THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

Quality Account Six Month Review

EXECUTIVE SUMMARY

The Trust Board approved the Quality Account Priorities 2016 and is now asked to review the progress to date. This paper outlines a six month review of progress and includes results where available.

RECOMMENDATIONS The Board are asked to i) note progress against the 2016/17 quality priorities ii) offer guidance on potential quality priorities for 2017/18.

Mrs. Anne Marie Troy-Smith, Quality Development Manager 8th November 2016

Agenda item A7(ii)

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THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

Quality Account Six Month Review

1. INTRODUCTION / BACKGROUND

Every year the Trust is required to publish a Quality Account which is an annual report written for the public about the quality of the healthcare services it provides. It contains both a retrospective and prospective account of the Trusts Quality Priorities, explaining outcomes and, crucially, looking forward to define the Quality Priorities for the next year. The Trust Board approved the Quality Account Priorities for 2016 and is now asked to review the progress to date.

2. PROGRESS TO DATE Patient Safety Priority 1 - To reduce all forms of healthcare associated infection (HCAI), we will quantify our success in this by:

Aiming for the annual number of Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia cases to be no more than zero

Reducing hospital acquired infections related to Clostridium difficile (C.difficile) to be no more than 77 cases in the next year.

As well as MRSA and C. difficile, the Trust monitors rates of Methicillin-Sensitive Staphylococcus Aureus (MSSA) and E. coli bacteraemia. Six Month Update During the period April 2016 to September 2016, there have been

Two MRSA bacteraemia cases finally assigned to the Trust. There is a ‘zero tolerance’ approach to MRSA infections

31 cases of hospital acquired C. difficile, against an annual target of 77 cases (39 cases were reported but 8 successfully appealed and were therefore not counted towards the target)

39 cases of MSSA bacteraemia

75 cases of E. coli bacteraemia The graphs below indicate the position of the Trust as at the end of September 2016 and the progress made over time in respect of reducing the incidences of these hospital acquired infections. The figures are reported to the Trust Board and Public Health England (PHE) on a monthly basis.

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There are a number of strategies that the Trust has implemented to monitor and reduce the number of HCAIs, these include:

Development of an Infection Prevention & Control (IPC) Operational Plan to replace Health Care Acquired Infection (HCAI) action plans; progress regularly reviewed by Infection Prevention Control Committee and Infection Prevention & Control. HCAI is a standing agenda item at the Trust main forums and Directorate level communication and governance meetings.

Following each case of MRSA bacteraemia a rapid review and Post Infection Review (PIR) Toolkit are completed. A Serious Infection Review Meeting (SIRM) is held and lessons learned are discussed and implemented. This information is collated in a quarterly report, which facilitates the sharing of lessons learned and best practice Trust-wide.

Following each C. difficile case attributed to the Trust, a root cause analysis (RCA) form is completed and the results compiled in a database. This information contributes to the production of the quarterly report. A SIRM is held where C. difficile is on the death certificate or where there are clear

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lessons to be learned (such as lapses in care). A period of increased incidence (two or more cases on a ward within 28 days) leads to a MDT review to discuss the cases.

The Trust has focused on areas where patients are identified at a higher risk of MSSA which include the Cardiothoracic and Renal Services Directorates. High risk patients are now identified and treated chlorhexidine washes. A new abbreviated RCA to examine the source and contributory factors of MSSA in the Trust is now being used and is helping identify themes and lessons to disseminate. ANTT is being focussed on to improve practice around insertion and care of invasive devices.

There are plans to change the SIRM process to focus more on reviewing actions identified at RCA to prevent HCAI, rather than being a forum for reviewing the clinical details of each individual case. The plan is that each Directorate will have a slot every few months (at an agreed interval) and will provide a progress update on what has been put in place in response to RCA findings.

Antibiotic stewardship is a standing agenda item at IPCC and a policy underpinning the core principles is now in place. A new phone app for antibiotic guidelines has been introduced across the Trust from August 2016. Antibiotic Leads have been appointed in the majority of medical specialties to lead on audit work. A number of the champions attend the Antimicrobial Steering Group meetings on regular basis to have input into the audit process. Pharmacy undertakes quarterly ward usage audits to demonstrate trends and will implement an annual Trust-wide prevalence audit. As part of a CQUIN, antibiotic review at 72hrs is being audited; there is a focus on reducing total antibiotic usage and use of Tazocin and Carbapenems.

Priority 2 - Sign up to Safety Priority2 – In 2015 the Trust signed up to the three year National “Sign up to Safety” Campaign. 2016/17 will see all projects progressing into their second year. This national project aims to save 6,000 lives and reduce avoidable harm by 50% and in doing so have pledged to undertake work in relation to five patient safety priorities. The following are progress report son each are: Six Month Update 1. Deteriorating patient NEWS/PEWS compliance bi-monthly audits provide data for feedback to the clinical areas which help to influence an improvement with NEWS/PEWS compliance. Electronic NEWS business case has been renamed ‘the eRescue project’. This is to capture the significantly broader remit than just electronic observation charts as it includes electronic patient whiteboards and automated alerting. It reflects the contemporary approach to patient deterioration where it is recognised that some patients deteriorate despite best care, the importance is to recognise this deterioration early where interventions are most likely to rescue the patient. Failure to rescue is the target of the project where delayed recognition results in

