Download Governing Body Meeting 28 March 2017

Meeting of Bristol Clinical Commissioning Group Governing Body
To be held on Tuesday 28 March 2017 commencing at 1.30pm at the Greenway Centre,
Doncaster Road, Southmead, Bristol, BS10 5PY
Draft Agenda
1:30pm
1
Apologies for absence
1.35pm
2
Declarations of Interest
1.40pm
3
Public Question Time
Members of the public are invited to ask questions
1.50pm
4
Minutes of the previous meeting and Matters
Arising
Enclosed
Leadership Reports
2:00pm
5
Chair’s Report
Martin Jones
6
Chief Officer’s Report
Jill Shepherd
7
Finance Review Committee Minutes February
2017
Danielle Neale
8
Planning and Performance Committee February
2017
Martin Jones
9
In-common Quality and Governance Committee
Minutes January and February 2017
Martin Jones
Items for Information Only
10
End of Life Care Steering Group Progress Report
11
Medicines Management Steering Group Progress
Report
12
Cancer Steering Group Progress Report
Finance Quality and Performance
210pm
13
Finance, Quality & Performance Report
Nicola Dunn
Alison Moon
Gill Ryan
Page 1 of 3
3:00
pm
14
University Hospitals Bristol Trust CQC Report
Alison Moon
15
Bristol Community Health CQC
Alison Moon
Refreshment Break
Strategy and Planning
Governance and Assurance
3:10pm
16
Carers Annual Report
Alison Moon
3:20pm
17
Information Governance Strategy
Nicola Dunn
3:30pm
18
Independent review of Children’s Cardiac
Services at UH Bristol – programme plan
Jill Shepherd
3:30pm
19
CCG Corporate Risk Register
Sarah Carr
3:40pm
20
Meeting Effectiveness Checklist
Did the meeting run to time
Did the right people attend
Were action items assigned where appropriate and to
the right people
Were items given sufficient time to discuss
Were all members able to contribute
Has the meeting’s business contributed to the
organisation’s aims and objectives in terms of:
- Strategy
- Planning
- Governance
Were any of the items inappropriate for this
Governing Body
Did the meeting received the administrative support
that it needed
Martin Jones
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3:45pm
Date of next meeting:
Tuesday 25 April 2017, 1.30pm, Vassall Centre, Gill
Ave, Bristol BS16 2QQ
Motion to Exclude Public and Press
That representatives of the press, and other
members of the public, be excluded from the
remainder of this meeting having regard to the
confidential nature of the business to be
Agenda Page 2 of 3
S:\Corporate\Governing Body\GB Open Session\2017 - Open Board Papers\03 March\00 Timed Agenda.doc
transacted, publicity on which would be
prejudicial to the public interest, Section 1 (2),
Public Bodies (Admission to Meetings) Act 1960.
Agenda Page 3 of 3
S:\Corporate\Governing Body\GB Open Session\2017 - Open Board Papers\03 March\00 Timed Agenda.doc
Agenda Item: 04
Meeting of Bristol Clinical Commissioning Group Governing Body
Minutes of the meeting held on 28 February 2017 commencing at 1.30pm at Barton
Hill Settlement, 43 Ducie Road, Barton Hill, BS5 0AX
Present:
Dr Martin Jones
Dr Kirsty
Alexander
Nicola Dunn
Richard Laver
Tara Mistry
Alison Moon
Danielle Neale
Jill Shepherd
Dr Pippa Stables
Dr Lesley Ward
In Attendance:
Sarah Carr
Rachel Anthwal
Boxie McGee
Bristol CCG Chair
Bristol CCG Governing Body Member & North &
West Locality Executive Group Member
Chief Financial Officer
Bristol CCG Governing Body Member & North &
West Locality Executive Group Member
Lay Member for PPI
Director of Transformation & Quality
Lay Member for Governance and Audit
Chief Accountable Officer
Bristol CCG Governing Body Member & Inner
City and East Locality Executive Group Member
Bristol CCG Governing Body Member & South
Locality Executive Member
Corporate Secretary
Delivery Director
PA
218 - 16/17
Apologies for Absence
Apologies were received from Ian Donald, Brian Hanratty, David Soodeen
and Becky Pollard. Pippa Stables and Danielle Neale arrived during the
meeting.
219 - 16/17
Declarations of Interest
Alison Moon declared an interest in item 15. There were no other
declarations.
220 - 16/17
Public Questions
A member of the public had submitted questions to the Governing Body
and asked the Chair read them out:
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“Will the CCG now consider its legal position in respect to the lies in the
present document that the STP has a £100million shortfall if they do
something and this has not been mentioned in the document?
Will the CCG look into each individual services and the inequity in the
provision of services currently and the costs for dealing with waiting
lists? Will the CCG specify which services will be reduced or cut due to
the £100 million in deficit in the STP?
When does the consultation end and when does the CCG need to
submit its findings to NHS England for the STPs.”
Martin Jones responded:
Action Minutes Page 1 of 11
The financial information in the STP was based on the existing reported
financial position of individual organisations including the CCG, and was a
projection of the estimated future position, as with any projection these
figures were subject to change. The STP identified a financial pressure
that would arise if the Bristol, North Somerset and South Gloucestershire
(BNSSG) health community continued to work in the same way as now.
The STP organisations were looking at ways of working differently in order
to manage demand for services differently and reduce the cost of
providing services. Any changes that could be proposed to individual
services would have an Equality Impact Assessment and the implications
for our population would be considered. Significant changes would be
subject to consultation.
Following the publication of the STP the BNSSG STP organisations were
working to develop a detailed programme and timetable for specific
projects across the three themes. This included agreeing how this work
will be resourced, e.g. identifying clinicians and managers to be involved in
and lead the projects, as well as ensuring appropriate programme and
project management to organise and support the work. Linked to this
were the development of plans for communication and engagement with
local people and other stakeholders including our workforce. There would
be a follow up session with representatives from the three HealthWatch
organisations and the voluntary sector workshops held in January would
also be followed up. Revised governance arrangements were being
developed that would enable effective collaborative working to deliver
change and ensure accountability. One of the considerations would be to
look at how patient and public involvement was represented within the
programme governance arrangements. The preparatory work described
above was expected to be completed by April 2017. As part of this a
summary of the feedback received to date and the actions the STP
organisations proposed to take in response to that feedback would be
published.
221 - 16/17
Minutes of the previous meeting
The minute at page 10, last paragraph should have read “Kirsty Alexander
asked about physiotherapy referrals from the north of the city”. With this
amendment, the minutes were agreed as a correct record. The action log
was reviewed.
Item 25/10/16 138-16/17 A briefing had been prepared on provider trusts
systems for identifying overseas patients. It was explained that the matter
was being discussed further with NBT and that the briefing would be
circulated once discussions were completed. The action remained open.
Item 20/12/16 177-16/17 Nicola Dunn explained that further information on
AWP sub-commissioning of acute beds at the Priory had been requested
and a response was expected. The action remained open.
Item 20/12/16 188-16/17 (4) An analysis of A&E data compared to urgent
care centre restricted access periods was circulated. There was no strong
correlation or causation between increased activity at UHB and the
Action Minutes Page 2 of 11
restriction of service at the urgent care centre. The data would be shared
with the A&E Delivery Board. The action was closed. It was asked if the
data comparison was a one-off exercise. This was confirmed, however it
was recognised that the data was helpful.
Item 20/12/16 192-16/17 Rachel Anthwal explained that the sterilisation
policy provided a safeguard for patients with learning disabilities. It
required the patient to be fully aware of the consequences of the
procedure and provided a number of criteria to be confirmed. If the
clinician was unable to confirm the questions an application for IFR
funding was required with an explanation as to why a patient with learning
difficulties should be sterilised. The action was closed.
Item 31/01/17 202 -16/17 Nicola Dunn explained that the STP submission
made in June 2016 had not included the 2016/17 savings in the do-nothing
scenario. The second submission included the savings and therefore
reduced the figures. The action was closed.
Item 31/01/17 209 -16/17 (1) and (2) Rachel Anthwal explained that NBT
had identified a significant number of Endoscopy cases that had missed
their surveillance date due to the Patient Administration System. The Trust
had confirmed that clinical validation of the cases had been completed and
that the key issues learned would be shared with commissioners. The
CCG had been informed that 6 patients had been identified as urgent and
had been seen. The Root Cause Analysis would be discussed at the
Quality Group. It was explained that the Trust planned to use Prime
Endoscopy and Care UK to undertake some of this work. It was noted that
capacity at Emersons Green was less than contracted and the uptake of
capacity at Prime had been delayed due to a delay in opening new
premises. The CCG was encouraging the maximisation of capacity.
Kirsty Alexander asked if there had been an impact elsewhere in the
system and commented that there had been issues with the ICE system.
Rachel Anthwal commented that diagnostic under performance had been
reported to the Governing Body and this situation had not helped. A
remedial action plan was in place which was monitored by commissioners.
Rachel Anthwal agreed to investigate issues with the ICE system. Item
31/01/17 209 -16/17 (2) was closed
Action Rachel Anthwal
Item 31/01/17 209 -16/17 (3) it was confirmed that the Category 1 target
included all responding crews and not only single responder vehicles.
Under the Ambulance Response Programme the Trust was moving to
reduce the ratio of single responder vehicles to double crews. It was
confirmed that the target was monitored. The action was closed
Item 31/01/17 209 -16/17 (4) and (5) It was confirmed that the creation of a
commissioner urgent care operational group had been discussed at the
Shadow Joint Commissioning Board. A weekly teleconference had been
created and there had been a discussion about the ED Board governance.
It was agreed to circulate a brief presentation on the governance
arrangements. The action was closed
Action Minutes Page 3 of 11
Action Rachel Anthwal
Item 31/01/17 209 -16/17 (6) It was noted that the concerns related to
MSK referrals to physiotherapy from the north of the city. Bristol
Community Health (BCH) had confirmed that there were variable waiting
times for services across the city. It was explained that service locations
in the north of the city were smaller, with limited capacity to offer additional
clinics. Patients were offered alternative venues. There was a discussion
about the innovative physiotherapy service provided at the Crest practice.
The action was closed
Item 31/01/17 209 -16/17 (7) Nicola Dunn informed members that NHS
England (NHS E) had confirmed that NBT had not signed up to their
Sustainability Transformation Fund control total for 2016/17. The action
was closed
Alison Moon informed members that Fiona Butter would be leaving the
CCG at the end of March and would not be taking forward the Out of
Hours re-commissioning; an alternative procurement lead would be
sought.
All other actions were closed
222 - 16/17
Chair’s Report
Martin Jones explained that the recruitment process for the Single Chief
Officer for BNSSG had been completed. Julia Ross, Chief Executive of
NHS North West Surrey CCG, and Senior Responsible Officer for the
Surrey Heartlands STP, had been appointed to the post. The BNSSG
Transition Executive Group (TESG) and CCG Chairs were liaising with
Julia Ross to ensure that she was fully briefed on local issues and involved
in the further development of the Transition Programme. It was explained
that one of the first priorities would be the creation of a single executive
team across BNSSG. The TESG had established an Organisational
Change Reference Group to ensure that appropriate HR arrangements
were in place for staff affected by change.
Each CCG had agreed constitutional changes to support the development
of a single commissioning voice. NHS England would need to approve
these amendments before they could be enacted.
223 - 16/17
Chief Officer’s Report
The Chief Officer’s Report was tabled. The report presented a briefing on
the Shadow Joint Commissioning Board meeting of the 18th January 2017,
and updates on the BNSSG Joint Assurance meeting and the annual
round of GP practice visits. There were no questions.
224 - 16/17
Financial Review Committee Minutes January 2017
The Governing Body received the minutes
225 - 16/17
Planning and Performance Committee Minutes January 2017
The Governing Body received the minutes
Action Minutes Page 4 of 11
226 - 16/17
In-common Quality and Governance Committee Minutes January
2017
It was explained that this item was deferred to the March Governing Body
meeting
227 - 16/17
Children’s Community Health Services Recommissioning Programme
Board Minutes 2017
The Governing Body received the minutes
228 - 16/17
Better Care Commissioning Board Minutes
Kirsty Alexander asked how Better Care worked with the STP, and asked
for an update on the programme progress. She observed that the scope
of Better Care arrangements varied nationally. Nicola Dunn explained that
Better Care was a governance structure for a number of work programmes
with the local authority. The programme was aligned to the CCG strategic
priorities. Widening the scope of the programme was within the CCG
remit and a pooled budget existed. Currently the focus was on the
effective use of resources within the pooled budget. This was an area that
the CCG would wish to develop in the future. It was noted that there were
three Better Care programmes within the BNSSG STP. As the 3 CCG
legal entities continued these would remain separate however there was
potential to create in-common meeting arrangements. It was noted that
there were other structures developing including the forthcoming election
for a Metro Mayor which would have a future impact. Martin Jones
commented that work was underway in relation to primary care models of
care.
The Governing Body received the minutes
229 - 16/17
Dementia Progress Report
Alison Moon highlighted the further increase in the dementia diagnosis
rate. The CCG was on track to achieve the target by the end of March and
continued to be the best performing CCG in the South West. The physical
in-reach service pilot had been successful in reducing admissions to
hospital and had moved to business as usual. The successful GP
Dementia Education Day was highlighted. Martin Jones commented that
at the Joint Assurance meeting North Somerset had been encouraged to
agree to a joint BNSSG model for dementia. Alison Moon welcomed this.
Tara Mistry informed members she had attended a Black and Minority
Ethnic (BME) experience of dementia report launch which the CCG had
been involved in. This had been a very positive event.
The Governing Body received the report
230 - 16/17
Quality report
Alison Moon commented that the CCG was working with NHS E to obtain
Primary Care data. It was noted that pressure continued in the system
which had impacted on performance. UH Bristol had reported mixed sex
accommodation breaches and breaches of 12 hour trolley wait targets due
to pressure on services.
Action Minutes Page 5 of 11
The CCG had received a comprehensive work force report from UH Bristol
which demonstrated the Trust’s focus on this area. The Trust had a lower
vacancy rate than comparator foundation trusts. The report provided
detailed assurance and had been commended by commissioners to other
providers. The UH Bristol CQC reported was expected to be published
later in the week and it was anticipated that this would be positive.
In relation to performance against threshold for Fractured Neck of Femur,
it was noted that there are issues relating to performance in this area
across BNSSG and that the MSK work stream within the STP was
intended to improve performance. Until this work stream took effect there
were unlikely to be sustainable improvements to performance.
NBT had reported a further Never Event in December 2016; the Trust had
a remedial action in place in response to the number of Never Events
reported. The Trust had reported further MRSA Bacteraemia case. The
increase in the number of overdue complaints was highlighted. The Trust
was commended for the system being introduced however it was not yet
addressing the backlog.
NHS E had informed Bristol and South Gloucestershire CCGs that CHC
services were under scrutiny as they were considered as adding to delays
in discharges. The CHC teams, including the BCH team were reviewing
how they worked together.
Avon and Wiltshire Partnership had reported recruitment issues in
Wiltshire, Bristol and the secure services. These issues had been
discussed with the Trust. GP practices had highlighted concerns about
the number of agency staff completing assessments. The AWP Quality
Improvement Group, established by NHS Improvement, had been stood
down and its activities were now included in the CCG Quality Sub Group
remit. A Warning Notice related to Section 136 Place of Safety Units
remained in place. Improvement plans were monitored at the Quality Sub
Group and the Trust had provided a timescale for improvements. The
Caring Solutions report commissioned by the CCG to review unexpected
deaths had been received. The Trust’s response and action plan would be
presented to the Governing Body in March
Action Alison Moon
Delayed Transfers of Care (DToC) were a significant issue across AWP.
The CCG was working intensively with Callington Road in relation to the
quality of care received by patients. The CCG had completed 2
observational visits as had the CQC. The Trust had established an interim
leadership to help improve standards.
Martin Jones commented that AWP had confirmed that the number of Out
of Area Placements across BNSSG had been reduced to four. This was
welcomed. Alison Moon commented that the level of detail shared by the
Trust in relation to DToCs demonstrated that the Trust understood why
delays occurred and how improvements could be made. It was explained
that patients waiting for long term placements was a particular issue; AWP
Action Minutes Page 6 of 11
had requested both health system and local authority support to resolve
this issue.
Care UK NHS 111 currently had no identified safeguarding lead, and this
issue needed to be resolved. Child Safeguarding training compliance was
below target. BrisDoc had reported deterioration in performance in
December for clinical advice within 2 hours, due to increased demand.
The CCG was on track to meet the threshold for the number of C Difficile
cases for 2016/17. Attention was drawn to the mortality rates reported the
Quality Report. The CCG had discussed with UH Bristol the dip in
performance reported for June 2016. The Trust had explained the
assurance process in place. Attention was drawn to the level of Harm
Free Care reported which was good for both UHB and NBT.
Jill Shepherd commented on the report that Weston Area Health Trust
(WAHT) was one of 11 higher than expected Trusts in terms of the
mortality indicator and asked if this was out of trusts nationally. This was
confirmed. Jill Shepherd commented that this Trust was significantly
underperforming in comparison to UH Bristol and NBT. It was asked if the
data in the report was validated. This was confirmed. A paper explaining
how data was collected, where it was generated, and how it was validated
would be presented to the March In-Common Quality and Governance and
Governing Body meetings. Alison Moon explained that the individual CCG
data in the quality report was owned by each CCG respectively. The
collation of data was completed centrally.
Kirsty Alexander sought clarity about the MSK pathway and fractured neck
of femur. UH Bristol had reported that this related to theatre configuration
and the small numbers of cases. This was confirmed, and it was
explained that the Trust had confirmed that it would try to consistently
achieve the standard; however given numbers and theatre configuration it
was not confident that performance would be sustainable. The Trust was
focused on the safety of patients and consistently met the NICE standard
which was different, and had also completed a ‘harm reconciliation’.
Tara Mistry commented on the CCG ownership of data, explaining that this
had been discussed at the In-Common Quality and Governance meeting.
Alison Moon explained that the discussion had been shared with her
counterpart in North Somerset who not been at the meeting. Alison Moon
had reiterated that a principle should be agreed that each local team had
confidence in the data they generated. A further discussion with North
Somerset, to establish the issues regarding data and how these could be
avoided in the future had been suggested. Martin Jones explained for
members of the public that validated data was data that had been through
stringent checks. On occasions, it would be appropriate to act on unvalidated data. Alison Moon commented that discussions were not only
focused on data and that a range of information was used to build up a
complete picture of quality.
It was noted that the date given for the issue of the CQC warning notice to
Action Minutes Page 7 of 11
AWP relating to the Place of Safety Units was incorrectly reported. This
would be amended.
Action Sarah Carr
The Governing Body received the report
231 - 16/17
Finance and Performance Report
Performance
Rachel Anthwal informed members that diagnostic performance fell
sharply in December 2016; the drivers for this were predominately the
reported endoscopy surveillance issues. An action plan was in place to
restore performance. Ongoing pressures were impacting on a number of
areas of performance including 12 hour trolley waits which had increased
at both UH Bristol and NBT. The cumulative quarter 3 results for 12 hour
trolley waits were 14 breaches reported at NBT and 21 reported at UH
Bristol. In December there had been 11 breaches at NBT and 18 at UH
Bristol. Pressures had also impacted on 4 hour performance. The quarter
3 result for the 4 hour target at UHB was 80.3% and NBT 78.3% against
the standard. It was clarified that the offer made by NHSI for funds to
improve urgent care performance and flow had been withdrawn.
Performance against the RTT standard remained stable at 90.3%. Funds
received from NHSE had been used to increase weekend surgical rates at
NBT and UH Bristol. Martin Jones commented that at the Joint Assurance
Meeting NHSI had challenged commissioners on their financial
commitment to achieve performance. It was apparent that MSK was a key
impediment to achieving the standard. NHSI challenged whether plans
were sufficiently robust and fast to achieve the changes required.
Governing Body members needed to assured regarding plans as the work
was part of the wider STP. Rachel Anthwal commented that it would be
helpful to report to the Governing Body at the next meeting on the
progress of the priority projects. This would include the pathway work
outside of hospital and the referral management service.
Action Rachel Anthwal
Seven of the eight cancer standards had been achieved in December.
This was welcomed. It was noted that having one cancer steering group
had a positive impact. An update on the bid for funds to NHS E was given.
It was explained that funding had been confirmed for the recovery package
and risk stratification but this would not be from April, as funding had not
been agreed for early diagnosis in 2017/18. Feedback on the bids had
been requested.
AWP out of area placements had shown improvement as reported,
however DTOCs were increasing across the Trust. It was reported that
hospital hand over delays continued to be an issue for the ambulance
trust. This would be discussed at the next ICQP meeting. The Trust
reported improvements in performance against the category one target, a
reduction in vehicle dispatch rates per incident and an increase in Hear
and Treat rates.
Action Minutes Page 8 of 11
Care UK (111) had reported strong performance against the target for
number of calls abandoned, calls transferred to clinical advisor and the
combined warm transfer and call back in 10 minutes measure.
Performance issues remained in relation to calls answered in 60 seconds,
ED referrals and ambulance referral rates. Contract Performance Notices
(CPNs) and remedial actions were in place and these were monitored on a
monthly basis.
Alison Moon commented on the AWP DToCs; it was important to raise the
profile of mental health DTOCs in a systematic manner. There was a
discussion about the inclusion of AWP DToCs in the weekly Alamac call.
This was agreed. It was noted that DTOCs were discussed with AWP at
its meetings.
Action Rachel Anthwal
It was noted that Rachel Anthwal had been seconded to support the STP
and members thanked her for her contribution.
Finance
Nicola Dunn drew attention to the revenue cost statement at Annex 1. As
at the end of January the CCG continued to forecast a deficit of £7.5
million; it was noted that return of the CCG headroom would reduce the
forecast deficit to £1.9 million. Attention was drawn to the acute and
specialist care overspend of £4.7 million; NBT showed an overspend
position of £3.9 million. It had been reported under item 4 that NBT had
not signed up to the STF control total, this meant that the CCG would be
able to levy fines and penalties against contract under performance. The
current risk assessment was this could amount to £1.8 million. Further
discussions would be needed with the Trust, NHS E and NHSI. If this
funding was available, when combined with the return of headroom, the
CCG could reach a break-even position, if other risks did not materialise. It
was noted that NBT were required to sign up to the STF control total in
April 2016. It was difficult to plan financially in these circumstances.
There were two months remaining for 2016/17 and there were early
indications of some adverse variances which required validation. There
would be a further update to the Governing Body at the March meeting.
The main drivers of the CCG deficit position were acute and specialist care
at £4.7 million, mental health and learning disabilities at £1.1 million and
the unidentified QIPP and RightCare opportunities. It was noted that
recovery plans had been implemented which had been successful. Under
spends were reported against medicines management, primary care
contracting, urgent care (out of hours), community services and Continuing
Healthcare (CHC). It was noted that the CHC underspend had been
countered by the national price increase for Funded Nursing Care. Nicola
Dunn highlighted the risks and mitigations and noted that colleagues were
working on plans for 2017/18 and the STP; it was important to maintain a
focus on achieving a break even position.
The Governing Body received the report
Action Minutes Page 9 of 11
232 - 16/17
Clinical Policy Review Group (CPRG) Recommendations
Martin Jones highlighted the recommendations of the CPRG. Kirsty
Alexander asked if the Cataract Surgery Policy could be shared with
ophthalmology colleagues, given the number of cataract referrals made to
GPs. This would help to ensure a shared understanding of thresholds.
Pippa Stables noted that if the number of referrals was increasing and the
criteria were not being followed there would be a review. There followed a
discussion about ophthalmology pilots. It was noted that there was a
community hub pilot in South Gloucestershire.
Tara Mistry commented on the Eye Lid and Ectropion and Entropion
policies. Her experience as patient was that there were issues regarding
the interrelationships between the providers. There were other ways to
ensure the best use of resources in addition to these policies. Martin
Jones agreed that it was important to be clear about pathways.
It was explained that the eyelid conditions policy had been withdrawn.
The Governing Body approved the policies recommended for
adoption by the CPRG,:
 Nasal Surgery
 Ectropion and Entropion Policy
 Cataract Surgery
 Cosmetic Contact Lens
 Vitreous Floaters Policy
 Strabismus
233 - 16/17
Independent review of Children’s Cardiac Services at UH Bristol –
programme plan
Alison Moon had declared an interest in this item. Jill Shepherd explained
that this was an update on the action taken to address the
recommendations of the Independent Review of Children’s Cardiac
Services. There were 7 actions to deliver the recommendations behind
the milestone action plan. The Trust had reported that there was currently
no risk to the delivery of the recommendations. 35 actions had been
completed and 37 actions were on track. All actions would be completed
by 30th June 2017. Danielle Neale asked if the CCG was assured that the
closure of recommendation 8 was appropriate. It was explained that
Bridget James, CCG Head of Quality, met regularly with the Trust and had
been assured. It was noted that NHSE commissioned the service, but that
the action plan was received at the CCG Governing Body as NHSE did not
have meetings in public locally to receive the action plan. The CCG was
responsible for the quality of services at UHB.
The Governing Body noted the update
234 - 16/17
CCG Corporate Risk Register
It was explained that a number of risks and actions reported on the
corporate risk register had been discussed as part of the performance,
finance and quality reports. It was highlighted that a number of risks had
been updated. Members were informed that a new risk focused on GP
practice sustainability would be added for the March meeting. Alison
Action Minutes Page 10 of 11
Moon commented on the risks relating to organisational change and noted
that there was a risk of losing staff during times of change. It was agreed
to explore this risk with a view to adding it to the register. It was
commented that South Gloucestershire CCG had reported a similar risk.
Action Sarah Carr
Governing Body reviewed the Corporate Risk Register
Meeting Effectiveness Checklist
Members considered the checklist and agreed the meeting had been
effective.
Motion to Exclude the Public & Press
Kirsty Alexander proposed and Richard Laver seconded the motion that
representatives of the press, and other members of the public, be
excluded from the remainder of this meeting having regard to the
confidential nature of the business to be transacted, publicity on which
would be prejudicial to the public interest, Section 1 (2), Public Bodies
Admission to Meetings) Act 1960
Action Minutes Page 11 of 11
Governing Body Action Log for 28 March 2017 (Agenda Item 04a)
Date of
Meeting
Minute
No.
Subject
Action Required
RO
Deadline
Date of
Update
25/10/16
138-16/17
Finance, Quality,
Performance
Report
20/12/16
177-16/17
31/1/17
Information to be provided
regarding how robust the internal
systems are at UHB and NBT
regarding identifying overseas
patients.
RA
Nov 2016
March
2017
this is to be discussed
further with NBT and a
briefing will be circulated
once discussions are
completed.
action log
contracting arrangements with
the Priory to be confirmed
ND
Jan 2017
March
2017
Further information on AWP
sub-commissioning of acute
beds at Priory facility has
been requested. Once
obtained this will be shared
with Governing Body
members
209-16/17
(1)
Finance, Quality,
Performance
Report
NBT’s clinical validation process
relating to gastroscopy backlog to
be requested
RA
March
2017
March
2017
further information to be
shared with commissioners
28/02/17
221-16/17
(1)
Minutes of the
previous meeting
Impact of diagnostic backlog on
systems such as ICE to be
investigated
RA
April
2017
28/02/17
221-16/17
(2)
Minutes of the
previous meeting
ED Board governance
arrangements to be shared with
Governing Body members
RA
April
2017
28/02/17
230-16/17
(1)
Quality Report
Caring Solutions Report to be
presented to the March meeting
AM
March
2017
March
2017
This item is deferred to April
2017
1
Update
28/02/17
230-16/17
(1)
Quality Report
Report to be amended with
correct date CQC warning notice
to AWP re Place of Safety Units
SC
March
2017
28/02/17
231-16/17
(1)
Finance and
Performance
report
progress on STP priority projects
to be reported to March meeting
RA
March
2017
28/02/17
231-16/17
(2)
Finance and
Performance
report
AWP DToCs to be added to
weekly Alamac calls
RA
March
2017
28/02/17
234-16/17
Corporate Risk
Register
Risk relating to transition and key
roles becoming vacant to be
added to the CRR
SC
March
2017
March
2017
March
2017
RO – Responsible Officer JS – Jill Shepherd, , ND – Nicola Dunn , SC – Sarah Carr, FB Fiona Butter
2
Risk added to the CRR.
Recommend action closed
Meeting of Bristol Clinical Commissioning Group Governing Body
To be held on Tuesday 28 March 2017 commencing at 1.30pm at the Greenway
Centre, Doncaster Road, Southmead, Bristol, BS10 5PY
Title: Chairs Report
Agenda Item: 5
Report from the Shadow Joint Commissioning Board (SJCB) 15.02.17
The BNSSG CCGs’ Shadow JCB met on Wednesday, 15th February. It was reported
that the Project Management Office (PMO) was gathering ideas for turnaround and
reviewing against the operational plan. Publication of the operational plan and how to
engage with the public were considered. The meeting considered the proposal for STP
project management support and reported back from the Sustainability and
Transformation Plan (STP) Executive meeting. It was reported that the first turnaround
steering group meeting had taken place. The next steps would include identifying what
would be fed into the STP process, by whom and how; and how to focus on converting
ideas into plans and then delivery. A number of on-going procurements were
discussed. The latest version of the Primary Care Strategy was considered and it was
agreed to take the final version of the document back to membership before seeking
approval at Governing Body meetings. Weston sustainability and recent performance
issues and mitigating actions were discussed. The meeting discussed proposals for
urgent care governance and it was agreed to clarify the link between the UC
Programme Board and the A&E Delivery Board and the STP/leadership structures.
Initial proposals for managing 24/7 CCG on-call, urgent care and system management
responsibilities were considered.
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 1 of 1
Meeting of Bristol Clinical Commissioning Group Governing Body
To be held on Tuesday 28th MArch 2017
commencing at 1:30 pm in The Greenway Centre, Bristol, BS10 5PY
Title: Chief Officer’s Report
Agenda Item: 06
Report from the Shadow Joint Commissioning Board (SJCB) 15.02.17
The BNSSG CCGs’ Shadow JCB met on Wednesday, 15th February. It was reported
that the Project Management Office (PMO) was gathering ideas for turnaround and
reviewing against the operational plan. Publication of the operational plan and how to
engage with the public were considered. The meeting considered the proposal for STP
project management support and reported back from the Sustainability and
Transformation Plan (STP) Executive meeting. It was reported that the first turnaround
steering group meeting had taken place. The next steps would include identifying what
would be fed into the STP process, by whom and how; and how to focus on converting
ideas into plans and then delivery. A number of on-going procurements were
discussed. The latest version of the Primary Care Strategy was considered and it was
agreed to take the final version of the document back to membership before seeking
approval at Governing Body meetings. Weston sustainability and recent performance
issues and mitigating actions were discussed. The meeting discussed proposals for
urgent care governance and it was agreed to clarify the link between the UC
Programme Board and the A&E Delivery Board and the STP/leadership structures.
Initial proposals for managing 24/7 CCG on-call, urgent care and system management
responsibilities were considered.
Section 136 service
The end-of-phase governance meeting – co-chaired by the PCCs of Avon and
Somerset and Wiltshire – was held on Friday 17th March. It was very well attended and
the discussions were constructive, pragmatic and ambitious. The following are the
headlines for the project:



