enclosure: l agenda item: 16 governing body … body... · summary of actions, if any, following...

Enclosure: LAgenda item: 16

GOVERNING BODYTitle of paper: Quality report

Date of meeting: 28 March 2018

Presented by: Yvonne Leese Title: Director of Quality and IntegratedGovernance& email contact: [email protected]

Prepared by: Anne Douse Title: Associate Director of Quality& email contact: [email protected]

Corporate Objective addressed by this paper (please select one or more with an X):

1. To commission safe, sustainable, efficient and affordable services to meet thehealth and wellbeing needs of the population of Greenwich and reduce healthinequalities with an additional focus on the urgent and emergency care systemimprovement along the pathway

x

2. To ensure the CCG’s position recovers to meet its financial and governance dutiesand performance standards

x

3. To nurture and support primary care to be resilient and thrive

4. To strengthen productive relationships with partners and the public to work as ahealth and care system

x

5. To actively engage with our communities to improve their experience of healthcare x6. To play an active and influential role in shaping SE London and London wide

commissioning.

Purpose of the report:This report has been compiled to update the Governing Body and provide assurance regarding thequality of commissioned services and highlight areas of quality improvement. The report alsoprovides an overview of the CCG position in relation to Continuing Healthcare (CHC) keyperformance indicators (KPIs) and the Quality Alert Management System (QAMS), including‘reverse reporting’ from commissioned services.

Key Highlights: Lewisham and Greenwich NHS Trust (LGT) has established a Quality Assurance Working

Group to oversee the implementation of their CQC inspection action plan. The CCG isrepresented at this group.

A commissioner “quality visit” took place at Lewisham Hospital Emergency Department inJanuary 2018 and a further visit to Queen Elizabeth Hospital (QEH) is planned.

NHS Resolution has provided all trusts with details of a CNST incentive scheme for trustproviding maternity services. The scheme requires trusts to discuss compliance with CCGsbefore submission on progress with the 10 actions by the end of June 2018.

Oxleas has reviewed themes from homicide investigations. Oxleas are taking part in work being undertaken across London Mental Health trusts

regarding treatment of clients with schizophrenia. The CCG performance in meeting the compliance requirements for NHSE targets for

Continuing Healthcare (CHC) decisions being reached within 28 days for Q3 has fallen

2

below trajectory and an improvement plan has been submitted to NHSE. The CCGforecasts that it will achieve the required standard by the end of March 2018 as planned.

Between 12 and 16 February 2018 there was a joint inspection of the multi-agencyresponse to children who go missing, are at risk of child sexual exploitation and who are atrisk of criminal and other forms of exploitation through gangs. The inspection included a“deep dive” focus on a number of cases in which these issues were known to be concernswhere children were involved. The report is awaited by the end of April 2018 after which apartnership Improvement Plan will be developed.

Summary of actions, if any, following this meeting:Actions will be followed up through Clinical Quality Review Groups (CQRGs) and Quality reviewswith providers.

Previous committee involvement: Quality Committee

Recommendations to the Greenwich Executive Group

The Governing Body is asked to note the content of this report

(Please provide details below where Yes is indicated )

Impact on Governing Body Assurance Framework (x) Yes x No N/AImpact on Environment (x) Yes No N/ALegal Implications (x) Yes No N/AResource and or financial implications (x) Yes No N/AEquality impact assessment (x) Yes No N/APrivacy impact assessment (x) Yes No N/AImpact on current NHS Outcomes Framework areas (x) Yes x No N/APatient and Public Involvement (x) Yes x No N/ACommunications and Engagement (x) Yes x No N/AImpact on CCG Constitution (x) Yes No N/A

Attachments:

i. Quality Report

GB Quality Report March 2018 Page 1

QUALITY BRIEFING REPORT

February 2018

Lewisham and Greenwich NHS Trust (LGT)

CQC inspection:Following CQC inspections in 2017, the trust has produced an action plan with actions to deliverimprovements in line with CQC recommendations. A key aspect of this is the quality assuranceworking group (QAWG) responsible for monitoring, tracking and reviewing progress of the overallimprovement plan. The Associate Director of Quality at Lewisham CCG has been confirmed as therepresentative for Lewisham, Greenwich and Bexley CCGs and will attend this meeting in future. TheClinical Quality Review Group (CQRG) continues to review progress and seek assurance on theeffective implementation of the plan.

