet people’s needs. Risks to people were not managed and minimised effectively.

Effective Requires Improvement

The service was not consistently effective.The training staff received was not effective in providing them with the knowledge and skills they required to deliver safe and appropriate care. The service was not complying with the requirements of the Mental CapacityAct (2005) and the Deprivation of Liberty Safeguards (DoLS). People had a choice of suitable and nutritious meals, and appropriate support was offered to people where needed.

Caring Requires Improvement

The service was not consistently caring.People spoke positively of the relationships they had with staff, and the CQC observed that staff interacted with people in a caring way. Improvements were required to ensure that people’s dignity and respect were upheld.

Responsive Requires Improvement

The service was not responsive. People did not receive support which was planned and delivered in line with their personalised care plans. People were not actively involved in the planning of their care and support. People did not have access to meaningful activity and stimulation, and told CQC representatives that they were bored. People did not know how to make complaints about the service.

Well-led Inadequate The service was not well-led. Robust systems were not in place for monitoring the quality of the service. Risks to people had not been independently identified. The culture in the service was not open and transparent, and people did not feel listened to. Staff were not involved in the development of the service.

of 44

10.2 Primary Care

Two GP practices in the Great Yarmouth and Waveney region have recently been rated as “Outstanding” by the Care Quality Commission (CQC) in recognition of the excellence of care being offered to patients (Sole Bay Health Centre and Park Surgery). Both practices are in an elite group from across the country to be given the rating following the inspections which both took place in November.

Sole Bay Health Centre, Reydon Sole Bay Health Centre provides a full range of GP services to approximately 5,060 patients in Southwold, Reydon and the surrounding villages.

The CQC singled out two initiatives in particular, which were:

The Southwold Care Services Improvement Partnership (CSIP), which is driven by the practice, has played a key role in caring for people aged 85 with complex needs, while discussions are ongoing regarding the development of a care home on land next to the surgery.

The Sole Bay Care Fund, which is an independent registered charity set up by the practice to provide short term emergency care, resources and equipment not normally funded by the NHS or social services, in turn helping to reduce unnecessary hospital admissions by allowing patients to remain at home.

Park Surgery, Great Yarmouth

Park Surgery provides a full range of GP services to approximately 10,600 patients in Gorleston, Bradwell and Caister in Great Yarmouth.

During the visit, inspectors heralded the high standards of safety in place at the practice and said risks were well managed. They noted that patients’ needs were assessed and care plans developed using best practice guidance.

Inspectors also said staff received appropriate training, the practice had good facilities in place and a clear leadership structure, while patients cared for by the Park Surgery said they were treated with compassion, dignity and respect.

The CQC singled out three initiatives for particular praise. They were:

• As a result of high teenage pregnancy and termination rates, one of the practice’s GPs undertook training to fit contraceptive implants and coils. Terminations have subsequently fallen by 60% since 2011. • The practice writes directly to every patient who does not attend for breast and bowel screening to make sure they have all of the information they need to make a clear and informed choice. Similarly, patients who do not attend for cervical screening are telephoned by the practice manager. • The practice uses a health trainer to help people manage their weight, drink less and stop smoking.

11.0 Recommendations The Governing Body note the content of this report.

of 44

Appendix 1 Care and Residential Homes (New Methodology)

DomainsSafe Effective Caring Responsive Well-led Overall rating Date of report

Abbeville Residential Care Home, Great Yarmouth R.I G G R.I G Requires

Improvement 23 November 2015

Abbeville Sands, Great Yarmouth R.I R.I R.I R.I R.I Requires Improvement 09 October 2015

Allied Healthcare, Beccles R.I R.I G R.I R.I Requires Improvement 16 February 2016

Amber Lodge, Lowestoft G G G G G Good 30 October 2015

Avery Lodge Residential Home, Great Yarmouth R.I R.I G G G Requires

Improvement 06 July 2015

Beech House Residential Home, Halesworth G G G G G Good 05 May 2015

Blyford Residential Home, Lowestoft This service, provided by Eastern Healthcare Ltd, has not yet been inspected since it was registered by CQC on 23 February 2015.

