foundation trust - nhs great yarmouth and · pdf filepage 1 of 43 title of meeting ... summary...

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Title of meeting Governing Body Agenda Item 9

Date of Meeting 29th September 2016 Confirm Part One or Two

Part One

Title of Paper Quality and Safety Report

Responsible Director Cath Byford, Director of Commissioning & Quality

Author Quality and Safety Team

Action 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 re-inspection undertaken on 6th and 17th August 2016, report awaited.

Mixed Sex Accommodation breaches continue due to lack of bed availability.

One Never Event reported in September 2016 involving a GYW patient.

East Coast Community Healthcare (page 10)

CQC inspection scheduled for week commencing 31 October 2016.

Staffing issues leading to temporary closures of Patrick Stead Hospital and Beccles MIU

Norfolk and Norwich University Hospitals NHS Foundation Trust (page 14)

CQC report published on 16 March 2016 judged the NNUH as ‘Requires Improvement’ overall.

One Never Event reported since April 2016, not involving a GYW patient.

Cancer performance remains challenging. Improvement in some metrics but 62 day pathway still not at nationally mandated levels

Norfolk and Suffolk NHS Foundation Trust (page 17) CQC report published on 3 February 2015 judged NSFT

as ‘Inadequate’ overall.

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Comprehensive improvement plan in place being managed by Monitor.

CQC re-inspection undertaken across Norfolk and Suffolk in July 2016, report awaited.

Norfolk Community Health & Care (page 19) See full report.

Integrated Care 24 (111 / Out of Hours) (page 19) Call response times being closely monitored.

East of England Ambulance Service NHS Trust (page 20) CQC inspection undertaken April 2016. Overall rating

‘Requires improvement’. EEAST performance is below both the national

standards and agreed recovery trajectories.

Infection Prevention & Control Performance (page 22) C. Difficile Infection (CDI) trajectory for 2016/17 is 70

cases. Local outbreaks of ESBL and Legionella

GYW CCG Complaints & PALS Enquiries (page 25) See full report.

Care Provider CQC Overview (page 27) See full report.

Summary of Quality and Safety Team Activity – April / May 2016 (page 33)

See full report.

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 ☐

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Links to strategic risk register:

Risk scoring and description:

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

Consequence (impact)

Ra

re

Un

lik

ely

Po

ss

ible

Lik

ely

Alm

os

t

Ce

rta

in

1 2 3 4 5

1 Negligible 1 2 3 4 5

2 Minor 2 4 6 8 10

3 Moderate 3 6 9 12 15

4 Major 4 8 12 16 20

5 Catastrophic 5 10 15 20 25

Without controls 4x4 =16 (Red)

With controls

3x3 = 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

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

N/A

QIPP/Better Care Fund N/A

Statute/Compliance/ Governance Issues

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

NHS Constitution

Equality Impact Positive ☐ Negative ☐ Neutral

Human Resources N/A

Patient Engagement N/A

System 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 Emergency CCG – Clinical Commissioning Group C.Diff – Clostridium Difficile CHC – Continuing Health care CQC – Care Quality Commission CQRM – Clinical Quality Review Meeting CQUIN – Commissioning for Quality and Innovation EEAST - East of England Ambulance Service NHS Trust ECCH – East Coast Community Healthcare ESBL - Extended-spectrum beta-lactamases FFT – Friends and Family Test GYW – Great Yarmouth and Waveney HCAIs – Healthcare Associated Infections HR – Human Resources IC24 – Integrated Care 24 INR – International Normalised Ratio IPC – Infection Prevention and Control JPUH – James Paget University Hospital NHS Foundation Trust KLOEs – Key Lines of Enquiry LAC – Looked After Children MDT – Multi-disciplinary Team MRSA – Methicillin Resistant Staphylococcus Aureus MSA – Mixed sex Accommodation NCHC – Norfolk Community Health and Care NICE – National Institute for Clinical Excellence

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NNUH – Norfolk and Norwich University Hospital NHS Foundation Trust NSFT – Norfolk and Suffolk Foundation Trust OOH – Out of Hours PIRs – Post Infection Reviews PSQC – Patient Safety and Quality Committee QIPP – Quality, Innovation, Productivity and Prevention QIR – Quality Incident Report RCA – Root Cause Analysis RTT – Referral to Treatment SHMI – Standard Hospital Mortality Index SI – Serious Incident SSNAP – Sentinel Stroke National Audit Programme WHO – 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/A

Commissioning N/A

QIPP and Delivery N/A

Information N/A

Contracting N/A

Engagement N/A

Governance N/A

Quality and Safety Rebecca Hulme – Deputy Chief Nurse

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1.0 James Paget University Hospital (JPUH)

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

June 2016

Area Total

Responses Total

Eligible Response

Rate %

Recommended % Not

Recommended

A&E 452 5429 8.3% 93% 2%

Inpatients 1252 6257 20% 97% 1%

Maternity – Antenatal Care

9 Not

available Not

available 89% 0%

Maternity – Birth

61 163 37.4% 100% 0%

Maternity – Postnatal Ward

45 Not

available Not

available 96% 0%

Maternity – Postnatal Community Provision

11 Not

available Not

available 100% 0%

July 2016

Area Total

Responses Total

Eligible Response

Rate %

Recommended % Not

Recommended

A&E 587 5897 10% 91% 3%

Inpatients 1145 6337 18.1% 96% 1%


9 Not

available Not

available 100% 0%

Maternity – Birth

34 195 17.4% 100% 0%


42 Not

available Not

available 100% 0%


8 Not

available Not

available 100% 0%

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 August 2016 will be published by NHS England on 6 October 2016 and the FFT data for September 2016 will be published by NHS England on 10 November 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.

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

CQC Inspection Area Ratings

Safe? Requires improvement

Effective? Good

Caring? Good

Responsive? Good

Well-led? Good

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/

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The CQC undertook a re-inspection on 16th and 17

th August ’16 for which the final report

is awaited.

1.3 Mixed Sex Accommodation (MSA)

No reported MSA breaches in August and September 2016 to date. 1.5 Serious Incidents (SIs) / Never Events

Serious Incidents reported:

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

Jul 2016

Aug 2016

3 3 5 5 3 2 4 4

A Never Event was reported by the Trust in September 2016. This is the first since July ’14.

The event is currently under investigation.

SIs that currently remain open (as at 06.09.16) pending investigation are noted within the

following table:

SI number Category Incident

Date Reported

Date Current Status

2016/13493 Delayed Diagnosis 10/04/16 18/05/16 Report received. Action plan

awaited.