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excess morbidity, preventable unplanned intensive care admissions, or mortality, preventable cardiac arrests. The decision to adopt an electronic chart solution developed in Oxford with NHS Innovation funding is a cost neutral agreement. A delay with some parts of the implementation has occurred, however we have accelerated the work on the electronic Patient Whiteboards. All existing adult patient wards have been reviewed with details of their existing whiteboards noted. The analysis of the contents has then been taken back to each ward to agree a minimum data set that offers maximum patient benefit. The electronic whiteboards will replicate existing information that is currently handwritten and offer the opportunity of pulling data from Cerner in real time to produce a contemporary display of information that will facilitate several aspects of patient care. This includes patient demographics and parent team consultant, expected discharge date and bed management data to improvement patient flow. Clinical alerts to improve Diabetes, Sepsis and Kidney Injury care, and also offers medication, nutrition, theatre, and isolation statuses. This will be trialed on ward 5 RVI and 20 FH in January 2017. A new PEWS system has been piloted and was implemented across GNCH in May 2016. The PEWS system incorporates parental and nursing concern as ‘red flags’ and this has attracted national interest. The views of young people were taken into account via the Young People’s Advisory Group (YPAG). Their concern focussed on the availability of an integrated pain scoring system. The PEWS reflects the Newcastle upon Tyne Hospitals and GNCH values of patient centeredness. Special consideration was given to enabling staff to speak up about their concerns in an ISBARD communication tool (Identification, Situation, Background, Assessment, Recommendation and Decision). The use of the charts and communication tool is audited at several levels: 2 monthly in collaboration with CGARD, monthly as part of the CAT tool and weekly by the newly appointed ward based PEWS champions. These audits show increasingly engagement with the new system. Work is underway to expand feedback learning from those children that triggered a 2222 call and/or unplanned PICU admission. At the FRH site the cardiac specific PEWS has been developed and is now in the pilot phase, with an expectation that it will be fully implemented at the FRH site later this year. The cardiac specific PEWS too is an innovative development in the identification of the deteriorating child. The description of the PEWS training strategy and package won first prize in the regional Great North Paediatric Conference poster competition. The SAFE morning ward huddles are piloted on ward 10 and ward 1b in an attempt to customise the RCPCH SAFE (Situation Awareness For Everyone) program to GNCH needs. These safety ward rounds are being evaluated for staff perceived utility and uniquely the paediatric physiotherapists have engaged in a ward compare and contrast evaluation, to better understand what works well.

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2. Medication safety Medication incident reporting data is published every 6 months by the National Reporting and Learning System. The table below shows that medication incident reporting rates are continuing to increase. Reporting rates are per 1000 bed days

Time period Trust rate National rate

Apr 14 – Sept 14 2.8 4.0

Oct 14 – Mar 15 2.7 3.7

Apr 15 – Sept 15 3.03 4.4

Oct 15 – Mar 16 3.4* Not available yet

Apr 16 – Sept 16 3.7* Not available yet

*Internal Trust data

Medication Incident Investigation Tool A tool that aids investigators in the identification of causal factors of medication incidents is now in widespread use. It is recommended that the tool is used for all moderate and above incidents and for all near miss incidents that had the potential to cause significant harm. Feedback from users has been very positive (see table below)

Yes No Neither

I found the tool easy to use 92% 8%

I feel that the tool is too detailed 8% 84% 8%

I feel that the tool takes too long to complete 8% 92%

The tool helps me to identify root causes easily 100%

The tool helped me to identify more root causes than I may have without it

100%

Using the tool has improved the incident investigation process

91% 9%

Using the decision tree helped me to decide what action to take next

75% 25%

I would recommend the tool to other investigators 100%

Following the success of the medication incident investigation tool a Trust generic tool is currently in development for the investigation of all types of incident. Medication Safety Thermometer The Medication Safety Thermometer is a measurement tool for improvement. It focuses on medicines reconciliation by a pharmacist, allergy status, medication omission and identifying harm from high risk medicines. Data has been collected for four wards as part of a national pilot for 2 years and work has been carried out within those ward areas to improve results. A focus on omitted doses has led to more appropriate recording of omitted doses within these areas. In order to raise Trust-wide awareness of omitted doses a revised critical medicines list has been produced, published on the internet and a medication safety bulletin circulated to all staff to remind them of the importance of not missing doses. Quality improvement work, led by two Teaching Fellows, is also underway on a medical ward at RVI tacking medicines reconciliation and drug

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chart review. If successful it is hoped that some of the improvement methods will be replicated in other areas. High Risk Medicines The high risk medicines which the Sign up to Safety Group have been focussing on are warfarin, insulin, direct acting oral anticoagulant drugs (NOACs) and disease modifying anti-rheumatic drugs (DMARDs). Interventions that have taken place (or are currently under development) to reduce harm from these high risk medicines include:

Establishment and review of insulin e-prescribing

Continuing education on the use of DOACs for doctors and pharmacists

Development of new Trust Hyperkalaemia Guidance

Implementation of an electronic system for monitoring DMARD patients

Additional of DOAC frequently asked questions guidance to the Trust intranet

for reference

Development of an insulin Always Event as part of a NHS England pilot is

currently in the very early stages.

Increasing Awareness of Medication Safety in order to improve reporting

Development of a 30 minute medication session for preceptor nurses and

theatre staff at induction, first delivered October 2016 and to be included in

every induction thereafter.

The establishment of ward medication safety walkabouts. These are in the

early stages of development but will give the ward staff the opportunity to

discuss their medication safety concerns with the Medication Safety Officer.

Cleansing of Trust data prior to submission to the NRLS to ensure that it is

accurate and appropriately graded.

Distribution of a monthly Medication Safety Bulletin Report! Learn! Improve!