Britten Court, Lowestoft R.I R.I G R.I R.I Requires Improvement 26 June 2015

Burgh House, Burgh Castle, Great Yarmouth G R.I G G G Good 08 January 2015

Cherry Lodge, Lowestoft G G G G G Good 15 May 2015

Chevington Lodge, Bungay This service, provided by Cygnet Care Limited, has not yet been inspected since it was registered by CQC on 12 April 2014.

Clarence Lodge,Gorleston R.I R.I G R.I R.I Requires

Improvement 19 August 2015

Eastview Residential Home, Lowestoft G G G G G Good 03 August 2015

Estherene House, Lowestoft This service, provided by QH (Rosewood) Limited, has not yet been inspected since it was registered by CQC on 16 October 2015.

Eversley Nursing Home, Great Yarmouth G G G G G Good 06 November 2015

Highfield Residential Home, Halesworth I R.I R.I R.I I Inadequate 05 February 2016

Holmwood Residential Home, Bungay This service, run by Holmwood Care Limited, has not yet been inspected since it was registered by CQC on 10 October 2014.

of 44

John Turner House (Leading Lives), Lowestoft G G G G G Good 09 October 2015

Joseph House, Reedham, Norwich G G G G G Good 29 May 2015

Kirkley Manor, Lowestoft G G G G G Good 04 September 2015

Lound Hall Nursing Home, Lowestoft This service, run by KRG Care Homes Limited, has not yet been inspected since it was registered by CQC on 01 March 2016.

Lydia Eva Court, Gorleston, Great Yarmouth This service, run by Norse Care Services (Limited), has not yet been inspected since it was registered by CQC on 12 June 2014.

Manor Farm, Kessingland, Lowestoft G G G G G Good 10 February 2015

Marine Court, Great Yarmouth G G G G G Good 09 November 2015

Marlborough House, Lowestoft G G G G G Good 09 October 2015

Marram Green, Kessingland, Lowestoft G G G G G Good 07 July 2015

Martham Lodge, Martham, Great Yarmouth This service, run by Hollyman Care Homes Limited, has not yet been inspected since it was registered by CQC on 01 January 2015.

Oaklands Residential Home, Reydon R.I G G R.I R.I Requires Improvement 06 October 2015

Pitches View, Reydon, Southwold G G G G G Good 02 March 2016

Ritson Lodge, Hopton, Great Yarmouth G G G G G Good 11 August 2015

Roseland Lodge, Great Yarmouth G G G G G Good 14 September 2015

Royal Avenue Residential Home, Lowestoft G R.I R.I R.I R.I Requires


Salisbury Residential Home, Great Yarmouth I I G G I Requires

Improvement 09 October 2015

Seahorses Nursing Home, Gorleston, Great Yarmouth G G G G G Good 20 March 2015

Shaftesbury Court Residential Home, Lowestoft This service, run by Sanctuary Care Home Limited, has not yet been inspected since it was registered by CQC on 03 July 2014.

St Barnabus, Southwold This service, run by St Barnabus Southwold, has not yet been inspected since it was registered by CQC on 01 October 2015.

of 44

St David’s Residential Home, Great Yarmouth G R.I G G R.I Requires

Improvement 25 February 2015

St Edmunds, Gorleston, Great Yarmouth This service, run by Eastern Healthcare Limited, has not yet been inspected since it was registered by CQC on 30 November 2015.

St Georges Care Home, Beccles G R.I G G R.I Requires Improvement 30 July 2015

St Marys House, BungayThis service, run by Innomary Limited, has not yet been inspected since it was registered by CQC on 01 July 2015.

Stradbroke Court, Lowestoft This service, run by Aps Care Limited, has not yet been inspected since it was registered by CQC on 04 September 2015.