2016/15448 Grade 3 Pressure Ulcer 06/06/16 07/06/16 Report received. Action plan

awaited.

2016/19477 Infection Control 20/07/16 20/07/16 Currently under investigation

2016/20056 Fall 20/07/16 27/07/16 Currently under investigation



2016/20529 Grade 3 Pressure Ulcer 29/07/16 02/08/16 Currently under investigation




The GY&W CCG Patient Safety and Clinical Quality Committee continue to identify SIs to be reviewed in more detail; with an in depth report being presented on a biannual basis. This focuses on completed RCAs and details behind any delays in submission. 1.6 Quality Issue Reporting (QIR) QIRs reported:

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

July 2016

Aug 2016

6 9 4 3 9 14 4 7

1.7.1 Open / Closed / Void 15 QIR remain open pending investigation, 3 are pending closure and 3 have been voided:

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QIR Ref Date

Reported Source of QIR Description of Concern Status

Date reminder

sent

JPUH/401 17/05/2016 Norfolk County

Council No care reinstated for discharge.

Under investigation

13/09/16

JPUH/404 07/06/2016 Park Surgery Inadequate examination. Pending closure

JPUH/405 10/06/2016 ECCH No care reinstated for discharge. Under

investigation 13/09/16

JPUH/407 21/06/2016 Beccles Medical

Centre Incorrect discharge summary.

Under investigation

13/09/16

JPUH/408 21/06/2016 Nelson Medical

Practice Inappropriate referral.

Pending closure

JPUH/409 21/06/2016 Nelson Medical

Practice Incorrect patient letter sent electronically from clinic.

Under investigation

13/09/16

JPUH/411 28/06/2016 ECCH No discharge summary or care arrangements.

Under investigation

13/09/16

JPUH/412 28/06/2016 ECCH No referral / discharge notice received.

Under investigation

13/09/16

JPUH/413 26/06/2016 NNUH Inadequate planning and communication.

Under investigation

13/09/16

JPUH/414 17/05/2016 ECCH Medication and prescribing error.

Under investigation

13/09/16

JPUH/415 15/07/2016 Park Surgery Dispensing error. Under


JPUH/418 27/07/2016 Chet Valley Medical

Practice No discharge summary.

Pending closure

JPUH/420 02/07/2016 ECCH Inappropriate discharge. Under


JPUH/421 15/08/2016 Andaman Surgery Transfer delay. Under


JPUH/422 23/07/2016 Cutlers Hill Surgery External communication failure regarding treatment.

Under investigation

13/09/16

JPUH/423 23/08/2016 ECCH No drug chart provided on admission.

Under investigation

13/09/16

JPUH/424 24/08/2016 EEAST Communication failure regarding admission.

Under investigation

13/09/16

JPUH/425 22/07/2016 Park Surgery Delay in receiving blood results. Under


Difficulties with discharge processes continue to account for the highest number of incidents reported which is monitored at the CQRM. 1.8 Infection Prevention & Control The ceiling of maximum c-difficile cases within JPUH for 2016/17 has nationally been determined as no more than 17 avoidable cases. More detailed information is supplied in section 8 of this report. 1.9 Stroke Performance

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): Apr – Jun ‘15 Jul – Sep ‘15 Oct – Dec ‘15 Jan – Mar ‘16

D1 Scanning B B B C

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D2 Stroke Unit B B C C

D3 Thrombolysis C D C C

D4 Specialist Assessments B B B C

D5 Occupational Therapy A A A A

D6 Physiotherapy C B A B

D7 Speech & Language Therapy D C C C

D8 MDT Working D D C D

D9 Standards by Discharge B B B B

D10 Discharge Process B B B B

Patient-Centred SSNAP Level B B B C

Representatives from the Patient Safety and Quality committee met in May with clinical staff

from the Trust to better understand the data presented in the report. The availability of staff

is the main challenge to improving performance against the measures.

1.10 Cancer Target Performance

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.

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

Q1 Q2 Q3 Q4

100%

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

Q1 Q2 Q3 Q4

100%

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

Q1 Q2 Q3 Q4

N/A

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

Q1 Q2 Q3 Q4

89.76%

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

Q1 Q2 Q3 Q4

97.73%

2 week wait from referral to date first seen –

All Cancers (Target – 93%)

Q1 Q2 Q3 Q4

96.32%

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1.12 Slips, Trips and Falls (July 2015 to June 2016) The graph below shows the number of inpatient falls covering the period from July 2015 to June 2016.

There was an increase in falls and in falls with harm in June 2016. However, throughout 2015/16, the Trust average of falls per 1000 bed days is 5.03 (year to date). This compares favourably with the national average for 2015 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.

2.0 East Coast Community Healthcare (ECCH) 2.1 CQC The CQC due to undertake a planned inspection during week commencing 3 October 2016. 2.2 Serious Incidents (SIs)

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

Jul 2016

Aug 2016

1 5 2 3 3 1 1 0

SIs that currently remain open (as at 06.09.16) are all being investigated within the contractual time-frame. These are noted within the following table:


Date Reported

Date Current Status





2 week wait from referral to date first seen –

Symptomatic Breast Cancers (Target – 93%)

Q1 Q2 Q3 Q4

96.75%

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Since August 2015, ‘Deep Tissue Injury’ has been added as a category onto Datix. A Deep Tissue Injury (DTI) is an undetermined, ungradable, and purple in colour pressure area. These areas are now reported as DTI’s and are reassessed on or before the 14th day, at which point it may have healed or may have developed into a Grade 3 Pressure ulcer and will be reported as a SI and investigated accordingly.

2.3 Quality Issue Reporting (QIR)

QIRs reported against ECCH:

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

July 2016

Aug 2016

5 4 2 0 1 1 1 1

2.3.1 Open / Closed / Void 2 QIRS are open pending investigation:

QIR Ref Date

Reported Source of QIR Description of Concern Status

ECCH/059 01/08/2016 Andaman Surgery Monitoring delay. Under

investigation

ECCH/060 29/07/2016 Alexandra Road

Surgery Monitoring failure.

Under investigation

2.4 Infection Prevention & Control The ceiling of maximum c-difficile cases with ECCH for 2016/17 has been locally agreed as no more than 4 avoidable cases. More detailed information is supplied in section 8 of this report. 2.5 Pressure Ulcers ECCH’s monthly Quality and Safety Report provides detail regarding the top 4 reporters only, therefore some totals appear higher than the detailed breakdown relating to each grade of pressure ulcer, the remainder relate to ‘other’ services.