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3. Sepsis

3.1 Adult Sepsis Education A comprehensive and innovative educational package has been developed to help staff identify and treat sepsis in adults. An 8 minute educational video based on the Sepsis 6 has been created and viewed over 1000 times of the Trusts YouTube channel. Sepsis 6 cards have also been developed and distributed widely; these act as an aide-memoire; displaying both the sepsis ‘red flags’ and the Sepsis 6 treatment steps on a card that can be stored behind a staff ID badge on a lanyard. This work has been shared at the national ‘Sepsis Unplugged’ conference in October and is due to be presented again at the national ‘Science of Improvement Conference’ in November. Training is now routinely delivered to nurses via the clinical nurse educators and is now part of the mandatory Basic Life Support (BLS) update sessions. Training to junior doctors has been conducted via most Directorates at departmental teaching sessions. In addition we aim to deliver a session to final year medical students; planned on the Preparation for Practice (P4P) course later this year. Foundation years have had education on the sepsis eRecord order set with the purpose of helping to optimise and increase usage. Education to consultants has been delivered at Clinical Policy Group (CPG) and Clinical Risk Group (CRG) meetings. Region-wide collaboration NUTH has retained an active involvement in the Health Education North East (HENE) sepsis group. The NUTH Sepsis 6 treatment protocol aligns with the rest of the region and the Trust’s Sepsis recognition protocol is one of two in operation around the region (and importantly aligns the Shelford group hospitals). Delivery of the Sepsis 6 bundle In the Emergency Department (ED) audit data shows an increase in compliance with the Sepsis 6 in ED from baseline of 41%. The use of the eRecord Sepsis 6 pathway has increased with education, from almost never being used up to July and then being used more than 40 times during each of August and September. Our Sepsis recognition pathway conforms closely to the NICE guidance. 3.2 Paediatric Sepsis In the wake of the deteriorating child PEWS process implementation, the paediatric sepsis process is now able to build on this work. The strategy has been to co-design a sepsis screening and action tool for use in A&E and the Paediatric Assessment Unit. This tool is currently piloted and is expected to be rolled out later this year. This tool incorporates nursing and parental concern as ‘red flags’ as well as early senior review and decision making. The expectation is that non physiological signs will thus be easier heeded and earlier appropriate action instigated. To date three paediatric sepsis videos have been released for education and awareness in co-design with parents and the Newcastle University Centre for Film and Digital Media. The films have been shown at national and regional meetings to great acclaim (October 5, AHSN NENC Patient Safety and Quality Improvement in the North East and North Cumbria, Gateshead; Sepsis unplugged 13-14 October, Brighton).

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A paediatric sepsis toolkit has been developed and is being implemented. This toolkit includes an updated antibiotic policy, lanyard aide memoir card, paediatric sepsis awareness posters, paediatric sepsis spot teaching by educational fellow and incorporates simulation training. The toolkit is underpinned by data obtained from A&E observations and process mapping. The paediatric sepsis leadership team engages with national entities such as the UK Sepsis Trust and has recently commented on the practicalities of implementing NICE sepsis guidelines in the BMJ. In collaboration with NEQOS and the AHSN RESILIENCE project a regional definition and data process is in the final stages of development. The expectation is that the uncommon yet potentially devastating paediatric sepsis will be tracked regionally and will enable shared learning and agreed pathways. Finally, in collaboration with the Institute of Health & Society, the level of successful implementation of these new ways of working will be formally assessed using Normalisation Process Theory.

4. Surgical safety During the period April-September 2016 one Never Event was reported which was a retained swab. This was thoroughly investigated and a number of surgical learning points were identified to prevent reoccurrence including a change to the count bags, consistency of staff involved in the different stages of the count, and human factor training. A Behaviour Audit tool has been tested to see how effectively it can measure team behaviours during surgery. This was found to be useful and will therefore be used if there are reported concerns about team dynamics. A ‘De-Brief’ template has been drafted to record the staff views of what went well and any problems after each procedure in a list and staff views. This is being piloted in theatres to see if it is useful and with a view to adding it to Surginet. A senior theatre team are developing a LocSSIP – a Local Safety Standard for Invasive Procedures – to cover all procedures in the Trust’s operating theatres which will enshrine the need for ongoing education around Human Factors and surgical safety for all teams working in theatres and will also introduce Team Debriefings at the end of lists. Once this has been approved we will move to produce LocSSIPs for all non-theatre areas where invasive procedures are carried out. Spinal infections Spinal surgery infections data is continuously reported and monitored, the infection rates are displayed below. Using the evidence a number of multi-disciplinary interventions have been collated and agreed as a bundle approach to guide the prevention of infections, these have been written for the pre-operative, intra-operative and post-operative phases of surgery. The spinal surgeons, theatres staff, ward nurses, microbiology and infection prevention staff meet regularly to develop and agree processes to reduce infections.