Squirrel Lodge, Lowestoft G G G G G Good 18 August 2015

The Coach House, Hemsby, Great Yarmouth R.I R.I R.I G R.I Requires


The Dell – Residential Home, Oulton Broad, Lowestoft The Dell G G G G G Good 22 February 2016

Wellbeing Care Support Services, Oulton Broad, Lowestoft G G G G G Good 11 November 2015

The Depperhaugh, Hoxne R.I G G R.I G Requires Improvement 02 September 2015

The Elms Residential Care Home, Gorleston, Great Yarmouth G G G G G Good 29 April 2015

The Grove, Lowestoft G G G G G Good 04 June 2015

The Heathers Nursing Home, Bradwell, Great Yarmouth This service, run by Heathers Care Home Limited, has not yet been inspected since it was registered by CQC on 06 January 2016.

The Laurels, Lowestoft G G G G G Good 15 January 2016

The Moorings, Earsham, Bungay G G G G G Good 21 August 2015

The Old Rectory, Acle, Norwich R.I R.I R.I R.I R.I Requires Improvement 09 October 2015

The Old Rectory, Winterton-on-Sea, Great Yarmouth G G G G G Good 17 April 2015

The Vineries, Hemsby, Great Yarmouth This service, run by The Vineries Limited, has not yet been inspected since it was registered by CQC on 06 January 2016.

Wainford House, Beccles I R.I R.I R.I I Inadequate 27 January 2016

Windmill Residential Home, Rollesby, Great Yarmouth G G G G G Good 09 July 2015

of 44

Windsor House, Lowestoft G G G G G Good 24 November 2015

Woody Point, Brampton, Beccles G G G G G Good 04 June 2015

of 44

Care and Residential Homes (Pre-existing Methodology)

Res

pect

ing

and

invo

lvin

g pe

ople

Con

sent

Car

e an

d W

elfa

re

Mee

ting

nutr

ition

al

need

s

Coo

pera

ting

with

ot

her p

rovi

ders

Safe

guar

ding

from

ab

use

Cle

anlin

ess

and

infe

ctio

n co

ntro

l

Man

agem

ent o

f m

edic

ines

Safe

ty a

nd s

uita

bilit

y of

pre

mis

es

Safe

ty a

nd s

uita

bilit

y of

equ

ipm

ent

Req

uire

men

ts

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g st

aff

Ass

es a

nd

mon

itorin

g qu

ality

of

Com

plai

nts

Rec

ords

1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsAll Hallows Healthcare Trust,Ditchingham, Bungay – Nursing Beds

Last inspection report 27 March 2014

Bungay House, Bungay Last inspection report 13 March 2014

Abbeville Lodge,Great Yarmouth Last inspection report 11 January 2014

Alexandra House,Great Yarmouth Last inspection report 22 May 2014

All Hallows Nursing Home,Bungay

Last inspection report 08 January 2014

Amber House, Gorleston Last inspection report 04 December 2013

Ashurst Care Home, Lowestoft Last inspection report 09 November 2013

Broadlands, Oulton Broad, Lowestoft Last inspection report 02 May 2013

Broadview Residential Home, Great Yarmouth

Last inspection report 14 February 2014

Brooke House, Norwich Last inspection report 29 July 2014

Carlton Hall Residential Home, Lowestoft


Decoy Farm, Browston, Great

Last inspection report 30 September 2014

of 44

Res

pect

ing

and

invo

lvin

g pe

ople

Con

sent

Car

e an

d W

elfa

re

Mee

ting

nutr

ition

al

need

s

Coo

pera

ting

with

ot

her p

rovi

ders

Safe

guar

ding

from

ab

use

Cle

anlin

ess

and

infe

ctio

n co

ntro

l

Man

agem

ent o

f m

edic

ines

Safe

ty a

nd s

uita

bilit

y of

pre

mis

es

Safe

ty a

nd s

uita

bilit

y of

equ

ipm

ent

Req

uire

men

ts

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g st

aff

Ass

es a

nd

mon

itorin

g qu

ality

of

Com

plai

nts

Rec

ords

1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsYarmouthEaling House, Martham, Great Yarmouth