Aug Sep Oct Nov Dec Jan Feb Mar April May June July

Grade 1 PU 2 1 5 1 1 3 5 2 2 4 5 5

Admission Prevention - South 0 0 0 0 0 0 0 0 0 0 0 0

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

District Nurses 2 1 3 1 1 3 4 2 1 4 4 4

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

Inpatient 0 0 0 0 0 0 0 0 0 0 0 1

Grade 2 PU 45 70 58 48 57 77 49 65 80 65 45 59

Admission Prevention - South 0 0 0 0 0 0 0 0 0 1 0 0


Community Matrons 0 1 0 0 0 0 0 1 0 0 0 0

District Nurses 39 59 55 43 55 70 46 59 73 60 42 54

Falls Prevention Team 1 0 0 0 1 0 0 1 0 0 0 0

Inpatients 3 7 1 3 1 1 1 2 2 3 0 1

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Lowestoft Out of Hospital Team 1 1 1 0 0 0 0 0 2 0 0 0


Hospice at Home 0 0 0 0 0 0 0 0 0 1 0 2

Grade 3 PU 15 14 14 14 15 16 18 22 15 18 20 17


Community Matrons 0 0 0 1 0 0 0 0 0 0 0 0

District Nurses 13 12 14 11 14 14 17 18 14 17 14 14

Inpatients 2 0 0 0 0 2 1 0 0 0 2 2



Grade 4 PU 3 5 5 0 2 5 6 0 2 1 1 0

District Nurses 3 4 3 0 2 4 6 0 2 1 1 0

Inpatients 0 1 1 0 0 0 0 0 0 0 0 0



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. In June ‘16, 59 Grade 2 Pressure Ulcers were reported and following review only one was assessed as being avoidable to ECCH. Out of the 17 Grade 3 Pressure Ulcers reported in May, one has been assessed as possibly avoidable to ECCH and a full investigation is being carried out to determine the root causes and whether the case can be deemed either avoidable or unavoidable. 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 learning. The Tissue Viability Nurse continues to deliver on-going staff training in relation to pressure ulcer management. Training is also offered to staff in local care agencies where pressure ulcer prevalence continues to be an issue. The health system pressure ulcer prevention plan is now well established. The RCA form was reviewed and updated in July 2016 in order to ensure that investigations are carried out consistently across the organisation. ECCH reports pressure ulcers as Serious Incidents when the defined criteria are met and in accordance with NHS England’s recommendations. 2.6 Slips, Trips and Falls 2.6.1 Recorded Patient Falls in Inpatient Areas

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A number of initiatives are in place within ECCH in the on-going prevention and management of falls. These include:

Delivery of a falls training pack for use with staff,

Exploring the potential benefit of additional assistive technology, The number of falls continues to increase in 2016. This rise is being monitored through ECCH CQRM. The number of inpatient beds will reduce from September 2016 on a temporary basis as Patrick Stead Hospital will be temporarily closed to admissions with a plan to suspend beds whilst staffing levels are reviewed. 2.7 Staffing

As with other health care providers within the system ensuring safe staffing continues to be challenging across the organisation. Recruitment to some vacancies has been successful but remains problematic in other key areas. This is due in part to the uncertainty about future health and care system configuration.

As a result of staff shortages and subsequent safety concerns at Patrick Stead Hospital, ECCH have taken the decision to temporarily suspend the inpatient service pending review. Individuals working at the hospital will be temporarily relocated to other services and supported whilst the review takes place.

The Quality and Safety team are working with the wider CCG to review bed capacity and demand across the system to ensure that patients impacted by the temporary closure have access to safe alternative care.

Safe staffing at Beccles Minor Injuries Unit has also been compromised due to vacant posts, staff absence and uncertainty about future models of care. This has resulted in the reduction in hours of operation. There have also been two occasions where short notice unscheduled closures have taken place. The reduced opening hours has been proposed as a temporary measure whilst future service provision is reviewed in line with national guidance regarding urgent care provision.

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3.0 Norfolk & Norwich University Hospital (NNUH)

3.1 Friends and Family Test

June 2016

Area Total

Responses Total

Eligible Response

Rate %

Recommended % Not

Recommended

A&E 440 6734 6.5% 88% 8%

Inpatients 877 13006 6.7% 87% 3%


12 Not

available Not

available 100% 0%

Maternity – Birth 43 456 9.4% 98% 2%


50 Not

available Not

available 100% 0%


7 Not

available Not

available 100% 0%

July 2016

Area Total

Responses Total

Eligible Response

Rate %

Recommended % Not

Recommended

A&E 312 7270 4.3% 97% 1%

Inpatients 764 12897 5.9% 96% 3%


4 * * * *

Maternity – Birth 26 514 5.1% 100% 0%


22 Not

available Not

available 95% 0%


5 Not

available Not

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 August 2016 will be published by NHS England on 6 October 2016 and the FFT data for September 2016 will be published by NHS England on 10 November 2016. 3.2 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.


Safe? Requires improvement

Effective? Requires improvement

Caring? Good

Responsive? Requires improvement

Well-led? Requires improvement

The Trust has developed a detailed action plan to address the improvements required. Progress against the action plan will be monitored through the NNUH CQRM.

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3.4 Serious Incidents (SIs) for GYW patients

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

Jul 2016

Aug 2016

0 0 5 0 2 0 1 0

SIs that currently remain open (as at 06.09.16) are all being investigated within the contractual time-frame. These are noted within the following table:


Date Reported

Date Current Status

2016/14073 Unexpected Death

18/05/16 23/05/16

RCA received for review – NNUH to provide information about ongoing monitoring of action plan.

2016/19377 Delayed Diagnosis 27/04/16 19/07/16 Currently under investigation

3.4.1 Never Events One Never Event has been reported:

Month Department GYW Patient

May 2016 Cardiology No

3.5 Quality Issue Reporting (QIR) for GYW patients Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

July 2016

Aug 2016

0 0 1 0 1 1 1 0

3.5.1 Open / Closed / Void 2 QIRs remain open pending investigation and relate to GYW patients:

QIR Ref Date Source of

QIR Description of Concern Status

Date reminder sent

NNUFT/397 26/05/2016 ECCH Medication issue. Under


NNUFT/399 07/07/2016 Cutlers Hill

Surgery Medication issue.

