report to the board of directors 2016/17 · report to the board of directors 2016/17 ... been...

Attachment 5

Report to the Board of Directors 2016/17

Date of meeting 24 June 2016

Subject Quality and Safety Report

Report of Medical Director, Director of Nursing and Director of Governance

Prepared by Anna Hills, Director of Governance

Purpose of report This Quality and Safety Report is intended to provide the Board of Directors with assurance regarding the status of key performance indicators for quality and compliance with external requirements for Serious Incidents (SIs), Never Events, patient safety incidents and alerts, Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) and the NHS complaints and litigation process. This report has been crossed referenced to the KPIs within the Performance Report later on the agenda.

Previously considered by

(Committee/Date)

N/A

Board Action Required Approval X Discussion

Decision Information

Executive Summary and recommendations The Board of Directors is asked to approve the report as providing sufficient assurance on the actions being taken.

240616 Quality Report Anna Hills, Director of Governance June 2016 REP/BOD/0606/V1 of 29

Strategic Context/Objective(s) and Board Assurance Framework links Strategic aim(s)

To be safe X To be effective X To be caring X To be responsive To be well-led X

Strategic objective(s) 1. Delivery of this year’s Quality priorities X 2. CQC compliance/improvement X 3. Financial control/performance requirements 4. Workforce strategy General - no specific link to a current year’s objective

BAF reference(s) 1 and 2

This paper provides assurance against the Trust objective(s) identified X

This paper is to close a gap in control/assurance in relation to the objective(s) X

Legal/regulatory Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Health and Safety at Work Act etc 1974

Equality Impact/risks: Equality Delivery System 2 – EDS2 Nov 2013)

Impact

Positive Negative Neutral

X

Assurance/monitoring Safety and Quality Governance Committee, with exception reporting to the Board of Directors for any areas requiring additional actions to be taken.


CONTENTS Introduction ..................................................................................................................... 4 Care Quality Commission ............................................................................................... 4 PATIENT SAFETY .......................................................................................................... 5

Healthcare Associated Infection .................................................................................. 7 Surgical Site Infections ................................................................................................ 7 Never Events ............................................................................................................... 7 Serious Incidents ......................................................................................................... 7 Falls ............................................................................................................................ 9 Hospital Acquired Thrombosis (HAT) ........................................................................ 10 Inquests..................................................................................................................... 15 Patient Safety Alerts .................................................................................................. 15

HEALTH AND SAFETY ................................................................................................ 16 Health and Safety Events/Horizon Scanning ................................................................ 17

Accidents/Incidents ................................................................................................... 18 RIDDOR Reportable Incidents (Staff and Patients) ................................................... 19

CLINICAL EFFECTIVENESS ....................................................................................... 21 PATIENT EXPERIENCE .............................................................................................. 23

Eliminating Mixed Sex Accommodation .................................................................... 29 Recommendation ...................................................................................................... 29


Introduction

The Board of Directors is required to self-certify that:

The Board is satisfied that the systems and/or processes referred to [in paragraph 5] should include but not be restricted to systems and/or processes to ensure: (a) That there is sufficient capability at Board level to provide effective organisational leadership on the quality of care provided; (b) That the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations; (c) The collection of accurate, comprehensive, timely and up to date information on quality of care; (d) That the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care; (e) That the Trust, including its Board, actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and (f) That there is clear accountability for quality of care throughout the Trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate.

This report provides evidence to support the Board of Directors in making this self-certification. This report is intended to provide information regarding the status of key performance indicators for quality and to provide assurance regarding compliance with external requirements for Serious Incidents (SIs), Never Events, patient safety incidents and alerts, Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) and the NHS complaints and litigation process. The content and format of this report will continue to develop over time and should be viewed in conjunction with the Quality and Performance dashboard. Activity data to provide context to this month’s report is available via the operational and performance reports.

Care Quality Commission The Care Quality Commission (CQC) conducted a planned inspection at the Trust in August 2015. This inspection resulted in an overall ‘Good’ rating for the Trust. However, the CQC required the Trust to make improvements in order to become compliant with the following HSCA 2008 (Regulated Activities) regulations: Regulation 15 (1) (a) (c) (e) The provider was failing to ensure equipment: including emergency equipment was properly checked. The provider failed to ensure in the theatres that all the environment was properly maintained. Regulation 17 (1) (2) (c) The provider was failing to ensure that each service user had an accurate, complete and contemporaneous record of their care including Do Not Attempt Cardio Pulmonary Resuscitation and had failed to ensure a consistent approach to end of life care pathway. The published report also suggested improvements that the trust should consider. The Trust has developed detailed improvement plans to address the issues identified at the inspection for each core service.


The Patient Safety and Effectiveness Committee has established a sub-group (EPSEC) which meets fortnightly to receive progress updates on the Trust and core service level improvement action plans. All of the actions are completed or progressing according to plan. We have been notified that the CQC will return to re-inspect the Trust on 16th and 17th August 2016. This is an opportunity demonstrate that we meet the standards required to improve the Trust rating. We have been allocated an inspection manager and are working up the detailed arrangements. An Inspection Preparedness Plan has been implemented to enable the Trust to meet the demands of the inspection process. This includes completion and submission of a Provider Information Request, a presentation by the Chief Executive and site visits and interviews with members of the Executive and our staff and patients. This plan also describes the actions we will take to prepare the Trust using dedicated communications and increasing the visibility of leads in service areas to offer challenge and support. The inspection team will be made up of 12 people and will comprise CQC Inspectors and specialists who will review the following areas:

Core Service Surgery Core Service End of Life Care Safety across all services

The inspection team could decide to expand their plan and therefore we are not complacent about our performance within the other domains and Core Services and have these under regular review. EPSEC can provide assurance to the Board that the improvement actions identified will be completed by the deadline of 30th June 2016 and during the weeks leading up to the inspection we will be focusing on ensuring that these actions have made the necessary impact on safety and quality.