It was noted that the experience of people using mental health services was
central to the work and that the description of ‘good’ that people developed on
29th November 2016 was a very important part of the principles for the future
model.
The meeting considered the recommendations in the report that had been
written following the various workshops that had taken place, and accepted
Option 2 as the way forward; implementation of the proposal across BNSSG,
BaNES, Swindon and Wiltshire.
The next stage of the programme will be a detailed design and implementation
phase with a properly configured programme of change.
Phase 3 starts on 27th March. The purpose of this phase (the final phase before
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 1 of 2
Meeting of Bristol CCG – date - subject
detailed planning for implementation and implementation) is to test the proposed new
pathway (and all the structural and other system / organisational adjustments that will
be necessary to support the pathway) against a range of scenarios. It serves to make
final adjustments to the pathway and structure; and also to de-risk piloting and roll out.
One of the important underlying principles for this programme is that the future model
will cost no more than the current model, but that the various agencies working together
better will make better use of scarce resources.
This work is a really good example of cross organisation system working, with
extremely valuable input from people with lived experience, which has made a real
difference to the discussions and the resulting proposed pathway.
Jill Shepherd
Chief Officer
March 2017
Page 2 of 2
Meeting of NHS Bristol CCG Financial Review Committee
Minutes of the meeting held on Tuesday 21st February 2017 in the CCG Conference
Room, South Plaza
Draft Minutes
Present:
Members:
Richard Laver
Governing Body Locality Representative (Chair)
Carew Reynell
Audit Committee Lay Member
David Finch
Audit Committee Lay Member
Rob Moors
Interim Deputy Chief Financial Officer
In Attendance:
Lucy Powell
PA to the Chief Financial Officer
Action
1
Welcome and Introductions and Apologies for Absence
Apologies were received from Danielle Neale, Jill Shepherd,
Martin Jones, Nicola Dunn, Alison Moon, Rob Presland and
Martin Sheldon.
It was noted that Rob Moors was standing in as Nicola Dunn’s
deputy as an officer member so the meeting was declared
quorate.
2
Declarations of Interest
There were no declarations of interest.
3
Minutes of previous meeting, matters arising and action log
The minutes of the previous meeting were agreed as correct.
However, it was asked that the key message regarding the
2017/18 QIPP plan was amended to read, “QIPP schemes have
been proposed for 2017/18 and these include schemes across
BNSSG and across the STP footprint”. This was agreed and
amended.
Rob Moors clarified that the amount attributed to QIPP schemes
has been allocated but the actual schemes themselves are still
under discussion.
Action Minutes Page 1 of 9
Action
David Finch asked that the minutes record that when the
Committee discuss the QIPP schemes, this is in fact the impact
of the amounts on the financial deficit for 2017/18.
The Committee reviewed the action log.
20/09 9(1) The Committee noted that the Corporate Risk Register
had not been discussed by the BNSSG CCGs and it was agreed
to leave this action open.
22/11 4(2) Rob Moors confirmed that Nicola Dunn had met with
the Section 151 Officer at Bristol City Council and confirmed that
actions have been identified for both organisations. Nicola Dunn
would provide more information at the March meeting. It was
agreed to leave this action open.
22/11 4(3) Rob Moors confirmed that the issues surrounding the
CSU inhousing have now been resolved. The contract is ready
for signature but has not yet been formally signed. Nicola Dunn to
confirm when the contract is signed.
Nicola
Dunn
Nicola
Dunn
22/11 7(2) Bristol CCG has received the proposed split for the
cost of the Ernst and Young report but the CCG does not agree
with the methodology. This will be discussed at the next STP
meeting by all organisations involved. It was agreed to leave this
action open and update at the next meeting.
David Finch asked which methodology was in the forecast and
Rob Moors confirmed that the higher amount has been allocated
in the budget.
22/11 11(1) Rob Moors explained that there are ongoing
discussions between AWP and the CCG and that Nicola Dunn
would update the Committee further at the next Committee
meeting.
13/12 4(3) Rob Moors explained that the actions involving
feedback regarding business cases were now all actioned
through the STP and turnaround work. The business cases would
be reviewed as part of this work and presented to the Financial
Review Committee as QIPP plans for 2017/18.
Nicola
Dunn
Nicola
Dunn
13/12 4(4) Rob Moors explained that the actions involving
feedback regarding business cases were now all actioned
through the STP and turnaround work. The business cases would
be reviewed as part of this work and presented to the Financial
Review Committee as QIPP plans for 2017/18.
13/12 4(5) It was noted that without Nicola Dunn or Rob Presland
at the meeting, there was no one to update the action regarding
the IT for primary scheme communications. This would be
Action Minutes Page 2 of 9
Action
updated at the next meeting.
13/12 4(6) Rob Moors explained that the actions involving
feedback regarding business cases were now all actioned
through the STP and turnaround work. The business cases would
be reviewed as part of this work and presented to the Financial
Review Committee as QIPP plans for 2017/18.
Rob
Presland
24/01 4(1) Rob Moors explained that there had been no senior
staff engagement related to the turnaround to report this month.
24/01 4(2) It was confirmed that Nicola Dunn responded to the
questions sent by David Finch last month. The action was closed.
It was agreed that David Finch would send a copy of the
responses to Richard Laver and Carew Reynell for their
information.
24/01 4(3) Nicola Dunn thanked Steve Freeman and his team for
their hard work and this was also added to the key messages.
This action was closed.
David Finch
24/01 5(1) It was confirmed that the QIPP Scheme schedule for
2017/18 had not been received. It was noted that this would be
part of the turnaround work and would be received as part of this.
24/01 7(1) David Finch confirmed that he had received the QIPP
reconciliation. This action was closed.
4
2016/17 Finance Report and Dashboards
Rob Moors reported that the forecast outturn had not changed
from the previous month. David Finch asked whether this was a
requirement from NHS England. Rob Moors confirmed that this
was not the case this month and noted that the CCG had seen
both positive and negative movements which had approximately
balanced in the accounts.
It was highlighted that the CCG is still awaiting the decision
regarding the NBT penalties. The CCG have discussed this with
NHS Improvement and it has been confirmed that the CCG can
levy penalties up until the point when NBT agree to the control
total. The CCG has not been officially notified of this.
It was confirmed that the headroom will be included in the
accounts during month 13. The month 12 reporting however, will
show the headroom as committed.
Carew Reynell asked whether the format to the annex one could
be amended to show the previous month’s forecast against the
current month’s forecast. This was agreed.
Rob Moors
Rob Moors
It was also noted that some of the sections discussed in the
Action Minutes Page 3 of 9
Action
financial narrative had not been amended from the previous
months and it was requested that these sections include more
detail for the March Committee meeting. These sections included
Better Care, Mental Health and development of QIPP schemes.
Rob Moors
David Finch asked why the CCG were charged by UHB for health
costs incurred by overseas patients. Rob Moors explained that
these were the rules as set out by the Department of Health. UHB
identify the patients and work out the cost of the treatment and
the CCG has to make a balance sheet provision for 50% of the
value. It was noted that once the bill is paid this will be transferred
to the CCG via the balance sheet. It was explained that should
the charges not be recovered then the CCG will pick up 50% of
the amount. It was clarified that the amount recovered is 150% of
the tariffed value.
David Finch also asked about the significant increase in the NI
and PAYE costs for March 2017. It was agreed to ask Steve
Freeman to respond to the Committee on this issue.
Carew Reynell noted that the Better Care section 256 funding
has deteriorated from month 9 to month 10 by about £400k. It
was agreed to ask Nick Tippet to provide an account to the
Committee members as to this change.
5
Rob Moors/
Steve
Freeman
Rob Moors/
Nick Tippet
2016/17 QIPP Report
Rob Moors reported an improvement of around £200k in the
month 10 position. This was attributed to changes in the activity
updates for month 9. It was noted that there had been positive
forecast changes for some schemes including prior approval, falls
reduction and the heart failure in reach service. However, there
had been a significant decrease in the expected savings forecast
for the GPST scheme.
Carew Reynell noted the total revised QIPP plan row on the QIPP
summary and highlighted the net 16/17 saving of £11.9m and
asked how this related to the original QIPP total of £25.1m. Rob
Moors explained that £13.2m was removed from the original total
of £25.1m which was the amount attributed to unidentified QIPP
and the RightCare schemes. This left the amount of QIPP to
achieve as £11.9m of which £8.7m is currently expected to
achieve. The Committee noted that 70% of the achievable QIPP
had been delivered for 2016/17. The Committee discussed how
this percentage relates to the possible QIPP to be delivered for
2017/18 and whether it is realistic to expect 70% achievement
again.
Richard Laver noted the schemes which had been not supported
Action Minutes Page 4 of 9
Action
by NHS England. It was explained that further questions
regarding these schemes will be asked of NHS England at the
meeting today. Rob Moors explained that the RTT performance is
linked to the waiting times scheme and that the CCG will be
discussing this further with NHS England as well.
David Finch asked how the QIPP scheme owners are held
accountable particular for savings expected. Rob Moors
explained that the Programme Management team (PMO) review
the business cases to check for achievability and consider
possible links with other schemes. The business cases are
reviewed by the Performance and Planning and Financial Review
Committees for scrutiny before being presented to the Governing
Body for approval. It was explained that during Turnaround the
Control Centres will be held accountable for any shortfalls in
savings.
It was clarified that the savings attributable to a scheme would
only be included within the bottom line QIPP savings once the
scheme had been reviewed and approved. The process has
evolved through the PMO and this has become more rigorous
though the Sustainability and Transformation Plan (STP) work.
6
QIPP Assurance Minutes
The Committee received the minutes.
David Finch asked whether the 2017/18 NBT Contract had been
signed. Rob Moors confirmed that the contract had been signed
but there were a couple of issues outstanding which are to be
audited and the results of these audits will determine whether the
items are removed from the contract. It was noted that any
disagreements throughout the contract year are discussed at
contract performance groups and challenges are made.
7
2017/18 BNSSG Turnaround Plan
It was explained that Martin Sheldon had sent his apologies to
this meeting due to the NHS England meeting in Taunton.
Rob Moors explained that the presentation included in the papers
had been presented to NHS England on the 31st January 2017
and following feedback, revisions have been made.
Rob Moors explained what the BNSSG financial gap of £77.4m
comprised of. The BNSSG CCGs had a shared financial gap of
£52.3m deficit. £8m of this was the shared control total so
£44.3m deficit was the combined financial gap to make up. This
£44.3m is part of the £77.4m plus the contracted QIPP and noncontracted QIPP which amount to £15m and £18.1m respectively.
This makes up the £77.4m financial gap for the BNSSG CCGs. It
Action Minutes Page 5 of 9
Action
was noted that this gap is purely for the CCGs and doesn’t
include the other STP organisations.
Carew Reynell asked how the control centres were different from
previous groups with a similar remit. It was noted that the control
centres work across the BNSSG CCGs and each of the Senior
Responsible Officers for each centre will be held accountable for
both the delivery of the schemes and the financial shortfalls. It
was noted that each control centre will have named PMO,
Finance and Business Intelligence support.
8
2017/18 BCCG Turnaround Summary
Rob Moors presented the Bristol analysis of the financial gap.
The 2016/17 forecast position was outlined and it was noted that
the planned surplus has reduced from 2015/16 at £5.7m into
2016/17 at £3.5m so the planned position for 2016/17 showed a
deterioration of £2.2m, however the £3.5m is still a planned
surplus.
The Committee reviewed the forecast outturn position and Rob
Moors explained the areas where there were significant changes
to the position, highlighting the Funded Nursing Care and QIPP
Non-Delivery financial pressures. It was explained that once the
headroom figure of £5.6m was added into this position the CCG
would have a forecast outturn of £7.6m. It was noted that the
£7.6m was made up of the current forecast outturn of £7.5m,
which with the headroom played in, makes a planned deficit of
£1.9m plus the £5.7m brought forward surplus makes the £7.6m
forecast outturn. This figure is then subject to some non-recurrent
adjustments and allocations which brings the underlying deficit to
£14.5m for 2017/18.
Carew Reynell asked how the PTS spend would affect this figure
and it was confirmed that the PTS costs are recurrent costs. It
was highlighted that the figures discussed were from a specific
point in time and that this would change and develop during the
year end accounting process.
The Committee reviewed the summary plan for 2017/18 noting
the starting position of the planned £14.5m deficit. Rob Moors
explained that the CCG would receive an £11.8m allocation for
growth, however the STP projected growth has been calculated
as a cost of £16.9m for the CCG. Rob Moors also highlighted
cost pressures regarding tariff inflation and the impact of the
HRG4+. The CCG is discussing this issue with NHS England
currently as the CCG has calculated that this will cost more than
predicted by NHS England. Other cost pressures included the
0.5% for contingency and the £2.5m investment in RTT as well as
£0.7m for primary care resilience.
Action Minutes Page 6 of 9
Action
The savings plans were outlined as contracted QIPP of £7.2m
and non-contracted QIPP of £11.1m. Rob Moors explained that
the contracted QIPP figure was the amount of QIPP expected in
the contracts, however there were no schemes badged against
this figure in order to reduce growth. These are part of the suite of
QIPP Schemes which are being presented to NHS England
today. With both QIPP figures assuming achievement then the
Bristol CCG’s Forecast outturn for 2017/18 would be £13.2m plus
a £1.1m surplus requirement.
It was confirmed that the contractual element of the QIPP savings
would involve schemes by the CCG and local primary care teams
to reduce activity in secondary care and so reduce costs for
secondary care charges.
David Finch asked whether the £14.3m gap challenge solutions
were being developed by the Turnaround Director and it was
clarified that this element only applies to Bristol CCG. The
turnaround work is developing plans for the whole BNSSG CCG
position. It was noted that the proposed plans to be reviewed by
NHS England amount to more than the total gap in order to
include some contingency for plans that don’t deliver as
expected.
Carew Reynell highlighted the £1.5m savings from QIPP
schemes started in 2016/17 and it was confirmed that these will
continue on into next year.
David Finch asked whether the turnaround work would provide
Bristol CCG with an itemised list of plans and budgets to work
through to achieve the gap. Rob Moors confirmed this and noted
that the schemes will work across BNSSG so for some of the
schemes, Bristol may achieve more than expected.
Carew Reynell asked that an update be presented to the FRC
next month regarding the plans, this was agreed.
The Committee requested that Martin Sheldon be invited to the
Committee meeting in March. It was agreed that Lucy Powell
would do this.
Nicola
Dunn
Lucy Powell
David Finch asked about the role of the FRC, in terms of the
QIPP scheme sign off, if the plans have been authorised by
Directors and NHS England through Turnaround. It was
confirmed that the FRC will be expected to monitor achievement
against the savings expected.
9
2017/18 Financial Plan
The Committee confirmed that this had been discussed in item 8.
Action Minutes Page 7 of 9
Action
10
2017/18 QIPP Report
The Committee confirmed that this had been discussed in item 8.
11
Corporate Risk Register
The Committee reviewed the risk register and Carew Reynell
noted that two new risks had been added regarding the move to a
single commissioning voice and how the resources allocated to
this work could affect achievement of targets. Carew Reynell also
noted the possible BNSSG review of the Risk Register and
commented that he thought this would be a good time to review
the risk register format.
12
Review of Committee Effectiveness
The Committee completed the review of committee effectiveness
as below:

Did the meeting run to time - Yes

Did the right people attend – No, it was noted that this was
due to the meeting to discuss Turnaround with NHS
England.

Were action items assigned where appropriate to the right
people - Yes

Were all items given sufficient time to discuss - Yes

Were all members able to contribute - Yes

Has the meetings business contributed to the
organisation’s aims and objectives in terms of:
o Strategy - Yes
o Planning - Yes
o Governance - Yes

Were any of the items inappropriate for this committee No

Did the meeting receive the administrative support that it
needed - Yes
13
Any Other Business
14
Key Messages
Action Minutes Page 8 of 9
Action
15

The forecast outturn has not changed from Month 9. The
CCG is continuing to forecast a deficit of £7.5m.

A £200k improvement in QIPP savings has been reported,
however the CCG still has a significant QIPP gap to fulfil.

The BNSSG CCGs are working together with Martin
Sheldon to develop ideas to reduce the BNSSG financial
gap for 2017/18.

These ideas have been presented to NHS England and
the CCGs are awaiting a response to these.
Dates of Next Meetings – Financial Review Committee
Tuesday 21st March: 12.00 – 14.00
Tuesday 18th April: 12.00 – 14.00
Tuesday 16th May: 12.00 – 14.00
Tuesday 20th June: 12.00 – 14.00
Administrator
Lucy Powell: 0117 900 3417
Action Minutes Page 9 of 9
Meeting of NHS Bristol CCG Performance and Planning Committee
Minutes of the meeting held on Thursday 16th February 2017 in Jill Shepherd’s Office,
South Plaza
Minutes
Present:
Jill Shepherd
Chief Officer
Martin Jones
Chair of Bristol CCG (Chair)
Nicola Dunn
Chief Financial Officer
Alison Moon
Director of Quality and Transformation
Ewan Cameron
ICE Locality Representative
Justine Mansfield
LEG Member, Bristol CCG
Justine Rawlings
Head of Strategic Planning
Kierstan Lowe
Communications Manager
Notetaker
PA to Claire Thompson & Delivery Directors
Action
1
Apologies
Apologies were received from Rachel Anthwal, Emma Gara,
Danielle Neale, Sarah Carr, Rob Presland, Steve Davies and
Jenny Bowker (shadowing).
2
Declarations of Interest
No declarations were made.
3
Minutes of the Performance and Planning Committee
meeting 8th December 2016 and Action Log
The Committee agreed that the minutes from the January
meeting were a correct record, there were no corrections.
The action log was updated as follows:

RTT work timetables– check whether this is trajectories
rather than timetables: trajectories would be useful
therefore it was agreed that this action should remain open
and that SS would speak with RA.

Histopathology “Look back” exercise – it was agreed
that this action should remain open.
SS
Action Minutes Page 1 of 6
Action
4

Corporate Risk Register, Lorenzo risk – Sarah Carr. It
was agreed that this action should be closed.

UC31: High Impact Users Group (UHB) - Sarah Swift
informed the group that discussions were ongoing. It was
agreed that this action should remain open

LTC28a: Community liver fibrosis testing
(elastography) – An overarching pathway was currently
being determined. It was agreed that this action should be
closed.

Action log – it was agreed to close this action as business
case numbers had been added to the action log.

Performance Report and Dashboards - It was agreed
that this action should remain open

Risk Register – rapid organisational changes - It was
agreed that this action should be closed.
Performance Report and Dashboards
SS provided an update on the latest performance position.
Diagnostic Performance:
There was a sharp decline in diagnostic performance at UHB and
NBT. The primary driver for this decline has been due to the
identification of a backlog of 600 endoscopy surveillance patients
at NBT. Bristol CCG was currently awaiting a detailed report.
Assurance had been received that the longest waiting patients
were reviewed and there were no clinical issues evident at this
time.
AM queried what action the provider had taken internally
regarding this issue: SS felt that the process would be taken into
account as part of the RCA. Once the RCA received, Bristol CCG
would be able to investigate this issue more deeply.
SS informed the group that recovery was on track for the end of
March.
Urgent Care:
Still failing across the system, SS reported slight improvement at
NBT over the period but a slight decline at UHB. In terms of
patient experience there was an increase in trolley waits.
The report mentioned a BNSSG Urgent Care bid of £500,000
submitted. SS alerted the group to the fact that since the report
was written, NHSE have indicated at the last assurance meeting
that the money for this may not exist.
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RTT:
UHB have been achieving since November, are continuing to
achieve and are forecasting to achieve for the rest of the quarter.
NBT are not achieving, primary issues are MSK and Gyne. A
small amount of national money has been received by the
providers to assist with waiting list initiatives.
Cancer:
62 days were achieved in November and December.
Histopathology delays have been much improved but a sustained
improvement was needed. In their November data, NBT were still
citing some histopathology delays in their 62 day breaches.
Bristol CCG have bid for some national money around early
diagnosis, recovery package and risk stratified follow-up. The
CCG was unsuccessful in early diagnosis however the letter
indicated that this may change. The SWAG Cancer Alliance were
successful for recovery package and risk stratification but not in
the first wave, therefore the funding would not be available in
April but for sometime in 17/18. It was determined that there was
low risk to Bristol patients as programs were already established this was a question of going further rather that maintaining the
current situation.
Acutes:
NBT already had contract performance notices in place.
Bristol CCG issued UHB with a contract performance notice
covering a number of the constitutional areas. Bristol CCG could
not impose financial contract sanctions against most of these bar
two: processing e-referrals and rebooking cancelled operations.
UHB would need to report these to their board although it was
unclear as to whether this would be an open or closed session.
ND observed that some of these failures of performance could
mean that Bristol CCG could levy some further penalties to UHB
around emergency readmissions.
BCH: the increase in activity at South Bristol Urgent Care Centre
was discussed including the impact on other local services. The
Elderly service breach around RTT was also discussed: more
information was requested around the wish to restrict referrals.
SS
AWP: improvements were noted however there was an increase
in DTOC caused by lack of specialist placements and care home
and other accommodation issues, work was under way to
address that.
ND led the discussion around AWP’s financial recovery plan
submitted to FIG. This did not include either impact assessments
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Action
or quality assessments – ND requested for further work to be
undertaken. Members of the committee expressed
disappointment in the fact that quality impact assessments had
not been considered. During the last contract performance
meeting AWP had detailed a new process by which every quality
impact assessment for all savings would be personally reviewed
by the Medical Director and the Director of Nursing.
AM
Action: AM to send QIA to ND for future FIGs.
SWASFT: improvement was noted since implementation of the
new target for Category 1 patients. Hospital handover issues
remain significant, affecting Urgent Care.
Care UK: poor performance in a number of areas, notably ED
Referrals, ambulance referrals and response time for call
answering. Care UK are citing workforce as the key challenge, a
number of mitigation actions are in place to address this issue.
GP Out-of-Hours: high demand recorded during Christmas,
safety was maintained. Action: SS to clarify what was meant by
phrase “the busiest BrisDoc has experienced”.
SS
Independent sector: activity has stabilised. Capacity & Demand
was discussed in relation to RTT. It was clarified that the mention
of Care UK in the document was Emmerson’s Green.
CCHP: there was positive news in terms of DNA appointments as
well as an improvement in the percentage of children seeing a
paediatrician within 18 weeks. Action: It was agreed that more
information was needed. Conversely, access to Speech and
Language therapy and occupational therapy services remained
challenging.
SS
AM noted that Bristol CCG were contemplating a contract
performance notice for the Looked After Children assessments as
there have been no improvements for a long time. There was a
Safeguarding Group Meeting scheduled for Monday 20th
February.
It was noted that the Performance Against Core Standards was
predominantly red for 52 week waits, 4 hour waits, ambulance
handovers and cancelled operations.
Cancer and IAPT were both green. The committee commended
the improvement in the Cancer performance and agreed that a
good news story should be considered. Action: KL to link with
SJC.
KL
- Planning Update
JR provided a brief planning update. On 27th February there was
Action Minutes Page 4 of 6
Action
a re-submission of numbers, trajectories and activity, however no
official feedback had been received since prior to the December
submission.
In terms of plans, the question of whether to have three
narratives or one single BNSSG narrative was brought to the
attention of the committee. The potential for differential financial
outcomes was examined. As individual organisations with
separate finances, each CCG had their own programs and plans
in place that were needed to be delivered separately through
turnaround.
These questions were expected to be answered at the planning
meeting scheduled for Tuesday 21st February, at which Martin
Sheldon was due to attend. ND informed the group that Martin
Sheldon would be in Taunton on Tuesday and would not be
attending the planning meeting as expected.
The local submission was discussed as well as the schedule of
submission and their various versions.
Action: JR agreed to speak to Maria Heard to clarify what was
required.
JR
The group raised concern over the fact that although there was
only one BNSSG PMO, things were in such embryonic stages
that if the Bristol PMO lead could not attend a replacement Bristol
representative should be organised.
Action: It was agreed that JR should attend the significant PMO
Planning Meeting on Monday 20th February in Rob Presland’s
absence.
5
JR
Bristol CCG Corporate Risk Register
SJC was on leave therefore this item was not discussed in detail.
Last month saw a lot of activity on the corporate risk register,
each risk had a named lead. The group was urged to review the
register as it made its way to the Governing Body and was asked
if there were any risks they wanted to discuss - the answer was
negative.
ND noted an update on Lorenzo, which meant that the action
could be closed on the action log.
6
Review of Committee Effectiveness
Did the meeting run to time - yes
• Did the right people attend - yes
• Were actions assigned appropriately, to the right people - yes
Action Minutes Page 5 of 6
Action
• Were items given sufficient time to discuss - yes
• Were all members able to contribute- yes
• Has the meeting’s business contributed to the organisation’s
aims and objectives in terms of:
- Strategy - Planning – Governance - yes
• Were any of the items inappropriate for this committee - no
• Did the meeting receive the administrative support needed - yes
7
Key Messages
There were none.
28/02/17
PA to Claire Thompson - BNSSG Delivery Director
PA to Sarah Swift - Delivery Director
PA to Rachel Anthwal - Delivery Director
PA to Jenny Falco – Acute Contract Manager
Action Minutes Page 6 of 6
-
In-common Quality & Governance Committee
Minutes of the meeting held on: 19th January 2017
Location: Room G.09/10, Castlewood, Clevedon
Minutes
Present:
Bristol -
Jill Shepherd, (JS) Chief Accountable Officer
Alison Moon (AM) Director Transformation and Quality,
Martin Jones (MJ) Chair
North Somerset -
Kathy Headdon (KH) Lay Chair (Meeting Chair)
Jacqui Chidgey-Clark (JCC) Director of Nursing & Quality
Jeanette George (JG) Chief Operating Officer
Debbie Campbell (DC) Deputy Director of Quality
Mary Backhouse (MB) Chief Clinical Officer
Mary Adams (MA) Patient and Public Engagement Manager
South Gloucestershire -
Jon Hayes (JH), CCG Chair
Anne Morris, (AMo) Director of Nursing & Quality
Mel Green, (MG) Head of Medicines Management
David Jarratt(DJ), Director of Operations
Sue Brown (SB), Head of Governance
In attendance
Marie Davies (MD) Head of Commissioning for Quality, BNSSG CCG
Viv De La Fuente (VDLF) Interim Head of Operations, BCCG
Sophie Jones (SJ) Complaints Manager/PA, NS CCG (note taker)
Caroline Laing (CL) Quality and Patient Safety Manager, NS CCG
Rebecca Aspinall (RA) Programme Support for Partnerships BCCG
Julian Simcox (JSi) Lay Volunteer, NS CCG
Quality and Governance Committee Minutes Page 1 of 14
Sarah Carr (SC) Corporate Secretary, BCCG
Niall Mitchell (NM), Head of IFR
Bridget James (BJ) Head of Quality, BCCG
Rob Osment (RO), Human Resources Business Partner, CSU
Chris Flook (CF), Deputy Chief Finance Officer, SG CCG
Item No
1
Action
Apologies
Apologies were received from Kirsty Alexander, John Rushforth, Jo
Hartland, Tara Mistry, Jeremy Maynard, David Soodeen, Jane Gibbs; Jon
Hayhurst; Steve Davies.
KH welcomed all to the BNSSG Quality and Governance Meeting.
2
Minutes of the previous meeting, Action Log, Matters Arising and NS
CCG DOI Register
Minutes of the previous meeting were agreed as an accurate record.
Please find attached the updated action log.
KH requested North Somerset Q&G Members sign the DOI register.
3
Regulatory Updates:
Quality Surveillance Group
No verbal update.
4
Risk and Governance:
1) Bristol Corporate Risk Register
SC advised there were a number of updates to the Corporate Risk Register,
however there were no significant movements in scores.
Action Minutes Page 2 of 14
Item No
Action
The Q&G Committee reviewed the Bristol Corporate Risk Register and
commented on the amendments, controls, assurances and actions reported
and recommended the Corporate Risk Register to the Bristol Governing
Body.
2) Bristol Serious Concerns Log
SC stated there were no new concerns to report.
3) Good Practice Guidance: Covert Administration of Medicines
MG talked about the Good Practice Guidance and advised Bristol has
updated the guidance for Care Homes. DC stated North Somerset have the
guidance in place but would be happy to have a joint policy and would
arrange a meeting to discuss this further.
ACTION: MG and DC meet and discuss alignment of the guidance across
BNSSG.
DC/MG
The Q&G Committee acknowledged and noted the content of the guidance.
4) Bristol Governing Body Assurance Framework
SC highlighted the amendments made to the assurance framework to reflect
internal audit findings. The Q&G Committee reviewed the Bristol Governing
Body Assurance Framework and commented on the risks, controls,
assurances and mitigating actions identified before recommending it to the
Bristol Governing Body.
5
Minutes for Review:
BNSSG Health Care Acquired Infection Group;
BJ advised the minutes from the November meeting were for information
only. AM advised there was a need to think about priorities for the next year
and include any wider key performance indicators.
BJ replied this was on the agenda for discussion at the next meeting. AM
requested an update following the meeting to come to the Q&G meeting in
Action Minutes Page 3 of 14
Item No
Action
March.
ACTION: BJ to provide an update to the Q&G committee following the
March BNSSG HCAI meeting.
BJ
6
Quality Reports:
1) Report and Dashboards
MD presented the Quality Report and highlighted the issues with some
benchmarking data. MD highlighted key areas;

Fractured NOF data flagged issues with sustainable achievement of
key standards will all providers.

There was a requirement for a consistent BNSSG RAG rating.

There were limitations with the current data availability
JS commented VTE data for Weston Area Health Trust is concerning having
halved. JCC replied Weston do not have an electronic reporting system with
the work being undertaken by a ward clerk but advised this was being
addressed with the Trust directly.
DJ asked AMo whether she felt North Bristol Trusts’ improvement was on
track. AMo replied that she was confident with the progress being made with
NBT reporting on all concerns at the quality meetings.
Weston SHMI was reported as a concern with the Medical Director and
CCG director involved with continued work to improve the SHMI. KH added
there were some areas of confidence and assurance following the report of
the mortality meeting from Dr David John (GP Governing Body member).
NHSI are involved and are also working with the Trust. JS replied given the
concerns raised regarding the Trust, there should be a BNSSG approach,
writing to NHSI addressing the concerns discussed.
MB replied NHSI attended along with the CCG. MA commented reports
Action Minutes Page 4 of 14
Item No
Action
have identified concerns but no actions have been taken to address these
issues. AMo added performance and sub-optimal care go hand in hand with
patients’ waiting in the Emergency Department which increases the risk of
mortality.
Concerns were raised regarding how WAHT are interpreting the definition
and recording of 12 hour breaches. Members asked that this be looked in to
and reported back to next meeting.
JCC
Action: Interpretation of definition and recording of 12 hour breaches at
WAHT to be clarified, and brought back to next meeting.
Following discussion KH summed up and an action was identified for the
Accountable Officers and the Directors of Nursing to write to NHSE
regarding the concerns highlighted at the meeting.
It was asked why the national DTOC figures were high. JCC replied there
was an ongoing problem with data at the Trust and was attending the
discharge meetings to help relieve the pressure. KH asked whether the
CCGs have any opportunities as commissioners to raise concerns with
professional bodies.
AM/AM
ACTION: The BNSSG Directors of Nursing to review what professional
bodies they have access to.
or/JCC
BNSSG
ACTION: Accountable officers and Directors of Nursing to write to NHSE
regarding the concerns highlighted around Weston Area Health Trust.
MJ, MB and DJ left the meeting.
Action Minutes Page 5 of 14
Item No
Action
Quality Report
UH Bristol
MD advised that the fractured Neck of Femur performance remains below
the 90% threshold. An update on the action plan arising from the British
Orthopaedic Association Review will be brought to the February Quality Sub
Group meeting.
BJ noted there was a focus on gaining assurance that no patient harm had
occurred as a result of a 12 hour trolley breach. She noted no harm had
been reported to date by UHB. BJ also noted that the paediatric cardiac
action plan and Verita action plan were monitored monthly via the Quality
sub group meeting.
NBT
NBT had a further Never Event in December and a contract performance
notice is in place. The first action plan was received and was reviewed at the
Quality sub group.
Bristol Community Health
A contract performance notice had been issued due to not meeting KPI
timescales within the South Gloucestershire CHC team. It was also noted
that there has been an increase in the number of reported pressure ulcers
within BCH. This is being monitored at the Quality sub group. There is a
BNSSG Pressure Ulcer Steering Group who are developing a strategy for
the reduction in pressure ulcers across the health community.
AWP
BJ commented that the CQC had received notifications of concern about the
quality of care on a specific ward at Callington Road Hospital and as a
response carried out an unannounced visit on January 10 th. AWP have
developed an action plan to address the issues and this is being monitored
Action Minutes Page 6 of 14
Item No
Action
by the CCGs.
BJ also noted that the CQC issued a Section 31 letter in response to noncompliance with actions following an inquest held in 2016. AWP have been
asked to submit an action plan in response to this to the CQC by 23rd
January 2017.
Care UK
AM informed Q&G members Care UK had received their CQC inspection
report which rated them as ‘Good’. She noted they were one of the best
performing out of hour’s provider with some outstanding areas and this
should be acknowledged.
MD asked Q&G members for clarity as to whether they were happy for the
content of the Quality Report to go in to the public domain. JCC asked
Quality Leads to ensure it is clear that public versions are labelled.
JS left the meeting. SC highlighted that due to JS leaving the meeting,
Bristol CCG were no longer quorate.
MD talked about the successful meeting that took place with PPG Leads to
discuss the ambition within North Somerset to simplify the Quality Report for
the public domain. JSi replied the Quality Report contains a vast amount of
information that is not easy to digest and can be difficult to report back to
other PPG Leads. SC added that the approach would be welcomed and
would be easy to summarise the data for the purpose of the public report but
asked what in-house checks would be undertaken. JCC advised that she
would sign off the report.
The Q&G Committee;

Noted the content of this report and its supplementary quality
dashboards

Noted the risks identified in this report and mitigating actions being
Action Minutes Page 7 of 14
Item No
Action
taken and discussed whether this provided commissioners with the
level of quality assurance expected from each provider.
2) Maternity Dashboard
BJ advised the paper provides an update on the maternity data which is
produced on a quarterly basis and includes maternity metrics and outcomes.
JCC asked for clarity in terms of the Ashcombe Unit at Weston being shut
since the New Year, has this impacted NBT and St Michaels Hospitals’
capacity. BJ advised that this had not been raised as an issue, but would
follow this up.
ACTION: BJ to confirm whether capacity issues at NBT and St Michaels BJ
Hospital were affected due to the close of the Ashcombe Unit.
KH asked whether there was a correlation with pregnancy and obesity due
to the spike in BMI by booking data for the last quarter. BJ was not aware
but would ask the Children’s and Maternity Commissioner to monitor this.
AMo added NBT have reviewed this and were looking at ways to improve
this.
The Q&G Committee noted the report.
3) Provider Serious Incident Data
MD advised individual CCG’s were working hard to reduce the number of
overdue SIs with providers. JCC added Weston was issued a contract
performance notice due to the number of outstanding SI’s.
The Q&G Committee noted the Serious Incidents reported during the month
of December 2016.
4) Bristol Sign up to Safety Update
BJ provided the quarterly update. It was advised there was a need to refresh
Action Minutes Page 8 of 14
Item No
Action
going forward with certain areas requiring focus such as; primary care and
care homes. It was advised that a BNSSG Pressure Ulcer Group was in
place but further work could be done. DC requested a meeting with BJ to
discuss the work being undertaken to prevent duplication of work across
BNSSG.
ACTION: DC and BJ to discuss work streams across BNSSG.
DC/BJ
AM asked whether there would be an interest for a system wide approach to
sign up to safety. It was agreed that this would be an area of work that could
be undertaken BNSSG wide.
The Q&G Committee;
 Noted the progress against Objectives
 Noted discussions will be held with partner CCGs to discuss future
reporting on Sign up to Safety actions
5) Bristol Independent Suicide Report
BJ outlined the purpose of the report. There were concerns around the
number of suicides in Bristol Locality of AWP therefore an external review
was commissioned. There were 26 cases of suicide and acts of deliberate
self-harm over a period of 15 months. The report mirrored concerns raised
by
the
CCG.
The
report
highlighted
recommendations
for
the
commissioners.
The Q&G Committee received and accepted the report findings and noted
that further work was required to review and accept the commissioner
recommendations listed in the report and to develop an action plan which is
brought back to the committee for approval.
6) Recovery Bristol Partnership: Case for Change
BJ presented the Case for Change paper. Following an unannounced CQC
inspection and concerns raised following the visit, AWP, along with the
Action Minutes Page 9 of 14
Item No
Action
voluntary sector have reviewed practice and the skill mix of staff. Further
work is being undertaken to review triage and psychosis services.
The Q&G Committee reviewed the report for assurance.
NM and RA entered the meeting
7
Contract Updates:
1) CQUINS update 16/17 and 17/18
AM commented the CQUINS for 16/17 and 17/18 involved a lot of work and
much had been achieved. There was a need to look at creating a single
CQUIN panel. DC added there was a need to ensure measurements were
consistent across the acute Trusts.
2) Quality Schedule 17/19
MD advised that work was being undertaken to align CQUINs and Quality
Schedules. A lot of work had gone in to the Quality Schedule to agree sign
off with the acute Trusts and community providers. AQP’s are awaiting sign
off. From April the Quality Schedule should include benchmarking on a lot of
the measures which will put BNSSG in a good position.
The Q&G Committee noted the agreed schemes for CQUINs and Quality
Schedules for the 2017/19 contracts.
8
Other Reports:
1) Bristol Carers
RA advised that the Integrated Care Team were predicting a £40k
overspend. The risk sits with Bristol City Council and the figure has been
scrutinised due to data migration. The carers support centre within Bristol
City Council are proposing a 10% cut. AM asked RA whether the council
have been asked to write formally with the impact of the proposed cuts. RA
replied it was advised NBT have seen a 33% increase and 55% at UHB for
Action Minutes Page 10 of 14
Item No
Action
carer’s assessments. JG added an impact assessment forecast should be
made available for all proposed cuts. RA added there is a proposal to write a
business case due to the increase in demand.
ACTION: SC to add the Bristol Carers Report to the Bristol Governing Body
SC
agenda.
The Q&G Committee noted the report and requested that the report is
presented at the Bristol Governing Body meeting.
2) Bristol ContactUs
SC explained that GP’s had raised a number of issues, including an issue
relating to the lack of information in NBT ED discharge summaries. AM
added there were queries around delays on clinic letters from NBT along
with patients receiving a discharge letter after missing one appointment. JH
asked whether it was possible to gather information around delayed clinic
letters and the departments involved. There was a discussion about the
future management of GP concerns regarding inappropriate referrals from
secondary care. It was agreed to review how these could be taken forward
in future.
ACTION: Kat Tucker to liaise with BJ to discuss how to manage Bristol KT/BJ
Contact Us going forward.
The Q&G Committee noted the content of the report.
3) South Gloucestershire GP Feedback Report
SB advised this was the quarterly report. GP’s make contact with the CCG
but this is not well used with some surgeries reporting consistently and
some not reporting at all. Due to the low level of reports it has not been
possible to identify any themes.
Action Minutes Page 11 of 14
Item No
Action
The Q&G Committee noted the number and types of issues reporting during
quarter 3, 2016/17.
RO entered the meeting.
4) BNSSG IFR Report
NM advised the report is a statistical report and on target to increase
activity. Overall performance is green and achieving against KPI targets. NM
commented the KPI targets were adopted by the CSU but would welcome
any comments or changes required following the transfer.
KH asked
whether Bristol were still unable to recruit a lay member. NM advised that
this was the case but were quorate. JG asked whether there was an
opportunity for the lay membership to be shared BNSSG wide. DC added
that it would be good to see an overall picture of the impact of the additional
prior approvals. NM agreed to discuss this work with DC.
NM/DC
The Q&G Committee;

Took an update regarding the IFR Team service delivery and current
status.