Emergency Care:The CQRG has requested evidence from the trust regarding the impact of emergency careperformance on clinical effectiveness and patient outcomes. This is particularly important in the lightof challenges faced in all aspects of urgent and emergency care due to increased demand over thewinter period.The CQRG was informed the Trust now has in place 4 hourly quality and safety reviews for allpatients to ensure any concerns are escalated utilising the agreed pathways. This action is in line withrecommendations arising from the CQC inspections. Additional quality rounds are undertaken by theHead of Nursing, Matron and Clinical Director to monitor the effectiveness of the quality and safetyreviews.Regular audits of delayed transfers of care are being carried out along with reviews of seriousincidents, complaints and patient feedback. Key themes identified are the need to improvecommunication related to patient discharge, long waiting times for emergency department andspecialist doctors. This is attributed to physical capacity in the department. CQRG has requestedaction plans to address the issues and regular updates.The trust reported three 12 hour trolley breaches in A&E on 17 January 2018 under the duty ofcandour.

Commissioner visits to emergency departments:In response to the increased activity within the two A&E departments quality visits were arranged atboth Lewisham and QEH during January 2018 by the three commissioning CCGs quality leads(Lewisham, Greenwich and Bexley). The first visit to Lewisham Hospital was carried out on 15January 2018 with broadly positive feedback (the full report is awaited). The second visit to QEH wasplanned to take place the following week, but was delayed due to pressure within the emergency caresystem and across SEL on the day. Another visit was arranged for 12 March 2018, but once againwas delayed due exceptionally high pressure within A&E; a further visit is being arranged as soon aspossible.

Maternity Services:NHS Resolution recently contacted all NHS Provider trusts with details of a CNST incentive schemefor those delivering maternity services to support the DH Maternity Safety Strategy. The process willrequire trusts to self-certify with board sign off progress on 10 actions by 29 June 2018. It isanticipated progress regarding the 10 actions will be part of regular quality monitoring discussions andreview by CCGs and trusts have been asked to discuss their compliance before submission to NHSResolution with commissioning CCGs.


Maternity deep dive:Pan London scorecard:The SEL maternity group is collecting GP views to review the current medical information processrequired for antenatal booking.Early access rates for women 12+3 booking at QEH is 83.3% (target= 85%). Antenatal booking ratesat 10 weeks is 44.5% target = 85%.

C- Sections:LGT have similar C section rates to others in SEL with the exception of PRUH. The trust is carryingout a number of audits based on the Robson criteria and has in place a number of iniatives to supportwomen to have a natural birth. Audit results will be reported to CQRG alongside action plans.

Saving babies lives:This is a national iniative with 4 work streams:

Reducing the number of women who smoke during pregnancy, the trust has trainedObstetricians and Midwives to establish whether pregnant women are smoking and to referthem to quit smoking services. However, referral rates are low at 1%. This programmerequires review by the trust with commissioners.

Improving the management of women with reduced fetal movements, information is providedto all women regarding fetal movements including appropriate advice.

Improving fetal monitoring, staff now undertake improved training and education, this includesa competency test. All fetal monitoring is monitored centrally on both the QEH and Lewishamsites.

Improving detection of small for gestational age babies, this includes compliance with NICErequirements and additional scans to aid early detection.

Episcissors:Commissioners noted the use of episcissors is nationally prescribed to reduce the incidence of 3rd

degree tears for women in labour. The trust is implementing the OASI (obstetric and anal sphincterinjury) care bundle which includes the use of episcissors.

Workforce report:The November workforce report highlights:

Vacancies = 16.55% ▲(16.27% in 16/17) trust target = 12% Agency pay as a percentage of total pay = 7.31▼ (7.6% in 16/17) trust target = 6%. Total trust pay to date = £13.6m ▼ (30% reduction on 2016 which was £17.2m) This was

attributed to Pan London pay rates for Doctors, moving to permanent and bank staff reducingagency spend.

Annual staff turnover = 14.45% ▲(13.87% in 2016/17) trust target = 12% Sickness and absence = 4.7% ▬ (4.73% in 16/17) trust target = 3.5%

The trust reported being able fill 90% junior doctor vacancies with agency staff to ensure appropriatestaffing levels.