Under investigation

13/09/16

3.6 Stroke Performance

Domain (D): Apr – Jun ‘15 Jul – Sep ‘15 Oct – Dec ‘15 Jan – Mar ‘16

D1 Scanning C C C C

D2 Stroke Unit C C C D

D3 Thrombolysis B C B B

D4 Specialist Assessments B B A B

D5 Occupational Therapy C C C B

D6 Physiotherapy B B B B

D7 Speech & Language Therapy D C C C

D8 MDT Working C C C C

D9 Standards by Discharge B B B B

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D10 Discharge Process A A A A

Patient-Centred SSNAP Level B C B B

3.7 Cancer Target Performance (2015/16) Performance for all cancer targets with the exception of the 62 day referral to treatment target has improved in Q1 with all bar one of the mandated targets achieved. Performance against the 62 day pathway performance remains a challenge. Whilst improvement has been made and sustained at >80% achievement, NNUH has yet to meet the 85% performance target. GYWCCG continue to raise concerns about cancer performance and monitors GYW patient pathways on a weekly basis with intervention as required. Attendance at Cancer PTL meetings and bi-weekly outcomes review meeting led by the lead commissioner continues. A number of patients are still waiting >100 days for first treatment. These pathways are all subject to individual scrutiny and root cause analysis (RCA). GYWCCG receives summary information regarding these patients but have requested that the full RCAs are made available for shared learning.

Backlog trajectory:

3.10 Referral to Treatment (RTT) GYWCCG remains 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. The Trust have increased theatre capacity with the provision of a mobile theatre to support day case activity and have increased outpatient capacity through contracts with third party providers. However there has been no impact on performance against the national target of 92%. Following concern nationally regarding processes to track follow up patients resulting in a number of serious incident reports, detail has also been requested from the NNUH relating to patients who have received first treatment and are awaiting systematic follow up. These

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patients are no longer on a referral to treatment pathway and as such are not routinely measured or reported on but can have significant disease. The lead commissioner is working with NELCSU to raise a formal request for this information

4.0 Norfolk and Suffolk NHS Foundation Trust (NSFT) 4.1 Care Quality Commission (CQC) and Monitor The Care Quality Commission (CQC) previously undertook an inspection of the Trust and overall judged NSFT to be Inadequate.

This resulted in the Trust being placed in Special Measures. NSFT developed a comprehensive improvement plan which 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 undertook a re-inspection across Norfolk and Suffolk during July ‘16. The Trust expects to receive the draft report following this visit imminently. 4.2 Serious Incidents / Never Events for GYW patients

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

Jul 2016

Aug 2016

6 2 5 4 2 2 4 4

4.2.1 Current Open Serious Incidents (SIs) reported for GY&W CCG patients: SIs that currently remain open (as at 06.09.16) are noted within the following table:


Safe Inadequate

Effective Requires Improvement

Caring Good

Responsive Requires Improvement

Well-led Inadequate

SI Number Category Incident

Date

Reported

Date Current Status

2016/8107 Unexpected Death of Community Patient (not in receipt)

10/03/16 23/03/16 Currently under investigation

2016/10669 Unexpected Death - Inpatient 16/04/16 20/04/16 Currently under investigation

2016/11135 Unexpected Death - Outpatient 14/04/16 25/04/16 Currently under investigation

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Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

July 2016

Aug 2016

1 4 1 0 1 2 1 2

4.4.1 Open / Closed / Void 2 QIRs remain open pending investigation and 2 are pending closure:

QIR Ref Date Source of QIR Description of Concern Status Date

reminder sent

NSFT/225 13/05/2016 Park Surgery Issue with Crisis Team service. Pending closure

NSFT/227 24/06/2016 Norfolk

Constabulary Incomplete assessment.

Under investigation

13/09/16

NSFT/229 08/08/2016 Bridge Road

Surgery Referral failure to Crisis Team service.

Pending closure

NSFT/230 25/08/2016 Cutlers Hill

Surgery Referral delay to Crisis Team service.

Under investigation

4.5 GYW Patients Placed Out of Area by NSFT As at midday on 12th September ‘16, there were 2 GYW patients placed outside of the NSFT geographical area.

2016/14201 Unexpected Death of Community Patient (in receipt)


2016/15896 Serious Incident by Inpatient (in receipt)




2016/16619 Allegation against HC Professional












2016/21436 Serious Incident by Outpatient (in receipt)



2016/21935 Unexpected Death 16/08/16 17/08/16 Currently under investigation





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5.0 Norfolk Community Health & Care (NCH&C)

5.1 Serious Incidents

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

Jul 2016

Aug 2016

0 0 0 0 0 0 0 1

SIs reported (as at 06.09.16) are noted within the following table:

5.2 Quality Issue Reporting (QIR) for GYW patients

Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

July 2016

Aug 2016

0 0 0 0 0 0 0 0

5.3 Specialist Amputee Rehabilitation Service

The CCG continues to receive an increased number of referrals for this service via the Individual Funding Request (IFR) process. The CCG’s Contracting and Quality and Safety Teams have arranged to meet with NCH&C to discuss the IFR process and associated referrals.

6.0 Integrated Care 24 6.1 Serious Incidents One SI has been reported in 2016-17 to date.


Jan 2016

Feb 2016

Mar 2016

Apr 2016

May 2016

Jun 2016

July 2016

Aug 2016

2 3 2 0 1 0 0 1

6.2.1 Open / Closed / Void 1 QIR is pending closure:

QIR Ref Date Source of

QIR Description of Concern Status

IC24/052 11/08/2016 ECCH Medication issue. Pending closure

6.5 Contract

SI Number Category Incident

Date

Reported

Date Current Status

2016/24101 Unexpected Death 07/08/16 10/08/16

RCA and action plan received – Action plan being monitored through CQRM. Closed on STEIS

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Concerns regarding call answering within 60 seconds resulted in a contract performance notice issued in April ’16 for which a remedial action plan is in place.

7.0 East of England Ambulance Service NHS Trust (EEAST)

7.1 CQC EEAST were inspected by the CQC in April 2016, the outcome of this inspection was an overall rating of ‘requires improvement.’