Advised on which information they would like reported on in the
future.

5) Bristol Workforce and Mandatory Training Report
RO presented the report for the period end 30th September 2016. There had
been an increase in head count to 227 due to the in-housing and an
increase in staff on bands 5 to 8.
The sickness absence is recorded as below the absence target with themes
relating to anxiety and stress. Statutory and Mandatory training is below the
target. SC asked for a progress update regarding IG training. RO replied Q3
report showed 86% up until the end of December with a target of 95%.
Action Minutes Page 12 of 14
Item No
Action
VDLF added as a result of the internal HR audit the CCG has been working
on areas highlighted with work being undertaken included in the action plan.
The Q&G Committee approved the Workforce Report.
KH handed over the chair responsibilities to DC and left the meeting
6) BNSSG Joint Formulary Group Year End Report 2015/16
It was noted that North Somerset received the report at the Q&G meeting in
November 2016. MG talked about the progress on the work with the
paediatric formulary group. It was proposed that a Clinical Lead takes a
stronger role within the process bringing operational direction. JH asked
whether Optimise RX is used across BNSSG. DC advised that it was rolled
out across BNSSG practices, with one practice in North Somerset and a few
in South Gloucestershire still to progress.
Caroline Laing joined the meeting
7) North Somerset CCG Infection Control Annual Report 15/16
CL gave a brief overview of the report. Highlights from 2015/16 included no
reported MRSAs bacteraemias by Weston and none to date since October
2014. There was an action for providers to improve communication and to
carry out visits to care homes to ensure the correct guidance is embedded
for patients with MRSA. Weston did not adopt the national guidance and
screen all patients for MRSA prior to hospital admission.
It was reported that Clostridium Difficile infection is decreasing within the
Trust and the Community Public Health is working with the CCG and has
held events for Care Homes and schools for Infection Prevention and
Control. Antibiotic prescribing continues to be monitored.
The Q&G Committee received and discussed the report.
Action Minutes Page 13 of 14
Item No
Action
8) APCRC Quarter 3 Report
The Q&G Committee noted the report.
9
Review of Committee Effectiveness:
Q&G members agreed the meeting was effective but it was noted that it is
difficult for everyone to attend the meetings and make themselves available
at the same time.
10
AOB:
JH asked why some Trusts’ were reporting their 12 hour trolley breaches
collectively. AMo replied that Trusts’ are required to enter the breaches on to
STEIS and produce a report within 72 hours of the incident occurring. If
harm is caused this would then go through a RCA process. Each incident
would require a clinical assessment before being removed from the system.
11
Meeting Finish
Date of next meeting: Wednesday 22nd February 2017
Location of next meeting: South Glos CCG, Downstairs Meeting Room
Action Minutes Page 14 of 14
Quality & Governance Committee
Minutes of the meeting held on: Wednesday 22 February 2017
Location: The Batch, 8A Park Road, Warmley, Bristol
Minutes
Present:
Bristol -
Alison Moon, Director of Transformation and Quality
Steve Davies, South Locality Executive Member
Tara Mistry, Governing Body Member, Lay Member PPI
(AM)
(SD)
(TM)
North Somerset -
Kathy Headdon, Lay Member
Jeanette George, Chief Operating Officer
Julian Simcox, Lay Volunteer
(KH)
(JG)
(JS)
South
Gloucestershire -
Anne Morris, Director of Nursing and Quality
Susan Brown, Head of Governance and Quality
John Rushforth, Lay Member (Chair)
Jane Gibbs, Chief Officer
Jonathan Hayes, Clinical Chair
Chris Flook, Deputy Director of Finance
(AMo)
(SB)
(JR)
(JGi)
(JH)
(CF)
In Attendance:
Sarah Carr, Corporate Secretary, BCCG
Marie Davies, Head of Commissioning for Quality, BNSSG
Jon Hayhurst, Head of Medicines Management, BCCG
Bridget James, Head of Quality, BCCG
Kat Tucker, Complaints and FOI Manager
(SC)
(MD)
(JH)
(BJ)
(KT)
Apologies:
Mel Green, Head of Medicines Management, SGCCG
Lucy Jones, Corporate Support Manager, SGCCG
Dave Jarrett, Director of Operations, SGCCG
Dr Jo Hartland, R&D Programme Manager, APCRC
Jill Shepherd, Chief Accountable Officer, BCCG
Martin Jones, BCCG
Dr Mary Backhouse, NSCCG
Debbie Campbell, NSCCG
Jacqui Chidgey-Clark, NSCCG
Kirsty Alexander – Governing Body Member, BCCG
Quality and Governance Committee Minutes Page 1 of 13
Item No
1
Action
WELCOME AND APOLOGIES
John Rushforth welcomed members to the Quality and
Governance Committee Meeting In Common. Apologies were
received from the above members.
It was noted that both Bristol CCG and North Somerset CCG
were not quorate. Unfortunately due to the number of meetings
taking place not all members were able to attend. It was noted
that there were no items on the agenda that would require
approval for Bristol CCG.
2
DECLARATIONS OF INTEREST
No new declarations of interest were made. There were no
declarations of interest relating to matters on the agenda and no
conflicts of interest were declared
3
MINUTES OF THE MEETING OF 19 JANUARY 2017
The accuracy of the minutes of the last meeting were discussed
at length and it was agreed that the three Directors of
Nursing/Quality would amend the minutes and send to the Chair
for final sign off. It was agreed that the Chair who hosts the
meeting at the time should be sent the draft minutes along with
the Directors of Nursing/Quality for checking and amending
where necessary.
Nurse
directors
Minute
takers
It was noted that John Rushforth, Dave Jarrett, Sue Brown, Jon
Hayes and Bridget James were in attendance at the last meeting
and that Jane Gibbs was not in attendance.
Action Log
The action plan will be updated and circulated to members of the
group.
RJ
Matters Arising
For matters arising see action plan.
Terms of Reference BNSSG Q&G In Common
It was noted that the Committee have still not received a signed
off copy of the Terms of Reference from North Somerset. JG
noted that North Somerset Governing Body did not approve the
Terms of Reference and it was agreed that following the Quality
and Governance Committee In Common meeting JG would take
the comments back to the Governing Body and request that the
JG
Page 2 of 13
Item No
Action
Terms of Reference be approved. JG confirmed she was happy
to discuss this with MD who would write a paper to reflect the
discussion.
4
REGULATORY UPDATES
Quality Surveillance Group
It was noted that the next Quality Surveillance Group meeting is
taking place on 9 March 2017. There will be a focus on Weston
Hospital and the Healthwatch Reports.
5
RISK AND GOVERNANCE
5.1
Bristol Corporate Risk Register
The report was presented by SC for review and comment.
There were no questions relating to this item.
5.2
South Gloucestershire Corporate Risk Register
The report was presented by SB for review and comment.
It was noted that Risk 79 has been identified for removal
from the register and Risk 84 would be added as a new
risk which related to the single Accountable Officer who
has been appointed across Bristol, North Somerset and
South Gloucestershire CCGs. The high level risks will be
presented to the Governing Body on 29 March 2017.
5.3
Bristol Serious Concerns Log
SC stated that there was no update following the last
meeting.
5.4
South Gloucestershire IG Toolkit
The report was presented for review and comment. It
was recommended that going forward the South, Central
and West Commissioning Support Unit (CSU) would
provide a single report which covers the three CCGs. To
ensure that specific CCG issues were covered the report
would be split into two sections. The report will be
produced on a quarterly basis. There were no questions
relating to the future process.
It was noted that the Information Governance Strategy
differed for all three CCGs. All CCGs confirmed that they
were happy for the strategy to be combined however
there were significant changes for Bristol who would want
to share these with their Governing Body. South
Gloucestershire agreed their Strategy but Bristol and
North Somerset would be subject to sign off from their
Page 3 of 13
Item No
Action
Governing Bodies.
6
5.5
Bristol Incident and Health and Safety Report
The report was presented by KT for review and comment.
KT informed the group that there have been no incidents
during Quarter 3. It was noted that training compliance
has significantly improved. It was agreed that the report
would now be presented on a 6 monthly basis.
5.6
South Gloucestershire Assurance Framework
The report was presented by SB for review and comment.
There have been no changes to the Assurance
Framework since the last meeting. The Assurance
Framework is due to be presented to the Governing Body
on 29 March 2017.
5.7
NBT Risk Register
The report was presented for review and comment. AMo
has informed the Trust that this was being discussed at
the Quality and Governance Meeting In Common. The
Trust confirmed they were happy with the process and
that any comments are discussed at the NBT/CCG
Quality Sub Group meetings. It was noted that North
Bristol Trust will be discussing the Extreme Risk Register
at their Board Meeting. JGi reported that the paper
provided ongoing assurance on the effective management
of NBT risks. AMo was asked to feedback to the Trust on
how well this was received and appreciated.
AMo
MINUTES FOR REVIEW
6.1
BNSSG Healthcare Acquired Infection Group
The minutes of the last meeting held on 20 December
2016 were presented to the group. It was noted that this
is now a BNSSG Group and there have been two
meetings held since the collective. The Committee noted
the minutes.

HCAI Draft Terms of Reference
The Terms of Reference were presented for review
and comment. It was noted that membership
includes a Public Health England Representative and
also Local Authority Representatives. The following
key points were noted: Add In Common
 Annual Plan to be added to the Terms of
Reference
BJ
Page 4 of 13
Item No
Action
JR mentioned that there was some detailed work that
requires full clarification and links. AM noted that the
terms of reference stated that it would be the
Directors of Nursing/Quality but that she did not
attend the group and did not feel it necessarily
needed director chair. It was agreed that the meeting
would be held bi-monthly going forward.
7
6.2
HR, Organisational Development and Training (HOT)
The report was presented for noting only. The group will
be reviewing the role of HOT going forward and in the
context of BNSSG Quality and Governance Committee.
6.3
Bristol PPI, Equalities and Comms
The report was presented for noting only. It was also
noted that Bristol CCG has been commended for best
practice in NHS Guidance.
QUALITY REPORTS
7.1
Reports and Dashboards
The report provided an overview of how each of the
BNSSG local NHS Healthcare Providers was performing
in relation to quality, patient safety and patient
experience.
UHB
UHB continue to perform well. Mixed sex accommodation
breaches have occurred in the Queens Day Unit as this
area has been used for additional beds overnight during
periods of escalation. Patients have been informed and
consent obtained before placing them in the beds. The
CCG has requested that actual numbers of breaches are
reported and to visit the area to review the measures put
in place to protect a patient’s privacy and dignity.
Trolley Breaches - There have been two 12 hour trolley
breaches in December 2016 and twenty one 12 hour
trolley breaches in January 2017. The 72 hour
investigations have not identified any patient harm and
the CCG has agreed to downgrade these incidents.
Fractured Neck of Femur – Performance continues to be
an issue for Bristol. It is difficult to achieve the target due
to the set up in theatres. The Trust is to undertake a
review of physiotherapy to complete a business case for
more physiotherapy support. This will also be discussed
at the next Quality Sub Group meeting. AM noted that
Page 5 of 13
Item No
Action
fractured neck of femur was now a part of the STP MSK
work stream and that this was the route for a more
sustainable solution
AWP
A warning notice issued from CQC relating to the Place of
Safety Units remains in place. CQC have also highlighted
21 “must do actions” and 33 “should do” actions during
the last inspection visit. CCGs are monitoring the
associated action plans and progress via the Quality Sub
Group with the expectation that this will improve.
It was noted that the Trust has received a Section 31
letter as they are not complying with Section 28. Bristol
CCG has responded to this and has asked to have sight
of the action plan.
Callington Road Hospital – issues have been raised
regarding the quality of care and safety in three wards.
An unannounced visit by the CQC was carried out in
January 2017 and an action plan has been developed but
the CQC have asked for a more detailed response. In
addition AWP has strengthened the hospital management
team to provide greater leadership for the inpatient unit.
Bristol CCG is working closely with the Trust to resolve
these issues. A joint safeguarding and quality site visit
took place in January 2017. A follow up meeting with the
Trust has been arranged to closely monitor the
improvement and will also be an agenda item at the
Quality Sub Group meeting and the Bristol CQPM
meeting with the expectation that this will improve.
It was noted that there has been some media interest
with regard to the number of suicides in the area. Bristol
CCG has noted these concerns and the independent
review they commissioned will be shared with other
Commissioners. Bristol CCG expects to see a strong
AWP response to the recommendations. It was
suggested that a deep dive into the suicides would be of
benefit and discussed at a future meeting.
AM
It was noted that the AWP Quality Improvement Group
has disbanded and all business is now discussed at the
AWP/CCG Quality Sub Group. AWP have recently
appointed a new Medical Director and Deputy Director to
support the quality agenda.
Bristol Community Health
Bristol Community Health was inspected with planned and
Page 6 of 13
Item No
Action
announced visits in November 2016. The inspection was
a comprehensive look at all the services provided by
Bristol Community Health. The Trust has received an
overall rating of Good although there are actions which
focus on children’s services. A full copy of the report can
be found on the BCH website.
NBT
Never Events – A further Never Event was reported by
NBT in December 2016 relating to a misplaced nasogastric tube. The 72hour report has been submitted to
the CCG and a full RCA investigation is underway. The
concern continues regarding the number of Never Events
reported by NBT in the year 2016/17. South
Gloucestershire CCG has issued a Contract Performance
Notice (CPN) in response to the Trust’s failure to ensure
Never Events do not occur. The CCG has requested the
Trust submit a revised Recovery Action Plan (RAP)
focusing on the issues highlighted from the RCA
investigations undertaken on each Never Event.
Safeguarding – an issue has been identified relating to
the Trust’s ED process for referring into children’s social
care. As a result of the issue a number of children could
have potentially been lost to follow up. The Trust has
carried out an investigation into the issue of child social
care referrals and has developed a RAP which was
submitted to the CCG for approval. All children have
been reviewed and no harm has been identified. The
action plan will be monitored through the NBT/CCG
Quality Sub Group.
Quality of ED Discharge Summaries – issues have been
identified through the South Gloucestershire Quality
Portal and the Bristol Contact Us email account with
regard to the quality of ED discharge summaries. South
Gloucestershire CCG has asked for an action plan to gain
assurance as to how the Trust will be addressing this
which will be monitored via the Quality Sub Group.
Complaints – the number of overdue complaints has
increased which has been attributed to operational
challenges over the winter period. South Gloucestershire
CCG has asked for an action plan.
MRSA – A total of 6 cases of MRSA bacteraemia have
been reported by NBT during 2016/17. A CPN was
issued in November 2016 for failing to achieve a zero
tolerance to MRSA bacteraemia. South Gloucestershire
Page 7 of 13
Item No
Action
CCG have requested the Trust to submit a revised RAP
focusing on the issues highlighted from the RCA
investigations undertaken. The Director of Public Health
will be working with the Infection Control Nurse at NBT
and an update has been requested at the Quality Sub
Group meeting on 16 March 2017.
WAHT
Never Event – Weston has reported a Never Event in
February 2017 relating to a retained guide wire following
the insertion of a chest drain. The 72hour report has
been submitted to North Somerset CCG and the full RCA
investigation is being undertaken. The patient was
transferred to Bristol for removal of the guide wire.
CQC Re-visit – the CQC re-inspection will take place
during week commencing 27 February 2017.
Contract Performance Notices – The Trust has been
issued with a CPN in December 2016 against six quality
areas.
Fractured Neck of Femur – an external review has been
undertaken and the report has not yet been received by
the Trust. North Somerset CCG is awaiting the report and
continues to monitor the data.
Pressure Ulcers – there have been a number of pressure
ulcers graded 2-4 reported in December 2016. A Trust
wide action plan is currently being implemented which
include a focus on clinical staff training. A BNSSG
Pressure Steering Group is already in place and the
strategy is currently being revised.
Weston Letters
Following the last Quality and Governance Committee In
Common meeting held on 19 January 2017, it was
agreed that a letter would be sent to Weston following the
concerns of the committee. North Somerset CCG wrote
to the Chairman raising these concerns and a reply was
sent to the Chairs. The Trust then scrutinised the
December minutes and a further letter was sent. The
minutes have currently been withdrawn from Bristol CCG
website to check data validation
The draft response has been sent to the Chairs for
approval. It was noted that the response from the CCG
will clearly state that it covers all points noted in both
letters received from the Chairman. The draft response
JCC
Page 8 of 13
Item No
Action
will also be shared with the Directors of Nursing/Quality
before it is sent.
It was noted that comments within the letters refer to the
SHMI and references the 4 hour trolley waits and serious
incidents. Currently a 12 hour trolley wait will generate an
SI and the numbers do not tally with what Weston are
reporting. A high number is generated for SI’s but when
validated has changed. There was a discussion in
relation to the validation of data reported by the CCG’s.
Only validated data is used at the meetings. It was
suggested that for the next Quality and Governance
Committee meeting that a report be presented to show
where the CCGs obtains the validated data. It was
questioned as to whether there is clear assurance that the
Trust is addressing the concerns. KH mentioned that she
understood that the BNSSG Quality Team would support
a review and analysis with the issues in the letter and a
Director of Nursing would lead. The Quality Team have
met and discussed how they would be responding to the
letter.
7.2
Provider Serious Quarterly Updates
The report provided information on the Serious Incidents
reported to Bristol, North Somerset and South
Gloucestershire CCGs during January 2017. AMo has
asked for patients to be highlighted when they present at
ED with a pressure ulcer when community acquired. A
copy of the NBT dashboard has been forwarded on to
Weston.
7.3
Serious Incident Quarterly Update
The report provided an update on activity for reported SI’s
for Quarter 3 for Bristol CCG. It was noted that managing
SI’s across BNSSG will be discussed at a Quality Away
Day in April 2017.
7.4
2016/17 QP Q3 Update
The report provided an overview of how Bristol CCG will
monitor performance against the quality premiums and
provides an update on the Quarter 3 position against the
2016/17 Quality Premium targets established by Bristol
CCG with NHS England. It was noted that South
Gloucestershire and North Somerset CCGs have not
been able to achieve their quality premium which was
disappointing and will be reliant on the CCG meeting their
constitutional standards. For 2017/18, Bristol, North
Somerset and South Gloucestershire CCGs have put
forward their options.
JCC
Page 9 of 13
Item No
8
Action
OTHER REPORTS
8.1
Bristol Safeguarding Children
The report was presented for review and comment. The
report has been reviewed in detail at the Bristol
Safeguarding Group on Monday 20 February 2017. Lisa
Harvey, Deputy Nurse Director/Head of Safeguarding for
South Gloucestershire CCG was in attendance. All
providers have not been able to achieve their 90%
compliance across all three training levels and actions
have been requested. The current position will remain
with each CCG to have their own training matrix until such
time as there is one HR function across all three CCG’s to
ensure a consistent agreed approach.
Serious Case Reviews - there are a number of Serious
Case Reviews in progress.
Safeguarding Standards - the safeguarding standards
have now been combined for both adult and children.
These standards are now in all large contracts across
BNSSG. A Safeguarding Assurance Online Reporting
Tool is currently being piloted by providers across
BNSSG. These results will then be shared with the
national NHS England safeguarding team.
Section 11 Audits – Five local safeguarding children
boards agreed to undertake a Section 11 audit of
safeguarding children arrangements across BNSSG. This
was a self assessment of practice.
Safeguarding work across BNSSG – the safeguarding
leads across BNSSG have reviewed the work they
undertake individually and also the work that can be
shared across BNSSG. The group now have a weekly
telephone conference call to share practice and identify
areas of joint working. The safeguarding work across
BNSSG will develop over the next 12 months and this
work will be reflected in the work plans for 2017/18.
8.2
Bristol Looked after Children
The report provides an update on performance against
the key indicators for looked after children’s health. Since
September 2015 there has been a significant dip in
performance against the key performance indicators
which was disappointing. It has now been agreed to hold
monthly review meetings in order to progress. It was
Page 10 of 13
Item No
Action
noted that learning could be taken from South
Gloucestershire following the CQC report from the looked
after children’s service.
8.3
Bristol Safeguarding Adults
It was noted that the report was presented at the
Safeguarding Group held on Monday 20 February 2017.
Detailed discussions took place on the areas of concern.
The group are now looking at how they can work across
BNSSG.
8.4
Bristol Care Home Quality Resilience
It was noted that the group discuss areas of concern and
look at where improvement of care can be made. There
are a number of serious adult reviews ongoing. There is
a clear link with supported housing and mental health
issues.
8.5
Bristol Child Death Overview Panel
This paper was withdrawn. AM informed the group that
she recently attended a stakeholder event and discussed
how the child death overview process could be made
simpler and more aligned with other processes in place.
It is hoped that NHSE will issue guidance in the summer.
8.6
Bristol Contact Us
The report was presented by KT for review and comment.
KT informed the group that a number of GPs are raising
concerns on a daily basis and there are some areas
which need to be defined. It was noted that an email has
been received from UHB who had recognised that they
had received a number of issues following discharge. As
well as responding to each issue, the CCG is also
recognising any trends. Work is currently ongoing with
counterparts in North Somerset and South
Gloucestershire CCG’s regarding ways in which the data
can be presented across the three CCG’s in future. A
paper with a proposal is expected to be presented to the
Committee in March.
8.7
KT
South Gloucestershire Update on CQUINS
The report was presented by SB for review and comment.
South Gloucestershire CQUIN Panel has been
established to ensure that a clear, robust and equitable
process is in place to support the decision making for
payment of CQUIN funding to providers. Plans are
underway to amalgamate the three panels for a BNSSG
approach going forward.
Page 11 of 13
Item No
Action
8.8
Bristol Quality Premium Q3 Update
This was discussed under agenda item 7.4.
8.9
South Gloucestershire FOI
The report was noted for information only.
8.10
South Gloucestershire Complaints
The report was noted for information only.
8.11
South Gloucestershire PALS
The report was noted for information only. In terms of
Contact Us, FOI’s and PALS, it was suggested that there
should be a BNSSG report covering all three CCG’s for
Quarter 4.
The Quality and Governance Committee In Common noted the
reports.
8
POLICIES FOR REVIEW
It was noted that there has been minor amendments to the
following policies: South Gloucestershire Complaints
 South Gloucestershire Travel Costs
 South Gloucestershire Policy on Policies
 South Gloucestershire Reckonable Services
 South Gloucestershire Banding
 South Gloucestershire Re-deployment
 South Gloucestershire Reimbursement
The policies have been discussed at the South Gloucestershire
Policy Review Group. JGi informed the group that she would like
to review the Reimbursement Policy and it was agreed that the
Chair would sign off the final versions.
8.12
BNSSG Working with Pharmaceutical Companies
The policy was presented by Jon Hayhurst and sets out
the framework of best practice, as well as the legislation
which must be considered when working with the
pharmaceutical industry by employees of Bristol, North
Somerset and South Gloucestershire CCG’s and
contractors. The following key points were noted: The policy does not contain any information on the
need for transparency
 There is a significant overlap with the standard of
business. Links with business standards to be added
 All CCG staff must declare any conflicts of interest.
JR
JH
Page 12 of 13
Item No
Action
Details of this should be added to the policy.
JH
KH asked about the consultation documents relating to
the sunshine register. The pharmacy industry populates
the sunshine register. This is published widely but has
not been drawn to the attention of the members. The
sunshine register details all funds given to the CCG and
other providers. JH offered to present a short paper at
the next meeting if the members would find this useful.
JH
9
REVIEW THE COMMITTEE EFFECTIVENESS
TM noted that the transition was difficult and that it felt harder to
engage coming from different CCG’s. AM mentioned that there
was sufficient time to look at the deep dives into the quality
report and commended MD in the way it was written. JG noted
the quoracy issues due to other meetings taking place. North
Somerset noted that there were a number of positives to
reassure their Board. This has strengthened the commissioning
voice and streamlining the policies and work.
10
Any Other Business
1.
11
Validating Data for Quality Report – this will be presented
at the next meeting.
Date of Next Meeting – The next meeting will take place on
Tuesday 21March 2017
Page 13 of 13
BNSSG End of Life Programme report
March 2017
Reporting Period from: December 2016
Programme Details
Programme Vision:
Programme Sponsor: Alison Moon
Clinical Lead: Dr Kate Rush
Programme Manager: Nina Vinall
Report date: 10 March 2017
Programme overall status
Programme delivery: GREEN
Benefits realisation: AMBER
*RAG definitions
Red
Amber
Green
Programme delivery
Milestones behind plan, no action to remedy
Milestones behind plan with action to remedy
Activities on plan to achieve milestones
Benefits realisation
Benefits realisation behind plan, action will not remedy
Benefits realisation behind plan with action to remedy
On plan to realise benefits
Overall Monthly Programme Summary
BNSSG EoL Programme Management – The Bristol End of Life Care Group has been successful incorporated into the new BNSSG End of Life Care
Board. Now have all providers and tertiary providers included in the membership.
The review of the NHS England’s End of Life Commissioners Checklist has been completed and a draft BNSSG End of Life Work Plan to be discussed
at the BNSSG End of Life Care Board to be held on 14 March 2017. This is behind the timescales set last year. Plan to ensure this is driven forward in
line with the STP requirements of the business case submitted by BCH in October 2016.
The Programme is now reporting into the Turnaround Control Centre for CHC and End of Life Care, all work streams need to align using the expertise
1
of the BNSSG End of life Care Board members.
Current agreed work stream and updates;
EPaCCS – Board meetings arranged, including meeting and links made with the One Care Consortium to arrange clinical input into the design process.
Procurement process has commenced to include purchase of a data interface extract to allow access of end of life data from EMIS to the Connecting
Care portal. To include workshops to present provider feedback and BI to move to building the system for May.
Anticipatory Prescribing – The final version of the printable AP chart has been distributed across all GP practices for use across BNSSG. The final
version of the AP chart continues to be held by Allyson Darran of Bristol Community Health, with Kate Rush remaining as clinical lead. This work is now
completed. This will be regularly reviewed to ensure compliance on completion and quality assurance in improving prescribing for patients.
Treatment Escalation Plans – The national publication of the form – ReSPECT, is currently being piloted and BNSSG have approached the national
programme for inclusion in the piloting phase. When published the final version will be included across BNSSG and included into the EPaCCS work – to
be discussed at the Board
End of Life Care Training – Work is still underway for a thorough piece of work is to identify the various providers of end of life care training and who is
in receipt of this training, progress has been slow due to response back from providers. This will identify gaps or improvements in provision, with a focus
on care home training provision to prevent non-elective admissions.
Deliverables for the next period
BNSSG End of Life Care Board;

Work plan - To finalise in line with the STP requirements

Education – To include in the work plan following the finalisation of the mapping and gapping exercise
EPaCCS;

To complete the project plan and design stage 1

To outline the procurement plan to progress to next stage
Treatment Escalation Plans;