Safer staffing:Commissioners noted the comprehensive safer staffing dashboard, but expressed concern regardingnursing establishment, recruitment and retention with high staff vacancies in accident and emergencymedicine. The trust reported this is also an issue for other London trusts and they had used moreagency staff to ensure safe staffing levels. They are mobilising a number of initiatives such asadopting learning from the St George’s model of skills academies and workshops.CQRG has information at each meeting and will continue to monitor and review the position with thetrust.


Under duty of candour the trust reported staffing shortages across different clinical areas andparticularly in nursing. This is monitored daily and staff redeployed to ensure safe care is provided.

Flu immunisation as a key CQUIN remains below the 75% target, currently 45%. The trust has inplace 10 internal peer immunisers to support achieving the target. The trust also reported havingaccess to 1,500 flu vaccines in case of a flu outbreak.

Complaints:The Trust performance for response to complaints has deteriorated again and most delays relate tothe surgery division. The Trust has put in place additional support and performance review and willcontinue to report progress.

Safeguarding:Children’s core safeguarding training compliance has further deteriorated. Medical staff compliancecontinues to be an issue of concern for staff is below compliance level, which is of concern. The Trustcontinues to take a number of actions and the issue will be reviewed at the next CQRG.Prevent WRAP training is at 66%, an improvement on the last report.

VTE compliance:The trust is in the process of changing the VTE audit from 10 notes across the trust to 5 notes perward to provide improved assurance on the trust performance with VTE requirements.

Serious Incidents:The Trust has now added falls and fractures to the serious incident (SI) criteria. This will increase thenumber of SIs reported by the trust. This addition was supported by commissioners as a positivemeasure.

National Early Warning Scores (NEWS):A further trust-wide NEWS audit was carried out in December 2017 utilising a revised audit toolfocusing on patients referred to the critical care outreach team (CCOT). The trust has put place inmeasures to embed NEWS across the trust and the audit demonstrated an improvement in escalatingdeteriorating patients, finding 6% of patients were not appropriately escalated. Ward scorecards areutilised as part of the incentive to provide assurance on ongoing compliance.

CQC regulation compliance:While the trust continues to work on improvements the breach of three CQC standards will remain inplace until a follow up review is conducted with a revised report.

Making Time in General Practice:The Making time in General Practice Group met in mid-January and DNA letters were part of theagenda, the group will report back to CQRG.

Fit notes: The trust has confirmed fit notes can be sent to GPs electronically.

Oxleas NHS Foundation Trust

Bromley CCG recently chaired the first of the new style quarterly quality meeting for trust widespecialist and mental health services. Greenwich and Bexley CCGs CQRG met for the first time on abi-borough basis, chaired by Greenwich CCG for community services, the next meeting agenda willbe to examine local mental health services, chaired by Greenwich CCG. The annual work programmeagreed by the three CCGs and the new format incorporates ‘deep dives’ into commissioned servicesto facilitate greater detail and exploration of the quality of each service.


Mental Health CQRG (Bromley, Greenwich and Bexley CCGs)

Mental Health Homicides:The trust has undertaken a review of the themes from the cases, these were similar to other mentalhealth SIs including CPA, discharge planning and engagement. Additionally drug and alcohol issueswere a contributing factor.

Anti-psychotics & Optimising Treatments QI Project:The CQRG received an update and presentation on the work being undertaken across London MentalHealth Trusts. In 2016/17 50% of acute bed occupancy related to patients with schizophrenia andthese are often long and complex admissions.

Challenges in the management of these patients are: Relapse Hospital admission (poor outcome for patients and NHS) Harm to self and others (1 in 10 take their own life and there is a lifetime risk of 16% harm

to others)

Clinical evidence based reviews confirm medications make a significant difference.Oral medications are particularly problematic where there is treatment reluctance/ resistance.One quarter of patients do not take oral medications 10 days after admission.SLP Prescribing Project Aims:• Minimise poor/non-adherence by increasing use of depot/long-acting medication• Maximise use of clozapine in suitable patientsThe current work streams within the project including information dissemination, benchmarking ofprescribing rates and participation in the POMH national quality improvement programme.