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Surgical consent To improve the compliance with surgical consent and in particular to improve the necessary knowledge of those obtaining consent, a proposal has been initiated to develop two training videos. These will be primarily aimed at consultants taking consent for surgical procedures. Other clinicians and junior doctors in training taking consent for treatments and procedures should also find this a helpful resource. The key steps to be covered in the video are:

Background, why important, changes due to Montgomery case

When and where to consent

Risks and benefits (discussion , tailoring to individuals, checking understanding)

Using supporting information

Documentation

The next 6 months will focus on the development, testing and evaluation of the video. A review of patient information leaflets has started with a collation of those in use in the MSU Directorate, currently they are being refined to ensure they are available for all surgical operations and in a consistent format with relevant content. Diabetic Safety Interventions to improve safety for patients with diabetes undergoing surgery include taking steps to improve patient involvement in this project, this includes identifying a patient representative on the safety committee to review patient responses in recent NADIA. Steps have been taken to improve liaison with GPs to collaborate to optimise patient’s diabetes control preoperatively to improve their surgical outcomes. The Trust participated in the annual NADIA survey in September 2016 and this will provide good audit data to measure improvement post roll out of diabetic protocols. The provisional data suggests significant improvement in appropriate blood glucose testing, reduction in insulin prescription errors and diabetes related management errors but we still have 34% insulin management errors which will now be a focus of this project with hypoglycaemia incidence.

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Foot assessments in diabetic patients are much improved – 98% patients had their feet assessed during admission – following change to care plans. The recently introduced diabetic protocols have been supplemented with different form for GI (versus GKI) which will be green. In addition to this NADIA survey we are redoing the baseline audit of patients with diabetes undergoing surgery and also the audit of diabetic care in patients undergoing limb amputation within the next 3 months to evidence progress in improving the safety of this patient cohort. We are currently setting up a themed quarterly report of Datix incidents to provide feedback to all staff to learn from the incidents. The Trust handbook for Diabetes management has been updated with all the new protocols with a FAQ section for use by doctors and nurses. An alert page in the front of all patients’ bedside folder containing care plans and NEWs is being developed to give immediate prompt that this patient is on insulin/warfarin and newer oral anticoagulants/steroids/has allergy for staff called to a patient in emergency situation. Blood sugar alerts are being included in the development of the electronic patient whiteboards 5. Obstetrics Staff continue to access the K2 Perinatal competency based training package. In addition to this the Practice Support team have been running fetal monitoring workshops for staff to attend on a monthly basis. Attendance lists are collated to demonstrate this additional training. The Practice Support team on the Delivery Suite now cover a 24/7 rota supporting midwives in clinical practice. They specifically support and develop the junior workforce and the increase in cover from 12 hours/day to 24 hours/day appears to be beneficial with staff achieving required competencies sooner than they would have previously. There is a formal evaluation planned that will commence in December 2016 that will evaluate the impact of this increase in provision from perspectives of the multidisciplinary team. Monitoring of the length of time band 5 midwives are taking to achieve their band 6 competencies and progressing to a band 6 midwife is being collated. The practice support team now attend all case reviews where HIE (brain injury) is suspected and the baby has required cooling. This enables the team to identify any specific education or practice elements to be addressed on a wider scale within the midwifery or obstetric work force. The electronic fetal monitoring equipment purchased is now in use on the Delivery Suite and Birthing Centre. The induction of labour area has network points and the facility to link to the centralised monitoring system which increases the surveillance of monitoring during the process of induction. This feature was previously only available from the delivery rooms for women receiving monitoring during labour/birth. Ongoing data of temperatures of babies being transferred in and/or out of the neonatal unit where cooling is indicated shows 100% compliance within the desired temperature range since the introduction of the neonatal cooling equipment.

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Priority 3 – The delivery of ‘Harm Free Care’ for all patients is a national and Trust priority. This priority would be to continue to build on the work undertaken in 2015/16 to prevent avoidable harm, disability or death from:

Falls.

Pressure ulcers.

Six Month Update Inpatient falls prevention continues to be a priority for staff across the organisation. Over the last 6 months the workstreams which have been led by the Falls Prevention Coordinator and the Trust Falls Taskforce Group have included:

Analysis and interpretation of falls data at ward, directorate and Trust level

to continuously monitor patterns, areas of increased incidence and areas of

improvement.

Root Cause Analysis (RCA) investigations of falls causing serious harm

(falls graded as moderate, major or catastrophic) to evaluate areas for

improvement or to recognise good practice. This includes the

dissemination of key messages from 6 monthly reviews of patient falls

RCA’s.

Analysis of Trust performance against evidence-based best practice

guidelines including NICE guidelines and national audit standards. An

action plan has been produced to identify where the Trust currently does

not fully comply with key recommendations including a 7 day walking aid

provision.

Trust-wide share and spread of the Post Fall Assessment Checklist which

was trialled extensively on Older People’s Medicine wards at Freeman

Hospital. This was trialled using a Plan-Do-Study-Act cycle of service

improvement methodology and was successful, therefore the wider spread

introduction of this document across the organisation will be conducted

using the same process.

Over the last year and most significantly over the last 6 months patient falls have reduced (see graph 1 below). In addition to this, falls with serious harm have also reduced (see graph 2 below). This is significant as the number of admissions of highest risk patients (i.e. emergency admissions, aged 65 years and over) has continued to increase year on year since 2011/12.

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Graph 1

210

220

230

240

250

260

270

280

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16

Total Number of Inpatient Falls per month (April - Sept 2016) and linear trend

Graph 2

Pressure Damage During the last six months we have continued to work to reduce the incidence of pressure ulcers. The challenge is to sustain any reductions already achieved by ensuring that practices are truly embedded into practice. Leadership and team working are two essential aspects of reducing pressure ulcers and any changes in nursing teams will somewhat affect performance. We have worked with one specific directorate and through a quality improvement programme we have engaged three wards to:

a) Establish a working group lead by one of the ward managers.

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b) Ensure that all patients at risk of developing pressure ulcer received:

Skin assessment at every positional change

Risk assess patients on admission

Prescribe a repositioning regime for all patients at risk of developing

pressure ulcers

Deliver intensive skin care

Place patients on the appropriate non-powered surface.