To review and possibly implement the new ReSPECT form when published
2
Key areas of concern
Programme concern – To ensure the STP business case aligns to the work plan to ensure objectives are met. Whilst ensuring any savings identified
do not affect the outcomes and quality of service or access to service provision for patients.
3
Progress Report
Medicines Management
GREEN
Sponsor: Jon Hayhurst
Director: Jill Shepherd
Date: March 2017
Achievements In Period
Two members of our team (Sharon Sexton and Kaz Yakhlef)
won a national award for their work with local care homes that
improves safety and quality.
A long-running and innovative tripartite QIPP scheme is soon to
begin as UHB have recruited to the embedded pharmacist post
that is being jointly funded by Bristol CCG and NHS England
Specialised Commissioning
Our ‘repeat prescribing hub’ that will in-house work from
member practices and generate savings as well as make
quality improvements commenced in March 2017. The service
will be continuously improved to ensure that it adds value for
practices as well as for the CCG.
We continue to benchmark well with similar CCGs on quality
measures as well as on prescribing spend.
Issues
There are risks of adverse publicity from some of the work
streams that we have been involved in this year (rationalising
OTC medicines use, and gluten-free food prescribing). Our
accompanying communications need to clearly describe the
financial context to patients.
NHS England will de-commission the Bristol Minor Ailments
Scheme at the end of March. This service enables patients that
do not pay for prescriptions to access OTC medication for
specific ailments without seeing a GP. Bristol CCG will explore
alternatives that would make savings for the CCG and for
which would be able to justify investments
Risks
Medium risk: NHS England decommissioning of Minor
Ailments Scheme in Bristol
Low risk: Medicines Management QIPP (financial)
Next Steps
The BNSSG Paediatric Joint Formulary, which will improve the
safety and effectiveness of prescribing for children in primary
and secondary care should be launched very soon now.
We will soon commence prescribing quality improvement
initiatives with our member practice that will help Bristol CCG to
achieve the new antibiotic prescribing measures introduced in
the 2017/18 Quality Premium.
We are participating fully in the financial turnaround process
that has begun in BNSSG. We will be working collaboratively
with our colleagues from neighbouring CCGs on a range of
projects.
We have a number of vacancies in the team, with recruitment
and retention becoming more of a challenge. The reasons for
this are positive; with many career opportunities locally for
pharmacists in our member practices. Bristol CCG practices
continue to be ahead of the game by improving their skill mix
through recruitment of a clinical pharmacist.
Action required of the Steering Group
Note our achievements and maintain our progress.
Date of next Report: June 2017
Progress Report
Cancer
Status: Green
Clinical lead: Dr Glenda Beard and Dr Catherine Zollman
Lead Director : Alison Moon
Management Lead: Bev Haworth
Work this quarter has been directed towards two main areas. Firstly, the
three National Transformation Bid submissions for Early Diagnosis,
Recovery Package and Risk Stratification. In addition, BNSSG Cancer
has a weekly control centre as part of the Turnaround process.
Date: 17 March 2017
Performance
UHB and NBT both achieved the 62 day performance national standard in
November. UHB achieved the standard for the first time since December 2015
and NBT’s November performance of 88.66% was the best since October 2013.
Inequality (prevention and early diagnosis)
•
•
•
A revised work plan has been drafted to provide focus for the work and
maximise use of appropriate resources. Work will initially be focused
on lung, breast and bowel/prostate.
An inequalities workshop was held at Wellspring on 26th January
involving local community groups. Verbal feedback on the meeting
agenda.
An updated JSNA chapter for Bristol is currently being drafted
NICE Guidance for Suspected Cancer
- Cancer Site Specific Pathways
A stock take has been carried out on the current and remaining forms.
Minor changes have been agreed however there are a few outstanding
issues that will be taken to the relevant site specific groups before a roll
out date is agreed. This is hoped to be before the end of April 2017. Good
communication with GPs will be essential.
GP direct access to diagnostic test
Unfortunately the successful bid submitted to the National Diagnostics
Fund has been superseded by the recent Transformation bids.
Cancer Alliances
Two further Alliance meetings have been held this quarter to progress work. The
governance arrangements are still being confirmed, the Alliance chair, James
Rimmer,will be writing to STP leads to facilitate this process going forward. A
delivery plan has been agreed which will be shared with STPs. Targets for the
associated metrics have been signed off by the BNSSG STP Cancer Working
Group in line with National requirements
National Transformation Bids Outcome: the BNSSG bids were unsuccessful for
Early Diagnosis and the remaining two require further work for phase two
funding.
Formal feedback for our bids is taking place on a call with NHSE on 29th March.
Post feedback we will hopefully be in a position to update the documents
accordingly with a view to receiving some funding later in 2017. We have
requested sight of successful bids and a clear understanding of how far off
success we are.
Living Well with and Beyond Cancer Commissioning (LWWBC)Strategy
A LWWBC workshop was held on 23rd February to discuss how we can nurture
and develop our LWWBC network, how we can evaluate the programme of work
and begin to define the learning and development needs for LWWBC.
Emma Ryan, Project Manager, is working up the evaluation and learning and
development plan on the back of the discussions had in group work at the event.
Patient Experience
Meetings have been held with the new Bristol CCG PPI lead and Christine Teller
to agree a draft patient strategy.
Further work is continuing with nurse leads at NBT and UHB to action outcomes
of the national patient experience survey.
Progress Report
Cancer
Status: Green
Clinical lead: Dr Glenda Beard and Dr Catherine Zollman
Lead Director : Alison Moon
Management Lead: Bev Haworth
Risks
High Risk:
Date: 9th December 2016
Issues
There are no known issues at this time.
Medium Risk:
Performance against key constitutional standards, in particular 62 day GP
referred, continues to remain poor.
The close working relationships built with stakeholders across BNSSG
over the years have the potential to be challenged when stakeholder
involvement occurs as part of the turnaround process.
Resources will be challenged as work is required at pace for Turnaround
in addition to delivery against the STP and National Cancer Delivery Plan.
Next Steps
Low Risk:
Action required of the Steering Group
Continued delivery of identified work programme for 2016/17, including
implementation of the national cancer strategy recommendations.
Date of next Report:
June 2017
Due to the resource implications of the weekly Turnaround Cancer Control
Centre, a review of meetings has taken place.
It has been agreed to stop the Cancer Steering Group meeting for the
foreseeable future. The bimonthly BNSSG STP Cancer Working Group will
continue and the Bristol Inequalities and LWWBC meetings will merge and
include a Bristol specific focus section at the end.
Meeting of Bristol Clinical Commissioning Group Governing Body
To be held on Tuesday 28 March 2017 commencing at 1.30pm at the Greenway
Centre, Doncaster Road, Southmead, Bristol, BS10 5PY
Quality, Finance and Performance Report
March 2017
Agenda Item: 13
1
Purpose
This paper provides Governing Body members with an overview of the important
topics discussed at its three sub committees: Quality and Governance, Financial
Review, and Planning and Performance. The purpose is to provide assurance
that the organisation is well informed about quality, finance and performance and
that these areas are being effectively monitored and managed, internally and
through contractual arrangements with providers. This provides opportunity to
challenge the speed or nature of action being taken.
Please note that the aim is to share information that is as up to date as is
available at the point of writing. This means that depending on the topic
information could relate to different time periods
2
Report Format
The content of the report is set out in the following table. It is structured in
sections, providing the key messages for each area of responsibility.
Section
1. Current Improvement and Assessment Framework Rating
2. Quality Key Messages
3. Finance Key Messages
4. Performance Key Messages
5. Activity Overview
6. Medicines Management Overview
7. Report Contributors
Page
3
3
7
12
18
19
20
Supporting information is provided in a set of annexes to this report, as follows.
Annex
No
1
2
3
4
5
5.1
Title
Revenue Cost Statement
Risks and Mitigation Schedule and Summary
of Identified Impact of 2015/16
Quality, Innovation, Productivity and
Prevention (QIPP)
Better Practice Payment Code
Statement of Financial Position
Monthly Cash flow
Related Section
Finance
Finance
Finance
Finance
Finance
Finance
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 1 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
Annex
6
7
8
9
3
Title
CCG Resource Limit
Quality Report
Performance Report
Glossary
Related Section
Finance
Quality
Performance
All
How have service users, carers and local people been involved?
Patients and members of the public have not been involved in this process.
4
Implications on equalities and health inequalities.
Not applicable.
5
Evidence Informed Commissioning
Not applicable.
6
Financial Implications
The organisation’s financial position is reported in full and discussed in detail at
the Financial Review Committee (FRC). Via this report and relevant annexes
Governing Body gains oversight of this. There are no direct financial
implications of reporting the position, although the position and how finance is
managed is a significant factor in NHS England’s assurance review of us against
the CCG Improvement and Assessment Framework. Issues and risks within the
reported position are covered in the report.
7
Legal implications
Not applicable.
8
Risk implications, assessment and mitigation
The corporate risk register captures the risks relating to finance and
performance. This report and processes behind it inform our assessment of
these risks and activate actions to mitigate them.
9
How does this fit with Bristol CCG’s Operational Plan or Strategic
Objectives?
This report supports monitoring the delivery of the CCG 2016/17 plan and
fulfilment of its strategic objectives.
10
Recommendation(s)
The Committee is asked to note and discuss the content of the report and decide
on any action required of staff, or to be asked via another group, to further
inform, gain assurance or improve the position.
Alison Moon, Quality and Transformation Director (CCG)
Nicola Dunn, Chief Finance Officer (CCG)
(Details of staff who contribute to the production of this report at set out in Section 7.)
Page 2 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
1. Current CCG Improvement and Assessment Framework Rating
The CCGs assurance rating performance remains consistent with that previously
reported, with no change in rating since the end of 2015/16.
Assurance Framework Area
1.
Better Health
2.
Better Care
3.
Sustainability
4.
Leadership
Overall Rating
Current Rating
Requires improvement
Requires improvement
Requires improvement
Requires improvement
Requires improvement
2016/17 rating categories are: Outstanding, Good, Requires improvement and Inadequate.
2. Quality Key Messages
UH Bristol:
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Care Quality Commission (CQC) – the CQC has published its report
following the inspection of UH Bristol. The Trust received an overall rating
of ‘Outstanding’. UH Bristol is one of only six acute trusts in the country to
be rated as ‘outstanding’ and the only one in the South West. Please see
the separate CQC paper and accompanying report for further details.
Paediatric Cardiac Report - an update on the report noted that no actions
are red rated and the action plan is due to complete at the end of June
2017. UH Bristol advised that the update would be going to the next joint
Bristol and South Gloucestershire Health Overview and Scrutiny Committee
for discussion.
Verita Report - a verbal update on the post Verita report was received. UH
Bristol reported that the family have received an unreserved apology from
the Trust. Professor Michael Stevens had worked through the 80+
questions submitted by the family and produced a set of responses that has
been shared with the family. An offer was made to the family to meet with
Michael Stevens with mediation support and this has at the current time
been declined by the family.
Fractured Neck of Femur (#NOF) - performance remains below the 90%
threshold. An update on the Action Plan arising from the British Orthopaedic
Association Review has been received and the Trust has been asked to
share the actions with the group assigned to look at #NOF across BNSSG.
NBT:
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MRSA - NBT have reported six cases of MRSA Blood Stream Infections for
year to date 2016/17. A Contract Performance Notice (CPN) was issued to
the Trust in November 2016. NBT are implementing an MRSA Remedial
Action Plan (RAP) devised from key learning from the first five cases.
Never Events - NBT has reported five Never Events for the year to date
2016/17. A CPN was issued to the Trust in November 2016. The CCG have
requested the final RAP and completed audits to be submitted to the
Page 3 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
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Quality Sub Group along with feedback from the ‘Stop Before You Block’
audit and the Trust’s visit to NHS Plymouth.
Overdue complaints - the number of overdue complaints has increase to
42 in January 2017. Of the cases closed in January 2017, 68% of them
were completed within the agreed timescale (against a target of 90%). The
CCG have requested an improvement Action Plan be presented for
approval at the Quality Sub Group.
Backlog of Endoscopy surveillance cases - NBT are currently failing the
six week diagnostic target and have a significant Endoscopy surveillance
recall backlog. The Trust has developed a RAP and the CCG has requested
assurance that each case has been clinically validated.
Backlog of discharge letters - there have been delays in the receipt of
discharge letters following outpatient consultations at NBT. The CCG have
requested the Improvement Action Plan be presented at the Quality Sub
Group.
CQC – the Trust can demonstrate the outstanding ‘Must-Do’ action from the
2015 CQC Inspection (relating to system flow) has been completed. NBT
will provide the CQC and CCG with a written report focusing on the actions
delivered that relate to quality and safety within the hospital as well as
reporting on how the Trust is managing high demand more effectively.
Friends and Family Test (FFT) - response rates for Inpatients and ED
remain below target, mainly attributed to incorrect patient phone details
(required for text and SMS) held by NBT. Work is currently ongoing to
address this and the Trust is also looking at replicating good practice from
the Directorates which are performing well with FFT.
Child protection referrals – a scoping exercise pertaining to risks
associated Emergency Department child protection referrals to children's
social care has been undertaken; key risk is referrals made to Bristol First
Response between 1 November 2016 to 1 February 2017. South
Gloucestershire’s Access and Response Team (ART) have not identified
an issue and has been receiving some referrals by fax. An audit is to be
undertaken of all children identified that met the threshold for referral during
November to February to ascertain what information was shared. First
Response and ART have agreed to accept a revised referral form as used
by UH Bristol which will make referrals via email easier.
Female Genital Mutilation (FGM) data - NBT are now submitting FGM
mandatory recording information to the Department of Health.
Deprivation of Liberty Safeguards (DoLS) – a review of DoLS in the
Intensive Therapy Unit (ITU) has been undertaken and a pathway is in the
process of being approved.
BCH:
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Quality Summit – following publication of the CQC inspection report of
BCH services, the quality summit to discuss the findings and associated
actions is to be held on 13 March 2017. BCH were rated as ‘Good’ overall.
FFT - the FFT response rates for the Walk in Centre (WIC) (7.5%) remains
significantly below the improvement trajectory (13%). BCH have been
asked to provide an Action Plan with expected recovery figures to improve
response rates. FFT for the Urgent Care Centre (12.2%) has improved and
is just below the expected improvement trajectory (13%).
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Meeting of Bristol CCG Governing Body 28th March 2017
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Patient Safety Incidents - medication incidents continue to occur as a
result of human error. Fortunately no harm was sustained by patients as a
result of these incidents. BCH have implemented EMIS scheduling system
alongside the T-Card system as it offers an effective visual representation
of the full caseload for review not provided by EMIS. BCH are ensuring all
staff administering or assisting with medications complete an e-learning
course on Safe Medicine Handling.
AWP Trust-wide:
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Monitoring CQC actions - at the February NHSI led Quality Improvement
Group meeting (which has monitored and managed the CQC related work
streams), the members agreed to stand down this group and transfer the
responsibility for monitoring compliance with the CQC actions to the
commissioners. Updates will be a standing agenda item for the Quality Sub
Group.
Red rated scorecard measures - a significant number of scorecard
measures remain Red rated for up to 6 months. It has been agreed that
AWP will embed a process where any score rated red for 2 months or more
will be reviewed and reported to the Quality Sub Group.
Capacity and demand –concerns continue about matching capacity with
demand (inpatient and community services). An action plan is in progress,
monitored via the CQPM, Quality Sub Group and local contract
performance meetings.
Safer staffing, recruitment, retention - challenges are ongoing
particularly with retention and use of temporary staff. Action plans are also
ongoing, monitored via the CQPM, Quality Sub Group and local contract
performance meetings.
CQC - a Warning Notice relating to illegal detentions in the Place of Safety
Units remains in place. The CCGs are monitoring monthly via the Quality
Sub Group and locality meetings with the expectation that this will improve.
The CQC has informed AWP they will re-inspect the Trust on 26 June 2017,
particularly the 136 suites.
SIs - despite some improvements concerns remain regarding evidence of
learning from SIs. The CCGs are facilitating a programme of collaborative
workshops to share best practice and agree what is required in terms of
reporting and evidencing learning. The next workshop will take place on 25
March 2017.
The Caring Solutions report commissioned by Bristol CCG to review
unexpected deaths – this has been received by the CCG. MH
commissioners and Quality Team members plan to review the
commissioner recommendations and draft and action plan to address
these. AWP has been asked to respond to the report and include the Trust
approach to zero tolerance of suicide; the report will be tabled at April 2017
Quality Sub Group.
Rapid tranquilisation - clinical practice relating to management of patients
requiring rapid tranquilisation remains a focus for commissioners - data this
month shows a decline. The CCGs are monitoring monthly via the Quality
Sub Group and locality meetings with the expectation that this will improve.
Page 5 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
AWP Bristol CCG Locality:
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Laurel Ward - high levels of sickness absence have been noted.
Delayed Transfer of Care (DTOC) – this increased in January 2017 and
remains a significant challenge.
User led visits to wards – the first visit has been arranged. It has been
acknowledged that a plan of regular visits is needed.
Smoking status - it has been noted that newly developed indicators are
currently causing under reporting due to the mechanics of the reporting
tool.
Staffing - pressures persist. Recruitment is in process with a good
response.
Long term management caseload – work pertaining to a project
examining patients who are referred in but don’t require assessments, and
also discharges from treatment has found a cluster of patients (men under
65) who were found to be difficult to place. Work is ongoing.
SWAST:
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Thematic Call Review – paediatrics had been chosen for the Thematic
Call Review session planned for February 2017. As the subject material
was not forthcoming from providers as requested, the session was
cancelled and needs to be rescheduled. SCWCSU will be writing to Care
UK NHS 111 and SWAST to emphasise the requirement for them to ensure
adherence to this Quality Schedule requirement.
Move to St. James North - SWAST have moved buildings from Acuma
House to St. James North (both within North Bristol) at the end of
January/early February 2017.
Performance – Purple responses within 8 minutes in January 2017 was
71.19%, which is below SWAST’s target of 75%. NHS England and
Sheffield University convened a second Ambulance Response Programme
(ARP) workshop in January; this smaller workshop built on the work of the
previous one and looked at potential future ambulance clinical quality
indicators as well as system metrics. This is expected to be published by
the end of the financial year.
Handover delays – this continues to be a challenge for SWAST.
SIs – previously identified themes arising from SIs continue to be
monitored, such as ‘spinal management’ and ‘No Clinical Decision in
Isolation’. The potential themes of “Staying on the line” and “Audit
Prioritisation” will be discussed with SWAST’s Clinical Development Team.
SCWCSU are planning to visit SWAST to look at the process of audit both
in the North and the South; due to the planned move to St. James North
this has been delayed as the priority is ensuring a smooth transition from
one building to another.
Care UK NHS 111:
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CCG Safeguarding Lead – B&NES CCG have offered to act as the
Safeguarding Lead for the 111 contract and commissioner agreement is
currently awaited. Once received, SCWCSU will prepare a Memorandum of
Understanding between commissioners to formally clarify responsibilities.
Page 6 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
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Leadership changes – the medical lead and contract manager for Care
UK for the South West NHS111 have moved to new roles. There is a risk
therefore to organisational memory and capacity in the intervening period.
New staff have been appointed and phased handovers are planned to
mitigate this risk.
Call audit – concerns were raised by commissioners at the IQPMB
regarding call audit scores. Care UK NHS 111 is to provide detailed
assurance for the next meeting.
Pathways Deferment - Care UK NHS 111 have deferred the next update of
Pathways which is now likely to take place in late February/early March
2017. This was agreed with commissioners to avoid peak call demand over
the winter period. Assurance was sought regarding any clinical risks arising
from the deferral.
Patient Satisfaction Survey – there have been low responses from the
over 65 age group to the electronic patient survey. Care UK NHS 111
advise that they will distribute a paper survey to this group on a quarterly
basis to capture feedback. Commissioners have also requested that Care
UK NHS 111 liaises with Healthwatch to seek independent feedback on the
service.
Clinical Advisor (CA) capacity – there are 23.18 WTE CAs in post,
remaining below the required establishment of 42.47 WTE. Care UK
NHS111 have redesigned their clinical rota to create more full time capacity
and have a national recruitment group that meets monthly to address
recruitment issues.
BrisDoc:
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No new exceptions
3. Finance Key Messages
Overview
The CCG has improved its forecast outturn position from a deficit of £7.50m in M10 to a
deficit of £5.48m in M11. This improvement is primarily down to the inclusion of
contract penalties at NBT and a favourable movement on the Mental Health out of area
placement budget as detailed below.
The CCG is not reporting achievement of the control total surplus of £3.46m in line with
the financial plan submitted to NHS England against the revenue resource limit (RRL)
of £579.19m.
Within the financial planning process the CCG were required to set aside 1% (£5.60m)
of the opening RRL as a Headroom reserve. This reserve cannot be accessed by the
CCG without the express permission of NHS England. Should permission be obtained
to release this reserve the CCG will be reporting a surplus of £0.13m.
The Operating Plan and Financial Plan for 2017/2018 are currently under scrutiny both
within BNSSG and by NHS England. Therefore approval is sought from the Governing
Body to commit to contractual expenditure from 1st April.
Page 7 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
Revenue Cost Statement (Annex 1)
The majority of forecasts presented here are based on month 10 information although
Prescribing information continues to be a further month in arrears and is based on
month 9 activity.
Acute Care
NBT
The position reported at month 11, adverse £2.7m, is based on the month 10 contract
monitoring information adjusted, where appropriate, for data challenges, incorrect
commissioner attribution, anticipated CQUIN achievement and contract penalties. The
position has improved by £1.3m when compared to month 10.
The main movements are as follows:
 Planned care adverse movement of £0.3m
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Urgent care adverse movement £0.3m
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Other Non-PbR beneficial movement £0.1m
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Penalties/Fines beneficial movement of £1.8m
The NBT reported position has significantly improved due to the penalties and fines
now being included in the forecast outturn. This is in agreement with NHSE.
As previously reported, a number of actions are on-going around contract challenges
and these will need to be resolved before year-end reporting. The main issues are
around Critical Care and Non Face to Face contacts both of which should have
outcome reports shortly. DQIP Action plan in place with clear delivery dates
UHB
Month 10 information received from UHB has shown a deterioration in the forecast
position of £0.5m. This has moved the forecast outturn to £2.4m. The reported
position is inclusive of actual QIPP and includes an adjustment to the CQUIN
achievement of 90% (benefit of £0.35m).
The main movements are as follows:
 Planned care beneficial movement of £0.1m
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Urgent care adverse movement £0.4m
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Critical care adverse movement £0.1m
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PbR Excluded Drugs & Devices adverse movement of £0.1m
Coding changes (for the 16/17 contract) and inaccuracies reported by UHB are
challenged as a matter of routine, although these are minimal and usually resolved in
the UHB FIG.
Page 8 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
Other
Over performance at the commercial sector elective care providers such as Spire,
Nuffield and Circle continues to be offset by underperformance at Emersons Green
Independent Sector Treatment Centre (ISTC).
Non contracted activity (NCA) is forecast to overspend by approximately £0.34m. This
is a beneficial movement of £0.30m when compared to M10. The reported overspend
is based on the cost of these treatments to month 9 as there is often a delay in the
CCG receiving charges from Providers which are unpredictable by nature.
Mental Health & Learning Disabilities
AWP
A risk share of 50:50 between the CCG and AWP has been agreed for Acute out of
area mental health activity from the date that Larch ward became operational. This is in
line with the assumptions made in previous months. AWP have also reclassified a
proportion of activity as older people which has improved the forecast as AWP pick up
100% of the risk on this activity in 2016/17.
Out of Trust MH
As indicated last month the latest AWP reports have shifted a significant amount of
activity from general acute into the older people’s category. This has improved the
CCG’s forecast position by approximately £0.8m however this benefit is offset in part by
an increase in the CCG’s usage of Cove and Dune older people’s wards which were
decommissioned by North Somerset CCG at the start of the year and sit outside of the
risk sharing agreement.
Other Mental Health
In order to more accurately reflect the expenditure on the Children’s Community Health
Partnership (CCHP) contract £4.3m has been moved to Mental Health in respect of the
CAMHS element. This was previously shown under the Community Services heading.
Medicines Management
The prescribing forecast has worsened by £0.3m from month 10. December was a
busy month nationally in terms of prescriptions and the increase emphasises the
unpredictable nature of this spend and the difficulties in establishing accurate forecasts.
Continuing Healthcare
The CHC forecast remains relatively stable at £2.6m underspend. The position on
funded nursing care has improved by £0.2m following a further detailed trawl and
cleanse of the data by the CHC team.
Running Costs
A comprehensive review of the impact of the in-housing of CSU staff has been
completed. The assessed impact of the in-housing plus the CSU LPF contract is that
the CCG will remain within its running cost allowance. There will also be scope to
manage Bristol CCG’s share of STP and turnaround costs within the available budget.
Page 9 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
Reserves
No significant changes from previous month.
Risks and Mitigation schedule and summary of identified impact of 15/16 (Annex
2)
Attached at Annex 2 is a risks and mitigations schedule showing £1.48m of risk offset
by potential mitigations totalling £1.48m which includes anticipated funding from NHS
England to cover restructuring costs. Should this materialise, the CCG would end the
year with a deficit of £5.48m. If permission were to be granted by NHS England to
release the Headroom reserve the CCG would achieve a small surplus of £0.13m.
The main areas of risk to the CCG include potential volatility to the Prescribing forecast
as seen in the final quarter of previous years, additional acute risks, and the risk that
the Section 117 forecast continues to increase. The primary mitigations relate to
successful challenges at NBT and further contract penalties which are still outside the
reported position.
The second table demonstrates the impact of 2015/2016. This will be updated every
month. As at end of February the position is that of net benefit of £1.2m being
accounted for in the current year.
QIPP (Annex 3)
The attached QIPP Programme Summary is an analysis of the QIPP schemes,
demonstrating performance against both financial and non-financial indicators. The
financial performance has been included in the revenue cost statement. As previously
reported, £13.2m of planned QIPP has moved to the Financial Recovery Plan (FRP)
and will be reported through that route. The forecast position is a £3.2m under
achievement, which remains the same as M10.
The £4.3m of new QIPP schemes that are part of the FRP have been added to the
QIPP monitoring schedule. The current forecast is an under achievement of £3.1m, the
same as M10.
The Recovery Plan Project Plan and the Tracker will provide the main processes to
ensure monitoring and any necessary correcting actions to minimise potential
slippage/under-achievement.
The identification of further QIPP schemes is now part of the BNSSG turnaround
process, which will consider CCG specific schemes but will look more to system
savings/efficiencies over the STP footprint. Governance processes are in place to be
able to give assurance to the Governing Body and the Governing Body will receive an
update on the position each month.
Better Practice Payment Code (Annex 4)
Annex 4 demonstrates that Bristol CCG is achieving its administrative duty to pay 95%
of all invoices, by value and by number. The Financial Services team is closely
monitoring invoice processing performance to ensure that the 95% target is maintained.
Page 10 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
Statement of Financial Position (Annex 5)
Annex 5 details the CCG’s statement of financial position at 28th February 2017. At this
point the CCG was holding total assets of £8.8m and current liabilities of £43.7m. More
detailed analysis can be found within Annex 5.
Cashflow (Annex 5.1)
Annex 5.1 details the CCG’s actual and forecasted cash flow for the financial year
2016/17. This is based upon the Maximum Cash Drawdown (MCD) figures as per the
NHS England Cash Report for January 2017 of £577.5m.
The bank balance at 28 February 2017 was £1.9m compared to a target of £500k. The
cashbook balance was £1.6m. In February cashflow forecast we plan to pay quarter 3
invoice for the Better Care Fund contribution to Bristol City Council of £3.7m. The
payment was delayed since the invoice has only just been received.
The CCG is planning for a cash balance at 31ST March 2017 of £50k. The cash position
is being monitored on a daily basis to achieve this target. There is an option available to
return surplus cash to the Department of Health. The transfer has to be undertaken by
21St March 2017
HMRC Compliance checks
The CCG has received a notice from HMRC of a PAYE compliance check covering the
period 25 February 2015 to 23 February 2016. HMRC will be visiting the CCG office on
6Th April 2017.
In June 2015 the CCG received a compliance check from HMRC on Governing Body
payments. The CCG engaged Grant Thornton to assist in dealing with HMRC.
There have been several delays due to changes in personnel at HMRC and Grant
Thornton. A letter was sent to HMRC at the beginning of February 2017 and we are
awaiting a response from HMRC.
IR35
HMRC new rules on intermediaries legislation (IR35) on off-payroll working in the public
sector takes effect from the 6 April 2017. This legislation covers the engagement of
contractors via their own companies or recruitment agencies.
The CCG has identified the key contractors and agencies workers and actions are in
place to ensure compliance with the legislation from April 2017.
CCG resource limit (Annex 6)
Annex 6 shows the CCG revenue resource limit at month 11 including detail on the
source of funding and whether this is recurrent or non-recurrent in nature.
The CCG received a further £0.068m in month 11 specifically in relation to Referral to
Treatment (RTT) at the main acute providers.
Page 11 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
Operating Plan and Financial Plan 2017/2018
As highlighted in the overview, the operating and financial plans are undergoing
rigorous scrutiny both within BNSSG and NHS England to ensure alignment and
affordability. Therefore, in the absence of approved plans, the Governing Body is asked
to approve in principle to commit expenditure from the 1st April at minimal contractual
levels.
4. Performance Key Messages
Bristol CCG Overall Position
 Following the sharp fall in December, driven by the large cohort of endoscopy
surveillance patients at NBT, Bristol CCG diagnostics improved in January but
remains some way below the national standard.
 Only one of the 8 cancer standards – Cancer 62 days (screening) was failed in
January with the overall Cancer 62 day standard being met for the third consecutive
month. Although UHB underperformed against the 62 day standard in January, they
are no longer reporting histopathology delays at NBT. A Cancer Alliance wide bid
has been submitted to NHS England of which Bristol is a key constituent. The CCG
has been informed that they may receive funding in relation to the recovery package
and risk stratified follow-up, but there will be additional work required on the current
bid and the funding will not be available until later in 17/19. The CCG is awaiting
further information from NHS England.
 Continuing pressure across the BNSSG healthcare system continues to impact
other areas with 12 hour trolley waits increasing significantly again at both UHB and
NBT. Ambulance handover delays also rose at both Trusts but the new SWASFT
Category 1 ambulance performance measure met the 75% standard for the third
consecutive month in Bristol. 4 hour performance rose slightly at UHB but fell at
NBT. Weekly BNSSG-wide A&E delivery board teleconferences are established to
monitor the 4 hour performance in an effort to reach 90% be end of March.
Temporary NHSE / NHSI oversight of A&E delivery board has been setup through
an Urgent Care Programme Board, Chief Executive membership.
 RTT performance continues the recent flat, but under performing, trend with UHB
meeting the standard for the third month but offset by NBT issues in MSK and
Gynaecology. Contract management processes and the RTT Delivery Board are
working to address these areas. Bid money from NHS England has been received
and will be used immediately to increase surgical rates at the weekend at NBT and
UHB to address performance and backlog.
UH Bristol: There were three 52 week waiters in January. Two were due to patient
choice and the other, in cardiology, resulted from an admin error. However, the RTT 18
week incomplete standard was met for the third consecutive month with February also
expected to achieve although there is a risk towards the end of April as a result of an
increase in the size of the elective waiting list. Although clearance of the backlog of
follow-up patients for specialties with non-recurrent funding is still behind plan, the list
has not increased further and UHB have assured that they have robust processes in
place to identify risk of harm from delays.
January also saw 19 Trolley waits reflecting continued A&E performance below both
trajectory and standard – albeit slightly improved. 2 acute physicians have now started
Page 12 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
in post in the Acute Medical Unit. Overall admissions were higher than last year and
the greater proportion of patients over 75 suggests higher acuity leading to more over
14 day stays and Delayed Discharges. Pressure contributed to the performance of Last
Minute cancellations worsening and there were 4 28-day re-booking failures - above the
agreed threshold of 3.
The Trust met 3 of its 6 national cancer standards in January. Cancer 62 day
performance for December dropped back below standard due to an increase in the
number of benign skin cancer cases and the effect of late/incomplete referrals from
other providers. Late referrals from NBT, however, have fallen and the overall
performance for the quarter was above the national average.
Diagnostics was below standard but an improvement on December. Although the
routine echocardiography backlog was addressed in January, patients waiting over 6
weeks for Sleep Studies increased significantly as a result of capacity lost following the
move of the service and ‘snagging’ issues. Sessions were also cancelled to free-up
physicians to undertake additional ward rounds. Recovery is expected by April with
further actions aimed at improving resilience.
Following issue of a Contract Performance Notice, a contract meeting has been held
with the provider to discuss poor performance in the following areas:
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Diagnostics
Last minute cancellations and 28 days rebooking
Follow-up waiting list reduction
Appointment Slot Issues
A&E 4 hours and ambulance handovers
62 day cancer
Referral to Treatment Time
Appropriate plans/trajectories are being put in place
NBT: Diagnostics remained well below the standard, in January, following identification
of the large cohort of endoscopy surveillance patients who had not been previously
reported on the national diagnostics submission. A root cause analysis will be shared
through Quality sub-group.
Trolley waits rose from 18 to 29 where continuing 4 hour A&E pressure saw
performance remaining below standard. Despite implementation of the “winter bed”
model in November, beds remain in short supply and high admission rates have
required the use of more escalation capacity leading to high occupancy. Ambulance
handover delays rose as a result and there were two 28 day re-booking delays.
RTT 18 week performance was just under trajectory driven mainly by Trauma and
Orthopaedics and Gynaecology. A CPN was issued for Gynaecology 18 Week RTT on
06/01/17 and RAP actions are underway. The Trust also failed to achieve the RTT
backlog trajectory.
Cancer performance improved in January with the Trust delivering all of its 7 national
targets. It also exceeded the 62 Day standard for Quarter 3. Commissioners have
formally lifted CPNs for cancer 31 and 62 days but will raise one for 2 week waits.
Page 13 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
BCH: There were fewer restrictions of service at the Urgent Care Centre in January;
but BCH state that this is due to overstaffing at a level that is not sustainable. However,
a business case for additional staffing for the UCC has not been approved as data
showed that there was no linkage between increased pressure at local EDs and when
the UCC had restricted access.
Referrals to the Podiatry service are now within the 10% tolerance level and, whilst still
an area of concern for BCH/commissioners, are no longer classed as a formal “cause
for concern”. However they will continue to be closely monitored.
The Elderly service is predominately for older people who require domiciliary physio or
OT. Most referrals are routine but some are urgent and the case mix has changed over
the past twelve months. The Elderly service RTT <18 week performance is currently
28.2% against 95% target due to an increase in referrals and changing acuity of
caseload leading to increased contacts required. This is a slight improvement on M9.
The service is forecasting a year end breach for RTT <18 week target which cannot be
recovered. The provider’s request for a restriction on referrals to Elderly service was not
supported by the CCG Leadership Group. However, the Group has asked
commissioners to work with BCH to look at appropriate alternatives for routine referrals
into the Elderly service.
The Muscolo-Skeletal physio service is forecast to meet the 95% target month on
month but will not recover YTD target due to the transfer of patients from Sirona in April
2016.
AWP (Inpatients): Inpatient services continue to perform well against almost all access
indicators. Larch ward continues to facilitate discharge through its step-down function
and out of area bed usage has reduced since Larch became operational. Across the
Trust out of area placements have reduced significantly with only 4 service users
currently placed out of Trust. However, Delayed Transfer of Care rates across the Trust
continue to rise with the number of Bristol CCG DTOCs increasing slightly in January
from 12.2% to 13.1% and the total number of DTOCs on Bristol wards also increasing.
The AWP Inpatient Head of Operations continues to have a weekly conference call with
Bristol CCG and BCC to reviews all delays, including DTOCs. Discharge countdown
processes have been implemented on all wards to improve action allocation within
AWP and with partner agencies. Most DTOCs are due to the need for specialist
placement or no provider being identified for social care placements; BCC and the CCG
have agreed to escalate this issue. Bristol CCG and BCC have created a joint role from
Better Care Fund to support improvements in DTOCs, and have created a Project Plan
to support this. Improved action tracking of the DTOC conference call has been
implemented to better track actions, progress and appropriate escalations.
Improvements are still required to ensure timely addressing of actions, particularly from
the Local Authority. Information has been requested as to appropriate targets and
timescales for decision making to support action and / or escalation. A system wide
DTOC group has been proposed to be manged through ICQPM and will be taken
forward at the next meeting. Each CCG has been asked to provide a paper to the next
ICQPM which outlines actions being taken to reduce DTOCs.
SWASFT: Trust wide performance for the new Category 1 incident response was below
the 75% target at 71.16%, showing an upward trend from December which was 69.70%
Page 14 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
and a year to date overall performance of 70.89%. Overall activity remains under plan,
although for December there has been year on year growth of 2.71% overall.
The provider continues to show improvements in performance and is taking action
around recruitment and retention to improve the resource position. SWASFT is also in
the process of revising operational rotas which will look to better match resource
against demand and improve performance. A programme of fleet investment is
intended to address an imbalance between Rapid Response and transporting needs,
which is an identified issue when operating within the Ambulance Response
Programme.
Care UK (111): There was underperformance in January against 60 seconds call
answering (93.9% against 95% standard), ED referrals (7.3% against 5% standard) and
ambulance referrals (10.6% against 10% standard). 60 seconds call answering dropped
due to one day of significant underperformance (2 January), when call volumes
significantly outstripped forecast in the morning period (possibly due to patients not
realising that GP practices would be closed as this was a bank holiday). Although the
provider managed to secure an additional 40 hours that morning, it was insufficient to
match demand. If performance on this day was excluded, the provider would have
achieved 95% for the month. Almost all national providers experienced the same
pressures with a subsequent impact on call answering performance.
Strong performance continues in call abandonment (0.9%, ahead of 5% standard), calls
transferred to a clinical advisor (34% against 30% standard), and the combined warm
transfer and call back in 10 minutes measure. This is particularly good given the clinical
workforce shortfall within the service.