PATIENT SAFETY

Mortality Crude Mortality Table 1 shows the actual number of deaths that occurred at the James Paget Hospital either as an admitted patient or within the A&E Department, this table is also reflected in a graphical format in Figure 1 as crude mortality and Figure 2 as a mortality rate per inpatient discharges from hospital.

240616 QAnna HillJune 201REP/BOD

Figure 1

Figure 2

Table 1Mortal

2013/1

2014/1

2015/1

2016/1

FiguresTrust’s which hhave beincludesrecommthe dev

Latest SThe latebeen re3 showsvalue o

Quality Report s, Director of G6

D/0606/V1

1 : Statistica

2: Statistica

: Actual deaity Ap

14 107

15 100

16 87

17 138

s 1 and 2 deMortality Le

has been adeen referreds two patien

mendations velopment o

SHMI resultest data avaeproduced bs that the Sf 109.7 and

Governance

al process c

al process co

aths within tr May

7 113

0 75

7 74

8 91

emonstrate aead, Dr Ail, dapted to cad for more dnts who susfrom the def a Mortality

ts ailable for Sbelow with SHMI at Qua by the Dr F

control chart

ontrol chart

the James PJun Jul

111 94

84 92

91 79

a mortality rhas reviewe

apture moredetailed revistained a faletailed repory dashboard

SHMI is for QSHMI scoresarter 2 of 20Foster Intell

t for actual d

for mortality

Paget Aug Se

91 6

89 9

91 7

rate above ted these de informationew by the Ml. Work is ort to the Boad.

Q2 of the fins multiplied

015/16 is abigence meth

deaths with

y rate within

ep Oct

66 87

92 99

72 85

the control laths utilisin

n to supportMedical Moron-going to ard of Direct

nancial yearby 100 for cove the nathodology is

Page

in the Jame

n the James

Nov Dec

83 83

93 104

76 110

limits for Apg part 2 of t

t mortality rertality Reviecontinue to tors in Marc

r 2015/16. Tcomparisonional averagrated ‘as ex

e 6 of 29

es Paget

s Paget

c Jan

3 100

4 119

0 112

pril 2016. Ththe crematioeviews. Thrw Group; thintroduce th

ch 2016, inc

The SHMI cn with HSMRge of 1.0, wxpected’.

Feb Mar

82 88

119 96

107 113

he on forms, ree cases his he

cluding

chart has R. Figure

with a


Figure 3

HealthSee Ind There hdate. There hoccurrin The Trucases o Surgic

Six rootrelated wired ereview oDirecto Surveill Never

There h

Seriou

The Seprocesshas beerequireddate. T

Incide

59819

59930 See Ind


D/0606/V1

3: Q2 of 201

hcare Assodicators 4 an

have been n

has been onng in May 2

ust has receor 13.1 per 1

cal Site Inft cause anato two hip rlbow. The Dof all orthoprs separate

ance on ca

Events

have been z

us Inciden

rious Incides to the comen followed d timescale

There were 2

ent Number

dicator 3 in t

Governance

15/16 SHMI

ociated Infnd 5 in the P

no (0) cases

ne (1) case o016.

eived notifica100,000 occ

fections alysis investreplacementDirector of Ipaedic surgily.

esarean sec

zero (0) Nev

ts

ent (SI) Regmmissioners

in terms of s to the com2 new SIs re

r Inciden

12/05/2

16/05/2

the Perform

I and HSMR

fection Performanc

s of hospital

of hospital a

ation of thecupied bed

igations havts, two fractInfection Preical site infe

ction infecti

ver Events r

ister contains. Assurancproviding 3

mmissionerseported as

nt Date

2016

2016

mance Mana

R (rolling 12

ce Managem

acquired M

acquired C

trajectory fodays.

ve been contured neck oevention an

ections whic

on rates ha

reported in 2

ns formal Sce can be pr3 day updates (or via priooccurring in

Descript

Pressure

Pressure

agement Re

2 month to p

ment Report

MRSA bacte

Difficile dur

or 2016/17.

nducted folloof femurs, ond Control (Dch will be pre

s commenc

2015/16 and

Is, which mrovided to Bes and root or agreemenn May 2016

tion

e Ulcer Grad

e Ulcer Grad

eport for SIs

Page

period show

t.

eraemia dur

ing 2016/17

This rema

owing surgione knee repDIPC) has resented to t

ced.

d 2016/17 y

ust follow thBoard that th

cause analynt), through.

de 3 - Hospi

de 3 - Hospi

per 1000 b

e 7 of 29

n)

ing 2016/17

7 year to da

ains the sam

cal site infeplacement arequested athe Board o

year to date

he agreed rehe correct pyses within out 2016/17

ital Acquired

ital Acquired

bed days.

7 year to

te,

me at 17

ections and one

a detailed of

.

eporting process

the 7 year to

d

d


Figure 4

Figure 5

Pressu Figure 6

Data foof comp

number of SIs

2014/1

2015/1

2016/1


D/0606/V1

4: SIs repor

5: Cumulativ

ure Ulcers

6: Hospital A

r hospital acpletion of th

0

2

4

6

8

Jun

Total SI's

April

15 9

16 5

17 ytd 3

0

10

20

30

40

50

60

70

80

Governance

rted June 20

ve SIs repo

s

Acquired G

cquired Grae root cause

n‐15 Jul‐15 A

4 7

May June

17 24

10 14

5

2014

2015

2016

015 to May

orted by yea

rade 3 Pres

ade 3 pressue analysis i

Aug‐15 Sep‐1

0 5

e July A

32

21

4/15

5/16

6/17 ytd

2016 (Total

ar

ssure Ulcers

ure ulcers isnvestigation

5 Oct‐15 Nov

4 5

August Sept

38 39

21 26

l = 41)

s

s provided tns.