Last inspection report 23 May 2014

Florence House, Great Yarmouth Last inspection report 30 October 2013

Genesis Residential Home, Great Yarmouth


Georgina House, Great Yarmouth Last inspection report 07 February 2014

Gresham Nursing Home, Gorleston Last inspection report 25 June 2014

Hales Lodge, Winterton-On-Sea, Great Yarmouth


Harleston House, Lowestoft Last inspection report 11 June 2013

Imber House, Lowestoft Last inspection report 28 June 2013

Ivydene Residential Home, Ormesby, Great Yarmouth


Levington Court, Lowestoft Last inspection report 08 November 2013

Lilac Lodge & Lavender Cottage, Lowestoft


Lynfield, Ditchingham, Bungay Last inspection report 06 November 2013

of 44

Res

pect

ing

and

invo

lvin

g pe

ople

Con

sent

Car

e an

d W

elfa

re

Mee

ting

nutr

ition

al

need

s

Coo

pera

ting

with

ot

her p

rovi

ders

Safe

guar

ding

from

ab

use

Cle

anlin

ess

and

infe

ctio

n co

ntro

l

Man

agem

ent o

f m

edic

ines

Safe

ty a

nd s

uita

bilit

y of

pre

mis

es

Safe

ty a

nd s

uita

bilit

y of

equ

ipm

ent

Req

uire

men

ts

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g st

aff

Ass

es a

nd

mon

itorin

g qu

ality

of

Com

plai

nts

Rec

ords

1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsNewnham Green, Gorleston Last inspection report 20 September 2014

North Bay House, Oulton Broad Last inspection report 13 November 2013

Oliver Court Great Yarmouth Last inspection report 05 December 2013

Orchards Residential Home, Bradwell Last inspection report 28 January 2014

Oulton Park, Oulton Broad, Lowestoft Last inspection report 03 October 2013

Park House, Great Yarmouth Last inspection report 16 May 2014

Pine Lodge, Great Yarmouth Last inspection report 24 June 2014

The Claremont, Caister-On-Sea, Great Yarmouth

Last inspection report 18 March 2014

The Gables Residential Home, Gorleston, Great Yarmouth


White House Residential Home, Beccles

Last inspection report 27 April 2013

of 44

Appendix 2GP Practices, Acute Hospitals and Community Hospitals (New Methodology)

DomainsSafe Effective Caring Responsive Well-led Overall rating Date of report

Alexandra Road Surgery (Alexandra and Crestview Surgeries), Lowestoft G G G G G Good 27 August 2015

Andaman Surgery, Lowestoft G G G G G Good 07 January 2016

Beccles Hospital, Beccles See ECCH section in main body of report for details.

Beccles Medical Centre, Beccles G G G G O Good 19 March 2015

Bridge Road Surgery, Oulton Broad, Lowestoft G G G G G Good 03 September 2015

Bungay Medical Centre, Bungay R.I G G G G Good 08 October 2015

Central Surgery, Gorleston Great Yarmouth G G G G G Good 31 March 2015

Coastal Villages Practice (Ormesby Practice), Great Yarmouth G G G G G Good 19 February 2015

Cutlers Hill Surgery, Halesworth G G G G G Good 17 September 2015

Falkland Surgery, Bradwell, Great Yarmouth G G G G G Good 05 March 2015

Family Health Centre, Gorleston, Great Yarmouth R.I R.I G R.I R.I Requires

Improvement 12 November 2015

Fleggburgh Surgery, Great Yarmouth G G G G G Good 04 February 2016

Gorleston Medical Centre, Gorleston, Great Yarmouth G G G G G Good 22 January 2015

Greyfriars Health Centre, Great Yarmouth G G G G G Good 22 January 2015

High Street Surgery, Lowestoft G G G G R.I Good 08 October 2015

James Paget University Hospital (JPUH), Gorleston, Great Yarmouth R.I G G G G Good 12 November 2015

Kirkley Mill, Lowestoft G G R.I G G Good 20 August 2015

of 44

Lighthouse Medical Centre (King Street and South Quay Surgery), Great Yarmouth This service, part of Eastern Norfolk Medical Practice, has not yet been inspected by CQC. The service commenced on 24 August 2015.