Survey of people who use mental health services:CQRG received a presentation on the annual CQC survey results for adults and older people. 85% ofmental health trusts across the country participate; however, the sample size is a very small subset ofthe total caseload with less than 1% response.

Improved Results:• Continuity of care and knowing who was in charge• Knowing who to contact in crisis

Declining Results:• Knowing who co-ordinates care• Formal annual meetings• Received crisis help after making contact• Explanation of care and treatment• Advice/support on physical health needs and finance/benefits

The results have been presented to Oxleas Patient Experience Group and to Borough Directorateswho were asked to consider the outcomes.

CQUINs:The trust outlined the following challenges with CQUIN requirements:

Flu – despite numerous efforts it was unlikely Oxleas would meet this target Frequent Attenders: Oxleas confirmed actions were underway in Bromley, but there were

challenges in Greenwich Staff Survey – whilst the final survey was not due until the end of Q4 Oxleas felt it unlikely they

would meet the target.


The CCGs agreed confirmation of agreement and sign-off decisions would be shared by the CCGs atthe CQRG meeting.

Quality Report:

Patient Experience:Patient feedback for the internal survey had a larger response rate than in the CQC national survey(not comparable questions). It was noted that the response figures for Bromley are lower as thisrelates to MH services only; Bexley and Greenwich include community services. The trust had ratedresponse from adults with Learning Disability Services red due to the low response rate which wasflagged to service managers to support improvement.

Safeguarding:Oxleas remain on target with PREVENT and WRAP training and have put in place a VIP protocol aspart of safeguarding procedures. The trust is recruiting an Adult Safeguarding lead.

Safeguarding Children:A joint review visit had taken place and the key issues identified were supervision training for CAMHs(this is continuing to be followed-up) and a drop in supervision in Greenwich, both issues are in theprocess of being resolved. The trust aims to ensure all Health Visitors have received level 3 trainingby the end of the financial year. A historic risk regarding the A&E liaison protocol related to Greenwich(QEH) and this is being audited by the trust.

Mortality & Learning from DeathsOxleas has begun to upload information onto their public website. A new template is now being usedand a record of structured judgement reviews is being progressed.

Workforce report:Oxleas has a programme to reduce vacancy rates and agency staff usage. The trust approach toretention has mainly focused on nursing and AHPs and this is being rolled out to other staff groups.

WRES:Oxleas is working on improving career opportunities, recruitment, protecting staff from harassmentand bullying and leadership opportunities. The trust has also set a WRES target to increase staff atband 8a and above. CQRG requested an update on progress at the next CQRG.

Community CQRG (Greenwich and Bexley CCGs):

The Bexley and Greenwich borough CQRG meeting focussed upon the community Rapid ResponseService (Greenwich) and JET (Bexley).

Rapid response:This service commissioned by Greenwich CCG has noted the increasing acuity of patients beingreferred to the service over recent months, there has also been an increase in referrals from LondonAmbulance Service. The team has constant access to a Consultant Geriatrician to ensure patientsreceive appropriate care and there is a daily handover with daily multidisciplinary (MDT) input.The service presentation highlighted staff shortages for senior physiotherapists, social workers andsocial work assistants which mirrors the position across London.The service presented information on clinical effectiveness and commissioners requested this shouldhave a greater emphasis on quality assurance in future. The service has recently undertaken a studyon falls and will focus on the patient journey in the next study.


Commissioners requested at least six months of data in future, instead of the one month provided toaid comparison. In addition information on both formal and informal complaints was requested as wellas more detailed information on actual patient numbers within the report.

Greenwich Intermediate Care:Commissioners requested admission and readmission rates to be audited on at least a twice yearlybasis

Greenbrook Healthcare (Urgent Care Centre (UCC) at QEH)

Patient Safety:Quarter 3 information indicates there have been no Serious Incidents (SIs) over the reporting period,a total of 34 incidents have been reported.

Safeguarding:Children:57 referrals were made to Social Services up to the end of Quarter 2 of 2017-18.191 children subject to a Child Protection Plan and 68 Looked After Children were seen in thedepartment. Two child protection referrals and 14 new referrals were made to social services. Sixchildren and young people with bullying and assault concerns were seen in the UCC.Adults:Within UCC there was one adult safeguarding alert and 5 adult safeguarding referrals were made toSocial Services. 2 adults were identified as having domestic violence concerns. 4 adults at risk withmental health issues, 1 with adults at risk with drug or alcohol issues and 2 adult carers at risk.