v‐15 Dec‐15 J

5 1

Oct N

43 4

30 3

Page

to March 20

Jan‐16 Feb‐16

2 2

ov Dec

49 53

35 36

e 8 of 29

016 due to th

6 Mar‐16 Apr

6 3

Jan Feb

61 65

38 40

he timing

‐16 May‐16

3 2

March

69

46

F

F

Nb

fFll


Figure 7

Data fotiming o

Falls

Figure 8: In

01020304050607080

Number of Falls

Total Falls

Falls with Har


D/0606/V1

7: Hospital A

r hospital acof completio

-patient falls

Jun‐15 Jul

66 7

rm 23 2

Governance

Acquired G

cquired Graon of the roo

s June 2015

‐15 Aug‐15 Se

70 61

28 20

rade 2 Pres

ade 2 pressuot cause ana

5 – May 201

ep‐15 Oct‐15 N

60 65

28 25

ssure Ulcers

ure ulcers isalysis inves

16

Nov‐15 Dec‐15

65 61

24 18

s

s provided tstigations.

Jan‐16 Feb‐1

50 57

18 18

Page

to February

16 Mar‐16 Apr‐

49 70

21 27

e 9 of 29

2016 due to

‐16 May‐16

0 53

7 16

o the

Total Falls

Falls withHarm


Figure 9: In-patient Falls per 1000 bed days May 2015 - April 2016

National Falls audit data for 2015 has identified a national average of 6.63 falls per 1000 bed days. The Trust average throughout 2015/16 is 5.03 falls per 1000 bed days.

Hospital Acquired Thrombosis (HAT) See Indicator 9 in the Performance Management Report for VTE risk assessment on admission. Figure 10: Numbers of HAT incidents

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

Jun‐15 Jul‐15 Aug‐15 Sep‐15 Oct‐15 Nov‐15 Dec‐15 Jan‐16 Feb‐16 Mar‐16 Apr‐16 May‐16

Series1 5.42 5.80 5.18 5.19 5.41 5.61 4.92 3.97 4.72 3.79 5.90 4.51

0

20

40

60

80

100

120

140

April May June July Aug Sept Oct Nov Dec Jan Feb March

2014/15

2015/16

2016/17 ytd


Safety Thermometer The Safety Thermometer survey is a national tool used to provide a snap shot of ‘harm free care’ on a single day each month. The survey is specific to four areas of harm:

Pressure ulcers Falls Catheter Associated Urinary Tract Infection Venous Thromboembolism

The survey combines pre hospital and hospital acquired harms and the table below illustrates the incidence (new) and prevalence (admitted with) of harm free care separately.

Hospital Acquired ‘Harms’

Revised Harm Free Care score

All pressure

ulcers

New pressure

ulcers

Falls with harm

All UTIs and

catheter

New UTI and catheter

New VTE

Harm Free Care

JPUH May 2016 (Sample size: 399) 3.79 96.21 5.69 1.63 0.00 2.17 1.63 0.54 91.60

National Figures May 2016 2.20 97.80 4.50 1.00 0.60 0.70 0.30 0.40 93.90

The Safety Thermometer should be used by Trusts to review their own trends against each of the harms. The following graphs demonstrate these trends; the red line represents hospital acquired harms whilst the blue line represents hospital acquired and admitted with harms together. These graphs demonstrate change over time however it is important to recognise this data is based upon point prevalence.

Figure 11: Pressure Ulcers

0

1

2

3

4

5

6

7


All Pressure Ulcers 2.96 4.75 6.2 5.47 3.49 3.37 4.76 6.63 2.05 5.78 3.26 5.69

New Pressure Ulcers 0.25 0.79 1.08 0.78 1.07 0.26 1.06 0.74 0.51 0.25 0.5 1.63

All PressureUlcers

NewPressureUlcers


Figure 12: Falls

Figure13: Catheter Associated UTIs

Figure 14: VTE

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40


Falls with Harm 0.99 1.32 0.00 0.26 0.27 0.78 0.00 0.25 0.26 0.00 1.00 0.00

0

0.5

1

1.5

2

2.5

3

3.5


All UTIs and Catheter 2.71 1.32 2.96 1.56 1.34 1.3 1.32 0.74 3.07 2.01 0.75 2.17

New UTI and Catheter 0.74 0.79 0.81 0.26 1.07 0.78 0.53 0.49 1.02 0.75 0.5 1.63

All UTIs andCatheter

New UTIandCatheter

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8


New VTE 0.49 0.53 0.27 0.26 0.27 1.55 0.26 1.47 0.26 1.51 0.25 0.54


Figure 15: Hospital Acquired Harm

Figure 16: Harm Free Care

0

0.5

1

1.5

2

2.5

3

3.5

4


Hospital Acquired ‘Harms’ 2.46 3.43 2.16 1.56 2.68 3.37 1.85 2.95 2.05 2.51 2.26 3.79

86.00

88.00

90.00

92.00

94.00

96.00

98.00

100.00


Revised Harm Free Care score 97.54 96.57 97.84 98.44 97.32 96.63 98.15 97.05 97.95 97.49 97.74 96.21

Harm Free Care 93.10 92.08 91.37 92.97 94.64 93.01 93.65 91.40 94.37 91.21 94.74 91.60

Revised HarmFree Carescore

Harm FreeCare


Patient Safety Incidents There were 8020 incidents reported by the Trust in total over the rolling year to end of April 2016. 4638 of these were reported as Patient Safety incidents which equates to 54%. The most recent report from the NRLS shows that for incidents reported between 1st April 2015 and 30th September 2015 the Trust sits in the top 50% of reporters for all acute (non-specialist) trusts. This has been made possible through raising awareness of what constitutes a Patient Safety Incident (PSI) and monthly monitoring of what has or, more importantly, has not been submitted as a PSI.