The Trust is continuing its recruitment campaign and work progressing the ‘Clinical hub’ approach. The focus is now ensuring adequate numbers of suitably skilled and qualified people to provide treatment and the appropriate mentoring and support of these staff. 7.2 SIs for GY&W Patients There was one serious incident reported in September regarding assessment / non-conveyance currently under investigation.There have been no Never Events from 1st April ’16 to date. 7.3 Staffing: EEAST has an agreed recruitment strategy to recruit more than 800 student paramedics which has the potential to impact on the skill mix and knowledge base of available emergency crews. 7.4 Demand: Concerns regarding the management of resources to meet service demand which has resulted in delayed emergency responses and transfers. 7.4.1 Norfolk and Waveney Comparative Performance (April and May ’16):

CCG Apr May Jun Jul

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

NHS GreatYarmouth and

Waveney

NHS Ipswichand EastSuffolk

NHS NorthNorfolk

NHS Norwich NHS SouthNorfolk

NHS WestNorfolk

Red 1

Apr May Jun Jul Target


Safe Requires Improvement


Caring Outstanding


Well-led Requires improvement

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0.00%

20.00%

40.00%

60.00%

80.00%


Waveney


NHS NorthNorfolk


NHS WestNorfolk

Red 2

Apr May Jun Jul Target

NHS Great Yarmouth and Waveney 65.33% 72.73% 63.41% 65.00%

NHS Ipswich and East Suffolk 61.76% 63.64% 61.33% 60.16%

NHS North Norfolk 43.86% 47.62% 46.51% 43.59%

NHS Norwich 63.41% 74.12% 80.82% 68.06%

NHS South Norfolk 36.73% 46.00% 56.52% 28.81%

NHS West Norfolk 50.00% 51.79% 64.06% 59.26%

Target 75% 75% 75% 75%

CCG Apr May Jun Jul




NHS Norwich 66.82% 66.67% 68.70% 65.17%


NHS West Norfolk 52.89% 53.78% 52.79% 50.37%

Target 75% 75% 75% 75%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%


Waveney


NHS NorthNorfolk


NHS WestNorfolk

A19

Apr May Jun Jul

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CCG Apr May Jun Jul




NHS Norwich 96.83% 95.92% 96.37% 95.03%


NHS West Norfolk 86.71% 89.67% 87.50% 84.24%

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 2016/17 The GYW CCG C. Difficile Infection (CDI) trajectory for 2016/17 is 70 cases. From 1 April to 21st September ‘16, there were 34 reported cases. Accountability for these cases is as follows:

7 cases James Paget University Hospital – 3 non-trajectory, 2 trajectory and 2 under review.

23 cases GYW Primary Care – 13 non-trajectory, 8 trajectory and 2 under review

3 cases Norfolk and Norwich University Hospital – 1 non-trajectory and 2 trajectory.

1 case Addenbrookes – non-trajectory.

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8.3 MRSA Four MRSA cases were reported in Norfolk and Waveney during May ’16, however, only one of these involved a GYW patient. This case has been reviewed and upheld by NHS England as Third Party attributable as there were no lapses identified in this patient’s care. This bacteraemia will show on the JPUH Third Party data as the patient was admitted to the acute hospital and treated with antibiotics for an infection. 8.4 Other HCAIs Legionella in care homes. GYWCCG were alerted via Public Health and the Infection Prevention and Control (IPC) Team of a care home resident from GYW with a confirmed legionella infection. Public Health and Environmental Health led on the management of the situation and GYWCCG were kept informed of progress against the action plan Legionella was also detected at high levels during water sampling at a second care home although there were no residents displaying symptoms of infection. GYWCCG contributed to the remedial action plan which was led by the local authority and Public Health England and also to contingency planning had it become necessary to find alternative accommodation for the residents. Extended-spectrum beta-lactamases (ESBL) Klebsiella Pneumoniae outbreak JPUH During July JHUH reported an SI which detailed high incidence of patients with ESBL Klebsiella Pneumoniae. The issue was identified through internal surveillance by the provider and action to further investigate and manage the situation was instigated promptly involving appropriate agencies and system partners. An action plan was developed in

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conjunction with the Health Protection Agency and the regional Public Health team including the IPC team. The plan included robust actions to reduce the number of ESBL Klebsiella pneumoniae cases acquired at the JPUH within a short timescale. GYWCCG have monitored progress against the actions and the number of reported cases has reduced to expected levels within August. The Health Protection Agency commended the provider on their handling of the outbreak and the actions taken and contributed to the recovery plan.

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GYW Complaints 9.1 2016/17 The CCG received 9 complaints during Quarter 1 2016/17, all of which have been closed. Quarter 1 - April to June 2016

Received Acknowledged

within 3 working days

Response to Complainant

Working Days to respond

Primary Complaint Upheld / Not

Upheld / Partially Upheld

12/04/16 yes 05/05/16 17 Commissioning Upheld

18/04/16 yes 19/05/16 23 CHC assessment Partially Upheld

19/04/16 yes 27/04/16 7 Commissioning Upheld

25/04/16 yes 19/05/16 18 CHC assessment Partially upheld

25/04/16 yes 13/05/16 14 Commissioning Not upheld

28/04/16 yes 20/07/16 58 CHC process Not upheld

17/05/16 yes 23/05/16 5 CHC assessment Not upheld

14/06/16 yes 18/07/16 21 Commissioning Partially upheld


Quarter 2 - 1 July 2016 to 31 August 2016

6 Complaints have been received for July and August. 3 complaints have been closed, one was closed but has been re-opened due to ongoing issues and 2 remain open as the investigations are continuing.

Received Acknowledged

within 3 working days

Response to Complainant

Working Days to respond

Primary Complaint Upheld / Not

Upheld / Partially Upheld

05/07/16 yes 19/07/16, re-

opened 5 CHC care Partially upheld


10/08/16 yes ongoing CHC Care



31/08/16 yes ongoing commissioning

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9.1.1 Continuing Healthcare (CHC) The complaints received associated with CHC are regarding the assessment process, provision of care and. 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. Lessons Learned from CHC Complaints There have been no new lessons learnt from CHC complaints but the importance of communication between all parties involved in the CHC process has been highlighted. Please see previous reports for lessons learnt and actions already undertaken. 9.1.2 Commissioner Complaints in this category relate to CCG decisions, in particular with regard to funding of current and future services. CCG funding policies are reviewed regularly, both internally and with other Norfolk CCGs, to ensure equity of access to services and consistent allocation of resources. However, this can lead to service users expressing their dissatisfaction. Example of Lessons Learned from Commissioner Complaints The importance of communication has again been highlighted from Commissioner complaints. The need to ensure all parties involved in decisions are kept informed and that the wording in policies is clear. Specifically the Non-Routine Treatments and Treatment Thresholds (NRTTT) which is to be revised to avoid any confusion. 9.2 Healthwatch Norfolk/ Parliamentary and Health Service Ombudsman (PHSO) On 7 July 2016 two members of the Quality and Safety Team attended the bi-annual

meeting at Healthwatch Norfolk. A representative from the Parliamentary and Health

Service Ombudsman (PHSO) came to the meeting to provide a presentation on the work of

the PHSO with regard to investigating NHS complaints, sharing learning and working better

together.