Quality of care was monitored by auditing documentation, namely the FOCUS charts. The FOCUS charts are interventional charts where each turning is documented alongside Braden, type of mattress and cushion used and other intervention pertaining safety. Once the audits reached 100%, incidence reduced. This data offered a powerful message to the three wards and the directorate achieved a reduction of 26.4% (baseline: Jan – Dec 2015) in their hospital acquired pressure ulcers. Through this process, the directorate has gained ownership of the problem and is determined to ensure that such reduction is sustained. The Trust will continue with a “zero tolerance” approach to Trust acquired pressure damage, supporting staff to report all instances of damage present on admission, and those that subsequently develop or deteriorate. The next task is to identify other wards where such quality improvement programme may be beneficial. Nevertheless, we are approaching the winter months and experience has taught that at times of high clinical demand, incidence rates increases and reduces again as acuity and workload reduces. Priority 4- Safeguarding Six Month Update The protection of vulnerable adults and children accessing Trust services from all forms of abuse including those at risk of, or subject to, Domestic Violence, Sexual exploitation, or Female Genital Mutilation (FGM) remains a priority and significant work stream. In the last six months Cause for Concern Notifications (CFC’s) continue to increasing specifically in relation to adult and women’s safeguarding activity & DOLs applications have also increased. With regard to ensuring the Mental Capacity Act (MCA), and Deprivation of Liberty (DoLS) Safeguards are robustly applied there is strong evidence of increasing awareness with 304 DOLs applications completed by the MCA / DOLs Lead or members of the safeguarding adults team from April 2016 to September 2016. This is an increase of 142% in comparison to the same period last year and an increase of 428% compared to 2014/15. Work is ongoing to ensure that those with Learning Disability are recognised, flagged on Trust systems and, reasonable adjustments provided to ensure they can access and receive high quality safe care. The team have been focusing on working with the Children’s Directorate to identify children with a diagnosis of learning disability to enable e-records are flagged. This will identify the child /

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young person and ensure pathways of care are reasonably adjusted to meet their individual needs. The Trusts Safeguarding teams continue to contribute to city wide work to enhance the protection of vulnerable adults and children through multiagency working, including case review, education and policy and practice development. This includes:

Both teams contributing to Serious Case Reviews / Appreciative Inquiries in

relation to children and adults.

Attendance at Newcastle Safeguarding Childrens Board (NSCB)/

Newcastle Safeguarding Adults Board (NSAB) sub-groups to support multi-

agency working.

Support to NSAB/NSCB multi-agency training programme

Safeguarding meetings.

Service development – work with 0-19 service re attendance at strategy

meetings.

The Trust have ensured the Specialist Safeguarding teams are supported to respond to increasing workloads, and that they are supported, and equipped to deal with the complexity and demanding nature of the work they undertake. Agreed metrics continue to be recorded, monitored, and analysed and reported to the Trust Board. These have now been integrated into the monthly Integrated Quality Report. These include:

The number and types of ‘Cause for Concerns’ (CFCs) raised.

Applications for Deprivation of Liberty Safeguards.

Cases of Female Genital Mutilation.

Contacts with individuals with Learning Disability.

Training activity.

To achieve these priorities and to build on the existing robust safeguarding arrangements the newly appointed Head of Safeguarding has progressed establishing a Corporate Safeguarding Team, under one management structure whilst ensuring the individual clinical specialisms and expertise of the named professionals is recognised. Practices have been developed, for example both safeguarding teams have implemented a duty nurse system. Work is ongoing to look at systems and processes within the team to increase efficiencies (e.g databases / use of Datix to capture incidents (CFC’s). A Named Midwife has been appointed. Colocation of all teams into one building has been achieved. Further work planned will include: Engaging with national developments in regard to Learning Disability mortality reviews whilst the Trust mortality review process is well embedded the regional processes are still being developed. The Trust will maintain its own processes until regional work is in place.

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The MCA / DOLs lead is actively working with wards to increase the profile and to support learning around MCA & DOLs applications. Currently undertaking an audit on a select number of wards to determine how many patients are subject to DOLs and further development of MCA Champions supported by the MCA Steering Group. Both adults and children’s safeguarding teams are contributing to the Joint Serious Case Review into Sexual Exploitation across the city. A joint sexual exploitation strategy has been developed by NSAB & NSCB and a flowchart to support clinicians has been widely disseminated across services within the Trust. Sexual exploitation is included in Trust training with more specialist training accessible through the NSCB multi-agency training programme for all staff. Work to increase the ability of staff to routinely and selectively enquire about Domestic Abuse and then respond appropriately, both in relation to patients and also staff ongoing. 114 domestic abuse enquiries have been made to the safeguarding adults team during the Q2 period with 11 formal Multi Agency Risk Assessment referrals (MARAC) made in the same time period. The Trust ‘Responding to Incidents of Domestic Violence/Abuse’ policy was updated in April 2016 Priority 5- Palliative & End of Life Care Six Month Update High quality care at the end of life is a key priority for Newcastle upon Tyne Hospitals NHS Foundation Trust. Dying occurs in hospitals and in the community and we have a responsibility to ensure that patients and families receive the information, support and care they require during this difficult time. Staff training

All clinical staff who care for patients at the end of life have a mandated online module to complete, in the last 6 months 74% of eligible staff have completed this.

We have delivered face to face training to 2328 staff in the last 6 months including junior Drs, health care assistants, AHPs. This has included 3 study days.