Month and Year

Number of Patient Safety

Incidents reported on Safeguard

Number of

Serious Incidents

Number of Never Events

None Minor/ Non-Permanent

Harm

Moderate/ Semi

permanent Harm

Major/ Permanent

Harm

Catastrophic/Death

Jun-15 395 4 0 302 70 23 0 0

Jul-15 433 7 0 325 91 17 0 0

Aug-15 383 0 0 308 67 8 0 0

Sep-15 376 5 0 276 87 12 1 0

Oct-15 356 4 0 264 77 14 1 0

Nov-15 368 5 0 284 73 10 1 0

Dec-15 422 1 0 329 77 15 1 0

Jan-16 401 2 0 320 72 9 0 0

Feb-16 349 2 0 254 77 18 0 0

Mar-16 429 6 0 335 80 12 2 0

Apr-16 384 3 0 302 65 15 1 11

May-16 342 2 0 265 61 16 0 0

Totals 4638 41 0 3564 897 169 7 1

Duty of Candour See Indicator 7 in the Performance Management Report. The Trust remains fully committed to delivering the ’Being Open’ policy and has developed a process for identifying incidents which are required to be communicated to patients under the Duty of Candour definitions. Below is a summary of compliance with this process for May 2016 and an update on reported compliance for April 2016.

1 Still awaiting confirmation of harm from Emergency Division

May 2016

Division

No of Moderate Harm and

above incidents

No of patients verbally informed

No of letters sent

Reasons for Delay/Exemption

Elective 2 1 One patient in hyper-

delirium with no NOK


NB: Italics denote figures reported in last month’s Quality and Safety Report

Inquests

There were 21 inquests pending as at 15th June 2016. A full investigation has been undertaken or is in progress into each and lessons learnt can be evidenced.

Patient Safety Alerts See Indicator 2 in the Performance Management Report. The Board of Directors can be provided with assurance that the Trust has declared compliance with all safety alerts as issued via the Central Alert System with exception of one alert, for which we are partially compliant as previously reported to the Board of Directors: NHS/PSA/D/2014/010 Standardising The Early Identification of Acute Kidney Injury (AKI) by integrating an AKI algorithm into local information management system. Compliance was required by 9th March 2015. Compliance is affected by national issues with the software however a work around is in place. Our software supplier has scheduled the installation of AKI V2.1 (the fixed release) on the 15th June. This will then be tested locally during week commencing 27th June with a provisional ‘go-live’ date of 4th July 2016. The Executive Team receives a weekly report on progress of all safety alerts and the Safety Committees review these in detail at each monthly meeting. Organisational Learning from Patient Safety Information and Analysis During May a number of recommendations were made following root cause analysis investigations into serious incidents. Furthermore, the Divisional reports to the Patient Safety and Effectiveness Committee provide information of the specific actions being taken to improve patient safety, such as:

Awaiting confirmation from Division re: letter

Emergency 1 1 1

Total 3 2 1

April 2016

Division

No of Moderate Harm and

above incidents

No of patients verbally informed

No of letters sent

Reasons for Delay/Exemption

Elective 2 2 1 Letter for second case delayed as patient died

Emergency 3 2 2

Patient passed away and decision taken not to undertake conversation with grieving family

Total 5 4 3


Following several Controlled Drugs (CD) incidents a number of actions have been identified: Bespoke CD training has been implemented for Band 7 and 6 nurses which will be

cascaded out to Band 5 nurses; A ‘ready-reckoner’ calculation tool for ketamine dosing has been introduced; Dispensing bungs have been purchased for measuring liquid CDs to aid measurement

and reduce the need for decanting thus reducing the amount of loss from bottles. Following a fall incident:

A bedrails warning sign has been developed which will be trialled through June on EADU.

HEALTH AND SAFETY Annual Health and Safety Audit Plan Divisional areas of the Trust are now completing a health and safety self-assessment, progress is monitored bi-monthly at the Health and Safety Committee. The audits will be copied to the central Risk and Safety Department to highlight themes and for benchmarking. A full audit plan for the Facilities Department for 2016/17 has been drafted with an initial pilot which was carried out within Waste, Goods Receipt, Goods Distribution, Postal and Logistics Services. This audit template was well received and a full audit schedule will now be implemented. Dept/Identified Theme

Facilities Management – Root Cause Analysis (RCA) - Release of 350g Gas Cartridge Within Storage Area of Trust Property

Findings

Inappropriate storage of gas cartridges

Inappropriate use of gas cartridges in unventilated area

Failure of gas cartridge safety valve

Lack of supervision/ instruction/ training of staff

Lack of clear safe operating procedures

Actions Full Trust RCA carried out – separate report completed.

Changes made

Appropriate storage of gas cartridges

Review of internal store room

Review of training and instruction of staff

Review of Control Of Substances Hazardous to Health and Safe Operating Procedures

Assurance Framework

Action plan to be monitored at Health, Safety and Staff Welfare Committee

Fire Update The 6 minute fire investigation period was introduced on Wednesday 8th June 2016. Training has been provided to those members of staff directly involved i.e. security porters and switchboard personnel. At the time of writing this report the fire alarm has not been activated so the success of the implementation of the new system has not been put to any test. Norfolk Fire and Rescue Service are aware that the new system is now in place. An issue was also raised with regard to helicopter landings, in that the air ambulance were only contacting A&E directly and not switchboard, this resulted in at least 5 helicopter landings without security presence, therefore the adjacent road was not being closed to traffic and the


helipad was not being checked for foreign object debris. A number of discussions took place with East of England Air Ambulance which has now resulted in them reverting back to the previous agreement of telephoning the switchboard directly of imminent landing; switchboard then passes the caller on to A&E and informs the porters. Health and Safety Events/Horizon Scanning HSE - Sharps inspection initiative 2015/16 Healthcare workers can be at risk of exposure to blood borne viruses (BBVs) due to the nature of their work. Although rare, injuries from sharps contaminated with an infected patient's blood can transmit more than 20 diseases, including Hepatitis B, C and human immunodeficiency virus (HIV). An inspection initiative was carried out in 2015/16 by the HSE to identify any common causes of non-compliance with legislation designed to protect staff from the risk of exposure to BBVs. A summary document, ‘Prevention and management of sharps injuries: Inspection of NHS Organisations’ report the findings. The key findings were as follows:

Health and safety breaches were identified in 90% of organisations visited; 83% failed to fully comply with the Sharps Regulations; Improvement notices were issued to 45% of the organisations visited.

The Trust’s Sharps Prevention Group will review the detail of these findings in order to implement the learning across the trust to reduce sharps injuries. NHS Foundation Trust fined £200,000 for safety failings - 27 May 2016 An NHS Foundation Trust has been fined for safety failings in its management of the use and maintenance of Anetic Aid QA3 trolleys. An investigation by the Health and Safety Executive (HSE) followed an incident that happened in March 2011 when a patient suffered a broken neck and a cut to his head as a result of a fall from a QA3 trolley. He died 26 days later. The investigation found that there was a lack of maintenance to the QA3 trolley and a lack of training in an essential aspect of its use.The Foundation Trust pleaded guilty to breaching Section 3(1) of the Health and Safety at Work etc Act 1974, and was fined £200,000 and ordered to pay costs of £76,305.62. Care Homes fined £400,000 over bedrail failures - 26 May 2016 The Health and Safety Executive (HSE) told the court that the Nursing Home had failed to ensure it managed the risk of bedrails through appropriate assessment and review of bedrail arrangements, and failed to train staff in the assessment of and safe use of bedrails. The court was told the company had a policy on bedrail management but it was not fully implemented as staff were not trained and assessments not conducted or reviewed when required. The case related to the management of bedrails in relation to a vulnerable resident who died at the home. The company failed to ensure the patient’s bedrail assessment was suitable and sufficient, reviewed following falls and deterioration in health and that staff were trained in bedrail risk assessment. The reviews of the bedrail assessment should have identified further measures to prevent the risk of falls, but staff that carried out the initial assessment and reviews were not adequately trained. Furthermore, measures identified to protect the resident where not implemented correctly and increased checks on the resident were not carried out as instructed by a medical professional.


At the hearing the company admitted breaching Section 3 (1) of the Health & Safety at Work etc. Act 1974; Regulation 9 of the Provision and Use of Work Equipment Regulations 1998, and was fined £400,000 with £15,206 costs. Foundation Trust fined over bedrail failures - 29 April 2016 An NHS Foundation Trust has been fined over its inappropriate management of the use of bedrails at its hospitals. HSE told the court that the Foundation Trust failed to ensure that they managed the risk of bedrails, which is a fundamental element of patient safety for which extensive and comprehensive guidance on risk, management and policies existed. An initial HSE visit to the Trust in February 2012 identified issues with bedrail management, and a second visit in May 2012 resulted in the service of an Improvement Notice (IN) on bedrail management and a letter with recommendations. The Trust identified actions to improve bedrail management, but failed to implement them. When the Trust was inspected in July 2013, inappropriate bedrails were found to still be in use and management systems were not appropriate to manage the risk. A further IN on identification and maintenance of third party bedrails was served. The Court was told that the Trust had a policy on bedrail management but did not have the systems or procedures to underpin the implementation of the policy. Elements of the failure were the lack of a system to identify and inspect third party bedrails; the lack of planned preventative maintenance on manual beds and bedrails; a lack of an effective system to rectify faults with inappropriate bedrails; lack of provision of appropriate training, and a lack of procedures to audit and monitor the effectiveness of the bedrail management system. The Foundation Trust admitted breaching Section 3 (1) of the Health & Safety at Work etc. Act 1974.and was fined £100,000 and ordered to pay full costs of £18,465. Accidents/Incidents All accidents and incidents, staff and patients, are reported via the Safeguard system and investigated to ascertain the underlying cause and any necessary further actions to prevent a recurrence. These are reviewed in detail by the Trust’s Health and Safety and Staff Welfare Committee. The graphs below detail the most common categories of incident during 2016/17 where staff or patient injury has occurred.


Figure 17: Patient Injuries reported 2016/17

Figure 18: Staff Injuries reported 2016/17

RIDDOR Reportable Incidents (Staff and Patients)

The graph below details all incidents, involving staff and patients, reported to the Health and Safety Executive under RIDDOR and includes those patient falls resulting in harm which are also reported as Serious Incidents.

14

9

7

43 3 3

2 2 2 2 2 2 21 1 1 1 1

0

2

4

6

8

10

12

14

16

Pressure Ulcer

Bruise

Fracture

Ache/pain

Haematoma

Skin Tear

Ulcers

Abrasion

Extravasation

Graze

Irritation ‐ Eyes

Superficial

Swelling/bump

Trauma

Break Cut

Faint

Inden

tation

Soft Tissue Injury

Number of Injuries

109

43

2 2 2 21 1 1

0

2

4

6

8

10

12

Needlestick

Ache/pain

Pain

Strain/sprain

Bruise

Burn

Fracture

Sore (Muscle)