The presentation was very informative and useful feedback was provided. The PHSO

representative said that they ‘found the meeting really useful’ and commented that

complaints managers were ‘all clearly committed to good complaints handling, sharing

good practice and supporting each other which is always good to see’.

Ongoing dialogue between complaints managers and case officers at the PHSO was

encouraged.

It was noted that Norfolk is below the national average for the PHSO to uphold complaints.

Below is a chart showing the number of health complaints received, investigated and the %

upheld for 2012/13 to 2015/16. This demonstrates that, following the Ombudsman’s

decision in 2013 to change their assessment criteria and investigate many more of the

complaints they receive, the overall percentage of complaints being upheld has inevitably

reduced giving the public and the organisations the Ombudsman investigates a much more

balanced and realistic picture of NHS complaints handling performance.

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NHS Organisational level data:

10.0 GYW PALS Enquiries The CCG has received an increase in PALS enquires for the period 1 April to 31 August 2016 compared to the same period in 2015-16, a total of 97 enquires have been received 24 of which have been from local Members of Parliament. As the nature of the enquiries varies considerably no trends or themes have been identified. Following the announcement of the proposed changes to the 4 services provided at Greyfriars in Great Yarmouth the PALS team have been the contact for the public who needed help or advice regarding the changes. To date, the PALS team has received 51 enquiries via telephone, email and letter. 11.0 Care Provider CQC Overview The CQC publish the compliance status of all registered providers of care on their website. This is not available in a dashboard format to facilitate review of 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 at Appendix 1. Prior to January 2015 providers were assessed and rated against 21 criteria. 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.

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.

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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.

In January 2015 the CQC 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 (correct as at 16 September 2016) 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 34 Care and Residential Homes (Pre-existing Methodology) – Page 38 GP Practices, Acute Hospitals, Mental Health & Community Services (New Methodology) – Page 40 GP Practices, Acute Hospitals, Mental Health & Community Services (Pre-existing Methodology) – Page 42 Key:

O Outstanding (No action required)

G Good (No action required)

R.I Requires Improvement

I Inadequate

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Summary of inspections since the last report (July 2016) - Britten Court, Lowestoft: Inspection report published 23 August 2016 and rated the home

as ‘Requires Improvement’. The previous inspection report was published on 26 June 2016.

- Chevington Lodge, Bungay: Inspection report published 6 September 2016 and rated the home as ‘Good’ overall and across all five domains.

- Holmwood Residential Home, Bungay: Inspection report published 9 August 2016 and rated the homes as ‘Outstanding’ overall and in three domains; Effective, Caring and Well Led.

- Salisbury, Great Yarmouth: Inspection report published 17 August 2016 and rated the home as ‘Requires Improvement’ overall and across all domains.

- St Edmunds, Gorleston: Inspection report published 18 August 2016 and rated the home as ‘Inadequate’.

- St Georges, Beccles: Inspection report published 31 August 2016 and rated the home as ‘Requires Improvement’.

- The Depperhaugh, Hoxne: Inspection report published 29 July 2016 and rated the home as ‘Good’ overall.

- Wainford House, Beccles: Inspection report published 10 August 2016 and rated the home as ‘Requires Improvement’ overall.

- Amber House, Gorleston: Inspection report published 28 July 2016 using the new methodology and rated the home as ‘Good’ overall.

- Florence House, Gorleston: Inspection report published 28 July 2016 using the new methodology and rated the home as ‘Good’ overall.

- Genesis Residential Home, Great Yarmouth: Inspection report published 16 July 2016 using the new methodology and rated the home as ‘Requires Improvement’ overall.

- Lilac Lodge and Lavender Cottage, Lowestoft: Inspection report published 15 July 2016 using the new methodology and rated the home as ‘Requires Improvement’ overall.

- The White House, Beccles: Inspection report published 24 August 2016 and rated the

home as ‘Inadequate’ overall.

11.1 Current Significant Concerns about Care Providers Abbeville Sands, Great Yarmouth (run by Abbeville RCH Limited): Abbeville Sands provides accommodation and care for up to 20 people, some of whom may be living with dementia. The CQC undertook an unannounced inspection at Abbeville Sands on 16 and 18 May ‘16. At this time, there were 16 people living in the home. Abbeville Sands was judged to be ‘Inadequate’ by the CQC, the inspection findings are summarised below:

Domain Rating Notes

Safe Inadequate The provider had not made significant improvements to reduce risks to people's welfare found during the August 2015 CQC inspection. Risks to people's health had not always been reviewed and people's medicines were not managed safely. The recruitment process was not robust to ensure the risks of employing unsuitable staff were minimised although staff knew how to minimise the risks to people of abuse and enough staff were available to meet people's needs.


Most staff training had expired. People's ability to make their own decisions had not been consistently determined and improvements were needed to ensure that people were supported and encouraged to eat and drink. People had access to health professionals to maintain their wellbeing and act upon any

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concerns, but external appointments required better organising.

Caring Requires Improvement

Staff had a kind and caring approach with people and ensured they were treated with dignity, but some people had reservations about the caring nature of some night staff members. People and/or their relatives were involved in discussions about how people's needs were planned and met.


People's individual preferences had been determined but there was little information to guide staff how to support people with specific health conditions. People were confident to raise concerns or queries with the manager and felt that they would be responded to.

Well-led Inadequate The service was not well led. The provider and the registered manager had a poor oversight of the quality of the service and had not made improvements in this area since the last inspection. The provider had failed to ensure that improvements were made since the August ‘15 inspection as many of the same issues remained. The manager had the support of the staff in the home who worked well together as a team but required better support and guidance from the provider and the registered manager.

Highfield Residential Home, Halesworth (run by Bupa Care Homes Limited): Highfield Residential Home is a care home providing care and support to a maximum of 40 older people. The CQC undertook an unannounced inspection over two days, on 16 and 23 October ‘15 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 Notes

Safe 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 were not put into place to minimise the risks. Appropriate checks were carried out on new staff.


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.


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.


The service was not consistently responsive. People did not always have access to appropriate stimulation and activity. Improvements are required regarding the involvement of people or their representatives 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.

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Abbeville Residential Care Home, Great Yarmouth (run by Abbeville RCH Limited): Abbeville Residential Care Home is a service that provides care and support for up to 38 older people and people living with dementia. At the time of the inspection there were 27 people living at the home. The CQC undertook an announced inspection on 9, 10 and 21 December ‘15; following their inspection on 28 January ‘15 where the overall judgement of ‘Requires Improvement’ was given due to breaches of legal regulations. The CQC determined that the provider is ‘Inadequate’ and their inspection findings, detailed in the report published on 12 May 2016, are summarised as follows:

Domain Rating Notes

Safe Inadequate Risks to people’s safety had not been regularly reviewed or updated. Records did not provide staff with adequate guidance about how to reduce risks to people and the management of medicines continued to be unsafe. The provision of staffing levels was not based on an effective dependency assessment tool.