Contract Performance Notices and associated Remedial Action Plans remain in
place for ED referrals and ambulance referrals (both CQUINs). The key
challenge continues to relate to workforce, particularly for clinical advisors.
Mitigating actions are as follows:
3 Clinical Advisors are currently in training. Clinical staffing levels are at their
highest for 12 months.
Increasing applications to the service, by attending job fairs, recruiting via
agencies. The provider is now also offering a “referral” bonus for clinical staff.
Continued use of the ambulance validation interception line (exceeding
validation target of 50% set by NHS England).
ED referral line continues at peak times. Of those calls validated, circa 70% are
diverted to an alternative service.
Ongoing use of the clinical prioritisation model to ensure the most acutely unwell
patients are managed first, as well as the Bridge which ensures demand is
evenly profiled across the Care UK network to support KPI delivery.
Next Remedial Action Plan review meeting to be held 10 March.
GP Out of Hours: Whilst demand remained high, performance for clinical advice was
strong this month with the KPI for a two hour call back being achieved. This was due to
a focus on designating “advice only” shifts in the clinical rota to improve patient flow and
safety.
Performance for Urgent face to face appointments was 88% against a target of 95%, as
the emphasis for performance has been put on the potentially higher risk patient group
who are waiting at home to be called.
Page 15 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
Independent Sector: Activity volumes at IS providers are improving following the
expected Christmas drop off. However the Care UK activity still has not risen back up to
its previous levels at April. Revised IMAS models have been received by providers
prepared to inform the RTT Choice project. These were presented at the Trauma &
Orthopaedics steering group and will be discussed further at the next RTT Programme
Board. Care UK, Spire, Circle Bath and SSS are engaging in the project on waiting list
transfers out from NBT to help reduce the 18 week wait patients. The IFR team have
undertaken Q2 CBA audits and these have highlighted that there are some policies in
Nuffield Health and Care UK that are not being adhered to. The CCG is expecting
refunds of approximately £45k following these audits.
Community Children’s Health Partnership (lead provider Sirona care and
health): The most recent performance report is for December 2016. However, as most
services are reliant on manual data entry from paper records, there is a time lag in
getting accurate data.
Community Children’s Health Partnership - CCG commissioned services
Community Paediatrics wait times show a slight improvement over the year; up to
93.1% in December, but poor performance in July 2016 means that the year to date, at
91.3%, is below target.
Physiotherapy performance dipped in December but this may be due to data lag. The
year to date performance is 98.4%. Occupational therapy performance dipped in
November and December, but the year to date performance is on target at 90%.
Speech and Language therapy performance was also poor in November and December
and is below target for the year to date at 84%. An action plan is in place to meet the 18
week target by the end of March.
The did not attend (DNA) rate for all services had improved in November, but dipped
again in December to 6.5% against a target of 6%. Poor performance over the summer
months means that the year to date rate is 6.5%.
The percentage of health contributions to Education Health and Care (EHC) Plans on
time is below target at 81% in the year to date. There have been some IT and
administrative issues contributing to this which are being addressed.
Community Children’s Health Partnership - Public health commissioned services
There have been small improvements in Health Visitor performance with a slight
increase against all main key performance indicators. However overall performance is
well below target. Only 53% of families having their new born visit within 14 days and
only 86% ever having a visit. Only 56% of twelve month reviews were completed on
time, although 74% had a visit by 15 months. The proportion of children having a 6-8
week review was better with 81% receiving a review against a target of 90%. Public
Health commissioners are working directly with this service, which is delivered by
Bristol Community Health in Bristol, to develop a recovery plan. An Action Plan will be
required in response to BCH’s CQC Inspection which identified children’s services as
requiring improvement. This is expected by the end of March.
Jointly commissioned services (CCG and Local Authority)
Page 16 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
Child and Adolescent Mental Health Service (CAMHS) is showing improvement.
The DNA rate was down to 5% in December against a target of 7.2%, and has been
continuously improving since September. Year to date performance for the number of
children having a first (choice) appointment within 8 weeks is on target at 90%. The
percentage having their second (partnership) appointment within 10 weeks has
improved throughout the year and was 100% in December. Overall performance
against the 18 week target was up to 94% in December.
Looked After Children’s Health. The proportion of looked after children with an up to
date health assessment is well below target in Bristol. In December only 69% of
eligible children had an up to date health assessment, against a target of 90%. The
provider has completed a detailed root cause analysis and a recovery plan is in place
with monthly review meetings. Additional clinics have been arranged and all children
without an up to date health assessment have been given an appointment before the
end of March. A Contract Performance Notice will be issued if improvements are not
made as a result.
IAPT Recovery Rate: Despite a seasonal drop in December and January, the
performance trend remains upward and on track to achieve the 50% target by the end
of Q4.
NHSE Recovery Funding is being used to work with AQP partner providers to support
improvements including marketing and awareness-raising, top-up treatment and
changes to attendance approaches. One provider is trialling “Big White Wall” online
therapy and has already demonstrated an improvement.
The Service Improvement Plan is updated regularly and Recovery is a standing item on
the IAPT Provider Forum agenda. Weekly individual therapist performance figures are
also sent to all providers.
Bristol waiting lists for Step 2 therapies have been reduced to near zero. However,
demand for Step 3 1:1 therapies remains high indicating the high complexity of referrals
to this service.
Referrals continue to be gathered from a wide range of the population using web-based
resources such as webinar-based course delivery and on-line course listings. The
online therapy provider, SilverCloud, has been commissioned as a pilot to deliver to
clinically suitable individuals. This launched mid-February and impact is still to be
analysed.
Page 17 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
5. Activity Review
Compared with the operational plan submission, in the first nine months of 2016/17,
Bristol CCG has seen reduced levels of activity in referrals, first and follow up
outpatients, and both elective and non-elective admissions. A&E attendances are over
plan.
In outpatients first attendances, although the overall CCG plan is underperforming,
UHB have seen a 4.4% increase when comparing the 2016/17 month 10 position to the
same period in the previous year. NBT have seen a larger increase of around 7.8% in
outpatient firsts in comparison to the same period last year. There has also been a
cumulative fall in independent sector outpatient firsts, although this is primarily at Care
UK.
Outpatient follow-ups have seen an increase of 24.1% at NBT, and a smaller but still
considerable rise at UHB, 6.7%, when comparing months 1 to 10 of 2015/16 and
2016/17. It is likely that data issues arising from NBT’s move to Lorenzo have affected
their 15/16 outpatients follow-up numbers. Overall, independent sector follow-up
appointments have increased by 2.4% when compared to the previous year.
In terms of elective care (including both elective inpatients and day cases), when
comparing the two month 10 positions, UHB have seen a slight -1.9% decrease in
activity. At NBT, there has been an increase of 6.5% in day cases & elective inpatient
care. There has also been a decrease overall in Independent Sector activity, again
primarily at Care UK.
For emergency care, UHB has seen an increase of 1.6% between the first ten months
of 2015/16 and the same period 2016/17, whereas NBT have seen an increase of
8.5%. This may partially be related to the recording of HOT clinics and ambulatory care.
Page 18 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
6. Medicines Management Overview
Forecast expenditure for 2016/17 on GP prescribing is £57.7m based on M9 data. This
is an underspend of £480k on the revised budget of £58.2m (a further £1m was
removed from the prescribing budget in year).
Bristol CCG attributes over £70m of expenditure each year to medicines prescribing or
supply, and related activity. A significant portion of this (c. £10m) relates to charges
levied by acute trusts for drugs they supply, with the remainder relating to primary care
activity. The largest single area of expenditure is primary care prescribing by member
practices (c.58m).
The main cost pressure in primary care prescribing currently is the uptake of new NICE
approved drugs in primary care (especially for atrial fibrillation and diabetes). Spend on
diabetes medicine is now being driven higher by the Bristol CCG Diabetes
Transformation Programme in general, and the HG Wells Project in particular. Spend
on prescribing to prevent stroke in atrial fibrillation will also be driven higher by Bristol
CCGs LTC initiative to participate in the WEAHSN Don’t Wait to Anticoagulate project.
These investments will result in better health outcomes in future years.
NHS England recommends that CCGs plan for 7% annualised growth in primary care
prescribing expenditure. The current figure for Bristol CCG is -0.8%, the 21st lowest
rate in any CCG in the south of England (averages -0.2%, with a range from -4.0% to
3.6%).
In order for Bristol CCG to meet its revised QIPP target for medicines management in
2016/17, growth will need to average -0.03%.
The figure for annualised volume growth in primary care prescribing for Bristol CCG is
3.0%, the 8th highest of any CCG in the south of England (averages 2.0%, with a range
from 0.2% to 7.5%).
NB There are 49 CCGs in the NHS South of England region.
Bristol continues to benchmark very favourably with its peers in terms of prescribing
spend per head, and per weighted head of population.
The Department of Health reduced the cost of primary care prescribing to CCGs by
£12m per month in June 2016 as a way to prevent over delivery of the margin (profit)
agreed negotiated with pharmacy contractors this year. This is contributing significantly
to the underspent position. We understand that this will end in April 2017, with prices
returning to their previous level with a corresponding cost pressure for the CCG.
Page 19 of 20
Meeting of Bristol CCG Governing Body 28th March 2017
7. Report Contributors
The main contributors to the production of this report were:
Robert Moors, Deputy Director of Finance (CCG)
Nick Tippet, Head of Management Accounts (CCG)
Rob Presland, Programme Management Office Manager (CCG)
Marie Davies, Head of Commissioning for Quality, BNSSG
Kris Stone, Commissioning Information Manager (CCG)
Rachel Anthwal, Delivery Director (CCG)
Sarah Swift, Delivery Director (CCG)
Mark Sims, Contract Business Manager (CCG)
Asifa Hojati, Performance Assistant (CCG)
Jon Hayhurst, Head of Medicines Management (CCG)
Page 20 of 20
Bristol Clinical Commissioning Group
REVENUE COST STATEMENT
FOR THE PERIOD TO 28 FEBRUARY 2017
Annual
Budget
YTD
YTD
Budget Expenditure
YTD
Variance
£'000
£'000
£'000
£'000
ACUTE AND SPECIALIST CARE
(Nicola Dunn)
North Bristol NHS Trust
University Hospitals Bristol NHS Foundation Trust
Emersons Green NHS Treatment Centre
Weston Area Health NHS Trust
Royal United Hospital Bath NHS Foundation Trust
South Western Ambulance Service NHS Foundation Trust
NHS Non Contract Activity
Patient Transport services
Independent Sector Acute Care
Individual Patient Treatment Approvals
Other Acute expenditure
Acute and Specialist Care total
117,648
151,677
6,046
295
1,767
15,816
5,538
2,371
5,044
57
3,905
310,164
107,888
139,088
5,542
271
1,620
14,498
5,076
2,174
4,624
52
3,530
284,362
110,365
141,438
3,591
318
1,855
14,498
5,462
2,668
5,897
27
1,389
287,508
MENTAL HEALTH & LEARNING DISABILITIES (Jill Shepherd)
Avon and Wiltshire Mental Health Partnership NHS Trust
Section 3 and Section 117
Improving Access to Psychological Therapies
Other Mental Health and Learning Disability Services
Mental Health and Learning Disabilities total
23,551
8,067
3,376
41,857
76,851
21,592
7,423
3,094
38,324
70,433
55,332
3,467
1,625
1,200
843
62,467
Percentage
Variance
Forecast
Expenditure
Forecast Percentage Previous month
Variance
Variance
forecast
%
£'000
2,703
2,363
(2,031)
52
257
(0)
340
589
1,473
(8)
(2,282)
3,456
2.3%
1.6%
-33.6%
17.6%
14.5%
0.0%
6.1%
24.9%
29.2%
-13.8%
-58.4%
1.1%
121,625
153,551
4,115
367
2,093
15,816
6,182
2,961
6,517
49
1,543
314,819
22,961
10,127
3,462
40,912
77,462
(590)
2,059
86
(945)
611
-2.5%
25.5%
2.6%
-2.3%
0.8%
22,961
10,067
3,451
37,168
73,647
-1.2%
-1.0%
8.2%
-6.5%
-9.9%
-1.1%
54,753
3,485
1,715
1,123
758
61,835
(579)
18
90
(77)
(84)
(632)
-1.0%
0.5%
5.5%
-6.4%
-10.0%
-1.0%
54,498
3,474
1,664
1,122
764
61,521
(14)
(276)
(138)
0
5
0
(2)
(43)
(153)
(620)
-5.3%
-22.9%
-90.0%
0.3%
0.4%
0.0%
-0.5%
-11.8%
-5.4%
-8.5%
264
1,015
17
69
1,592
530
488
350
2,941
7,265
(15)
(299)
(150)
0
(1)
0
1
(47)
(165)
(675)
-5.3%
-22.8%
-90.0%
0.0%
0.0%
0.0%
0.2%
-11.8%
-5.3%
-8.5%
264
1,013
17
69
1,592
530
488
350
2,938
7,260
3,941
1,129
1,243
6,314
(107)
(48)
(7)
(163)
-2.7%
-4.1%
-0.6%
-2.5%
4,266
1,228
1,356
6,850
(151)
(57)
(17)
(224)
-3.4%
-4.4%
-1.2%
-3.2%
4,300
1,228
1,356
6,883
36,085
7,008
7,639
8,348
1,434
1,360
2,892
64,766
36,085
7,067
7,046
8,016
1,422
1,352
2,590
63,579
(0)
60
(593)
(332)
(11)
(8)
(302)
(1,187)
0.0%
0.8%
-7.8%
-4.0%
-0.8%
-0.6%
-10.4%
-1.8%
39,365
7,909
7,686
8,766
1,552
1,448
2,916
69,642
(0)
264
(647)
(341)
(12)
(36)
(239)
(1,012)
0.0%
3.5%
-7.8%
-3.7%
-0.8%
-2.4%
-7.6%
-1.4%
39,365
12,244
7,833
8,877
1,552
1,481
2,924
74,276
23,996
5,477
29,473
22,045
5,020
27,065
19,506
6,638
26,144
(2,539)
1,618
(921)
-11.5%
32.2%
-3.4%
21,400
7,241
28,642
(2,596)
1,765
(831)
-10.8%
32.2%
-2.8%
21,485
7,411
28,896
103
510
561
1,072
1,817
1,461
5,524
92
468
513
983
1,665
1,339
5,059
43
468
414
940
1,264
1,176
4,305
(49)
0
(99)
(43)
(401)
(163)
(754)
-52.8%
0.0%
-19.3%
-4.4%
-24.1%
-12.2%
-14.9%
47
510
453
1,025
1,433
1,279
4,749
(55)
(0)
(108)
(47)
(383)
(181)
(774)
-53.9%
0.0%
-19.2%
-4.4%
-21.1%
-12.4%
-14.0%
53
510
309
1,025
1,433
1,279
4,610
7,716
2,578
10,294
7,058
2,364
9,422
6,580
2,438
9,019
(478)
75
(403)
-6.8%
3.2%
-4.3%
7,716
2,578
10,294
0
0
0
0.0%
0.0%
0.0%
8,257
2,018
10,275
RESERVES
(Nicola Dunn)
Unallocated (pending further contract negotiations)
1% Headroom reserve
0.5% Contingency reserve
Unidentified QIPP
Rightcare QIPP opportunities
Pipeline QIPP schemes
Manage demand to avoid additional IHAMs activity
Review of 2015/16 balances
Surplus
Reserves total
0
5,601
2,880
(10,194)
(3,000)
0
0
0
3,463
(1,250)
0
0
2,640
(8,727)
(2,667)
0
0
0
3,174
(5,579)
0
0
0
0
0
0
0
(1,195)
0
(1,195)
0
0
(2,640)
8,727
2,667
0
0
(1,195)
(3,174)
4,384
0%
0.0%
-100.0%
-100.0%
-100.0%
#DIV/0!
#DIV/0!
0%
-100.0%
-78.6%
0
5,601
0
0
0
0
0
(1,294)
0
4,307
0
0
(2,880)
10,194
3,000
0
0
(1,294)
(3,463)
5,557
0.0%
0.0%
-100.0%
-100.0%
-100.0%
#DIV/0!
#DIV/0!
0.0%
-100.0%
-444.6%
0
5,601
0
0
0
0
0
(1,164)
0
4,437
BRISTOL CLINICAL COMMISSIONING GROUP (CCG)
579,191
526,545
530,467
3,922
0.7%
584,666
5,475
0.9%
586,623
Revenue Resource Limit (RRL) at M11 (£'000)
579,191
MEDICINES MANAGEMENT
Primary Care Prescribing
Central Drugs
Other Prescribing
Home Oxygen Service
Medicines Management Practice Support
Medicines Management total
(Jill Shepherd)
PRIMARY CARE CONTRACTING
Memorandum of Agreement
Primary Care Provider Services
Mental Health Primary Care Provider service
Practice Education
Over 75s funding
Prescribing Incentive schemes
LEG member costs
Referral Management Schemes
Other Primary Care applications
Primary Care Contracting total
(Jill Shepherd)
URGENT CARE (OUT OF HOURS) SERVICES
Brisdoc Out of Hours contract
111 Service
GP Support Unit
Urgent Care (Out of Hours) Services total
(Nicola Dunn)
COMMUNITY SERVICES
(Nicola Dunn)
Bristol Community Health Services
Children's Community Health Partnership
Joint working between Health and Social Care
Better Care Fund previous section 256 funding
Hospices
AQP services
Other Community Services
Community Services total
CONTINUING HEALTHCARE
Continuing Healthcare
NHS Funded Nursing Care
Continuing Healthcare total
%
£'000
£'000
2,477
2,350
(1,951)
48
235
0
386
494
1,273
(25)
(2,141)
3,145
2.3%
1.7%
-35.2%
17.6%
14.5%
0.0%
7.6%
22.7%
27.5%
-48.7%
-60.7%
1.1%
120,351
154,040
4,015
347
2,024
15,816
5,878
2,961
6,516
49
1,623
313,620
21,335
9,395
3,185
37,615
71,530
(257)
1,972
90
(709)
1,097
-1.2%
26.6%
2.9%
-1.9%
1.6%
50,708
3,178
1,501
1,100
772
57,260
50,111
3,146
1,624
1,028
696
56,605
(597)
(32)
123
(72)
(77)
(655)
279
1,314
167
69
1,592
530
487
397
3,105
7,940
256
1,205
153
63
1,460
486
446
364
2,847
7,279
242
929
15
63
1,465
486
444
321
2,694
6,659
4,417
1,285
1,373
7,074
4,049
1,177
1,250
6,476
39,365
7,645
8,334
9,107
1,564
1,484
3,155
70,654
(Nicola Dunn)
SUPPORT COSTS
Community Services Re-Procurement
Research and Development
Safeguarding
Public Health England
Estates Management Recharges
Other Support costs
Support Costs total
(Nicola Dunn)
RUNNING COSTS
CCG Running Costs
CSU recharge
Running Costs total
(Nicola Dunn)
Schedule of risks and mitigations outside the reported financial position
Feb-17
Annex 2
M11
£m
Ledger position
5.48
Potential release of headroom reserve
(5.60)
Revised ledger position assuming headroom released
(0.13)
Notes
Without access to the 1% headroom reserve the CCG are reporting a deficit.
Surplus assuming headroom is released
Risks
Other 16/17 acute risks
Prescribing
Section 117
CHC
Additional costs of corporate restructure
Total risks
Full value
1.00
1.00
1.00
0.50
0.18
3.68
Risk rated
0.40
0.50
0.28
0.12
0.18
1.48
Other Acute risks excluding NBT
General volatility
Forecast continues to increase, figs from BCC
General volatility
Costs incurred due to creation of BNSSG structure
Mitigations
Jnt working with Council
NBT challenges
Contract penalties NBT
Assume corporate restructure costs funded by NHS England
Total mitigations
Full value
0.40
2.50
0.67
0.18
3.75
Risk rated
0.20
0.60
0.50
0.18
1.48
From FRP
From FRP
Additional penalties not in position
Assumption that costs in relation to the corporate restructuring will be funded by NHS England
-0.07
0.00
Net risk
Position as submitted in non-ISFE return to NHS England:
Risk adjusted forecast without Headroom
Risk adjusted forecast with Headroom
5.48
(0.13)
SUMMARY OF IDENTIFIED IMPACT OF 15/16
In Forecast
NBT arbitration
NBT M12
UHB M12
Creditor reversal
£m
1.90
0.46
0.85
-4.41
Forecast if CCG are unable to access Headroom reserve
Forecast if CCG are able to utilise Headroom
Annex 3
QIPP 2016/17 Report for Finance Committee
for the Period up to 28th February 2017
16/17 Planned Savings £000
Programme
Scheme Name
Nursing support to Extra Care
Housing (ECH pilot)
Gross Saving CCG Investment
RecIY
Required RecIY
144
97
16/17 Annual Forecast Net
Savings £000
Forecast
Variance
From 16/17
Plan
16/17
Forecast
Saving
Net 16/17
Saving
47
16/17 Year to Date (YTD) savings £000
0
Project Start
YTD Actual YTD Variance
End Date
Date
YTD Plan
-47
42
0
-42
Jun-16
Mar-17
Baseline
Revised
Financial Financial
Benefit
Benefit
Start Date Start Date
Jul-16
Closed
Senior
Responsible
Clinician
Senior
Responsible
Director
Peter Goyder
Richard Lyle
Project RAG
Status
Better Care inc. Urgent Care
Care homes
102
102
0
0
0
0
0
0
Apr-16
Mar-17
Jul-16
Oct-16
Peter Goyder
254
Ambulatory Emergency care
106
0
254
0
-254
230
0
-230
Apr-16
Mar-17
Jul-16
Closed
Peter Goyder
43
0
-43
38
0
-38
Sep-16
TBC
Jul-16
Closed
Lesley Ward
Better Care inc. Urgent Care
Out of Hospital Models of Care
116
0
116
87
-29
103
84
-19
Jul-15
Jun-16
Jul-16
Dec-16
Kirsty Alexander
Mitigations: No timescales currently provided for an updated
business case. Assumption currently is that investment will be
used to support in year financial recovery.
Risks: Team are fully staffed and working well to support 10
Care Homes with nursing. Currently reviewing GP care home
LES returns data and due to deliver ‘NEWS’ training into care
homes as a tool for the registered nurses and carers to assist in
avoidance of hospital admissions from care homes. Month 10
data shows 80% of the year to date gross savings plan is being
achieved.
Mitigations: Project is on track
Risks: Plans for 16/17 failed to deliver QIPP. Community Web
and Integrated Nursing pilot teams are going ahead but are
expected to be subsumed into the Sustainability and
Transformation Plan Integrated Primary and Community Care
workstream when fully operational.
R
Claire Thompson
Mitigations: Additional schemes need to be identified to mitigate
in year impacts and identify opportunities for future years.
Risks: Scheme will not be going ahead for 2016/17 due to
resourcing and design issues, in addition to delays with the Front
Door pilot. Scheme lead confirmed that this will not be submitted
as a QIPP plan for 17/18.
R
BRHC ED Demand
Management “Paediatric ED
Project” (Children's emergency
admissions)
G
Richard Lyle
R
63
R
Richard Lyle
G
Out of hospital model of care
(Phase 1) including :Frailty
Primary Care Home
BPCAg
Risk stratification
Test and Learns Integrated Multi-disciplinary
team
BC2a Aim 2
Integrated nursing team
BC2b
Aim 2
Community Webs BC2c
Aim 1
Risks and Mitigations
Risks: Project was closed by Better Care Transformation Board
in July, with recruitment issues to the service model specified as
being problematic. Forecast reflects full in year savings as
currently at risk.
R
Care Home Support Team
Financial RAG
Status
R
Claire Thompson
G
A
Mitigations: Additional urgent care schemes need to be identified
to mitigate in year impacts and identify opportunities for future
years.
Risks: Patient flow action plan agreed with UHB and Month 10
data continues to show positive signs, with both A&E and non
elective admission data growing at a smaller rate than the
previous year. The QIPP plan is therefore showing as being
achieved for the year to date, although this is still being
monitored closely as data for the Winter period in Quarter 4
could be subject to fluctuations.
Mitigations: No further mitigations identified, but a review of
performance year to date on activity levels is recommended.
Front Door for Urgent and
Emergency Care
131
125
6
0
-6
5
0
-5
Feb-16
Jul-17
Jul-16
Apr-17
Lesley Ward
Claire Thompson
Risks: Project was only live for 1 week in November before a
clinical incident put the pilot on hold. An investigation is currently
underway and should be concluded by March. This will inform
future decision as to whether the pilot can restart again within
the current financial year.
R
R
Mitigations: Current assumption is that the project will not go live
again this financial year. This will mean no QIPP savings are
delivered in year. A post mortem and coroners inquest will be
completed by March, during which time clinicians will be involved
in reviewing the service design.
Programme
Scheme Name
Discharge to Assess
Gross Saving CCG Investment
RecIY
Required RecIY
510
0
Forecast
Variance
From 16/17
Plan
16/17
Forecast
Saving
Net 16/17
Saving
510
510
YTD Plan
0
YTD Actual YTD Variance
459
405
-54
Project Start
End Date
Date
Jul-15
Dec-16
Baseline
Revised
Financial Financial
Benefit
Benefit
Start Date Start Date
Apr-16
Apr-16
Senior
Responsible
Clinician
Senior
Responsible
Director
Peter Goyder
Richard Lyle
Project RAG
Status
Better Care inc. Urgent Care
Community
A
Financial RAG
Status
G
Risks and Mitigations
Risks: A number of data quality issues have arisen at M10.
Firstly, the restated year to date activity has resulted in 117 more
Excess Bed Days reported at Month 9, before the M10
performance has been calculated. The effect of this has been
seen mostly at NBT where forecast savings could deteriorate by
£100k as a result. Secondly, M10 NBT data is missing which
makes the M10 forecast difficult to estimate. Lastly, M9 and M10
performance at UHB was 600 Excess Bed Days over plan,
bringing the UHB year to date position down from a reduction of
725 in M9 to 625 in M10.
Mitigations: Data Quality and operational performance is to be
reviewed before the year end forecast is updated, but this could
potentially cause a significant change to the year end position of
the QIPP scheme.
Homelessness Support Team UHB
87
100
-12
-12
0
-11
-4
7
Apr-16
Oct-17
Aug-16
Dec-16
Kate Rush
Alison Moon
A
G
Plan has been forecast at M11 until these issues have been
investigated.
Risks: Scheme is reporting slippage until February due to
recruitment of posts to make the service operational. However,
this scheme requires a net investment in 16/17 to support future
years savings, so any delay in year will support CCG financial
recovery planning, but will still require net investment in 17/18.
Mitigations: Ongoing management via Urgent Care Programme
Board. Business case for continuation currently being reviewed.
Better Care inc. Urgent Care
Frailty
Falls reduction plan
100
0
100
25
-75
90
25
-65
Apr-16
Mar-18
Jun-16
Oct-16
Peter Goyder
Richard Lyle
G
R
Risks: Data quality issues in identifying post codes for fallers
have been resolved. Data for Month 10 shows performance
below plan at UHB, but activity is well above plan at NBT. This
has resulted in an adjustment to the forecast savings where
essentially only the scheme impacts at UHB are likely to deliver.
UHB forecast downgraded to £20k ion Month 11 due to year to
date performance.
Mitigations: Analysis of the reasons for performance variance
between the two Trusts is to be undertaken by the scheme lead
during Quarter 4 to inform planning for 17/18.
GP Support Unit (GPSU) at
UHB
174
0
174
157
-17
157
139
-18
Apr-15
Mar-17
Apr-16
Apr-16
Lesley Ward
Claire Thompson
Risk: Project has now moved into Business as Usual within
UHB, but is being monitored for QIPP delivery. Month 10 data
shows activity reductions in excess of plan at UHB, but not at
NBT.
G
Better Care inc. Urgent Care
GP Support
GP Support Team (GPST) at
NBT
516
367
149
0
-149
134
0
-134
Apr-15
Mar-17
Apr-16
Apr-16
Peter Goyder
Claire Thompson
53
38
16
16
0
14
16
2
Apr-16
Mar-17
Apr-16
Apr-16
David Soodeen
Mitigations: Review of the variance in performance between
UHB and NBT to be completed by scheme leads during Quarter
4 to inform business planning for 17/18.
Risk: Month 10 data shows no savings forecast at NBT. UHB is
much more favourable with savings in excess of plan, but this
was slightly unexpected and is therefore being reviewed to
ensure data quality is robust.
G
Clinical Review Officer - AWP
A
R
Jill Shepherd
G
G
Mitigations: Review of the variance in performance between
UHB and NBT to be completed by scheme leads during Quarter
4 to inform business planning for 17/18. This will include a joint
review with South Glos commissioning where some small
savings are being forecast for South Glos patients, whereas no
savings are evident for Bristol patients.
Risks: Clinical Review Officer in post and benefits monitoring
against Section 3 expenditure is live. Currently forecasting full
end of year achievement relating to cost avoidance of this
scheme, although Section 3 expenditure continues to show
growth overall.
Mitigations: Ongoing management by Mental Health Programme.
Regular highlight reports from Clinical Review Officer in place to
establish impact of interventions.
Personality disorder pathway
and the relevant community
provision - AWP
147
64
83
0
-83
75
0
-75
Apr-16
Mar-19
Jun-16
Apr-17
David Soodeen
Jill Shepherd
R
R
Risks: Service redesign for the Pathway is underway but
implementation is behind schedule due to difficulties recruiting a
clinical post. The scheme is now unlikely to deliver in year and a
new business case is being developed for 17/18 to extend
across the STP.
Mitigations: Commissioning and clinical resource in place to
implement the pathway. Planned investment in 16/17 is under
review and is likely to incur cost in Q4 only.
Programme
Scheme Name
Out of Area Placements
Gross Saving CCG Investment
RecIY
Required RecIY
1,200
0
Forecast
Variance
From 16/17
Plan
16/17
Forecast
Saving
Net 16/17
Saving
1,200
815
-385
YTD Plan
YTD Actual YTD Variance
1,080
815
-265
Project Start
End Date
Date
Jun-15
Mar-17
Baseline
Revised
Financial Financial
Benefit
Benefit
Start Date Start Date
Jul-16
Apr-17
Senior
Responsible
Clinician
Senior
Responsible
Director
David Soodeen
Jill Shepherd
Project RAG
Status
Mental health and Learning Difficulties
280
100
180
0
-180
162
0
-162
Jun-15
Mar-17
Apr-16
Apr-16
Pippa Stables
1,000
0
1,000
0
-1,000
889
0
-889
May-16
Mar-17
Jun-16
Jan-17
David Soodeen
113
0
113
0
-113
102
0
-102
Apr-15
Mar-17
Apr-16
Apr-16
David Peel
187
0
187
0
-187
168
0
-168
Apr-15
Mar-17
Apr-16
Apr-16
David Peel
60
0
60
49
-11
54
44
-10
Apr-15
Mar-17
Apr-16
Apr-16
David Peel
Mitigations: Work required to review the metrics for benefits
realisation as there is a risk that inclusion of secondary
diagnoses codes could skew figures where patients aren't
eligible for the dementia flexi beds. Delivery continues to be
managed by the Mental Health Programme Board and a
business case has been completed for moving this to business
as usual in 17/18 with an additional bed at Saffron Gardens.
Risks: The savings profile for the Section 117 and Section 3
target ramped up significantly from Q2 with more than £300k
profiled each Quarter. However, the latest information shows
forecast overspend against plan in both Section 3 and Section
117. The forecast has therefore been reduced accordingly and
mitigations will be captured as part of the CCG financial recovery
plan.
R
Mitigating actions: Most of the mitigating actions financially are
covered by the CCG Financial Recovery Plan. However, work
will continue in key areas on Section 3 and Section 117 to
influence the end of year position. For Section 3 the Clinical
Review Officer QIPP scheme is in place and opportunities to
stretch the scale and pace of delivery for Personality Disorder
pathways have been agreed across BNSSG as part of the STP.
A plan to reduce Section 117 spend is also in development and
a task and finish group has been set up to review options to reintroduce CCG control over spend, review the way people are
put onto Section 117, review existing placements to discharge
people and reduce the costs of Provider rates as part of planned
re-commissioning in 2017. The Better Care Section 75 risk share
agreement is also being reviewed by the Better Care team, with
the objective of capping liability of spend against S117 to deliver
within agreed parameters.
Claire Thompson
R
Risks: NBT and UHB have agreed 15% activity shift, but this is
less than the 30% expected and modelled, and further shift is
unlikely to be achieved. Month 10 data shows no reductions at
NBT for the year to date nor UHB, with continued slippage in the
Basal Cell Carcinoma service being implemented by UHB. This
is because UHB are proposing a local tariff. Risk remains that
Trust are very unlikely to deliver unexpected changes, or the
impact of changes is obscured by other growth.
R
Mitigations: Options are limited in terms of the contract, so
mitigating actions will have to be found elsewhere within Planned
Care schemes. Review of project completed with PMO and
agreed that UHB and NBT forecasts downgraded to £0 as no
evidence to support achievement.
Claire Thompson
R
Cataract follow up
R
Jill Shepherd
G
Daycase to outpatient
appointments - UHB
Mitigations: Larch bed is operational allowing 10 patients who
are currently out of area to be moved back within AWP capacity,
resource mapping has confirmed Bristol is paying for an
additional 3.5 beds overall which should reduce out of area
charges, a mental health delayed transfers of care project is
underway to improve flow and commissioners are establishing
the correct coding for delayed transfers of care so that recharge
arrangements can be agreed with local authorise. Contract
negotiations for 17/18 have also concluded with a 50/50 risk
share agreement on out of area placements for next year.
Risks: Beds fully utilised and project on track. Month 10 data
shows activity reductions not being met at UHB or NBT.
Forecast amended in Month 10 to reflect no in year achievement
for this scheme.
R
Daycase to outpatient
appointments - NBT
R
Alison Moon
G
MH contracts - Other providers
(non-NHS, incl. VS)
S3 and S117 stretch
Risks and Mitigations
Risks: Year to date savings were made up to Month 7 due to
the delayed investment in the opening of 10 beds at Larch Ward.
This went live in October. Latest data for Month 10 also shows
lower than expected out of area bed utilisation. It is unclear at
the moment if this is due to Larch beds or other factors, but
regardless of this the end of year forecast outturn has improved
by £185k as a result as at Month 11. The remaining savings of
£385k remain at risk.
A
Dementia Flexi Beds
Financial RAG
Status
Claire Thompson
Risks: 80% of overall savings plan is forecast to be achieved
with UHB delivering to plan, although Emerson's Green and
Nuffield are not showing any activity impacts yet and are unlikely
to start until 17/18. End of year forecast amended accordingly.
G
A
Planned Care
Mitigations: Work ongoing to review independent sector
implementation plans to achieve required activity improvements.
Planned Care
Programme
Scheme Name
DVT - GP Care - UHB
Gross Saving CCG Investment
RecIY
Required RecIY
184
0
Forecast
Variance
From 16/17
Plan
16/17
Forecast
Saving