Audits:The UCC has a programme of monthly audits, all audits have improvement plans and feedback tostaff incorporated; the reported audits were:

Child and Adult Safeguarding, indicating a number of learning points, but also two aspects ofexemplary practice.

A consultation notes audit showing an improvement on the previous audit. Streaming referral audit Emergency Department referral, the results indicate overall improvement in the quality of

referrals and an increase of referrals to the ED.

Patient Experience:Complaints and ComplimentsA total of 15 complaints and two compliments were received in Quarter 3. All complaints wereacknowledged within three working days and 13 received a response within 4 weeks. The complaintsrelated to staff behaviour and attitude, the environment, waiting times, x-ray, diagnosis, medication,and the out of hours service.

Friends and family75.46% of patients attending UCC were likely or extremely likely to recommend the UCC to friendsand family.

UCC attendance 148 unregistered patients attended the UCC and 60 patients were supported to register with a

GP 72 patients attended for dressings and 62 could potentially have been seen in Primary Care.


Circle (Musculo-Skeletal Service)

VTE assessment:Circle reported a reduction in VTE assessment compliance to 95% at BMI Shirley Oaks. However,compliance remains within tolerance levels.

LGT performance:PROMS (Patient reported outcome measures) continue to improve month on month for the contract,now at 56% (target =80%)18 RTT at 87.6% in the last report, Circle is monitoring and reviewing the 18 week RTT trajectory withLGT in the light of the national directive.LGT has provided exception reports for routine physiotherapy assessments and orthopaedicassessments. These issues are reviewed at each meeting with Circle alongside action plans andplans for improvement.

Continuing Healthcare

Quality Premium 17-18

Table 1 – Monthly NHS CHC assessments <15% DST to take place in an acutehospital settingMonth July Aug Sept Oct Nov Dec JanTrajectory <15% <15% <15% <15% <15% <15% <15%Performance 9% 5% 5% 7% 5% 8% 14%

Table 2 Quarterly

July Aug Sept Oct Nov Dec Jan

Performance 9% 5% 5% 7% 5% 8% 14%

<15% DST Completed inAcute

15% 15% 15% 15% 15% 15% 15%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Less

than

15

%o

fD

STC

om

ple

ted

inA

cute

Sett

ing


NHS CHC assessments <15% take place in anacute hospital setting

Quarter Q2 Q3 Q4Trajectory <15% <15% <15%Actual 9% 10%Variance >6% >5%

Table 3- Monthly

NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the Checklist(or other notification) >80%Month July Aug Sept Oct Nov Dec Jan Feb MarchTrajectory 50% 50% 50% 51% 55% 60% 65% 75% 82%Performance 50% 63% 50% 44% 64% 77% 36% 79Variance >0% >13% >0% <7% >9% >17% <29% >4%

Q2 Q3 Q4

<15% DST in Acute 15% 15% 15%

Actual 9% 10%

0%

2%

4%

6%

8%

10%

12%

14%

16%

<15

%D

STC

om

ple

ted

inA

cute

Quarterly Performance


Table 4- Quarterly

NHS CHC eligibility decision is made by the CCG within 28 days from receipt of the Checklist(or other notification) >80%Quarter Q2 Q3 Q4Trajectory 50% 55% 74%Actual 54% 62% TBCVariance >4% >7

July Aug Sept Oct Nov Dec Jan FebMarc

h

Trajectory 50% 50% 50% 51% 55% 60% 65% 75% 82%

Performance 50% 63% 50% 44% 64% 77% 36% 79%

>80% Completed within 28Days

80% 80% 80% 80% 80% 80% 80% 80% 80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

>80

%C

om

ple

ted

wit

hin

28

Day

s

Monthly Performance

Q2 Q3 Q4

Trajectory 50% 55% 74%

Actual 54% 62%

>80% Completed within 28Days

80% 80% 80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

>80

%C

om

ple

ted

wit

hin

28

Day

s

Quarterly Performance


Exception reporting for 80% of DST being completed within 28 daysThe CCG’s performance dipped from▲ 69% in December 2017 to ▼36% in January 2018 which was

29%▼ below the internal trajectory. This was due to challenges in capacity with Nurse Assessors and

the Social Worker. The following actions have been implemented to manage the issues going forward

and ensure planned consistency with meeting the monthly performance trajectory.