The service was not always effective. People received enough food and drinks to meet their needs but they had little choice about their meals. People had regular and timely access to health professionals. Staff received training but staff competency was not assessed to ensure that the training had been effective. Staff understood the principles of the Mental Capacity Act 2005 to make sure that the rights of people who lacked capacity to make their own decisions were protected.


The service was not always caring. Staff treated people with kindness and compassion. In general, people’s privacy and dignity was respected although there were occasions when this was compromised. People were not involved in the planning of their own care.


The service was not always responsive. People’s care needs were not always reviewed regularly to ensure that staff were aware of people’s current care needs. The activities co-ordinator worked hard to reduce the risk of people experiencing social isolation but people still felt that there were limited activity options.

Well-led Inadequate The service was not well-led.

St Edmunds Residential Home, Gorleston (run by Eastern Healthcare Limited): St Edmunds Residential Home provides accommodation and care for up to 39 older people. The CQC undertook an unannounced inspection on 23 and 30 June and 6 July 2016. The findings 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 Notes

Safe Inadequate Suitable precautions had not been taken to reduce the risks to people from the legionella virus or poor water temperature control.

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Arrangements were not in place to ensure that gaps in the staffing rotas for afternoon and night shifts were filled to cover staff sickness and leave. Medicines were not stored at a safe temperature.


Suitable arrangements were not in place to support people requiring a diabetic diet or to ensure people had enough to drink. Training was required to equip staff with the knowledge to respond appropriately to behaviour that challenged. Consent was sought before people were supported by staff.


Some practices in the home did not promote people's privacy, dignity or independence.


Care plans were not always in place to guide staff in how to meet people's health or emotional needs. People knew how to make a complaint and were confident that if they were to make a complaint it would be appropriately

Well-led Inadequate The provider had failed to take action when high temperatures were recorded in the taps. The provider had failed to ensure that a legionella risk assessment had been carried out in a timely manner when they took over the operation of the service.

The White House, Beccles (run by Healthcare Homes Group Limited): The White House residential home provides accommodation and personal care for up to 33 people. At the time of the unannounced inspection on 15 and 20 June 2016, there were 29 people using the services. The findings 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 Notes

Safe Inadequate Staffing level arrangements were not sufficient to ensure people's needs were met at all times. Risks assessments were in place, but some required more detailed information to ensure staff were provided with guidance on how to reduce risks to people. Risk assessments were not always reviewed in a timely manner. Bathing equipment was unsafe for use. Infection control procedures were not effective.


The service was not always effective. Staff induction training was not robust enough to ensure staff were confident in their roles. Staff acted in accordance with MCA principles, but some DoLS authorisations and MCA assessments were out of date. Peoples' nutritional needs were monitored. People had access to healthcare services to maintain good health.


Staff did not always have the time to provide meaningful Interactions with people, which at times were task focussed and hurried. The CQC could not be assured that people were fully involved in the planning of their care. Peoples' privacy and dignity was respected.


The service was not always responsive. Care plans held inconsistent information and were not always detailed enough to reflect people's individual needs. Activity provision was not sufficient to meet individual needs. People and relatives knew how to complain.

Well-led Inadequate The provider had not ensured that the service was operating effectively to ensure that people were receiving safe and effective care at all times. There were not effective procedures in place to

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monitor the quality of the service. Where issues were identified these were not addressed.

The CQC continues to monitor arising concerns and issues with care homes through chairing the bimonthly multi-agency SharePoint meetings attended by a wide range of stakeholders including CQC, Suffolk County Council, Norfolk County Council and Public Health. 12.0 Summary of Quality and Safety Team Activity May / June / July (to date) 2016 Since the last Governing body report the team have contributed to the following

Clinical visit to Westwood Surgery with ECCH

Icanho neuro-rehabilitation visit - part 2 - Emmanuel Hall

Big listen Evaluation

Clinical Visit to Patrick Stead Hospital

Thurne Ward review

Workforce Partnership - Educational Development Meeting

General Practice Forward View Local Planning Event

Review of Beds with Care at Park House

Interview panel for JPUH Head of Midwifery 13.0 Recommendations The Governing Body note the content of this report.

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Appendix 1 Care and Residential Homes (New Methodology)

Domains

Safe Effective Caring Responsive Well-led Overall rating Date of report Abbeville Lodge, Great Yarmouth

R.I R.I R.I R.I I Requires

Improvement 30 June 2016

Abbeville Residential Care Home, Great Yarmouth

I R.I R.I R.I I Inadequate 30 June 2016

Abbeville Sands, Great Yarmouth

I R.I R.I R.I I Inadequate 01 July 2016

Allied Healthcare, Beccles

R.I R.I G R.I R.I Requires

Improvement 22 February 2016

Amber House, Gorleston

G G G G G Good 28 July 2016

Amber Lodge, Lowestoft

G G G G G Good 30 October 2015

Ashurst Care Home, Lowestoft

G G G G G Good 26 May 2016

Avery Lodge Residential Home, Great Yarmouth

R.I R.I G G G Requires

Improvement 06 July 2015

Beech House Residential Home, Halesworth


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 R.I R.I R.I Requires

Improvement 23 August 2016

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

Cherry Lodge, Lowestoft


Chevington Lodge, Bungay G G G G G Good 06 September 2015

Clarence Lodge, Gorleston



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.

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Eversley Nursing Home, Great Yarmouth

G G G G G Good 06 November 2015

Florence House, Great Yarmouth


Genesis Residential Home, Great Yarmouth

R.I R.I G G R.I Requires

Improvement

Georgina House Domiciliary Care Agency, Great Yarmouth

This service has not yet been inspected since it was registered by CQC on 8 June 2016.

Hales Lodge, Winterton-On-Sea, Great Yarmouth


Harleston House, Lowestoft

G G O G G Good 30 June 2016

Highfield Residential Home, Halesworth

I R.I R.I R.I I Inadequate 05 February 2016

Holmwood Residential Home, Bungay

G O O G O Outstanding 09 August 2016

Imber House, Lowestoft

G R.I G G R.I Requires

Improvement 23 March 2016

Ivydene Residential Home, Ormesby, Great Yarmouth


John Turner House (Leading Lives), Lowestoft


Joseph House, Reedham, Norwich


Kirkley Manor, Lowestoft

G G G G G Good 04 September 2015

Lilac Lodge & Lavender Cottage, Lowestoft



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 Residential Home, Great Yarmouth


Marlborough House, Lowestoft


Marram Green, Kessingland, Lowestoft


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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.