We deliver education on the junior doctor and main Trust induction programmes.

NESCN Caring for the Dying Patient documentation supports excellent end of life care in all care settings. This document is an individualised plan of care for patients in last days or hours of life and incorporates the 5 Priorities for Care in One Chance to Get it Right (LACDP 2014). Its use has been supported by extensive education and training. It has been used by the community teams in Newcastle to support care for patients at home since April 2015, it is now used in 24 acute wards across the Trust including Critical care areas and Assessment Suite.

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Monitoring of care through bi-annual audit in the acute and community settings continues. This provides evidence of excellent care and also provides the opportunity for capturing carer and patient views at the time of care delivery to continue to improve. The Trust participated in the National End of Life Care Audit – Dying in Hospital in 2015 and the results were published on March 2016. The Trusts results were excellent, with compliance across nearly all of the quality domains well above the national averages. The Trust did not achieve on one organizational indicator, the provision of a 7 day specialist palliative care service in the acute setting. Work is in progress to try and secure funding for this extended service. To provide seamless care on discharge home patients who live in Newcastle are transferred with their continuous subcutaneous infusion in place, with plans to extend this to patients who live outside of Newcastle in collaboration with NEAS. The Macmillan End of Life project commenced in February 2016. One to one support is offered to patients who are dying, and their families, by a band 5 nurse and health care assistants. Carer packs are also provided with toiletries, neck pillows, blankets, a charitable fund “A Gift of Kindness” has been set up to continue to fund these packs. “Just carry on what you are doing…it is invaluable at a time of sadness, stress and a smiling face has helped so much.” “We were touched that staff were available to sit with Dad whilst we were not there. We were overwhelmed by the kindness.” End of life care is supported by projects such as the Primary Care Standards project which works with primary care teams to identify and support patients at the end of their life and their carers. This project currently works with 10 primary care teams with plans to support a further 6. The Care Homes project provides a dedicated palliative care nurse who supports, through education and training, 20 care homes in Newcastle to deliver good end of life care. Clinical Effectiveness Priority 6 – Mortality: To monitor mortality indicators with the aim of reducing avoidable deaths and build on developments achieved in 2015/16. Six Month Update The Trust continues to perform well both regionally and nationally across all reported mortality indicators. The Summary Hospital-level Mortality Indicator (SHMI), the Hospital Standardised Mortality Indicator (HSMR) all show the Trust to be performing within the expected limits with the Trust’s average SHMI showing the lowest in the region.

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The North East Quality Observatory System (NEQOS) conduct an analysis at a regional and national level to support the Trusts mortality monitoring process. Their most recent publication (October 2016) again demonstrates the Trusts strong national performance and shows our rates to be within expected for HSMR as shown in funnel chart below.

HSMR for July 2015 to June 2016 (99.9% and 95% control limits without adjustment for over

dispersion)

Although the Trust’s overall mortality rates are within expected levels it is important to drill down into the data to ensure there are no pockets of poor performance being hidden by good outcomes elsewhere. Each quarter SHMI is analysed by diagnostic group (based on the Clinical Classification System (CCS) set by the NHS IC) and if, over four quarters, there appears to be more than a 20% difference between the actual number and the expected number of deaths the clinical leads are asked to conduct an in-depth case note review. In the past 6 months the Trust has monitored mortality ratings produced by SHMI and found no

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CCS groups requiring in-depth case note review. The Trust will continue to monitor all CCS groups on a regular basis. The Trust has also moved forward with the new mortality review database. This is currently ready to be piloted within M&M meetings with the plan to go “live” across all Directorates within the next six months. In addition a new mortality surveillance group has been established with the first meeting to take place in January 2017. Priority 7 - National Audits and and Confidential Enquiries

Six Month Update There are a total of 73 National Audits and Confidential Enquiry studies relevant to the Trust in the 2016/17 Quality Account. Whilst in previous years, the Confidential Enquiries had focused primarily on the National Confidential Enquiry into Patient Outcome and Death, in 2016/17 a number of studies have been added under the heading of Child Health Clinical Outcome Review Programme and a new development has been the National Neurosurgery Audit Programme. Once the results of national audits are received by the Clinical Governance and Risk Department (CGARD), a request is sent to the appropriate lead clinician for the audit asking them to complete a baseline assessment in terms of implementation across the Trust. The results of the baseline assessment are then reported to the Trust Board and Clinical Effectiveness, Audit and Guidelines Committee to provide assurance of the Trust’s performance and where improvements are to be made, that the issues are identified and subsequently monitored by the directorates in their clinical governance meetings and reported to the Clinical Effectiveness, Audit and Guidelines Committee in their annual reports. A planned development will be the sharing of areas of good practice with national audits / highlighting demonstrable improvements in relation to the Trust’s performance. Priority 8 - NICE Quality Standards (QSTs) Six Month Update Whilst the publication of new QS by NICE progresses unabated, the three QS which the Trust has prioritised for 2016/17 are QS1 Dementia, QS49 Surgical Site Infection and QS66 IV fluids in adults in Hospital. QS1 Dementia A vast amount of work continues to be undertaken in relation to dementia including participation in a multi-faceted national clinical audit (May – October 2016) looking at both service provision and user opinion on service delivery. This has resulted in the clinical team leading on QS1 declaring compliance in all but one of the standards. A significant training programme has been undertaken with a cumulative total of 9,634 staff receiving tier 1 training since April 2012 (as of December 2015) 807 tier 2 training and seven tier 3 training. A band 7 Dementia Nurse Specialist was