Graze

Soft Tissue Injury

Trauma

Number of Injuries


Figure 1

IncidenHSE unwork mTrust’s

MontandYear

Apr-1

May-1

May-1

May-1

Jul-15

Aug-1

Sep-1

Sep-1

Oct-1

Mar-1


D/0606/V1

19: RIDDOR

ts of reportander RIDDOust be repocompliance

th r

IncideDate

5 24/04/2

15 04/05/2

15 01/05/2

15 29/05/2

5 13/07/2

15 09/08/2

15 08/09/2

15 09/09/2

5 07/10/2

6

07/03/2

10/03/2

22/03/2

07/03/2

Governance

R reported i

able death, OR within 10

rted within e with these

ent e

ReDaRID

2015 24/04

2015 06/05

2015 19/05

2015 10/06

2015 03/08

2015 25/08

2015 09/09

2015 22/09

2015 14/10

2016 10/03

2016 17/03

2016 29/03

2016 28/04

injuries (all)

specified in0 days of the15 days of treporting re

eport ate of DDOR

Dare

4/2015

5/2015

5/2015

6/2015

8/2015

8/2015

9/2015

9/2015

0/2015

3/2016

3/2016

3/2016

4/2016

njury, or dane incident. the incidentequirements

ays to eport

0

2

18 Inju

12

21 Ovwit

16 Ovwit

1

13

7

3

7

7

52

IP wIV dA&neefing Del

ngerous occOver-seven. The tables.

ury - should h

ver 7 day abshin 15 days

ver 7 day abshin 15 days

was asked todrug abuser E. Needlesticedle through ger to increas

lay in reportin

Page

currence mun-day absen overleaf de

Comme

have been re

sence - shoul

sence - shoul

o help with caand Hepatitisck injury sustglove. IP imm

se bleeding a

ng due to ori

20 of 29

ust be repornce due to inemonstrates

ent

eported within

d have been

d have been

annulation ofs C positive ptained with hmediately sqand applied a

ginally being

ted to the njuries at s the

n 10 days

n reported

n reported

f a known patient in ollow ueezed

alcohol.

g


categorised incorrectly. Further information submitted to the HSE following their email on the 3rd June.

Apr-16 05/04/2016 13/04/2016 8

06/04/2016 11/04/2016 5

11/04/2016 19/04/2016 8

May-16 None None N/A

Organisational Learning from Health & Safety Information and Analysis The following actions have been identified upon review of health and safety incidents, audits and reports:

Key Theme/ Risk Actions

Main themes identified during the Facilities Management – Waste, goods receipt, goods distribution, postal, logistics services HTM-07-01 Health Care Waste – trust is non-

compliant in the storage and handling of clinical waste, this is reported at Hospital Infection Control Committee following on from pre-acceptance clinical waste audit.

Staff access in ramp area an issue with Tugs/ storage and pedestrians and potential of unauthorised access.

Review waste non-compliance at HS&SW Committee

Review access of ramp at HS&SW Committee

CLINICAL EFFECTIVENESS

Clinical Audit Forward Plan See Indicator 64 and 65 in the Performance Management Report. Below are the figures showing progress to achievement of the 2016/17 Forward Plan:

Priority 1 and 2 Must-do audits

Elective Emergency Corporate Total

Number of Audits on Plan 48 44 11 103

Due to start by May 31st 2016

22 19 5 46

Started 21

(95%) 17

(89%) 5

(100%) 43

(93%)

Clinical Audit Forward Plan 2016/17 Completion Rate to 31/05/16 Based on figures for ‘Must-Do’ audits (Priority Rating 1 and 2), excluding continuous national audits

Elective Emergency

Audits started 21/22 17/19

Audits completed 1/2 3/4


Due to complete by May 31st 2016

2 4 1 7

Completed 1

(50%) 3

(75%) 1

(100%) 5

(71%)

NICE Guidelines The figure for implementation of all types of relevant NICE guidance is 86% (389/452) as at 09/06/16 (Note: this figure includes Quality Standards for the first time in this report). There are 29 pieces of guidance currently awaiting initial review. NICE Quality Standards NICE Quality Standards are based on best practice guidance and lay out processes and measures for quality improvement. The current position on Quality Standard implementation is as follows:

108 relevant to JPUH (including 6 potentially relevant, awaiting review to confirm). 49 implemented (4 with a direct review; 45 with implementation inferred from linked

NICE guideline reviews). 18 not implemented (3 with a full gap analyses; 15 to be reviewed by clinicians to

complete gap analyses) 41 to be reviewed by clinicians.

Clinical Guidelines March 2016 There are 267 JPUH Guidelines, 86 Joint Guidelines and 23 guidelines which are either NICE, EOE or National Guidelines available for staff via the Trust intranet. Of the JPUH guidelines:

Number of JPUH Guidelines out of date

Number of JPUH Guidelines out of date in

90 days In Date Total

96 23 129 248


PATIENT EXPERIENCE

Compliments May 2016 Categorisation of the compliments captured at a Trust level on the internal Safeguard reporting system has enabled a further breakdown of the themes to be explored as detailed below. There have been 20 compliments logged during May on safeguard. Patient Experience and Compliments on service have presented as the two main themes this month.

Division Total Department Total

Emergency 14Accident And Emergency JPUH 9

Elective 4 Not specified 2

Not specified 2 Endoscopy Suite 2

TOAL 20 Ear, Nose & Throat OPD 1

Maternity 1

Category Total Ophthalmology OPD 1

Patient Experience 9Short Stay Medical Unit (SSMU) 1

Compliment On Service (General 6 Ward 1 1

Kind 1 Ward 16 1

Medical Care 1 Ward 4 1

Nursing Care 1 TOTAL 20

Professional 1

Responsive To Needs 1

TOTAL 20

In addition, 803 compliments have been recorded at departmental and Divisional level. When combined, a total of 823 compliments have been captured Trust wide (both at Corporate level and at ward/department level) during May. This is an increase of 332 compliments when compared to the April data (n = 491). The compliments captured enable us to evidence some of the positive feedback received into the Trust. Social Media/NHS Choices/Patient Opinion The Trust regularly receives feedback via social media (Facebook, Twitter), NHS Choices and Patient Opinion. The Trust level data breakdown of the feedback and services accessed is detailed below for May 2016:

Date Source Department Feedback May Facebook No department identified Negative May Facebook Ward 4 Positive May Facebook A&E Negative May NHS Choices Gastrointestinal Positive May Facebook Elective – not specified Positive May Facebook A&E/Ward 6 Positive May Facebook Non specified Positive May NHS Choices A&E Negative May NHS Choices A&E Negative May NHS Choices Audiology/hearing aid department Positive


During May the feedback has been predominantly positive attributed to the care and kindness of staff. However, there have been four negative comments; one did not specify the department and all others were attributed to A&E. The ‘non-specified’ feedback related to a patient’s frustration regarding misdiagnosis on four occasions. A response was entered requesting the individual get in touch so that the issues experienced could be investigated, however to date this has not happened. The A&E feedback related to a patient’s frustration of being discharged without an x ray to help establish the cause of the pain, another related to the attitude of the staff nurse tending to a patient and the third related to a patient being informed to go home as there was no one available to perform the required diagnostic tests over the bank holiday weekend. In all cases, a response was submitted requesting that the individuals contact the Trust so that the issues could be investigated further. The issues raised in respect of the A&E feedback are currently being investigated by the senior management team. One of the patients concerned has made contact to share their experiences in more detail and the PALS team are currently supporting the Divisional teams to explore and respond to the issues raised. National Surveys The NHS patient survey programme is currently under consultation with responses due by 21st July 2016. The proposals include:

Discontinuation of the outpatient survey (currently 3 yearly) to incorporate relevant questions into the adult inpatient survey (annual survey);

A review of the A&E survey to incorporate all relevant urgent care services and run every two years (currently 3 yearly);

Increase the frequency of the children and young people’s survey to every two years (currently 3 yearly);

Continue the maternity survey with no changes (2 yearly);

Pilot a new community health services survey;

Continue the mental health survey annually.

National Cancer Patient Experience Survey 2014 Progress to the action plan initially formulated following the National Cancer Patient Experience Survey results is currently under review and this action plan has been reinstated as an agenda item at the Cancer Operational Group to ensure on-going monitoring. Updates are due to be provided at the next Carer and Patient Experience Committee in June. National Cancer Patient Experience Survey (NCPES) 2015 This year, the NCPES results are being published as official statistics. This means that the results will be released in a more controlled way than in previous years and will not be shared prior to the publication date. Anticipated official statistics publication of the national results is 7th June, with CCG and Trust level data being published on 5th July 2016. National Inpatient Survey 2015 The Care Quality Commission published the 2015 National Inpatient survey results on 8th June 2016. Overall, the results demonstrate good performance in line with other Trusts, however,


there are some areas for improvement where the Trust’s performance fell into the lowest scoring 20% of all Trusts; namely planned admission delays, discharge delays and incidences of mixed sex accommodation. However, the findings also evidence the Trust as falling into the top scoring 20% of all Trusts in the following areas; pain control, information and communication of anaesthetic procedures, information and communication at discharge and respect and dignity. The survey findings also evidence a 2% decrease in relation to noise at night. National Inpatient Survey 2016 The National Inpatient Survey 2016 is scheduled to commence in August 2016. Sampling will be drawn from July and posters offering an opt-out opportunity are currently being displayed in all inpatient ward areas to ensure that patients are made aware that the survey will be taking place and that they may be contacted. Posters are displayed a month prior to the sampling month to ensure that all patients who may be contacted have had sufficient notification. National Maternity Survey 2015 An action plan for the National Maternity was presented at the April CAPE meeting and will be monitored via the maternity, Divisional and Corporate Governance structures going forward to ensure improvements are made to address the areas of decline for the Trust based on the previous survey findings. Governors’ feedback The Governors ward and departmental visits continue to take place on a monthly basis; with two governors attending each department/ward supported by a member of senior Trust staff. Feedback is provided to the Divisions following each visit for improvement actions to be implemented, where necessary, and for shared learning to take place in relation to both the positive and the ‘requires improvement’ comments. During May, the feedback from the patient experience visits evidence that staff are seen by patients as caring, friendly and kind. Negative comments, whilst minimal, related to noise, a delayed delivery of required care and communication issues. During May, visits were carried out on Ward 12 and Ward 7. A summary of the feedback is provided below: Positive patient experiences Recommendations for

Improvement Outcome/Action taken

Ward 12

Staff friendly and introduce themselves

One patient advised that they wear a hearing aid and if staff stand on the wrong side of the patient it is difficult for the patient to hear them

This was added onto the staff handover so all staff were aware

Staff caring One patient reported that there is insufficient space between beds in 6 bedded bays when using a commode behind the curtains; patient finds this difficult

All staff will try to encourage all patients to use the facilities and will only use a commode behind the curtains in certain situations

Staff seen to support infection prevention, always use gel/wash hands

Son of one patient advised that he felt his mother had been left too long before stoma bag emptied and therefore patient

Consultant advised patient has high output stoma; stoma bags have been changed recently to provide additional drainage bag


was left in a mess facility and therefore enhanced comfort for patient. Success of this will be monitored going forward.

Patients privacy and dignity needs are respected in that curtains are drawn appropriately as required

One patient reported that they would like a bigger clock in the bay that also displays a date so that patients know what day/date it is.

The clocks we have are the large dementia clocks that are throughout the hospital and that also have the date on them.

Patients spoken to would recommend to friends and family

One patient reported the ward was a bit noisy at night – noise from other patients.

As a general medical ward with a high percentage of patients with acute confusion or delirium,noise from other patients can sometimes be an issue, especially at night, earplugs are available and the night staff actively encourage patients to use them.