Net 16/17
Saving
184
45
YTD Plan
-139
YTD Actual YTD Variance
166
33
-133
Project Start
End Date
Date
Jun-15
Mar-17
Baseline
Revised
Financial Financial
Benefit
Benefit
Start Date Start Date
Apr-16
Apr-16
Senior
Responsible
Clinician
Senior
Responsible
Director
David Peel
Claire Thompson
Project RAG
Status
300
0
300
300
0
270
334
64
Apr-16
Mar-17
Apr-16
Apr-16
David Peel
200
0
200
0
-200
180
0
-180
Oct-15
Mar-17
May-16
May-17
Kirsty Alexander
89
32
57
0
-57
51
0
-51
Apr-16
Oct-20
May-16
Apr-17
Sasha Beresford
285
155
130
130
0
117
117
0
Apr-16
Oct-20
May-16
May-16
Jon Hayhurst
G
Alison Moon
Mitigations: Month 10 reported swing in savings was
unexpected and data quality is to be reviewed for Month 12. The
forecast has been adjusted to reflect the latest data in Month 11
but this could still be subject to change.
Risks: Specialist Respiratory appointed by NS CCG but shared
by BNSSG, with Bristol not receiving support until May 2017.
Full slippage therefore expected into 2017 financial year.
R
Jill Shepherd
Mitigations: Impact on QIPP for Prescribing budget will be picked
up by additional year schemes to achieve the budgeted
reduction required.
Risks: Funding with NHS England delayed start up but has now
been resolved. Post unlikely to start until 17/18 so therefore full
slippage expected.
A
Meds Mgt
Stoma - Ostomy and
continence supplies: value for
money and waste, cease
primary care prescribing and
delivery via specialist nurse
teams
Mitigations: Project resource secured in September to deliver
the full project and priorities will now include a prices and
specification review to maximise GP sign up to the scheme by
the end of the financial year. Likelihood is that scheme will slip
into 17/18 with revised scope as part of financial recovery plans.
Risks: Roll out of new policies on track and Month 10 data
shows reductions at both NBT and UHB.
R
Embedded Commissioning post
Pharmacist to address high
cost "pass through" drugs UHB
R
Claire Thompson
G
High dose steroid inhalers
Risks and Mitigations
Risks: Month 10 data shows some in year achievement against
plan, but not to full level required. Risk assessment reflects
reported delays in clinical testing of kit, review of GP prices
proposed via LEGs and likelihood of at least one Quarter's worth
of planned benefits not being delivered in year.
A
IFR Prior approval
Financial RAG
Status
R
Alison Moon
G
G
Mitigations: Benefits impact on high cost drugs is reported from
UHB, so a review of alternative schemes to recover the gap will
be identified by Programme leads. Prescribing data however
looks positive for the year to date with the overall savings target
being achieved.
Risks: Project is on track overall but there are some
dependencies with new prescribing schemes which could impact
on scope including initiatives to centralise repeat prescribing
Financial savings show delivery for the year to date and no
impact on the end of year forecast.
Mitigations: Ongoing management by Medicines Management
Programme.
Prescribing Stretch target
1,500
0
1,500
1,500
0
1,333
1,335
2
Jul-16
Mar-17
Sep-16
Sep-16
Jon Hayhurst
Jill Shepherd
Risks: Level of risk is reducing due to new business cases being
identified as part of Financial Recovery. Prescribing data for
Month 9 also shows end of year target remains feasible for the
stretch (although subject to fluctuation). Forecast has been
adjusted to show full achievement based on year to date
expenditure at Month 9.
G
Additional schemes to reduce
prescribing budget
2,913
0
2,913
2,913
0
1,722
2,303
581
Apr-16
Mar-17
May-16
May-16
Jon Hayhurst
G
Jill Shepherd
Mitigations: Potential ideas are being scoped by the Medicines
Management Programme and PMO, including for example the
centralisation of repeat prescription requests to reduce costs,
but this is a large project and highly risky unlikely to deliver in
year. Alternative options continue to be explored by the
Medicines Management Programme lead and Finance Director
and are reflected in the financial recovery plan.
Risks: Profiled savings ramp up from £191k in Quarter 1 to
£597k in the remaining Quarters of the year, with many schemes
still requiring finalised business cases and plans. Medicines
Management Programme lead still expects full achievement to
be recovered and this is evidenced by Month 9 prescribing data.
G
G
Mitigations: New projects continuing to be reviewed as part of
the BNSSG turnaround process.
Programme
Scheme Name
Respiratory Programme
Gross Saving CCG Investment
RecIY
Required RecIY
20
0
Forecast
Variance
From 16/17
Plan
16/17
Forecast
Saving
Net 16/17
Saving
20
20
YTD Plan
0
YTD Actual YTD Variance
18
9
-9
Project Start
End Date
Date
Jun-16
Mar-18
Baseline
Revised
Financial Financial
Benefit
Benefit
Start Date Start Date
Jun-16
Senior
Responsible
Clinician
Jan-17 Gill Jenkins / Kirsty
Alexander
Senior
Responsible
Director
Project RAG
Status
Financial RAG
Status
Alison Moon
Risks and Mitigations
Risks: Financial profile shows benefits starting in Q1, but this
was in error. Actual savings begin in Quarter 4, with full QIPP
forecast to be achieved. Proxy data for M10 shows small
reductions at UHB but growth at NBT.
G
G
Mitigations: Ongoing management by Long Term Conditions
Programme. BNSSG programme now agreed as part of STP
and workshop scheduled in January to review plans.
Tissue viability beds
61
57
4
3
-1
3
0
-3
Apr-16
Mar-17
Aug-16
Aug-16
Gill Jenkins
Alison Moon
Risks: None to report. Beds fully occupied and performance
monitoring in place. Data validation to be completed but plan is
on track.
G
HG Wells – Integrated Model of
Care for Diabetes Phase 2
168
226
-58
-58
0
-52
-52
0
Apr-15
Mar-18
Jun-16
Aug-16
Gill Jenkins
G
Alison Moon
A
G
Mitigations: Ongoing management by Community
Commissioning.
Risks: Benefit start date slipped from June to August (2 months),
largely due to lack of project management capacity to support
scale of roll out required, in addition to Practice feedback about
the software implementation. £225k of the original investment
expected to be fully committed. £144k will be on the DSNs,
remaining funding likely to be spent on Practice support rather
than the House of Care expert patient and social prescribing
components of the business case.
Long Term Conditions
Mitigating actions: Project resource secured and updated
business case received as part of two year operational planning.
Investment schedule also required alongside a review of profiled
Practice based training and activity impacts.
Expansion of community heart
failure service
105
80
25
50
25
22
40
18
Apr-15
Mar-18
Apr-16
Sep-16
Gill Jenkins
Alison Moon
Risks: Project was delayed by 4 months due to Provider
recruitment but is now live and supported by above plan
reductions in activity at UHB and NBT.
G
Non oral anti-coagulant for
patients with atrial fibrillation NBT
149
227
-78
-78
0
-63
-58
5
Mar-15
Dec-17
Oct-16
Dec-16
Shaba Nabi
G
Alison Moon
Mitigations: Project is now live and has moved into benefit
monitoring.
Risks: Delayed start to December due to delay in clinical
champion recruitment but activity can still be completed in the
same timeframe. Plan for 16/17 was always to make a net
investment, with savings expected in 17/18. Risk of insufficient
activity to generate proposed savings is still live, mitigated by
Provider incentives and package of support.
Mitigations: Ongoing management by Medicines Management
Programme. Still planned to commit spend in year.
A
Children's and
Maternity
Expansion of children's
community nursing service UHB
50
0
50
0
-50
45
0
-45
Sep-15
Mar-17
Apr-16
Apr-16
Kirsty Alexander
Claire Thompson
G
Sub Total Transformational QIPP
NBT transactional Initiatives
11,305
1,832
9,474
6,472
-3,004
7,603
5,585
-2,018
2,200
0
2,200
1,980
-220
2,017
1,647
-370
G
R
Risk: Difficult to show impact on QIPP with contract data but
proxy data shows reduced outpatient appointments. Risk
remains of difficulties experienced in evidencing cashable
savings.
Mitigations: Project to be closed down and moved into business
as usual QIPP monitoring.
Nicola Dunn
Transactional QIPP
Risks: Arbitration ruling for NBT on rehab counting and coding
challenges enforced from June, meaning two months of benefit
lost.
G
A
Mitigations: Minimum of 10 months achievement expected, and
possibly more depending on activity levels in 16/17.
Transactional QIPP
Programme
Scheme Name
Running Cost Allocation
Efficiency Savings
Gross Saving CCG Investment
RecIY
Required RecIY
267
0
Forecast
Variance
From 16/17
Plan
16/17
Forecast
Saving
Net 16/17
Saving
267
267
YTD Plan
0
YTD Actual YTD Variance
0
0
Project Start
End Date
Date
Baseline
Revised
Financial Financial
Benefit
Benefit
Start Date Start Date
Senior
Responsible
Clinician
0
Senior
Responsible
Director
Project RAG
Status
Nicola Dunn
0
13,194
0
-13,194
0
0
0
Sub Total- Original QIPP
26,966
1,832
25,135
8,719
-16,416
9,620
7,232
-2,388
QIPP Transferred to
Financial Recovery Plan
-13,194
0
-13,194
0
13,194
13,772
1,832
11,941
8,719
-3,222
9,620
7,232
-2,388
127
0
127
0
-127
G
Mitigations: Monthly financial review by Deputy Finance Director.
R
Risks: Still awaiting North Somerset and South Glos CCG
approval of proposals. Funding approved by Bristol CCG to
support the interface services. Risk rating reflects likelihood of in
year delivery.
R
Mitigations: Confirm BNSSG support and secure funding to
support interface service in South Glos and North Somerset
CCG.
Risks: Policies and procedures have been communicated and
stakeholder management with localities was completed in
October 2016.. Risk rating reflects likelihood of in year delivery.
Nicola Dunn
Unidentified
13,194
Risks and Mitigations
Risks: None to report, full achievement expected by year end.
G
Unidentified including Rightcare
Financial RAG
Status
Total - Revised QIPP
Plan
Review the INF Policy
Aug-16
Mar-17
Nov-16
David Peel
Claire Thompson
G
Review INF Policy
450
0
450
0
-450
Aug-16
Mar-17
Nov-16
David Peel
Claire Thompson
G
Mitigations: None required at this stage.
Referral management centre
500
0
500
0
-500
Sep-16
Mar-17
Nov-16
David Peel
Claire Thompson
Risks: Proposal not fully scoped and requires Project Brief.
Risk rating reflects likelihood of in year delivery.
R
Review of contracts
500
0
500
0
-500
Oct-16
Mar-17
Mar-17
David Peel
Claire Thompson
A
Review INF Policy
57
0
57
0
-57
Oct-16
Mar-17
Nov-16
David Peel
500
0
500
0
-500
Aug-16
Mar-17
Nov-16
David Peel
Financial Recovery - QIPP Mitigations
700
0
700
0
-700
Sep-16
Mar-17
Nov-16
Lesley Ward
600
0
600
350
-250
Aug-16
Mar-17
Nov-16
Peter Goyder
Ensure CHC policy compliance
Ensure CHC policy compliance
650
0
48
0
0
0
650
0
48
650
0
48
0
0
0
Sep-16
Aug-16
Aug-16
Mar-17
Mar-17
Mar-17
Sep-16
Sep-16
Sep-16
Jon Hayhurst
Peter Goyder
Peter Goyder
R
Mitigations: Audit trail required to confirm whether or not going
ahead.
Risks: Adjustment made in Month 8 due to front door project
being put on hold due to a clinical incident in November. Risk
rating reflects likelihood of in year delivery.
Claire Thompson
R
Nicola Dunn
A
Prescribing Projects
R
Mitigations: Confirm support with NHS England.
Risks: Governing Body have rejected proposal for criteria at age
35. Plans being reviewed. Risk rating reflects likelihood of in year
delivery.
Mitigations: Review plans for age criteria.
Risks: Highly unlikely to go ahead, awaiting formal response
from NHS England regional team for support.
R
Joint Working with the Council
R
Claire Thompson
R
Management of the Front Door
Mitigations: None stated, initiative to be closed.
Risks: NHS England may not support scheme. Programme
Manager sending new letter in December. Risk rating reflects
likelihood of in year delivery.
Claire Thompson
G
Prescribing switches
R
R
Mitigations: Ongoing review of alternatives at Urgent Care
Working Group required including where benefits are likely to
accrue. Front door project status to be reviewed pending
outcome of clinical investigation.
Risks: Only part achievement forecast due to status of
negotiations with Council. Achievement attributed to lower than
expected activity on Eating Disorder pathways and better than
expected performance on DTOCs due to work of Discharge to
Assess pathway. Month 10 forecast reduced by £50k.
Mitigations: Ongoing review of plans.
Risks: Recovery plan includes contract management (£200k)
and additional schemes (£450k). Month 10 forecast adjustment
improved by £250k in line with Prescribing data for Month 9.
Jill Shepherd
A
G
G
G
G
G
Nicola Dunn
Mitigations: Ongoing management by Medicines Management
Programme Manager.
Risks: Plans are in place for cost control scheme.
Nicola Dunn
Mitigations: Work ongoing to improve bed capacity for CHC
assessment out of hospital.
Risks: Tasks complete, only operational guide to be completed.
Mitigations: Complete revisions to operational guide.
Programme
Scheme Name
Ensure CHC policy compliance
Gross Saving CCG Investment
RecIY
Required RecIY
154
Net 16/17
Saving
0
154
16/17
Forecast
Saving
Forecast
Variance
From 16/17
Plan
154
YTD Plan
YTD Actual YTD Variance
0
Project Start
End Date
Date
Aug-16
Mar-17
Baseline
Revised
Financial Financial
Benefit
Benefit
Start Date Start Date
Sep-16
Senior
Responsible
Clinician
Senior
Responsible
Director
Peter Goyder
Nicola Dunn
Project RAG
Status
4,286
0
4,286
1,202
-3,084
Key
Project RAG
Red
Project is behind
plan with no
agreed plan for
recovery.
Amber
Green
Project is behind plan Project is on
but with an agreed
plan
plan for recovery.
Finance RAG
Red
Project is
forecast to
deliver <75% of
identified
savings
Amber
Project is
forecast to
deliver >= 75%
and <95% of
identified
savings
Green
Project is
forecast to
deliver >=95% of
identified
savings
Risks and Mitigations
Risks: Final revisions to enhanced care policy to be completed.
G
Total - Financial
Recovery QIPP
Mitigations
Financial RAG
Status
G
Mitigations: Complete policy and operational guide revisions.
Annex 4
NHS BrIstol CCG BPPC Performance Report
Feb 17
Feb-17
Number
£' 000
NHS
NHS
NHS
Total bills paid in month
Total bills paid within target
% bills paid within target
668
667
99.85%
31,210
31,210
100.00%
Non NHS
Non NHS
Non NHS
Total bills paid in month
Total bills paid within target
% bills paid within target
1,018
991
97.35%
15,375
15,208
98.91%
YTD
NHS
NHS
NHS
Total bills paid in year
Total bills paid within target
% bills paid within target
Number
3,432
3,370
98.19%
£' 000
328,090
323,296
98.54%
Non NHS
Non NHS
Non NHS
Total bills paid in year
Total bills paid within target
% bills paid within target
10,802
10,381
96.10%
168,404
165,083
98.03%
Commentary
Prepared by S Freeman
Date 9/03/17
Annex 5
NHS Bristol CCG
Statement of Financial Position
10/03/2017
31/03/2016
Actual
£'000
28/02/2017
Actual
£'000
144
50
51
Trade & Other Receivables
Cash
8,952
55
7,065
1,692
5,302
400
Understated plan debtors figure. February figure down on January debtors figure of
1,763 £8m
1,292
Total Currents Assets
9,007
8,757
5,702
3,055
Total Assets
9,151
8,807
5,753
3,054
Trade & Other Payables
-38,312
-43,686
-35,978
Accrual variances Bristol City Council Better Care Fund Qtr 3 £6m, accruals for
-7,708 acute contracts over performance £6m
Total Current Liabilities
-38,312
-43,686
-35,978
-7,708
Total Assets less Current Liabilities
-29,161
-34,879
-30,225
-4,654
General Fund
-29,161
-34,879
-30,225
-4,654
Total Taxpayers' Equity
-29,161
-34,879
-30,225
-4,654
0
0
0
0
Non- current Assets
28/02/2017
28/02/2017 Commentary
Plan Variance to Plan
£'000
£'000
-1
Current Assets
Current Liabilities
Taxpayers' Equity
Balance
£'000
Maximum Cash Drawdown Analysis @ Mth 11
(Total amount of cash available to the CCG as approved by NHS England)
Maximum Cash Drawdown (MCD)
MCD as per NHS England Cash report
Adjustments
Adjusted Maximum Cash drawdown as per Cashflow report
577,710
-168
577,542
Cash Utilisation Analysis
YTD Cash drawdown plus risk pool contribution
YTD Prescribing plus Home Oxygen Therapy
470,583
54,166
Total Cash Utilised YTD
524,749
Available cash for this financial year
52,793
Planned use of Available Cash as per cashflow statement
Cash drawdown in March
Supplementary in March
Drugs and Home Oxygen for March
45,000
2,942
4,851
Total
52,793
Surplus cash can be returned up to 21/03/17
Based on 2016/17 Annual Cash Forecast submission January 2017 which is based
on mth 9 outturn position..
Agreed correction to capital allocation
Annex 5.1
NHS Bristol CCG Monthly Cashflow 2016/17
as at 10 March 2017
Opening Cash Balance
Cash Drawdown
Cash Drawdown - Supplementary
CHC Topslice
PPA & HOT Topslice
Income DOH
Income CHC recharges
Income Other - invoices
Total Cash Available
Capital Grants
NHS
Better Care Fund Pool -BCC
Funded Nursing Care - BCC
BCH
CCHC Sirona
Non NHS Bacs
Non NHS Cheques
Fast Payments
Standing Orders/Direct Debits
Pay
PAYE/NI
Pension
PPA & HOT Topslice
CHC Payments retro
CHC Topslice
Total Cash Outlay
Month End Cash Balance
Target Cash Balance - 1.25% of cash
drawdown
Act
April
Act
May
Act
June
Act
July
Act
August
Act
Sept
Act
Oct
Act
Nov
Act
Dec
Act
Jan
Act
Feb
Plan
March
£'000
99
44,000
£'000
5,492
42,000
£'000
7,168
40,000
£'000
4,948
47,000
£'000
860
39,000
£'000
306
43,000
£'000
484
39,000
£'000
47
48,000
£'000
7,228
42,000
£'000
1,264
40,000
£'000
303
46,000
£'000
1,933
45,000
2,942
583
4,694
189
14
2,296
51,875
5,066
131
2
2,202
54,893
5,240
992
5,129
89
22
5,327
50,427
4,721
1,535
32
1,609
51,203
4,824
89
77
3,430
47,904
4,688
89
14
3,862
56,700
4,881
694
40
2,724
57,567
5,059
89
2
2,795
49,209
5,113
89
9
2,734
54,248
4,851
787
760
54,160
4,751
89
3
2,003
58,794
24,927
27,303
35,097
32,705
30,860
30,874
28,451
30,349
29,203
7,383
28,673
876
31,424
32,000
4,921
3,147
2,583
9,672
207
1
311
141
115
4,694
2
583
46,383
6,294
2,583
5,700
189
2
3
315
157
113
5,066
0
2,583
5,572
111
12
1
320
160
113
5,240
3
5,000
3,665
2,583
8,482
133
1
2
319
159
112
4,751
22
3,277
2,583
6,985
163
422
4
408
154
104
5,129
32
4,277
2,583
7,281
117
39
3
416
192
139
4,721
77
3,277
2,583
7,922
17
1
1
417
206
144
4,824
14
3,277
2,583
7,618
159
1
3
419
197
138
4,688
40
3,277
2,583
8,067
139
6
3
424
195
140
4,881
2
3,277
2,583
7,614
44
1
1
418
208
143
5,059
9
3,277
2,583
9,021
26
92
3
432
200
144
5,113
3,277
2,583
9,075
50
0
3
420
196
145
4,851
47,725
49,212
57,934
50,121
50,719
47,857
49,472
56,303
48,906
52,315
57,521
0
361,866
13,180
5,000
40,322
30,996
93,009
1,355
577
28
4,619
2,165
1,550
59,017
201
583
614,468
5,492
7,168
4,948
860
306
484
47
7,228
1,264
303
1,933
50
50
550
525
500
588
488
538
488
600
525
500
575
563
Completed by S Freeman
2,058
57,571
10/03/2017
Total
£'000
99
515,000
2,942
583
59,017
4,862
215
31,800
614,518
Bristol CCG agreed allocations for month 11 (February)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
Q80 - South West
Q80 - South West - Local Office
Type
Rec/
NonRec
Non-Recurrent
Recurrent
Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Recurrent
Recurrent
Programme
Programme
Running Costs
Programme
Programme
Programme
Programme
Programme
Programme
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
X24 - NHS England (Central)
Q80 - South West
X24 - NHS England
X24 - NHS England
Q80 - South West
X24 - NHS England
X24 - NHS England
Q70 - Wessex
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Non-Recurrent
Programme
Programme
Programme
Programme
Programme
Programme
Programme
Programme
Programme
Programme
Programme
Programme
Running Costs
Programme
Contra Organisation
Funding
Stream
Annex 6
Revenue
Resource
£000
5,737
560,129
10,275
184
(184)
244
35
1,004
(437)
Revenue
Cash
£000
5,737
560,129
10,275
184
(184)
244
35
1,004
(437)
43
20
35
102
20
420
79
554
45
102
50
648
19
68
579,191
43
20
35
102
20
420
79
554
45
102
50
648
19
68
Description (80 Characters)
Return of Surplus/(Deficit)
Initial CCG Programme Allocation
Initial CCG Running Cost Allocation
Eating Disorder Service Q1
Q1 Eating Disorder Service Correction
Q1 Eating Disorder Service Correction
Q1 TB Corrections
PMS Premium
Care UK ISTC Dental transfer
11H - GP Development Programme - reception and clerical training - contact
[email protected] for further details
Primary Care Homes Q1 & Q2 - South Bristol Primary Care Collaborative
Latent TB Q2 - NHS Bristol CCG
CYP Local Transformation Mental Health M7 - NHS Bristol CCG
Q3&4 Primary Care Homes funding - Sth Bristol Primary Care Collaborative
Mth08 CEOV adjustment
CSDF - Batch one funding
collaborative fees reference Matt Barz
Perinatal / IAPT underspend allocation M10
CYP WL & WT Reduction: 2nd tranche
therapeutic support services for Adult Sexual Assault services
non-recurrent allocation to mitigate impact of NHS PS move to market rents
non-recurrent allocation to mitigate impact of NHS PS move to market rents
RTT funding
Month of
transaction
Mth01
Mth01
Mth01
Mth03
Mth03
Mth03
Mth03
Mth03
Mth05
Mth05
Mth05
Mth06
Mth07
Mth07
Mth08
Mth08
Mth10
Mth10
Mth10
Mth10
Mth10
Mth10
Mth11
Bristol, North Somerset and
South Gloucestershire CCGs
Governing Body
Quality Report
March 2017
January 2017 Data
1
Contents
Introduction: BNSSG Quality Report
Slide 3
Provider comparison: overview and comparison of quality indicators
Slides 4-13
BNSSG Providers overview of CQC Status
Slides 14-19
Provider updates: Notable Practice, Hot Off The Press Key Risks (since January 2017) and Key
Messages for January 2017
Slides 20-37
CCG Information
Slides 38-44
BNSSG-wide reporting: National Safety Thermometer
Slides 45-48
Exception reports:
– Acute services
• University Hospitals Bristol NHS Foundation Trust (UH Bristol)
• Weston Area Health Trust (WAHT)
• North Bristol NHS Trust (NBT)
– Mental Health
• Avon and Wiltshire Mental Health Partnership (AWP)
– Community services
• Bristol Community Health (BCH)
• Sirona
– Urgent Care
• South Western Ambulance Service Foundation Trust (SWAST)
• Care UK NHS 111
• BrisDoc
Slides 49-80
Patient Advice and Liaison Service (PALS)
Slides 81-83
Serious Incidents
Slides 84-94
Areas for future development
Slides 95-96
Glossary
Slide 97
Additional Assurance circulated to Committee: Evidence Briefing / Quality Dashboards
Attached
2
Quality Exception Report
Introduction and Context
The purpose of this exception report is to update the Bristol, North
Somerset and South Gloucestershire Clinical Commissioning Groups
Quality and Governance Committee Group with details of any key
quality issues that have arisen over the last month. Reporting will
become increasingly aligned with the Quality Schedules which requires
providers to report against national and local quality indicators on a
periodic basis.
Content
3
BNSSG Acute Provider
Overview and Comparison of
Quality Indicators
Content
4
Utilising the Covalent System
•
The following slides are produced using the system already used by the performance team.
It is called Covalent and it is an integrated system that allows users to collate, monitor and
report on Performance Indicators and other key organisational metrics, with built in
improvement plan tracking to improve overall performance.
•
There are currently a limited number of consistent quality measures across the contracts
and specifically in this report we have looked at acute services. For the 2017-19 contract
the Quality Schedules have been aligned which will allow greater benchmarking, not only
for acute services, but across the wider BNSSG health system.
•
There is also an in-build report designer that allows the creation of templates for
reports. Once set up, multiple reports can be easily generated using simple queries e.g. a
full dashboard or an exception dashboard. Individual reports can be combined together into
a dossier report, for example for urgent care, and a variety of different views can be
generated and included in the reports. This can be done as a more routine report or as a
bespoke report.
Content
5
BNSSG Acute Provider
Comparison Quality Indicators
SHMI
Org
Indicator
NBT
NBT
UHB
UHB
WAHT
WAHT
Summary Hospital-level Mortality Indicator (SHMI)
SHMI Banding
Summary Hospital-level Mortality Indicator (SHMI)
SHMI Banding
Summary Hospital-level Mortality Indicator (SHMI)
SHMI Banding
Key to SHMI Bandings
Band 1 = SHMI is higher than expected
Band 2 = SHMI is as expected
1.20
Band 3 = SHMI is lower than expected
Nat.
Sep-15 Dec-15 Mar-16 Jun-16 DoT
Control Value
Value Value Value
Limit
1
0.902
0.902
0.905 0.9244
3
2
2
2
1
0.978
0.977
0.988 1.0118
2
2
2
2
1
1.122
1.167
1.164 1.1529
1
1
1
1
SHMI
1.15
On 15 December 2016 NHS Digital
published the quarterly statistics for
Deaths Following Time in Hospital,
England (July 2015 – June 2016).
WAHT was reported as being one
of 11 higher than expected Trusts.
UH Bristol, though rated lower than
expected, the SHMI had slightly
increased to above the national
control limit.
1.10
1.05
1.00
0.95
0.90
0.85
NBT
UHB
WAHT
Nat.Control Limit
Content
6
Fractured Neck of Femur
Apr-16 M ay-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 M ar-17
Target Value Value Value Value Value Value Value Value Value Value Value Value DoT
Org
Indicator
NBT
Percentage of patients with fractured neck of femur operated on within 36 hours
90%
UHB
Percentage of patients with fractured neck of femur operated on within 36 hours
90%
WAHT Percentage of patients with fractured neck of femur operated on within 36 hours
90%
80%
89%
87.50% 74.10%
57%
70%
86%
86%
74%
71%
86%
85%
81%
72% 73.50% 61.30% 58.30% 73.70% 69.20% 51.70%
88% 76.20% 85%
90%
74%
85%
86%
70%
79%
Fractured Neck of Femur
95%
Achieving the 90% compliance target
for patients with fractured neck of femur
being operated on within 36 hours
remains a challenge for all the Trusts
especially UH Bristol. WAHT’s data is
unavailable for January 2017.
90%
85%
80%
75%
70%
65%
60%
55%
50%
NBT
UHB
WAHT
Target
Content
7
Friends & Family Test
A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17
T arget
Value
Value
Value
Value
Value
Value
Value
Value
Value
Value
Friends & Family Test - Provider Response Rate (inpatient)
30%
21.30%
30%
26%
26%
28.30%
26%
23%
22.40%
20.30%
21.50%
Friends & Family Test - Provider Response Rate (inpatient)
30%
35.20%
42.40%
30.70% 33.70%
35.90%
30.60%
31.70%
WAHT Friends & Family Test - Provider Response Rate (inpatient)
25%
40.40%
41.90%
42%
44.10% 33.40%
35.70%
31.50%
34.60%
31%
34.10%
NBT
Friends & Family Test - Provider Response Rate (ED)
15%
29.40%
17.50%
12.50%
16.10%
17.90%
15.50%
16.10%
15.10%
12%
13.20%
UHB
Friends & Family Test - Provider Response Rate (ED)
15%
14.80%
13.50%
15.50%
12%
16.80%
15.50%
17.30%
18.90%
15.40%
21.20%
WAHT Friends & Family Test - Provider Response Rate (ED)
15%
4.90%
5.20%
4.50%
3.50%
5.20%
4.40%
2.90%
3.80%
1.60%
5.90%
Org
Indicato r
NBT
UHB
40.50% 36.50% 36.80%
Value
Value
DoT
The target threshold for Inpatient FFT response rates differs between acute providers (30% for NBT and UH Bristol
and 25% for WAHT). This has been aligned to 30% in the BNSSG Quality Schedules for 2017/19.
Content
8
Complaints
A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17
T arget
Value
Value
Value Value Value
Value
Value
Value
Percentage of complaints responded to within agreed response time
90%
N/A
66%
66.70% 85.40% 91.60%
87.80% 88.40% 82.80% 79.80%
68%
Percentage of complaints responded to within agreed response time
90%
81.60%
WAHT Percentage of complaints responded to within agreed response time
95%
71%
Org
Indicato r
NBT
UHB
73.10% 73.80% 86.60% 90.60%
55%
87%
86%
55%
86%
40%
Value
Value
Value
Value D o T
92.30% 93.40% 97.40% 87.50%
67%
71%
63%
Complaints Response Rate
100%
90%
The target threshold for responding to
complaints within the agreed response time
currently varies (90% for NBT and UH Bristol
and 95% for WAHT). This has been aligned to
90% in the BNSSG Quality Schedules for
2017/19. WAHT’s data is unavailable for
January 2017.
80%
70%
60%
50%
40%
30%
NBT
UHB
WAHT
Target
Content
9
HCAI
A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17
T arget
Value
Value
Value
Value
Value
Value
Value
Value
Value
Value
Number of M eticillin Resistant Staphylococcus aureus (M RSA) bacteraemia (post 48 hours)
0
0
0
0
0
0
3
1
1
0
1
UHB
Number of M eticillin Resistant Staphylococcus aureus (M RSA) bacteraemia (post 48 hours)
0
0
0
0
0
0
0
0
1
0
0
WAHT
Number of M eticillin Resistant Staphylococcus aureus (M RSA) bacteraemia (post 48 hours)
0
0
0
0
0
0
0
0
0
0
NBT
Incidence of Clostridium difficile (Post 72 hours)
43
0
1
5
2
7
4
1
3
2
3
UHB
Incidence of Clostridium difficile (Post 72 hours)
45
2
5
1
3
2
5
1
3
5
4
WAHT
Incidence of Clostridium difficile (Post 72 hours)
18
3
2
0
0
0
0
0
1
0
Org
Indicato r
NBT
Value
Value
DoT
NBT have failed to achieve the zero tolerance MRSA Bacteraemia standard, reporting a total of 6 cases of MRSA cases in
the last year (since April 2016). The target threshold and the Rag rating criteria for Clostridium difficile is different for each
acute provider. WAHT’s data is unavailable for January 2017.
HCAI - MRSA
HCAI - CDIFF
4
8
7
3
6
5
2
4
3
1
2
1
0
0
NBT
UHB
WAHT
Target
NBT
UHB
WAHT
Content
10
VTE Assessment
A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17
T arget
Value
Value
Value
Value
Value
Percentage of adult inpatients who have had a VTE assessment on admission to hospital
95%
91.50%
91.50% 93.80% 95.30% 95.30% 95.70% 95.60% 95.30%
96%
95%
Percentage of adult inpatients who have had a VTE assessment on admission to hospital
95%
99.30%
99.10%
99%
99.10%
WAHT Percentage of adult inpatients who have had a VTE assessment on admission to hospital
95%
92.09% 85.50% 86.68% 75.24% 78.95% 68.88% 44.47% 53.90% 70.22%
Org
Indicato r
NBT
UHB
Value Value Value
99%
99.10% 99.10%
Value
99%
Value
99%
99.40%
Value
Value D o T
VTE Assessment Rate
100%
90%
80%
The criteria for Rag rating is currently not
aligned - NBT is rated amber at 94.80% whilst
WAHT doesn’t appear to have an amber rating.
WAHT’s data is unavailable for January 2017.
70%
60%
50%
40%
NBT
UHB
WAHT
Target
Content
11
Slips, Trips and Falls
A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17
T arget
Value
Value
Value Value Value
Value
Value
Value
Value
Value
Rate of slips, trips and falls per 1,000 bed days
5.60%
7.17%
7.09%
6.29%
6.15%
6.68%
6.73%
7.30%
7.50%
5.70%
7.30%
Rate of slips, trips and falls per 1,000 bed days
4.80%
4.24%
3.93%
4.57%
4.57%
3.81%
4.38%
4.76%
4.04%
3.74%
3.74%
WAHT Rate of slips, trips and falls per 1,000 bed days
5.60%
5.40%
4.30%
5.20%
5.90%
4.20%
5.50%
4.60%
4.20%
6.50%
Org
Indicato r
NBT
UHB
The target thresholds for the rate of slips trips
and falls per 1000 bed days are set internally
by the providers and are different for each
organisation. The criteria for Rag rating is
currently not aligned - NBT is rated amber
some months whilst WAHT doesn’t appear to
have an amber rating. WAHT’s data is
unavailable for January 2017.
Value
Value D o T
Slips, Trips & Falls per 1,000 Bed Days
8.0%
7.5%
7.0%
6.5%
6.0%
5.5%
5.0%
4.5%
4.0%
3.5%
3.0%
NBT
UHB
WAHT
Target
Content
12
Safeguarding Training - Children
A pr-16 M ay-16 Jun-16 Jul-16 A ug-16 Sep-16 Oct-16 N o v-16 D ec-16 Jan-17 F eb-17 M ar-17
T arget
Value
Value
Value
Percentage of staff completing safeguarding Level 1children (rolling 12 months)
90%
N/A
N/A
82%
Percentage of staff completing safeguarding Level 1children (rolling 12 months)
90%
N/A
90%
90%
WAHT Percentage of staff completing safeguarding Level 1children (rolling 12 months)
90%
93.30%
NBT
Percentage of staff completing safeguarding Level 2 children (rolling 12 months)
90%
N/A
N/A
83%
UHB
Percentage of staff completing safeguarding Level 2 children (rolling 12 months)
90%
N/A
88%
87%
WAHT Percentage of staff completing safeguarding Level 2 children (rolling 12 months)
90%
83.40%
NBT
Percentage of staff completing safeguarding Level 3 children (rolling 12 months)
90%
N/A
N/A
79%
UHB
Percentage of staff completing safeguarding Level 3 children (rolling 12 months)
90%
N/A
75%
76%
WAHT Percentage of staff completing safeguarding Level 3 children (rolling 12 months)
90%
80.80%
73%
Org
Indicato r
NBT
UHB
Value
Value
Value
Value
Value
Value
Value
91%
91%
92%
92%
91%
91%
91%
94%
94.70%
94.70%
89%
90%
90%
84%
83.40%
81.80%
75%
76%
77%
83.20%
79.70%
79.10%
93.90% 94.80% 94.50% 93.80%
87%
84%
84.90% 86.40% 85.60% 84.80%
76%
75%
67.20% 74.20% 86.20%
94.30% 94.60%
87%
88%
84.90% 85.30%
75%
72%
85.50% 85.30%
Value
Value
Safeguarding - Childrens Level 2
The frequency of reporting compliance with
Safeguarding children currently varies from quarterly to
monthly reporting. Adult Safeguarding training is
currently not reported on as this is measured differently
for each Trust. Reporting has been aligned to monthly
as per the Safeguarding standards contained within the
BNSSG Quality Schedules for 2017/19.
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
NBT
UHB
WAHT
Target
Content
13
DoT
BNSSG Providers Care Quality
Commission (CQC) Status
Content
14
BNSSG Provider CQC Ratings
The following tables provide an overview of CQC inspection ratings pertaining to providers within the BNSSG CCG locality.
Outstanding
Provider
Good
Requires Improvement
CQC Rating
Date of
Inspection
Date of
Report
Link to Report
Additional Information
Is the service safe? – Good
Is the service effective? – Outstanding
Is the service caring? – Good
Is the service responsive? – Requires Improvement
Is the service well-led? – Outstanding
22-24/11/16
and
1/12/16
2/3/17
http://www.cqc.org.uk/sit
es/default/files/new_repo
rts/AAAG3535.pdf
CQC noted the Trust had
taken clear action to make
improvements since the
last inspection, not only in
areas identified for
improvement, but those
identified as strengths.
There was a strong safety
culture. Patients reported
that care was delivered to
a consistently high level
and that staff were caring
and compassionate.
Is the service safe? – Inadequate
Is the service effective? – Requires Improvement
Is the service caring? – Good
Is the service responsive? – Requires Improvement
Is the service well-led? – Requires Improvement
5/6/15
26/8/15
http://www.cqc.org.uk/sit
es/default/files/new_repo
rts/AAAD5267.pdf
Re-inspection due week
of the 28 February 2017.
Trust will perform a preinspection check on 3
February 2017 and the
CCG are invited to be part
of the team.
Is the service safe? – Requires Improvement
Is the service effective? – Requires Improvement
Is the service caring? – Good
Is the service responsive? – Requires Improvement
Is the service well-led? – Good
16/12/15
6/4/16
http://www.cqc.org.uk/sit
es/default/files/new_repo
rts/AAAE8140.pdf
The Trust can
demonstrate the
outstanding ‘Must-Do’
action from the 2015 CQC
Inspection relating to