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recruited in March 2015 who supports and trains clinical staff to care for people with dementia. The CCG’s have supported and funded an additional two band 6 Dementia Nurse Specialists who commenced employment in January 2016. Training figures submitted for quarter 2 indicate that the total number of staff trained was 13,451 comprising: 12,581(Tier 1), 863 (Tier 2) and 7 (Tier 3). Part of the role of the Dementia Nurse Specialists is to facilitate Tier 2 training to specific areas / directorates and a rolling programme has been established to deliver a Tier 2 Best Practice in Dementia Care course for inpatient and community staff. A dementia champions study day was held earlier this year aimed at Tier 2 training to promote dementia core skills, education and training framework Health education England. A further champions’ study day is to be held in September 2017. New Hospital Care plans have been piloted extensively and these will be rolled out across the Trust at a major launch with a view to raising awareness and enhancement of clinical practice. The Trust has developed Guidelines for Managing Behavioural Problems and Agitation in Dementia Managing Delirium in Inpatients Core care plan on Managing Behavioural and Psychological Symptoms of Cognitive Impairment. In addition, carers can receive bespoke social work assessment if indicated to identify their individual needs and enable them to receive the support they require. QS49 Surgical Site Infection Significant progress has been made in relation to moving towards compliance in relation to the NICE QS. Since the previous report, agreement has been received to incorporate the requirement that patients are notified regarding the removal of hair from the surgical site area into the Patient Information leaflet “Coming into Hospital – Information for Inpatients and Day Case Patients”. The Clinical Assurance Tool (CAT) already provides data relating to patients who have had hair removed in theatre by a clipper with a disposable head and a snapshot audit of patients will be undertaken to ascertain whether the inclusion of the removal of hair into the patient information leaflet was being adhered to by patients in Quarter 4. An antimicrobial Stewardship Working Group was established in May 2016 and meets monthly to review key guidelines. In addition, an Antimicrobial ePrescribing Strategy is in development which will include rollout of task lists for junior doctors and alerts for Microbiology / Infectious Diseases for key areas. Antimicrobial leads have been established in most clinical areas with the task of undertaking a Take5 monthly audit. This audit helps monitor appropriateness of antibiotic prescribing. Good antibiotic prescribing contributes to less antibiotic resistance and shorter hospital stay or shortened care in the Community setting, whilst improving patient experience and reducing patient harm. Collecting data for the audit helps prescribers familiarise themselves with the elements of a good antibiotic prescription. This tool must be completed monthly on 5 patients on each inpatient ward. Members of the Working Group have attended slots / sessions on directorate clinical governance meetings to raise awareness. The Trust is to run an awareness week for all staff November 15th- 21st 2016 to promote the Antibiotic Guardian campaign. This will consist of a message being placed on the intranet on

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a daily basis in relation to the NICHE Pneumonic, training sessions across both the Freeman and RVI site on the 25th November – these sessions will include components on NICHE/Surgical Prophylaxis and Public Health England. The sessions will be run at lunchtime with the provision of a light lunch to minimise clinical disruption and attract as many ward based staff as possible. Hopefully this will enable as many staff as possible to attend and share key lessons learnt through poster presentations from all clinical areas in both the acute Trust and Community settings. It is anticipated this will provide the ideal fora highlighting the key messages on the spread of antibiotic resistance as well as providing professionals with essential tips on prevention. In relation to adults having surgery under general or regional anaesthesia and having normothermia maintained before, during (unless active cooling is part of the procedure) and after surgery, despite a significant amount of audit having been undertaken in this area, the Trust remains non-compliant and hence the risk has been placed on the Perioperative & Critical Care Services risk register. Audit is currently underway in some anaesthetic rooms recording the patients’ temperature on admission to the anaesthetic room. Furthermore, the Directorate Manager, Perioperative & Critical Care Services, has emphasised the importance of staff ensuring normothermia pre-operatively through communication with the matrons. There is currently an audit being carried out within theatres at the RVI in relation to measuring compliance with theatre standards in the majority of the 33 theatres. The purpose of this is to assess the amount of theatre traffic and general theatre etiquette displayed in the theatre environment across all disciplines. An initial two theatres have been audited and the findings demonstrate that theatre trollies and tables were cleaned in between cases as per Trust policy, staff were dressed as per the Uniform policy with hair tucked under caps and no visible jewellery. Moreover, it appeared, in both theatres, that theatre traffic is minimal and the nursing staff had displayed good theatre etiquette. Only one issue was identified in the pilot and this was that the Assisting Surgeon wore his mask covering his mouth only and not his nose. The audit is to be rolled out across the other theatres on a phased basis. The Trust provides extensive information and advice on wound and dressing care. All information has to be approved by the Trust’s Patient Information Panel so that it is deemed appropriate for patients. Workstreams have been established in the community to reduce unnecessary prescribing as part of the Antimicrobial Stewardship Action Plan. A lead pharmacist looks at consumption data which is reviewed at the monthly Working Group meetings and acted upon. As part of the Trust’s awareness week for all staff November 21st – 25th, laminate credit sized cards for staff to carry that will carry the NICHE pneumonic message and also the QR code to the antibiotic guideline application for staff to access. Clinical governance leads report any surgical site infection data as part of the Patient Safety and Quality Reviews In addition, the work in relation to antimicrobial stewardship will be overseen by the Antimicrobial Working Group and the Antimicrobial Steering Group. Progress will also be monitored by the CQUIN delivery group and in the quarterly CQUIN reports that have to be submitted to the Commissioners demonstrating progress in practice.