The CHC nurse assessors will provide a weekly highlight report, to ensure that any delays can

be anticipated and managed pro-actively in month

A meeting had been scheduled with RBG to agree medium/long term plans for Social Work

capacity

CHC nurse assessors to gain access to provider clinical information systems to ensure timely

completion of assessments

The CHC nurse assessors are where possible, utilising the Multi-Disciplinary Team

(MDT) capacity in the community, and where discharge-to-assess patients have been sent to

Duncan House, to use both the Social Worker and MDT team to support DST assessments

thereby reducing demand on the one and half days allocated social work capacity.

Data is being collected weekly by the CHC Administrator to enable the Commissioning

Manager to track and monitor the position and anticipate delays taking remedial action where

necessary.

The CCG has recently submitted its Q3 improvement plan to NHSE for non-compliance of the 80%

target of decisions made within 28 days. Although the CCG exceeded its internal performance

trajectory of 55% by 7%, it was still 18% below the expected national performance target. The CCG is

forecasting achievement of the key performance indicators by March 2018 as planned.

Quality Improvement Highlight Summary

LGT: A&E 4 hourly quality and safety reviews for all patients to ensure any concerns are escalated

utilising the agreed pathways, supports the improvements required in the CQC report Use of episcissors, following concerns raised by commissioners regarding the non-use of

episcissors by the trust, the trust is now putting in place nationally prescribed practice toreduce the incidence of 3rd degree tears for women in labour. The trust is implementing theOASI (obstetric and anal sphincter injury) care bundle which includes the use of episcissors

A multiagency discharge event (MADE) took place at QEH in February 2018 involvingGreenwich CCG and Local Authority, Bexley CCG and Local Authority, NHSI, South EastLondon surge hub and LGT senior medical and nursing staff. This followed a one day reviewby ward and clinical staff of all patients with a length of stay greater than 7 days. The reviewexamined the patient journey, learning and actions that needed to be taken by all agencies toimprove this in the future.

Oxleas: Recruitment a Safeguarding Adult lead following recommendation by the CCG Mortality and learning form deaths process continues to be embedded and improved by the

trust.

Infection control: Post infection reviews are in place with acute trusts and general practice to ensure effective

action plans are in place and learning from reported cases


Quality Alert Report April – December 2017

The Quality Alert System is the process by which Greenwich GP practices are able to feed concernsderived from their interactions with patients and providers of services commissioned by NHSGreenwich CCG. Between 1 April and 31 December 2017 the CCG received and processed 72Quality Alerts and Reverse Quality Alerts. Below is a breakdown of the member practices and serviceproviders who raised alerts through the QAMS system.

Providers


Themes Trend

The highest number of concerns related to poor communication on discharge summaries beingreceived by practices. This has been fed back to LGT via the CQRG and as a result the clinicaldivisions are all working towards the Trust standard to improve this. This will be reviewed regularly atCQRG until an improvement is seen and sustained.


Outcomes of Quality Alerts

Reverse Reporting from Providers

The CCG received 16 reverse quality alerts from NHS Lewisham and Greenwich Trust :

Themes


Outcomes

LearningCommunication to all GPs to confirm with the patient at point of referral that they have they most up-to-date patient information and contact details.GP to emphasise at point of referral the importance of the patient being available for the 2 week waitappointment.Referral forms to be checked to ensure all relevant information has been included.

Status

UpdateQAMS App will also be available soon to GPs using Vision


Joint Targeted Area InspectionBetween 12-16 February 2018 Ofsted, CQC, HMI Constabulary and Fire & Rescue Services and HMIProbation undertook a joint inspection of the multi-agency response to children who go missing, are atrisk of child sexual exploitation and who are at risk of criminal and other forms ofexploitation throughgangs. The inspection included a “deep dive” focus on a number of cases in which these issues wereknown to be concerns where children were involved.

The report from this inspection is awaited by the end of April 2018 after which a partnershipImprovement Plan will be developed.

enclosure: l agenda item: 16 governing body … body... · summary of actions, if any, following...

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