system flow has been
completed.
UH Bristol
WAHT
NBT
Inadequate
Content
15
Good
Provider
BCH
NSCP
Sirona
BrisDoc
Care UK
NHS 111
South West
Requires Improvement
Inadequate
CQC Rating
Date of
Inspection
Date of
Report
Link to Report
Additional
Information
Is the service safe? – Good
Is the service effective? – Good
Is the service caring? – Good
Is the service responsive? – Good
Is the service well-led? – Outstanding
16-18/11/16,
27-28/11/16,
30/11/16 and
1/12/16
16/2/17
http://www.cqc.org.uk/sites/de
fault/files/new_reports/AAAG0
260.pdf
Several areas of
outstanding practice
were highlighted.
There were also
identified areas for
improvement.
No need for the service to take further
action.
Note: The last CQC inspection undertaken
was under their previous inspection regime
whereby each type of service was not rated
13/11/13
25/2/14
http://www.cqc.org.uk/sites/de
fault/files/old_reports/1310911016_Castlewood_INS
1-688423521_Scheduled_2502-2014.pdf
Inspection undertaken
in November 2016;
preliminary findings
were very positive
specifically in staff
engagement and
voluntary sectors.
Not previously inspected for South
Gloucestershire services.
Sirona is registered with the CQC.
Inspection undertaken
in October 2016;
awaiting report.
CQC found that BrisDoc provided a service which
was safe, effective, caring, responsive to people’s
needs and the service was well-led.
11-12/2/14
and 14/2/14
7/5/14
https://www.cqc.org.uk/sites/d
efault/files/new_reports/AAAA
0496.pdf
Inspection recently
undertaken. Initial
feedback has been
positive; report is
awaited.
Is the service safe? – Good
Is the service effective? – Good
Is the service caring? – Good
Is the service responsive? – Good
Is the service well-led? – Good
27-28/9/16
6/12/16
http://www.cqc.org.uk/sites/de
fault/files/new_reports/AAAG0
065.pdf
Some “Outstanding”
features noted.
Content
16
Good
Provider
Requires Improvement
CQC Rating
Date of
Inspection
Date of
Report
Link to Report
Additional Information
Is the service safe? – Requires Improvement
Is the service effective? – Requires Improvement
Is the service caring? – Outstanding
Is the service responsive? – Good
Is the service well-led? – Requires Improvement
7- 10 June,
17, 20 and
22 June
6/10/16
http://www.cqc.org.uk/
sites/default/files/new
_reports/AAAF7807.p
df
Following the CQC visit
SWAST invited commissioners
and SCWCSU to a presentation
to feedback the findings of the
inspection. Engagement was
sought from commissioners and
SCWCSU in a workshop session
to consider ways for improving
the weaker areas identified.
SWAST has since produced an
action plan which will be
reviewed/monitored via the
IQPMB.
Is the service safe? – Requires Improvement
Is the service effective? – Good
Is the service caring? – Good
Is the service responsive? – Good
Is the service well-led? – Requires Improvement
16/5/16
8/9/16
http://www.cqc.org.uk/
sites/default/files/new
_reports/AAAF7896.p
df
A Quality Summit took place on 2
November 2016 following the
announced Trust-wide CQC
inspection. The Warning Notice
relating to illegal detentions in the
Place of Safety Units, issued in
December 2014, remains in
place. Overall the CQC reported
improvements from the 2014
inspection. The CQC highlighted
21 Must Dos and 33 Should Do
actions and AWP will devise
locality based quality
improvement plans to address
these with one overarching
quality improvement plan for
Trust wide actions. The CQC has
informed AWP they will re-inspect
the Trust on 26 June 2017,
particularly the 136 suites.
SWAST
AWP
Inadequate
17
Content
Good
Provider
Nuffield Health
Care UK
Emersons
Green NHS
Treatment
Centre
New Medical
Systems Ltd
Spire Bristol
Hospital
Requires Improvement
Inadequate
CQC Rating
Date of
Inspection
Date of
Report
Link to Report
Additional
Information
Is the service safe? – Good
Is the service effective? – Good
Is the service caring? – Good
Is the service responsive? – Good
Is the service well-led? – Good
14/8/16
4/8/16
http://www.cqc.org.uk/location/1918228984/reports
Purpose of this
inspection was to
follow up on the
last inspection in
February 2015
where CQC
found concerns
with the services
for children and
young people.
Is the service safe? – Good
Is the service effective? – Good
Is the service caring? – Good
Is the service responsive? – Good
Is the service well-led? – Good
30 & 31
March and
11 April
2016
22 July
2016
https://www.cqc.org.uk/location/
1-2251815469/reports
4/3/14
29/3/16
http://www.cqc.org.uk/location/1129783097/reports
Service not yet inspected.
Provider is registered with the CQC.
There's no need for the service to take further
action.
Note: The last CQC inspection undertaken was
under their previous inspection regime whereby
each type of service was not rated
Recent CQC
inspection
undertaken on
13-16
September 2016;
expecting receipt
of report.
Content
18
Good
Provider
Circle Hospital
(Bath) Ltd
Somerset
Surgical
Services
Requires Improvement
Inadequate
CQC Rating
Date of
Inspection
Date of
Report
Link to Report
Additional
Information
No need for the service to take further action.
Note: The last CQC inspection undertaken was
under their previous inspection regime whereby
each type of service was not rated
7/2/14
19/2/14
http://www.cqc.org.uk/sites/defa
ult/files/old_reports/1119269999_Circle_Hospital_Bat
h_Limited_ta_Circle_Bath_INS11227735907_Responsive__Follow_Up_19-02-2014.pdf
No need for the service to take further action.
Note: The last CQC inspection undertaken was
under their previous inspection regime whereby
each type of service was not rated
14/2/14
19/3/14
http://www.cqc.org.uk/sites/defa
ult/files/old_reports/1447803434_Weston_Area_Healt
h_Trust_Weston_General_INS1
-469122305_Scheduled_19-032014.pdf
Content
19
Provider Updates:
Notable Practice,
Hot Off The Press Key Risks
(Since January 2017)
and
Key Messages January 2017
Content
20
UH Bristol
Notable Practice
•
Fundamentals of Care - the Trust was commended on the continued good performance relating to the
fundamentals of care – low numbers of falls and pressure ulcers and good response rates and performance
within all Friends and Family (FFT) areas, particularly in the Emergency Department (ED).
•
Emergency Laparotomy Collaborative (ELC) - the work of the ELC has the potential to improves outcomes for
patients with compliance with the ELC care bundle. Initial results from work undertaken by the ELC has identified
a reduction in length of stay and time to theatre. An update on this work will be brought to a future Quality Sub
Group meeting.
•
Workforce - the Trust has made improvement against workforce Key Performance Indicators (KPIs) with the
exception of sickness absence. Benchmarking against other Acute Trusts identified that UH Bristol compares
favourably for vacancies, turnover, appraisal compliance and staff FFT.
Hot off the Press Key Risks (Since January 2017)
•
Care Quality Commission (CQC) – the CQC has published its report following the inspection of UH Bristol. The
Trust received an overall rating of ‘Outstanding’. UH Bristol is one of only six Acute trusts in the country to be
rated as ‘outstanding’ and the only one in the South West. Please see the separate CQC paper and
accompanying report for further details.
•
Paediatric Cardiac Report - an update on the report noted that no actions are red rated and the action plan is
due to complete at the end of June 2017. UH Bristol advised that the update would be going to the next joint
Bristol and South Gloucestershire Health Overview and Scrutiny Committee for discussion.
•
Verita Report - a verbal update on the post Verita report was received. UH Bristol reported that the family have
received an unreserved apology from the Trust. Professor Michael Stevens had worked through the 80 plus
questions submitted by the family and produced a set of responses that has been shared with the family. An offer
was made to the family to meet with Michael Stevens with mediation support and this has at the current time
been declined by the family.
Key Messages December 2016
•
Fractured Neck of Femur (#NOF) - performance remains below the 90% threshold. An update on the action
plan arising from the British Orthopaedic Association Review has been received and the Trust has been asked to
share the actions with the group assigned to look at #NOF across BNSSG.
Content
21
WAHT (1)
Notable Practice
•
MRSA Bacteraemia - there have been no cases of hospital acquired MRSA Bacteraemia reported since October
2014.
•
Quality Sub Group and Integrated Quality and Performance Meeting (ICQPMB) meetings – these have been
changed to take place on the 3rd Thursday of the month from the previous 1st Thursday of the month; this will take
effect as from 1 April 2017.
Hot Off the Press Key Risks (since January 2017)
•
Norovirus - there have been three outbreaks of Norovirus in February 2017: Cheddar Ward was closed for 7 days,
Hutton Ward was closed for 14 days and Steepholm was closed for 7 days.
Key Messages January 2017
•
January’s validated data unavailable - there was no validated Trust data available for January from WAHT at the
time of writing this report; national data has been used where appropriate.
•
Care Quality Commission (CQC) return visit – the CQC’s re-inspection commenced on 28 February 2017.
•
Dr Foster Summary Hospital–level Mortality Indicator (SHMI) - the SHMI has shown a slow improvement for the
first quarter of 2016/17. The Trust have in place seven quality improvement projects which aim to produce
measurable reductions in mortality; these are monitored via the Mortality Review Group. Monthly mortality updates
are provided for the Quality Sub Group. The GP Clinical Lead for North Somerset CCG leads on SHMI. The Mortality
Reduction Action Plan and Ensuring Effective Learning From Mortality Reviews Action Plan are both monitored at the
Quality Sub Group.
There are two external reports outstanding that consider the #NOF pathways and the Management of Colorectal
patients which the Trust will share with the CCG on receipt.
•
VTE Risk Assessment - a new VTE clerk has been appointed in the Trust which will ensure continuity and resilience
for reporting and data collection. The leadership and governance of the process will move to the Critical Care and
Resuscitation Committee in order to integrate the VTE assessment with other clinically led documentation. Following
the Contract Performance Notice (CPN) issued in December 2016 there is an action plan in place which is monitored
at the Quality Sub Group and the Trust have provided a trajectory to achieve the 95% compliance rate by April 2017.
22
Content
WAHT (2)
Key Messages January 2017 (continued)
•
4 hour ED performance - this has continued to worsen each month since May 2016 with performance in
December 2016 at 66.85%. The 95% national standard is not expected to be achieved during 2016/17. The
agreed monthly Sustainability and Transformation Plan (STP) trajectory continues to fail since July. The STP is
based on the cumulative position, which at the end of December worsened to 77.01%, which is below trajectory.
Draft performance of 63.69% for January continues to show a worsening position. Daily Green to Go meetings
continue and daily system calls. The Discharge to Assess Pathway 2 is in place and being further developed.
QUAD (provider partners) meetings have been reconstituted to supplement the Urgent Care Network. Additional
bed capacity is in place at Clevedon Court. Minor Injury Unit (MIU) diverts to Clevedon MIU are in place. The
Integrated Discharge Team is being re-developed to take forward further system actions. A weekly trajectory has
been agreed which was achieved for the first two weeks in February but has since failed.
•
Out Patient Pending List - at the time of writing this report an update on the pending list has not yet been
received (this was due two weeks ago and has been chased). This remains a standing agenda item for the Quality
Sub Group and will be raised again at the March 2017 meeting.
•
62 day Cancer Standard - a Remedial Action Plan (RAP) with trajectories has been provided by the Trust
following the exception letter issued by the CCG in December 2016. This is monitored via the Quality Sub Group,
the ICQPMB and the BNSSG Cancer Group.
•
Patient Discharge letters - the E-discharge Action Plan was accepted by the CCG subject to further
development; monitoring of progress and updates from the E-discharge meeting will be undertaken at the Quality
Sub Group. The CCG have requested the review of non-electronic discharges. The Discharge Meeting was
cancelled in January due to the Trusts internal pressures.
•
Serious Incidents (SI’s) - following the CPN issued in December 2016 with regard to the number of outstanding
open SI`s, the Trust have a Serious Incident Management Plan in place which will be monitored by the CCG at the
fortnightly SI panels and the Quality Sub Group.
•
General Dementia Training - the Trust`s Dementia Improvement Action Plan was accepted following the CPN
issued in December 2016. The plan will be monitored via the Quality Sub Group.
Content
23
WAHT (3)
Key Messages January 2017 (continued)
•
Pressure ulcers - there was a total of 93 pressure ulcers grade 2–4 reported in December 2016; of these 29
were hospital acquired pressure ulcers (HAPU) and 64 were inherited. The Trust have an overarching Prevention
and Reduction of HAPU Action Plan which also incorporates the actions from the SI Pressure Ulcer RCA action
plans. This is monitored at the SI panel and the Quality Sub Group.
•
Complaints response rates - following a 40% response rate in September 2016 the rate had steadily increased
to 70% until December when it fell to 63% against a 90% target. Weekly meetings remain in place with the
Complaints Manager and the Associate Directors of Nursing at the Trust. Monitoring will continue via the Quality
Sub Group.
Content
24
WAHT – Safeguarding
Notable Practice
•
Safeguarding Supervision Policy - the new Interim Named Nurse Safeguarding Children has revised the
supervision policy to include a wider range of staff receiving safeguarding supervision at more frequent intervals.
•
Safeguarding referrals - WAHT raised 9% of all safeguarding cases within North Somerset; of these 42% were
considered for further section 42 enquiries, this was the highest value in relation to other agencies. This was
viewed very favourably by the Safeguarding Adults Partnership Board, acknowledging that the standard of
referrals were good and identified real safeguarding concerns.
•
New Complex Needs Sister commenced in post - the role includes Learning Disability work, Domestic Violence
champion and a focus on complex needs for inpatients.
Key Messages January 2017
•
Safeguarding Children Training at Level 3 - this remains a concern and is currently reported at 79.1 % against a
compliance level of 90%. The Safeguarding Board are commencing a new multiagency level 3 training on site at
WAHT in April 2017 and there are protected places on existing courses for WAHT staff until training figures have
improved. The CCG has asked for a breakdown of specific directorates training compliance.
•
Training mix - it has been identified that the training matrix may have inaccuracies for senior medical staff,
therefore there is potential for compliance to fall further when it is identified which additional staff members should
be included at level 3. This is being reviewed by the Trust and will be monitored via the Quality Sub Group.
•
Capacity issues - the Interim Named Nurse for Safeguarding Children is 0.6 Whole Time Equivalent (WTE),
leaving capacity issues in the Trust on Thursdays and Fridays.
Content
25
NBT
Notable Practice
•
Falls - NBT has significantly reduced the number of falls resulting in serious harm over the last four months with a total of
5 reported during October 2016 to January 2017. This compares with 14 in the previous four months, June to September
2016.
Hot Off the Press Key Risks (since January 2017)
•
MRSA - a further case of an MRSA blood stream infection was reported by NBT in January 2017, bringing the total
number of cases to 6 since September 2016.
Key Messages January 2017
•
MRSA - A CPN was issued to the Trust in November 2016. NBT are implementing an MRSA RAP devised from key
learning from the first five cases.
•
Never Events - NBT have reported five Never Events for the year to date 2016/17. A CPN was issued to the Trust in
November 2016. The CCG have requested the final RAP and completed audits to be submitted to the Quality Sub Group
along with feedback from the ‘Stop Before You Block’ audit and the Trust’s visit to Plymouth.
•
Overdue complaints - the number of overdue complaints has increased to 42 in January 2017. Of the cases closed in
January 2017, 68% of them were completed within the agreed timescale (against a target of 90%). The CCG have
requested an improvement action plan be presented for approval at the Quality Sub Group.
•
Backlog of Endoscopy surveillance cases - NBT are currently failing the six week diagnostic target and have a
significant Endoscopy surveillance recall backlog. The Trust has developed a RAP and the CCG has requested assurance
that each case has been clinically validated.
•
Backlog of discharge letters - there have been delays in the receipt of discharge letters following outpatient
consultations at NBT. The CCG have requested the improvement action plan be presented at the Quality Sub Group.
•
CQC – the Trust will demonstrate the outstanding ‘Must-Do’ action from the 2015 CQC Inspection (relating to system flow)
has been completed. NBT will provide the CQC and CCG with a written report focusing on the actions delivered that relate
to quality and safety within the hospital as well as reporting on how the Trust is managing high demand more effectively.
•
FFT - response rates for Inpatients and ED remain below target, mainly attributed to incorrect patient phone details
(required for text and SMS) held by NBT. Work is currently ongoing to address this and the Trust is also looking at
replicating good practice from the Directorates which are performing well with FFT.
Content
26
Safeguarding NBT
Notable Practice
•
Head of Safeguarding commenced – this post is full time and AFC Band 8b.
Hot Off the Press Key Risks (since January 2017)
None identified.
Key Messages February 2017
•
•
•
Emergency Department child protection referrals – a scoping exercise pertaining to risks associated with child
protection referrals to children's social care has been undertaken; key risk is referrals made to Bristol First
Response between 1 November 2016 to 1 February 2017. South Gloucestershire’s Access and Response Team
(ART) have not identified an issue and has been receiving some referrals by fax . An audit is to be undertaken of
all children identified that met the threshold for referral during November to February to ascertain what information
was shared. First Response and ART have agreed to accept a revised referral form as used by UH Bristol which
will make referrals via email easier.
Female Genital Mutilation (FGM) data - NBT are now submitting FGM mandatory recording information to the
Department of Health.
Deprivation of Liberty Safeguards (DoLS) – a review of DoLS in the Intensive Therapy Unit (ITU) has been
undertaken and a pathway is in the process of being approved.
Content
27
BCH
Notable Practice
•
Safety Thermometer - harm free care remains consistently above the national benchmark (94.11%) and above the
benchmark for community providers (94.14%).
•
Patient Leader Programme – this has been completed by 17 Healthcare Change Makers. BCH are completing an
evaluation of the programme. A meeting has been set for later this month for the course participants to continue their
work with building collaborative relationships in communities as a system resource.
Hot Off The Press Key Risks (Since January 2017)
•
Quality Summit – following publication of the CQC inspection report of BCH services, the quality summit to discuss
the findings and associated actions will be held on 13 March 2017. BCH were rated as ‘Good’ overall.
Key Messages January 2017
•
FFT - response rates for the Walk in Centre (WIC) (7.5%) remains significantly below the improvement trajectory of
13%. BCH have been asked to provide an action plan with expected recovery figures to improve response rates. The
FFT for the Urgent Care Centre has improved to 12.2% and is just below the expected improvement trajectory of
13%.
•
Patient Safety Incidents - medication incidents continue to occur as a result of human error. Fortunately no harm
was sustained by patients as a result of these incidents. BCH have implemented the EMIS scheduling system
alongside the T-Card system as it offers an effective visual representation of the full caseload for review not provided
by EMIS. BCH are ensuring all staff administering or assisting with medications complete an e-learning course on
Safe Medicine Handling.
Content
28
NSCP
Notable Practice
•
Quarter 3 CQUINS – these were achieved and full payment was agreed with a key message that frontline
healthcare workers had an uptake rate of flu vaccine of 75% as of 31 December 2016. The CCG have requested
any learning from this success to be shared with Public Health.
Hot Off The Press Key Risks (Since January 2017)
None identified.
Key Messages January 2017
•
FFT - NSCP has a range of measures in place to ensure that the FFT is accessible to all service users and are
rolling out a programme to capture the FFT responses from housebound patients managed by the Integrated Care
Teams (ICT).
•
Safe Staffing – there are no nationally mandated standards for community services but NSCP have built a RAG
tool into the ALAMAC system and commenced a pilot on 6 February 2017 with the Weston ICT.
•
Pressure ulcers - in January 2017 there were 28 pressure ulcers reported – 7 were acquired and 21 were
inherited. The number of category two acquired pressure ulcers has fallen from 15 in December to 4 in January
2017.
•
Staff turnover – this is at 14.47% in January 2017; there were eleven starters and ten leavers spread across
Bands 3-6; there are no specific hotspots or concerns identified.
•
Sickness absence – this increased in January 2017 to 5.6% which is higher than the comparators NSCP use.
34% was related to cough/cold/flu and 19% to gastro related illness.
29
Content
NSCP Safeguarding
Notable practice
•
Training compliance - Adult and Children's Safeguarding training at all levels are above the compliance level of
90% with positive feedback across all staff groups.
•
Positive effects of training – this has been demonstrated by increased reporting of appropriate safeguarding
adults cases reported on NSCPs Datix reporting system.
•
Supervision process for safeguarding adult cases – this is being rolled out across the provider to mirror the
process embedded for Children's Safeguarding supervision.
•
Roll out of the Egton Medical Information System (EMIS) computer system – this has provided a direct
communication link with general practice in North Somerset.
Hot Off The Press Key Risks (Since January 2017)
None identified.
Key Messages January 2017
•
Early Help Assessments – these are not being evidenced. Work continues to map the family health needs
assessment currently completed to the North Somerset Council Early Help module.
NSCP Safeguarding Children Training
%
90
80
Safeguarding Child L2
70
60
100
Safeguarding Child L1
90
%
100
NSCP Adult Safeguarding Training
80
70
Safeguarding Child L3
60
Safeguarding Adult
L1
Safeguarding Adult
L2
TRAJECTORY
TRAJECTORY
Content
30
Sirona 2017
Notable Practice
•
Overall Sirona perform well in most areas however there are three areas of concern namely cleaning standards at
Thornbury Hospital, FFT at Yate MIU and the incidence of pressure ulcers; these areas of concern are contained
within the report.
Hot Off The Press Key Risks (Since February 2017)
•
None identified.
Key Messages January 2017
•
Environmental cleanliness - hospital cleaning at Thornbury has improved to 80%. The action plan has been
implemented and is being monitored.
•
FFT - the response rate at Yate MIU remains below target at 9% in January 2017.
•
Pressure ulcers - the incidence of pressure ulcers continues to rise.
Safeguarding
•
Head of Safeguarding Adults post - this role will now be filled after April 2017.
•
South Gloucestershire Safeguarding Adult Board (SGSAB) and South Gloucestershire Safeguarding
Children Board (SGSCB) - Sirona is engaged in the SGSAB and SGSCB and sub groups of both Boards.
•
Safeguarding quality assurance visit – this was undertaken by the CCG and Sirona’s Child Safeguarding Lead
in February 2017.
Content
31
AWP Trust-wide
Notable Practice
•
Agency utilisation - use of agency staff is beginning to show an improving trajectory.
•
Workforce - workforce information shows some improvement in sickness and supervision/mandatory training.
•
Out of area placements – whilst variable this is significantly improved on this time last year and currently sits at a record low of 8
(Trust-wide).
Hot off the Press Key Risks (since January 2016)
•
Monitoring CQC actions - at the February NHSI led Quality Improvement Group meeting (which has monitored and managed the
CQC related work streams), the members agreed to stand down this group and transfer the responsibility for monitoring
compliance with the CQC actions to the commissioners. Updates will be a standing agenda item for the Quality Sub Group.
•
Red rated scorecard measures - a significant number of scorecard measures remain Red rated for up to 6 months. It has been
agreed that AWP will embed a process where any score rated red for 2 months or more will be reviewed and reported to the
Quality Sub Group.
•
Capacity and demand –concerns continue about matching capacity with demand (inpatient and community services). An action
plan is in progress, monitored via the CQPM, Quality Sub Group and local contract performance meetings.
•
Safer staffing, recruitment, retention - challenges are ongoing particularly with retention and use of temporary staff. Action
plans are also ongoing, monitored via the CQPM, Quality Sub Group and local contract performance meetings.
Key Messages January 2017
•
CQC - a Warning Notice relating to illegal detentions in the Place of Safety Units remains in place. The CCGs are monitoring
monthly via the Quality Sub Group and locality meetings with the expectation that this will improve. The CQC has informed AWP
they will re-inspect the Trust on 26 June 2017, particularly the 136 suites.
•
SIs - despite some improvements concerns remain regarding evidence of learning from SIs. The CCGs are facilitating a
programme of collaborative workshops to share best practice and agree what is required in terms of reporting and evidencing
learning. The next workshop will take place on 25 March 2017.
•
The Caring Solutions report commissioned by Bristol CCG to review unexpected deaths – this has been received by the
CCG. MH commissioners and Quality Team members plan to review the commissioner recommendations and draft and action
plan to address these. AWP has been asked to respond to the report and include the Trust approach to zero tolerance of suicide;
the report will be tabled at April 2017 Quality Sub Group.
•
Rapid tranquilisation - clinical practice relating to management of patients requiring rapid tranquilisation remains a focus for
commissioners - data this month shows a decline. The CCGs are monitoring monthly via the Quality Sub Group and locality
meetings with the expectation that this will improve.
32
Content
AWP: Bristol CCG Locality
Notable Practice
•
Out of Area placements – there has been an positive impact of opening Larch with the reduction in the number of
Out of Area placements; in the preceding week there had been no out of area placements used for Bristol patients.
Hot Off The Press Key Risks (Since January 2017)
•
Laurel Ward - high levels of sickness absence have been noted.
Key Messages January 2017
•
Delayed Transfer of Care (DTOC) – this increased in January 2017 and remains a significant challenge.
•
User led visits to wards – the first visit has been arranged. It has been acknowledged that a plan of regular visits
is needed.
•
Smoking status - it has been noted that newly developed indicators are currently causing under reporting due to
the mechanics of the reporting tool.
•
Staffing - pressures persist. Recruitment is in process with a good response.
•
Long term management caseload – work pertaining to a project examining patients who are referred in but don’t
require assessments, and also discharges from treatment has found a cluster of patients (men under 65) who
were found to be difficult to place. Work is ongoing.
Data source: LCQPM minutes
Content
33
AWP: North Somerset CCG Locality
Notable practice
•
Quarter 3 CQUINS – these were achieved and full payment was agreed.
Hot Off The Press Key Risks (Since February 2017)
•
None identified.
Key Messages January 2017
•
Local Quality and Performance Report – this is very performance driven; the CCG have requested that exception
reporting against the Quality Schedule should be included in the monthly locality Quality and Performance Report. A
meeting was held following the North Somerset Quality and Performance meeting to agree the format.
•
Pressure ulcers and falls - there have been 2 pressure ulcers reported and 65 falls reported in the last six months.
Further information was requested at the February Quality and Performance meeting. The CCG are organising a
meeting with the Clinical Matron to discuss the detail behind the data.
•
Safety thermometer - a VTE harm was recorded on Juniper ward in January 2017; further information has been
requested.
•
Sickness absence – this has decreased to 5.49% in December from 6.53% in November 2016; there was no data
pertaining to January 2017 available at the time of writing the report. Although the Trust are working with both Human
Resources and Team Managers the CCG have requested a further breakdown of the data, for example, long and
short term sickness.
•
Mandatory Training – this is non-compliance in seven areas: Basic Life Support, Care Programme Approach (CPA)
and Risk, Food safety awareness, Psychiatric Emergency Response Team (PERT), Practical Patient Handling, Safe
assistance of moving patients and Safeguarding Children Level 3. The CCG have requested an action plan to
demonstrate how training compliance will improve which will be monitored via the monthly Quality and Performance
meeting.
•
Cardiac arrest support - WAHT are withdrawing their Service Level Agreement to attend Juniper Ward with cardiac
arrest support as from 31 March 2017. The CCG have requested assurance as to what processes will be in place from
1 April 2017 when this support is withdrawn.
Content
34
SWAST
Notable Practice
•
Multi-agency Root Cause Analysis (RCA) reports / media cases - during January 2917, SWAST have been
examining the way they identify and handle multi-agency SIs. This involves them identifying which cases might be
appropriate to investigate in this manner and considering potentially notifying commissioners of this in the 72 Hour
Report. The Trust has also been open and transparent with regard to media incidents, where they have conducted
swift investigations following identification and then sought deletion where appropriate via the standard procedure.
Hot Off The Press Key Risks (Since January 2017)
•
Thematic Call Review – paediatrics had been chosen for the Thematic Call Review session planned for February
2017. As the subject material was not forthcoming from providers as requested, the session was cancelled and
needs to be rescheduled. SCWCSU will be writing to Care UK NHS 111 and SWAST to emphasise the
requirement for them to ensure adherence to this Quality Schedule requirement.
•
Move to St. James North - SWAST have moved buildings from Acuma House to St. James North (both within
North Bristol) at the end of January/early February 2017.
Key Messages January 2017
•
Performance – Purple responses within 8 minutes in January 2017 was 71.19%, which is below SWAST’s target
of 75%. NHS England and Sheffield University convened a second Ambulance Response Programme (ARP)
workshop in January; this smaller workshop built on the work of the previous one and looked at potential future
ambulance clinical quality indicators as well as system metrics. This is expected to be published by the end of the
financial year.
•
Handover delays – this continues to be a challenge for SWAST.
•
SIs – previously identified themes arising from SIs continue to be monitored, such as ‘spinal management’ and ‘No
Clinical Decision in Isolation’. The potential themes of “Staying on the line” and “Audit Prioritisation” will be
discussed with SWAST’s Clinical Development Team. SCWCSU are planning to visit SWAST to look at the
process of audit both in the North and the South; due to the planned move to St. James North this has been
delayed as the priority has been to ensure a smooth transition from one building to another.
35
Content
Care UK NHS 111
Notable Practice
•
ED validation line – more regular operationalisation of the ED validation line at peak times has been agreed with
Care UK NHS 111 for Quarter 4 2016/17. Although performance against the KPI improved on days when the line
was in operation, commissioners are awaiting formal, detailed reporting to understand the effectiveness of the
line.
Hot Off The Press Key Risks (Since January 2017)
•
CCG Safeguarding lead – B&NES CCG have offered to act as the Safeguarding Lead for the 111 contract and
commissioner agreement is currently awaited. Once received, SCWCSU will prepare a Memorandum of
Understanding between commissioners to formally clarify responsibilities.
•
Leadership changes – the medical lead and contract manager for Care UK for the South West NHS111 have
moved to new roles. There is a risk therefore to organisational memory and capacity in the intervening period. New
staff have been appointed and phased handovers are planned to mitigate this risk.
•
Call audit – concerns were raised by commissioners at the IQPMB regarding call audit scores. Care UK NHS 111
is to provide detailed assurance for the next meeting.
Key Messages January 2017
•
Pathways Deferment - Care UK NHS 111 have deferred the next update of Pathways which is now likely to take