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QS66 IV fluids in adults in hospital Following the initial audit, previously reported, the results have been disseminated widely to a variety of Trust fora. These include the Trust Board, Clinical Effectiveness, Audit and Guidelines Committee. In addition, as the Shelford Group had been struggling with implementing the requirements of the QS, CGARD had shared the Trust’s approach and results with each of the Shelford members. The intention is to reaudit the NICE guideline in Quarter 3 and the results will then be compared to the initial audit to ascertain whether improvements have been made. Since the previous report discussions have been held with the Risk Management Department regarding the possibility of having a specific category identified on DATIX for reporting incidents of fluid mismanagement. Agreement in principle had been received, and a review of the current incidents on DATIX demonstrated that there had been no instances of fluid mismanagement reported as critical incidents. This standard will become compliant once the category “Fluid mismanagement” has been established and data for Quarter 4 has been reported. Patient Experience Priority 9 – Patient Experience Six Month Update The Trust continues to perform well in measures of Patient Experience as reported to Trust Board and the public on a monthly basis through Board Reports and Open and Honest Care reports. Work related to Equality Diversity and Involvement that has progressed in the first six months is summarised below. Meeting the NHS and Social Care Accessible Information Standard The Accessible Information Standard came into effect as of 1st August 2016. The directive requires health and social care providers to meet five essential criteria when managing communication with disabled patients / customers; Asking about communication needs, recording these, creating alerts, sharing the information and meeting these needs. The Trust is able to meet the core requirements of the Standard and work is on-going to develop the required IT infrastructure to embed this information on every patient’s electronic record. The Trust have worked collaboratively with charities, 3rd sector organisations and other service providers to understand the needs of disabled service users and ensure the solutions created to meet the standard will improve communication for these patients in a meaningful and sustainable way. Develop new objectives for the Equality Delivery System and review grades for 2016 The development of new objectives has been completed and approved at the September Trust Board. These include:

To be in the top 100 of employers listed in the Stonewall Equality Index by

2020.

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Use the NHS WRES to understand the differences in staff experience

between White and BME employees and reduce the reported differences

Increase the recruitment of people with learning disabilities year on year

proportionally.

Systems, processes and resources in place to enable the Trust to comply

with the Accessible information Standard.

Understanding of the health and well-being issues affecting trans people

promoted and actions undertaken to ensure that trans people have positive

experiences within the Trust.

Reduce social isolation and loneliness through work that is within the scope

of the Trust.

Carers feel supported, and if they wish, involved in the care of the person

they care for.

Carers are aware of the statutory Carers Assessments and

support available for Carers in in the community.

Improve equality data in relation to complaints.

Completing the new work with carers A Carers pack and welcome poster have been developed and distributed to all adult clinical wards. The pack outlines the Trust’s commitments to Carers, provides information about Carers Assessments and where Carers can find support in the community. Practical support for Carers has also been put in place, including; flexible visiting, the provision of meals by the Catering Department if the Carer is staying for a longer period of time and fold- out beds have been ordered to support Carers who wish to stay overnight. The Trust has made a pledge to support the principles of John’s Campaign which is focused on ensuring that Carers of people with dementia should be able to support their loved ones at whatever time is most helpful to the patient and whatever time is do-able for the carer. Awareness of the changes has been raised through face to face training, an animation video, written guidance for staff, clinical forums and information on the Trust intranet. Complete the report on the experience of patients working with BSL interpreters This report, written in collaboration with Deaflink, has been completed and demonstrated that Deaf people had variable experiences communicating within the Trust. The Trust is excelling in meeting the needs of Deaf people in some departments and, when preferred interpreters are booked, they are providing a first rate service. However, the experience of health care relating to BSL interpreting is not consistently a quality experience for Deaf people and the report has been used to inform staff training and the introduction of the Accessible Information Standard.

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Progress the work on the British Sign Language Video Relay pilot The Trust will imminently launch a 12 month pilot for services allowing the 24 hour, 7 day per week provision of British Sign Language services for deaf patients. Whether the patient is attending the Trust in an unplanned emergency or at home and wishing to contact a Trust member of staff immediately, there will be services available to ensure that they are able to communicate via BSL with staff. The Trust will be the first to offer such a service. Partnership across the Trust, Local Authority and 3rd Sector so that the Trust can contribute to reducing social isolation and loneliness This work now comes under the banner of ‘Connected People, Connected Communities’. A conference was held in June 2016 bringing together Public Sector, Third Sector and Voluntary organisations together to build on, and add value to, existing developments including; introducing asset based approaches, health and care integration and developing social prescribing models. A subgroup of the Trust’s Equality, Diversity and Human Rights Group developed a poster presentation for the event and has started to consider how we can use waiting areas as a place for people to find information about connecting with others in the community and when they are in hospital. Developing a robust equality analysis process for business development and Board papers Training for Directorate Managers and authors of Board papers has been completed, Equality Analysis documentation and guidance has been reviewed and are awaiting approval. There have been examples of how equality analysis can positively affect business cases, such as reviewing ‘Did not attend data’ by age and postcode revealed that young people in the east of the city were not attending Rheumatology clinics. As a result of this analysis the service has been moved to Benfield Park resulting in improved attendance.

3. SUMMARY To date the Trust has made significant progress with its quality priorities.

4. RECOMMENDATION(S) The Board are asked to i) note progress of the 2016/17 quality priorities ii) offer guidance on potential quality priorities for 2017/18.

Mrs. Anne Marie Troy-Smith, Quality Development Manager 8th November 2016

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