Patients report hygiene is good on the ward

One patient’s daughter was upset that her father was given bad news without discussing with the family first so that one of the family members could be present. Daughter also expressed concerns over mixed messages re diagnosis, patient told he had cancer, then advised otherwise, then told again after further investigation that he did have cancer.

This incident occurred in EADU just before the patient was transferred to the ward. Feedback shared with EADU Ward Manager for appropriate action and feedback

Staff respectful

Ward 7

Ward Sister reported to be very helpful

Noise issues at night.

Food 10/10 One patient reported that they would like to have a TV/radio.

Care excellent One patient reported a delayed discharge as waiting for the urologist to remove his catheter so that he can go home.

Sister explained that the urologist has been and this case is more complex as the patient has gone into retention on both occasions that the catheter has been removed.

Staff kind and attentive One patient reported a delayed discharge, advised that the staff telephoned his wife at lunch time to collect and they are still waiting at 4 pm.

Sister advised that she is trying to provide education regarding the discharge processes and communications given to patients by staff.

One patient spoken to reported staff use hand gel and that there is a sense of security and ‘good will’ on the ward

Curtains used appropriately to protect privacy and dignity

One patient on holiday for the second consecutive year and has


had cause to attend here on both occasions; described the hospital as being like a ‘good hotel’

‘First class treatment’

‘food excellent’

‘staff kind’

Staff appear happy

Staff introduce themselves

Complaints Figure 20:

The Trust received 18 complaints during May, comprising of 43 issues. Whilst the complaints actual numbers continue to remain low, the number of issues highlighted evidences that when patients/relatives/carers do have cause to raise concerns formally; the issues tend to be multiple which increases the complexity of the complaint. By exploring category type, all aspects of clinical treatment, continues to be the overriding issue from the complaints feedback, in line with the national picture. Values and behaviours presented as the second top category type for May with communications and information to patients/carers presenting as the third. When exploring the complaints categories further, attitudes of medical staff presented as the main theme, communication and information the second top theme and attitude of nursing staff as the third theme. Accessible Information Standard Work continues to progress the implementation of the Accessible Information Standard requirements and the action plan for implementation requirements. Updated communications will be cascaded via leadership brief during June.

April May June July Aug Sept Oct Nov Dec Jan Feb March

2014/15 23 39 63 81 102 129 151 171 185 200 232 251

2015/16 22 37 55 70 91 114 129 148 156 174 196 206

2016/17 ytd 14 32

0

50

100

150

200

250

300

2014/15

2015/16

2016/17 ytd


Friends

Figure 2

Area

A&E

Inpatienand Daycase

Maternit(combin

Outpatie

Trust Summa

Figure 2

During and 1% MaterniDuring Trust an


D/0606/V1

s and Fami

21: Friends

PercRecom

ts

es

ty ed)

ents

ary

22:

May 96% o% would not

ity May, 95% ond 0% woul

Governance

ily Test (FF

and Family

Trust S(May 2

centage mmended N

91

97

95

97

96

f patients rerecommend

of respondeld not.

FT)

y

Score 2016)

PercentaNot Recomm

3

1

0

1

1

eport that thd this Trust.

ents accessi

TruResp

Ra(M20

age mended

9.2

18.2

-

-

-

hey would re

ng collectiv

ust ponseate

May 16)

PerReco

28%

20%

-

-

-

ecommend t

ve maternity

Page

NHS Eng(Apr

rcentage ommended

86

96

96

93

-

this Trust to

y services w

28 of 29

land Score r 2016)

PercentNot Recomm

8

1

1

3

-

o friends and

ould recom

EnRe

2

age mended

1

2

d family

mend the

NHS ngland

esponse Rate (Apr 2016)

12.9%

25.4%

-

-

-


A&E During May, 91% of respondents would recommend and 3% would not recommend A&E services to friends and family. Themes from FFT Whilst FFT feedback predominantly evidences that patients would recommend services to family and friends, the Trust continues to explore where improvements can be made in relation to those that would not recommend our services based on the narrative detail provided in the FFT responses. Outpatient Departments During May, positive themes have evidenced staff to be helpful, friendly and professional. Requires improvement themes relate to waiting times. Inpatient areas During May, positive themes evidence staff as thoughtful and attentive. Requires improvement themes relate to noise levels, communication and a perceived need for more staff. Maternity During May positive themes evidence staff to be caring, supportive and wonderful. Requires improvement themes relate to more staff required and communication issues. A&E Positive themes evidence a quick, efficient service. Requires improvement themes relate to the environmental issues; untidiness, lack of magazines, water facilities, wheelchair availability and cleanliness of waiting area. Eliminating Mixed Sex Accommodation See Indicator 48 in the Performance Management Report. There were no breaches of the mixed sex accommodation requirements during May 2016.

Organisational Learning from Patient Experience All feedback captured is shared with the Divisional teams for implementation of improvement actions/shared learning amongst teams and continued monitoring:

‘Know how we are doing’ boards are currently being developed for outpatient areas;

Mini Clip boards have been purchased to enhance FFT data collection processes, based on their successful implementation in the Day Care Unit;

FFT champions are being allocated in some ward/department areas to support an enhanced FFT response rate;

Revised recruitment processes have been established with local colleges of further education/sixth form colleges to support an enhanced student volunteer cohort;

Nine prospective dementia befrienders are currently going through the recruitment process to support an enhanced experience for patients with dementia;

Escort processes have been revisited for patients transferring from emergency care to wards. Nurses are to escort patients so that they feel reassured and a safe, and so thorough, informative handover between the two clinical areas can be achieved

Recommendation The Board of Directors is asked to approve the report as providing sufficient assurance on the actions being taken.

report to the board of directors 2016/17 · report to the board of directors 2016/17 ... been...

Documents