North Bay House, Oulton Broad


Oaklands Residential Home, Reydon

R.I G G R.I R.I Requires

Improvement 06 October 2015

Oulton Park Care Centre, Oulton, Lowestoft

G G G G G Good 08 April 2016

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


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

Requires Improvement

07 July 2015

Salisbury Residential Home, Great Yarmouth

I I I I I Requires


Seahorses Nursing Home, Gorleston, Great Yarmouth

G G G G G Good 20 March 2015

Shaftesbury Court Residential Home, Lowestoft


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.

St David’s Residential Home, Great Yarmouth

G R.I G G R.I Requires

Improvement 25 February 2015

St Edmunds, Gorleston, Great Yarmouth

I R.I R.I R.I I Inadequate 18 August 2016

St Georges Care Home, Beccles

R.I R.I R.I R.I I Requires


St Marys House, Bungay

This 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


The Coach House, Hemsby, Great Yarmouth

R.I R.I R.I G R.I Requires


The Dell – Residential Home, Oulton Broad, Lowestoft


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Wellbeing Care Support Services, Oulton Broad, Lowestoft


The Depperhaugh, Hoxne


The Elms Residential Care Home, Gorleston, Great Yarmouth


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


The Old Rectory, Acle, Norwich R.I R.I R.I R.I R.I


09 October 2015

The Old Rectory, Winterton-on-Sea, Great Yarmouth


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

G R.I G R.I R.I Requires


White House Residential Home, Beccles

I R.I R.I R.I I Inadequate 24 August 2016

Windmill Residential Home, Rollesby, Great Yarmouth


Windsor House, Lowestoft


Woody Point, Brampton, Beccles

G G G G G Good 04 June 2015

of 43

Care and Residential Homes (Pre-existing Methodology)

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Co

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ab

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g

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Rec

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1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 Comments

All Hallows Healthcare Trust, Ditchingham, Bungay – Nursing Beds

Last inspection report 27 March 2014

Bungay House, Bungay


Alexandra House, Great Yarmouth

Last inspection report 22 May 2014

All Hallows Nursing Home, Bungay

Last inspection report 08 January 2014

Broadlands, Oulton Broad, Lowestoft


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 Yarmouth

Last inspection report 30 September 2014

Ealing House, Martham, Great Yarmouth


Gresham Nursing Home, Gorleston

Last inspection report 25 June 2014

of 43

Res

pe

cti

ng

an

d

inv

olv

ing

peo

ple

Co

ns

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Care

an

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are

Me

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ab

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pre

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ab

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Rec

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1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 Comments

Levington Court, Lowestoft

Last inspection report 08 November 2013

Lynfield, Ditchingham, Bungay

Last inspection report 06 November 2013

Newnham Green, Gorleston

Last inspection report 20 September 2014

Oliver Court, Great Yarmouth

Last inspection report 05 December 2013

Orchards Residential Home, Bradwell


Park House, Great Yarmouth


Pine Lodge, Great Yarmouth

Last inspection report 24 June 2014

The Claremont, Caister-On-Sea, Great Yarmouth


The Gables Residential Home, Gorleston, Great Yarmouth


of 43

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

Domains

Safe Effective Caring Responsive Well-led Overall rating Date of report Alexandra Road Surgery (Alexandra and Crestview Surgeries), Lowestoft


Andaman Surgery, Lowestoft


Beccles Hospital, Beccles

The CQC undertook a responsive inspection on the 15 August 2014 in response to concerns that one or more of the essential standards of quality and safety were not being met, this was specifically in relation to the inpatient ward at the hospital. At this time the hospital was meeting the standard for care and welfare of people who use services but was not meeting the standard for assessing and monitoring the quality of service provision. Improvements were required in relation to the leadership at ward level and the systems in place that allowed the service to monitor and assess the quality of the service provided. The CQC undertook a follow up inspection of the service on 27 August 2015 to ensure that these actions had been taken and found that the provider had completed and implemented an action plan and improvements had been made. The CQC judged that the provider was now meeting required standards.

28 September 2015

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


Cutlers Hill Surgery, Halesworth


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


12 November 2015

Fleggburgh Surgery, Great Yarmouth


Gorleston Medical Centre, Gorleston, Great

Yarmouth G G G G G Good 22 January 2015

Greyfriars Health Centre, Great Yarmouth


High Street Surgery, Lowestoft

G G G G R.I Good 08 October 2015

of 43

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

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)


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 since CQC registration on 20 June 2016.

of 43

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

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1 2 4 5 6 7 8 9 10 11 12 13 14 16 17 21 Comments

Patrick Stead Hospital, Halesworth Last inspection report 01 May 2013

Beccles House –

Community Service Last inspection report 21 December 2013

of 43

Appendix 3 Acronyms used in report

A&E – Accident and Emergency CCG – Clinical Commissioning Group C. Diff – Clostridium Difficile CHC – Continuing Health Care CQC – Care Quality Commission CQRM – Clinical Quality Review Meeting CQUIN – Commissioning for Quality and Innovation EEAST - East of England Ambulance Service NHS Trust ECCH – East Coast Community Healthcare ESBL - Extended-spectrum beta-lactamases FFT – Friends and Family Test GYW – Great Yarmouth and Waveney HCAIs – Healthcare Associated Infections HR – Human Resources IC24 – Integrated Care 24 INR – International Normalised Ratio IPC – Infection Prevention and Control JPUH – James Paget University Hospital NHS Foundation Trust KLOEs – Key Lines of Enquiry LAC – Looked After Children MDT – Multi-Disciplinary Team MRSA – Methicillin Resistant Staphylococcus Aureus MSA – Mixed Sex Accommodation NCHC – Norfolk Community Health and Care NICE – National Institute for Clinical Excellence NNUH – Norfolk and Norwich University Hospital NHS Foundation Trust NSFT – Norfolk and Suffolk Foundation Trust OOH – Out of Hours PIRs – Post Infection Reviews PSQC – Patient Safety and Quality Committee QIPP – Quality, Innovation, Productivity and Prevention QIR – Quality Incident Report RCA – Root Cause Analysis RTT – Referral to Treatment SHMI – Standard Hospital Mortality Index SI – Serious Incident SSNAP – Sentinel Stroke National Audit Programme WHO – World Health Organisation

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