Longshore Surgeries, Kessingland, Lowestoft G G G G G Good 19 March 2015

Millwood Surgery, Bradwell, Great Yarmouth G G G G G Good 13 August 2015

Newtown Surgery, (Newtown and Caister Medical Practice) Great Yarmouth G G G G O Good 05 February 2015

Norfolk Community Health and Care, (NCHC), Norwich RI G G G G Good 19 December 2014

Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUH) R.I R.I G R.I R.I Requires

Improvement 16 March 2016

Norfolk and Suffolk Foundation Trust (NSFT) I R.I G R.I I In Special Measures 03 February 2015

Park Surgery, Great Yarmouth G G O O O Outstanding 21 January 2016

Rosedale Surgery, Carlton Colville, Lowestoft G G G G G Good 22 January 2015

Sole Bay Health Centre, Reydon, Southwold G G O G O Outstanding 11 February 2016

Victoria Road Surgery, Oulton Broad, Lowestoft G G G G G Good 19 November 2015

Westwood Surgery, Lowestoft This service has not yet been inspected.

of 44

GP Practices, Acute Hospitals and Community Hospitals (Pre-existing Methodology)

Res

pect

ing

and

invo

lvin

g pe

ople

Con

sent

Car

e an

d W

elfa

re

Mee

ting

nutr

ition

al

need

s

Coo

pera

ting

with

ot

her p

rovi

ders

Safe

guar

ding

from

ab

use

Cle

anlin

ess

and

infe

ctio

n co

ntro

l

Man

agem

ent o

f m

edic

ines

Safe

ty a

nd s

uita

bilit

y of

pre

mis

es

Safe

ty a

nd s

uita

bilit

y of

equ

ipm

ent

Req

uire

men

ts

rela

ting

to w

orke

rs

Staf

fing

Supp

ortin

g st

aff

Ass

es a

nd

mon

itorin

g qu

ality

of

Com

plai

nts

Rec

ords

1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 CommentsPatrick Stead Hospital, Halesworth Last inspection report 01 May 2013

Southwold Hospital, Southwold Last inspection report 27 February 2014

Beccles House – Community Service Last inspection report 21 December 2013

of 44

Appendix 3

Acronyms used in report

A&E – Accident and EmergencyCCG – Clinical Commissioning GroupC.Diff – Clostridium DifficileCHC – Continuing Health careCQC – Care Quality CommissionCQRM – Clinical Quality Review MeetingCQUIN – Commissioning for Quality and InnovationEEAST - East of England Ambulance Service NHS TrustECCH – East Coast Community HealthcareFFT – Friends and Family TestGYW – Great Yarmouth and WaveneyHCAIs – Healthcare Associated InfectionsHR – Human ResourcesIC24 – Integrated Care 24INR – International Normalised RatioJPUH – James Paget University Hospital NHS Foundation TrustKLOEs – Key Lines of EnquiryLAC – Looked After ChildrenMDT – Multi-disciplinary TeamMRSA – Methicillin Resistant Staphylococcus Aureus MSA – Mixed sex AccommodationNCHC – Norfolk Community Health and CareNICE – National Institute for Clinical ExcellenceNNUH – Norfolk and Norwich University Hospital NHS Foundation TrustNSFT – Norfolk and Suffolk Foundation TrustOOH – Out of HoursPIRs – Post Infection ReviewsQIPP – Quality, Innovation, Productivity and PreventionQIR – Quality Incident ReportRCA – Root Cause AnalysisRTT – Referral to TreatmentSHMI – Standard Hospital Mortality IndexSI – Serious IncidentSSNAP – Sentinel Stroke National Audit ProgrammeWHO – World Health Organisation

of 44

· web viewexecutive summary (maximum 500 word limit) ... infection p. revention & control...

Documents