place in late February/early March 2017. This was agreed with commissioners to avoid peak call demand over the
winter period. Assurance was sought regarding any clinical risks arising from the deferral.
•
Patient Satisfaction Survey – there have been low responses from the over 65 age group to the electronic
patient survey. Care UK NHS 111 advise that they will distribute a paper survey to this group on a quarterly basis
to capture feedback. Commissioners have also requested that Care UK NHS 111 liaises with Healthwatch to seek
independent feedback on the service.
•
Clinical Advisor (CA) capacity – there are 23.18 WTE CAs in post, remaining below the required establishment
of 42.47 WTE. Care UK NHS111 have redesigned their clinical rota to create more full time capacity and have a
national recruitment group that meets monthly to address recruitment issues.
36
Content
BrisDoc
Notable Practice
•
Increased Patient Demand – the increase in demand for services continues into January 2017. BrisDoc
maintained patient safety with improvements in response time for clinical advice within 2 hours (96%) and routine
responses (99%). BrisDoc have maintained actions put in place in December 2016 including patient calling and
prioritisation of clinical cases to ensure that patients received an appropriate response during periods of high
demand.
Hot Off The Press Key Risks (Since January 2017)
•
No new exceptions
Content
37
CCG Information
Content
38
Bristol CCG Infection Prevention and Control
January 2017
Clostridium Difficile
The table below shows the number of C. Difficile cases against threshold for April – January 2017.
Acute
cases
non-acute
cases
Total
cases
Threshold
April
2
May
6
June
3
July
3
Aug.
7
Sept
4
Oct.
1
Nov
4
Dec
4
Jan
6
Feb
(0)
6
8
11
8
9
6
5
6
4
7
(3)
8
14
14
11
16
10
6
10
8
13
18
8
11
16
13
11
9
9
7
10
March
Total
30
59
97
9
10
131
The number of C. Difficile infection cases for Bristol CCG was above the monthly threshold. There were 13 cases
against a threshold of 10. However, overall there have been 110 cases recorded to the end of January 2017 against a
threshold of 112.
MRSA
The table below shows the number of MRSA pre 48 hour bacteraemia cases (3) assigned to Bristol CCG from April to
January 2017. MRSA cases reported in brackets in February 2017 are currently under investigation.
April
May
June
July
Aug
Sept
0
1
0
1
0
0
Oct
Nov
Assurance
0
1
Dec
Jan
Feb
0
0
(4)
March
Total
3
Third Party
The number of MRSA cases assigned to third party (9) from April to January 2017 is shown in the table below.
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
0
2
0
1
2
1
1
1
0
1
Feb
March
Total
Data Source: PHE HCAI Database
9
Data Source: PHE HCAI Database
Content
39
NS CCG HCAI
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Jan
YTD
North Somerset CCG Infection Prevention and
Control / Health Care Acquired Infections (HCAI`s)
Escherichia Coli (Ecoli) ALL
15
13
9
10
14
11
12
11
9
13
107
2016/17
Trajectory
n/a
Methicillin-resistant
Staphylococcus
aureus (MRSA)
TRUST
0
0
0
0
0
0
0
0
0
0
0
0
Methicillin-resistant
Staphylococcus
aureus (MRSA)
COMMUNITY
0
0
0
0
0
0
1
1
1
0
3
0
North Somerset C-difficile cases in the Acute
Trust and in the Community are currently
tracking below the Department of Health
North Somerset CCG trajectory for the
Methicillin-resistant
Staphylococcus
aureus (MRSA)
3rd PARTY
0
2
0
0
0
0
1
0
0
0
3
0
year.
Clostridium difficile
(C-diff) TRUST
3
2
0
0
0
0
0
0
0
0
5
16
Acute
Clostridium difficile
(C-diff) COMMUNITY
(WAHT)
microbiology)
1
2
3
1
0
6
0
1
0
3
17
87
inclusive of
Community
and Acute
Clostridium difficile
(C-diff) COMMUNITY
(NBT/UHB
microbiology)
3
Assurance
0
1
4
0
5
0
0
2
2
15
In December 1 case of MRSA was assigned
to North Somerset CCG following a Post
Infection Review (PIR).
In March one case of community acquired
MRSA Bacteraemia has been reported by
UH Bristol and preliminary assigned to the
CCG. A full PIR will be undertaken.
NSCCG Community acquired Cdifficle cases 2016/17
TOTAL REPORTED
AVOIDABLE
LIVE #
UNAVOIDABLE
CLOSED
WITH GP
OUT OF AREA
WITH TRUST
WITH CCG
WITH CCG
WITH TRUST
OUT OF AREA
WITH GP
CLOSED
LIVE #
UNAVOIDABLE
TOTAL REPORTED
Data Source: PHE HCAI Database / CCG records /
UH Bristol/NBT/WAHT Microbiology notifications
AVOIDABLE
0
10 20 30 40
Content
40
North Somerset CCG Quality Incidents
All Incidents reported via DATIX
each month
Apr May
2016 2016
Jun Jul Aug
2016 2016 2016
Sep Oct Nov Dec Jan Feb Mar
Total
2016 2016 2016 2016 2017 2017 2017
AWP (Avon & Wilts Mental Health
Partnership)
1
0
0
0
0
0
0
1
0
0
0
0
2
NBT (North Bristol NHS Trust)
1
3
6
4
2
0
1
2
1
1
1
0
22
NSCP (North Somerset Community
Partnership)
0
1
1
0
1
0
0
1
2
0
1
0
7
Other Secondary Provider
Taunton & Somerset NSH FT
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
1
0
0
0
1
1
0
0
0
1
3
UHB (University Hospitals Bristol NHS
0
Trust)
5
4
3
0
3
6
2
0
2
1
0
26
WAHT (Weston Area Health Trust)
TOTAL
17
26
28
39
21
28
12
15
11
15
15
22
17
24
26
29
22
26
17
21
1
1
201
262
14
16
Reports continue to be generated on the CCG Datix system to share concerns for North Somerset patients
and the healthcare provided to ensure patient safety is central to all patient contact. The chart above
indicates that a high percentage of cases relate to WAHT as the main Acute health service provider for North
Somerset. All reported cases are shared with the applicable provider for information/action.
Data Source: North Somerset CCG Datix
Content
41
North Somerset CCG Quality Incidents
Apr May Jun Jul
Aug Sep Oct
Weston incidents list by category and month
2016 2016 2016 2016 2016 2016 2016
Discharges- Discharge planning failure
0
0
4
3
1
0
Discharges- Patient discharged with IV Cannula in situ
1
2
2
2
0
1
Pressure Ulcer Incidents
5
2
3
2
0
0
Discharges- Patient discharged without any discharge letter
1
0
2
1
2
0
Nov Dec Jan
2016 2016 2017
0
1
6
2
6
2
0
3
1
4
2
0
Feb
2017 Total
6
3
24
3
3
24
3
0
19
2
1
15
Discharges- Requests for dosset boxes at discharge from
hospital
1
2
2
0
0
1
4
0
3
0
0
13
Discharges- Patient discharged with inaccurate discharge
letter
Discharges- Inappropriate or unsafe discharge
Discharges- Other problems with medication at discharge
2
1
0
3
1
0
2
0
2
0
0
1
1
1
0
1
0
1
0
0
1
0
0
0
1
3
0
1
3
1
0
2
4
11
11
10
Discharges- Incorrect medication provided to patient at
discharge
0
3
2
2
1
0
0
0
0
0
0
8
0
0
0
0
0
1
12
0
1
0
0
0
0
14
0
0
0
0
1
0
20
0
1
1
0
2
0
15
2
1
0
1
0
1
11
0
0
0
2
1
2
9
0
0
2
0
0
0
13
0
1
0
0
0
0
13
4
0
0
1
0
0
21
0
1
2
0
0
0
22
0
1
0
0
0
0
14
6
6
5
4
4
4
164
Outpatients- Other problems with medication at an
outpatient appointment
Discharges- No medication provided to patient at discharge
Documentation (including records, identification) other
Other - please specify in description
Failure to provide follow up after outpatient appointment
Discharges- Poor follow up of patient at discharge
Total
The top themes are discussed at the monthly Quality Sub Group meetings. Medication on discharge has risen and will
be discussed in the March meeting. All medication related incidents are highlighted to the CCG’s Medicine
Management Team who in turn discuss the cases at their regular meetings with the Trust.
Data Source: North Somerset CCG Datix
Content
42
North Somerset CCG Complaints/Compliments
(All Patient Experience Resources) January 2017
Patient Experience Source
CCG HW PALS
SI
MP
Total
Patient Experience sources
in January 2017
Issues, Mitigation and Actions
Solicitor writes to the CCG asking for a review of
Continuing Health Care Eligibility for a retrospective
period.
2
0
0
0
0
2 Continuing Health Care Team to carry
out a retrospective review.
Daughter of a patient complains about the
Continuing Health Care eligibility decision and
primarily the communication at WAHT.
1
0
0
0
0
1 WHAT were asked to investigate. The
Continuing Health Care Team have
carried out a retrospective
assessment.
Family complained about the decision not to move a
family member to an alternative care home.
1
0
0
0
0
1 Commissioning Manager met with the
family to find a local resolution.
Family member experienced a delay when qualified
for a Fast Track referral for Continuing Health Care.
1
0
0
0
0
1 The Continuing Health Care Team
reviewed the complaint and
responded.
Professional staff were great.
0
1
0
0
0
1 Feedback received by Weston Area
Health Trust.
CAMHS - Repeat prescriptions for child are a
problem every time. The prescriptions to the
pharmacy often miss out vital information and have
to chase up the prescription.
0
1
0
0
0
1 Feedback received by WHAT.
Data Source: North Somerset CCG
Content
43
North Somerset CCG Patient and Public
Involvement (PPI)
Overview of key work streams for January 2017
•
BNSSG – PPI work on STP – North Somerset’s Sustainability STP Spotlight Project (Weston) is progressing; a draft
engagement plan is in progress. Work is being undertaken on various aspects of the engagement plan, including mapping
the calendar of meetings and liaison with Healthwatch and equality based groups such as homeless people meeting at
Somewhere to Go.
•
BNSSG – Personal, Fair and Diverse Champions – a new task was to lead set up of this campaign across BNSSG. A
scoping and planning meeting has developed an action plan for advancement.
•
360 degree stakeholder survey – an excel spreadsheet was loaded up to the Ipsos-Mori Portal ; this portal enables
submission of contact details of stakeholders who are later asked to participate in the survey. No opt out emails were
received. Field work is to continue through January 2017.
•
North Somerset Health Overview and Scrutiny Panel - liaison continues to prepare for informal briefing meetings and a
full panel meeting is expected to take place on 9 March 2017.
•
Healthwatch North Somerset (HWNS) - a liaison meeting was held on 17 January 2017. Discussed was the potential for a
Patient Reference Group for the North Somerset Sustainability Project (Weston).
•
North Somerset Voluntary Sector Liaison:
 Voluntary Action North Somerset (VANS) liaison – there is a meeting to discuss progress on Service Level
Agreement and a liaison meeting this month.
 Black or Minority Ethnicities (BME) Engagement – Equality Delivery System 2 (EDS2) peer assessor sessions are
planned for completion of this process.
 Lesbian, Gay, Bisexual and Transgender (LGBT) Engagement – there is a meeting on 27 January 2017. The Chair
has been invited to Accountable Officer selection process.
 North Somerset Patient Participation Group (PPG) Chairs: there has been a meeting with PPG leads and the Head
of Commissioning For Quality (BNSSG CCGS) to discuss the public facing version of the BNSSG quality report. The
next PPG Chairs meeting is on 22 February 2017 at Weston Hospital (as part of the Weston Spotlight engagement
process).
•
STP - Prevention, Early Intervention and Self-care – papers and presentation have highlight a need for stakeholder
involvement. A project to support the work stream is being discussed at the North Somerset PPG Chairs meeting. The
project would focus on social prescribing and signposting. Sunnyside Surgery’s PPG Chair has sent a paper to leads for
discussion. A response was provided and discussed with Healthwatch North Somerset’s CEO.
Data Source: North Somerset CCG PPI Lead
Content
44
BNSSG Provider Comparison:
National Safety Thermometer
Content
45
BNSSG Safety Thermometer
The NHS Safety Thermometer "Classic" allows teams to measure harm and the proportion of patients that are 'harm free'
from pressure ulcers, falls, urine infections (in patients with a catheter) and venous thromboembolism during their working
day, for example at shift handover or during ward rounds. Same day weekly reporting of data provides an overview of how
well patients are receiving ‘Harm Free Care’ (as quoted from the Safety Thermometer website).
UH Bristol remain above the overall national Acute average
in providing Harm Free Care; WAHT remains below and NBT
continues to be just under the acute average.
NSCP are above the overall national average for Harm Free
Care, BCH remains close to the average and Sirona is below
the average.
AWP are in line with the Mental health Ward average in
providing Harm Free Care.
AWP Harm Free care
%
100
96
AWP
January
February
March
April
May
June
July
August
September
October
November
December
January
92
Data Source: National Safety Thermometer
Content
Average
46
BNSSG Safety Thermometer Acute ‘NEW’ Harm
Acute New Harms - UHB
%
WAHT
2.5
2
1.5
1
0.5
0
Falls with harm
January
February
March
April
May
June
July
August
September
October
November
December
January
UHB
Pressure Ulcers
NBT
Acute Average
Catheters and New
UTI
VTE
3.5
3
2.5
2
1.5
1
0.5
0
Pressure Ulcers
Falls with harm
January
December
November
October
August
September
July
May
June
April
UH Bristol remains below the national average for
New Harms in January 2017 with a decline in falls
with harm and a rise in catheters/new UTIs; WAHT
has seen a decline in new harms and are now in line
with the national average; and NBT are slightly above
national average.
March
Catheters and New UTI
January
%
Acute New Harms - WAHT
February
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
January
February
March
April
May
June
July
August
September
October
November
December
January
%
NEW Harms in Acute Trusts
VTE
All Acute Average
2.5
2
1.5
1
0.5
0
Pressure Ulcers
Falls with harm
January
February
March
April
May
June
July
August
September
October
November
December
January
%
Acute New Harms - NBT
Catheters and New
UTI
Data Source: National Safety Thermometer
Content
47
BNSSG Safety Thermometer Community and
Mental Health Adult Ward ‘NEW’ Harm
BCH has seen a rise in new falls with harm in January 2017 (and is slightly above the national average); NSCP remain
below the national average for all areas; and Sirona is above.
AWP remains in line with the national average for new harms.
3
2.5
2
1.5
1
0.5
0
Pressure Ulcers
Falls with harm
Catheters and New UTI
VTE
January
February
March
April
May
June
July
August
September
October
November
December
January
%
Community New Harms NSCP
Pressure Ulcers
Falls with harm
Catheters and New UTI
VTE
All Community Average
3
2.5
2
1.5
1
0.5
0
AWP
ALL Average
January
February
March
April
May
June
July
August
September
October
November
December
January
3
2.5
2
1.5
1
0.5
0
AWP All New Harms
%
%
Community New Harms BCH
All Community Average
48
Data Source: National Safety Thermometer
Content
Exception Reporting
Acute Services:
UH Bristol, WAHT and NBT
49
Content
UH Bristol – Fractured Neck of Femur
January 2017
The Issue
• The Trust have reported a further deterioration in overall performance in January at 42.3% compared to 44.8% in
December 2016, maintaining non-compliance against the national standard of 90%.
• An improvement was noted in time to theatre in 36 hours for January (69.2%) compared to December 2016 (51.7%).
Reasons for poor performance include lack of theatre capacity (7 patients) and medically unfit for surgery (1 patient).
Provider Actions
• The Trust reports that they are taking actions to build a future service model across Trauma and Orthopaedics.
• Recruitment has commenced for a fixed term Middle Grade Medical Ortho-geriatrician enabling consistent cover
during annual leave periods.
• The business case for a Band 6 Specialist Fracture Nurse will form part of the 2017/18 operating plan.
• Proposals have been submitted to split the wards into one elderly trauma and fractured neck of femur ward.
Feedback on the proposals is awaited.
• A review of physiotherapy is underway to complete a business case to increase physiotherapy support to support
fractured neck of femurs patients on the trauma and orthopaedic wards across seven days.
Assurance & CCG Response
• The Clinical Services Review Final Report and Action Plan are monitored quarterly at the Quality Sub Group
meetings to review progress and an update was brought to the February meeting.
• The Trust have been asked to share the recommendations of the Clinical Services Review with the BNSSG group
looking at fractured neck of femur provision across the STP footprint.
• The Quality Schedule for 2017/19 includes a requirement to ensure compliance with best practice tariff.
Recovery timescales
Issue highlighted April 2013. Recovery is expected in March 2017.
Data Source: UH Bristol IPR
Content
50
WAHT – Mortality
The Issue
• The Dr Foster Summary Hospital-level Mortality Indicator (SHMI) remains a concern.
• The Trust data suggests continued stabilisation and some marginal improvement in the mortality indicators for the first
quarter 2016/17 (Q1 = 115).
Provider Actions
• The Trust have shared two action plans – The Mortality Reduction Plan and Ensuring Effective Learning from Mortality
Reviews, which have been accepted by the CCG. These will be monitored through the Quality Sub Group.
• There are two external reports outstanding that consider the Fractured Neck of Femur Pathway and the Management of
Colorectal Patients.
Assurance & CCG Response
• Dr Foster figures have been released for Q1 2016 and are showing a slight improvement from the previous data.
• The minutes of the Mortality Review Group were shared at the February Quality Sub Group and the Mortality Action Plans
will be updated by the Trust in February 2017 and shared at the March Quality Sub Group.
Assurance
Oct- Nov- Dec- Jan- Feb- Mar- Apr- May15
15
15
16 16 16
16
16
Recovery timescales
WAHT
Time-frame to achieve as in Action Plans.
Dr Foster Data
1.17
1.16
1.15
National guide
<100
<100
<100
Data Source: Dr Foster / WAHT IPR
Jun16
Content
51
WAHT - 4 Hour Emergency Department (ED) Performance
December 2016
The Issue
• 4 hour ED performance has continued to worsen each month since May 2016 and the national standard is not expected to be
achieved during 2016/17.
• November performance data is 68.47% against a 89.18% trajectory. Performance for December is 66%.
Provider Actions
• Implementation of an agreed plan with phasing of initiative continues as part of the Emergency Care Improvement Project. This
combines the actions required of the Trust by the BNSSG A&E Delivery Board and includes work plans for ED clinical streaming,
improving patient flow and improved discharge processes.
• The Trust have provided an updated RAP linked to the national reset actions, with new trajectories for 4 hour performance in
response to the Exception Report letter issued by the CCG on 20 December 2016.
• Daily Alamac calls continue.
• The Trust is participating in an audit of ambulatory care with NHS Elect.
• Direct admits from SWAST in place as from 23 January 2017.
Assurance & CCG Response
• Daily Green To Go meetings continue to take place with care navigators and brokerage teams being a consistent presence.
• Flow continues to be managed within the daily call system.
• Discharge to Assess capacity has been increased to discharge medically fit and stable patients from the hospital with therapy
support.
• Regular review of information that clearly identifies blocks and any commissioning gaps is identified.
• QUAD (provider partner) meetings have been reconstituted to supplement Urgent Care Working Group for tactical and
strategic system discussion.
• There is additional bed capacity at Clevedon Court.
• Minor Injury Unit (MIIU) diverts to Clevedon MIU are in place.
• Integrated discharge Team is being re-developed to take forward further system actions.
Recovery Timescales
An Sustainability and Transformation (STP) trajectory to achieve 93% by March is
in place but has not been achieved since June 2016.erTimescales
Data Source: WAHT IPR
52
Content
WAHT – VTE December 2016
The Issue
• VTE Risk assessment has shown a gradual improvement for two months in a row.
Provider Actions
• A new VTE clerk has been appointed in the Trust which will ensure continuity and resilience for reporting and data
collection.
• The leadership and governance of the process will move to the Critical Care and Resuscitation Committee in order to
integrate the VTE assessment with other clinically led documentation.
Assurance & CCG Response
• Following the CPN issued in December 2016 there is an action plan in place which is
monitored at the Quality Sub Group and the Trust have provided a trajectory to achieve
the 95% compliance rate by April 2017.
Assurance
100.0%
80.0%
%
Recovery timescales
WAHT VTE Compliance
Dec-16
Nov-16
Oct-16
Sep-16
Aug-16
Trajectory
Jul-16
40.0%
Jun-16
VTE
May-16
60.0%
Apr-16
Monthly trajectory’s shared with a goal to reach 95%
compliance by the end of April 2017
Data Source: WAHT IPR
Content
53
WAHT - Serious Incidents
The Issue
• Serious Incidents (SIs) – there is a backlog of SI`s open on the STEIS reporting system. The CCG are waiting for assurance
to ensure that learning from the Root Cause Analysis (RCA) investigations has taken place at the Trust.
Provider Actions
• The Trusts Internal Governance structure is being reviewed which would involve a Governance Lead for each
directorate to assist in the assurance of learning from SIs and to ensure that reporting compliance is in line with
national guidance.
• A review of all open cases is being undertaken with the support of the CCG to obtain the required assurance to close
cases.
• From mid-February 2017 there will be two SI panels per month to reduce the backlog of SI`s.
• The Trust have a SIRI Management Plan in place which was created in December 2016.
Assurance & CCG Response
• The CCG are working closely with the Trust
with meetings arranged every two weeks to review progress and
Assurance
obtain the necessary assurance as to the learning and embedding of the learning from SI’s.
• Monitoring of the Improvement Plan continues.
Recovery timescales
To close the current outstanding cases by the end of March 2017.
Data Source: WAHT IPR / STEIS
Content
54
WAHT - Cancer Standard
The Issue
• The 62 Day Cancer Standard is not being met.
Provider Actions
• The Trust have provided an updated RAP and revised trajectory following an Exception Report letter issued in
December 2016.
• A breach reallocation policy is currently being implemented.
• Following discussions at the January 2017 Quality Sub Group it was agreed to review and discuss the action plan
outside of the meeting.
Assurance & CCG Response
• The RAP is monitored through the Quality Sub Group, ICQPMB and BNSSG Cancer Group meetings.
Assurance
Recovery timescales
Monthly monitoring and improvement by March 2017.
Data Source: WAHT IPR
Content
55
WAHT
- Safeguarding
Safeguarding
Training
of staff at WAHT
Training January 2017
The Issue
• Safeguarding Child Training at all levels has fallen month on month since September 2016. Level 2 and 3 is of the highest
concern due to the staff most likely to have the interaction with children.
• The training matrix may have inaccuracies for senior medical staff, therefore there is potential for compliance to fall further
when it is identified which additional staff members should be included at level 3.
Provider Actions
• Multiagency level 3 training will be held on site at WAHT from April 2017 and there will be protected places on existing courses
for WAHT staff until training figures have improved.
Assurance & CCG Response
Staff Safeguarding Training WAHT
100
• Continual monitoring by the Safeguarding
Leads at the Trust and the CCG.
95
Safeguarding Child L1
Safeguarding Child L2
85
Safeguarding Child L3
%
90
Safeguarding Adult L2
TRAJECTORY
Jan-17
Dec-16
Nov-16
Oct-16
Sep-16
Aug-16
Jul-16
Jun-16
May-16
Apr-16
75
Mar-16
The CCG requested a trajectory at the WAHT
Safeguarding meeting and Quality Sub Group in
February 2017.
Safeguarding Adult L1
80
Feb-16
Recovery timescales
Data Source: WAHT IPR
Content
56
NBT - MRSA Remedial Action Plan January 2017
The Issue
• NBT have reported six cases of MRSA Blood Stream Infections for the year to date 2016/17; the latest case was
reported in January 2017.
• A CPN was issued to the Trust in November 2016.
Provider Actions
• NBT are implementing an MRSA RAP devised from key learning from the first five cases.
Assurance & CCG Response
• The CCG’s Director of Nursing and Quality has met with South Gloucestershire’s Director of Public
Health to discuss providing the Trust with further support to deliver the action plan.
• The implementation, progress and completion of the RAP will be monitored by the CCG via the Quality
Sub Group.
Assurance
NBT Attributed MRSA cases 2016/17
Recovery timescales
Recovery is expected by 31 March 2017.
Data Source: NBT IPR
Content
57
NBT - Never Events Remedial Action Plan January 2017
The Issue
• NBT have reported five Never Events for the year to date 2016/17.
• A Contract performance Notice (CPN) was issued to the Trust in November 2016 in response to the Trust’s failure to
ensure Never Events do not occur.
Provider Actions
• NBT have submitted a Remedial Action Plan (RAP) in the form of a Driver Diagram to the CCG for approval; this
has not yet been signed off by the CCG as dates and National Safety Standards for Invasive Procedures
(NATSSIPs) need to be included.
Assurance & CCG Response
• The CCG have requested the final Action Plan and completed audits identified within the Action
Plan to be submitted to the March Quality Sub Group along with feedback from the ‘Stop Before
You Block’ audit and the Trust’s visit to NHS Plymouth.
• The CCG have requested NBT’s Theatre Board to provide internal assurance in relation to the
Action Plan.
NBT Never Events 2016/17
Recovery timescales
Recovery is expected by 31 March 2017.
Data Source: NBT IPR / STEIS
Content
58
NBT - CQC Action Plan (2015) January 2017
The Issue
• One outstanding ‘Must Do’ action remains from the December 2015 CQC Inspection Action Plan which relates to
system flow; the original agreed delivery of improvement was 31 January 2017.
Provider Actions
• NBT are able to demonstrate that the work has been completed and will provide the CQC and CCG with a written
report focusing on the actions delivered that relate to quality and safety within the hospital as well as reporting on
how the Trust is managing high demand more effectively.
Assurance & CCG Response
• The CCG has requested NBT provide an overview of the report sent to the CQC and the KPMG
Internal Audit report (commissioned as part of the Trust’s continuous cycle of improvement) at the
April Quality Sub Group meeting.
Recovery timescales
Assurance
Recovery is expected by 30 April 2017.
Data Source: NBT IPR
Content
59
NBT - Complaints Management January 2017
The Issue
• The number of overdue complaints has increased to 42 in January 2017.
• Of the cases closed in January 2017, 68% of them were completed within the agreed timescale; the target is 90%.
Provider Actions
• NBT has attributed the rise in overdue complaints to the increase in operational pressures within clinical
services.
• NBT Heads of Nursing are focusing their efforts on improving the situation and reducing the number of
overdue complaints.
• The Trust are devising an improvement plan for complaints management and the Head of Patient Experience
at NBT is currently focusing on the outstanding overdue complaints.
Assurance & CCG Response
• The CCG have requested an improvement action plan be presented for approval at the March
Quality Sub Group.
• The CCG will continue to monitor NBT’s management of complaints via the Quality Sub Group.
Recovery timescales
Recovery is expected by 31 March 2017.
Data Source: NBT IPR
Content
60
NBT - Administration Backlog January 2017
The Issue
• Delays in the receipt of discharge letters following outpatient consultations at NBT.
Provider Actions
• Following a request from the CCG, NBT are to devise an improvement plan to include internal targets,
targets currently being met by NBT and how improvement will be achieved against trajectory.
Assurance & CCG Response
• The CCG have requested the improvement action plan be presented at the March Quality Sub
Group.
• The CCG will continue to monitor NBT’s administrative turnaround times via the Quality Sub
Group.
Recovery timescales
Assurance
Recovery is expected by 30 April 2017.
Data Source: NBT IPR
Content
61
NBT - Friends and Family Test (FFT) January 2017
The Issue
• The FFT response rates for Inpatients and the ED remain below target; this mainly attributed to incorrect patient phone
details (required for text and SMS) held by NBT.
Provider Actions
• NBT’s Head of Patient Experience is currently working with IM&T in order to identify the exact problem with patient
phone numbers and is also looking at Directorates which are performing well with FFT in order to replicate good
practice.
• The Trust may revert to the paper system for collecting FFT if the issue can not be resolved quickly.
Assurance & CCG Response
FFT Response Rates for Inpatients and ED July 16 – Dec 16
NB – NHSE data 2 months in arrears
• The CCG will continue to monitor FFT via the Quality Sub
Group.
Recovery timescales
Recovery is expected by 31 March 2017.
Data Source: NBT IPR / NHSE
Content
62
NBT - Gastroenterology Surveillance January 2017
The Issue
• NBT are currently failing the six week diagnostic target and have a significant Endoscopy surveillance recall backlog.
• NBT have attributed the backlog due to an ineffective recall process employed by the Trust.
Provider Actions
• The Trust are working to ensure a more robust patient recall process is in place and have developed a RAP.
The Trust are currently on track to meet the improvement trajectory outlined in the RAP and the backlog
should be cleared by the end of March 2017.
Assurance & CCG Response
• The CCG has requested NBT provide assurance that each case has been clinically validated.
• The implementation, progress and completion of the RAP will be monitored by the CCG via the Quality Sub Group.
• The Cancer Working Group will ensure patients are not managed off the system.
Assurance
Recovery timescales
Recovery is expected by 31 March 2017.
Data Source: NBT IPR
Content
63
Exception Reporting
Mental Health:
AWP and Local Mental Health
Services
Content
64
AWP –Trust-wide Workforce January 2017
The Issue
•
•
•
•
•
•
•
•
•
Trust-wide statutory/mandatory training remains rated amber at 82.3% (below the threshold of 85%).
Supervision has improved and is now rated green at 89.8% (85% threshold).
Appraisal remains rated red at 87.7% but is slightly improved on last month (below the threshold of 95%).
Sickness has improved slightly but remains rated red at 4.94% (threshold 4.6%).
Safeguarding training rates: level 1 amber at 88%, level 2 amber at 81% and level 3 red at 76.4% (threshold 90%).
Challenges remain with retention of staff.
The vacancy rate has increased and is reported at 7%.
Trust-wide turnover remains unchanged and is reported at 14%.
Agency/temporary staff usage – shows a slight increase this month from 25% to 27% at Trust-wide level.
Provider Actions
• The Trust reports that action plans are in place.
• Any measure rated red for 2 or more
consecutive months will be reviewed via the
Performance meeting and reported to
commissioners via the Quality Sub Group.
Assurance & CCG Response
• The CCGs are monitoring monthly via the
Quality Sub Group and locality meetings with
the expectation that this will improve.
Recovery timescales
Issue Highlighted April 2013. Recovery is
expected in March 2017.
Month 8 (Nov 2016)
%
Appraisal rate
Supervision rate
Sickness rate
Statutory/mandatory
training rate
Vacancy rate
Turnover rate
Agency/temp staff
Trust wide
Bristol CCG
75.6
89.9
4.95
82.4
S Glos
CCG
99
97.8
3.8
88.8
North
Somerset CCG
95.8
93.5
5.49
89.2
97%
80.9
4.94
94
7
14
27
4
11
x
7
9
x
88
90.5 AWP
92.6 VCS
82.5 AWP
90.7 VCS
78.2 AWP
90.7 VCS
93.3
4
9
No data this
month
94.5
Safeguarding
training rate - level 1
Safeguarding
training rate - level 2
Safeguarding
training rate - level 3
88.2
86.9
64.9
52
81
76.4
Source: AWP IPR Board paper 65
Content
AWP – Rapid Tranquilisation January 2017
The Issue
• Clinical practice relating to management of patients requiring rapid tranquilisation continues to be monitored – with
recording of physical health measures showing a decline against trajectory this month but improvement overall.
• Clinical practice relating to use of restraint/restrictive practices is monitored monthly since high levels of the use of
restrictive practices and physical restraint were reported in September 2016. Guidance recently published reiterates
that face down restraint should not be used. AWP will update the Quality Sub Group verbally in March regarding the
Trust’s policies and procedures and use of this practice, followed with a written report in April 2017.
Provider Actions
• There is a query as to whether the restrictive practice information links in any way to the lower levels of
training (Prevention and Management of Violence and Aggression - PMVA) which has been rated red for
6 + months); assurance is pending.
• The Trust has action plans in place.
Assurance & CCG Response
• The CCGs are monitoring monthly via the Quality Sub Group and locality
meetings with the expectation that this will improve.
Recovery timescales
66
Issue Highlighted April 2013. Recovery is
expected in June 2017.
Source: AWP Clinical Executive
Report Board paper
Content
AWP – CQC Update December 2016
The Issue
• A Warning Notice relating to illegal detentions in the Place of Safety Units remains in place. The CQC highlighted 21
Must Do and 33 Should Do actions and AWP have devised locality based improvement plans to address these with
one overarching improvement plan for Trust-wide actions. The CQC has signalled intent to revisit the unit before
June 2017. On 30th January a service user was illegally detained in the 136 suite in Bristol longer than 72 hrs
Provider Actions
• An action plan is in place for the Place of Safety actions.
• The Trust have developed locality based improvement plans to address the Should Do and Must Do actions.
• The 136 breach was reported as a serious incident in February and is being fully investigated
Assurance & CCG Response
• The NHSI led Quality Improvement Group held its last meeting in February 2017 and the Quality Sub Group will
take over monitoring compliance with the CQC actions from March 2017.
• The Trust has shared their improvement plans with NHSI/NHSE and the CCGs.
• Monitoring will be monthly with the expectation that this will improve.
Recovery timescales
Assurance
• Recovery is expected in March 2017 for the place of safety actions.
• Further improvements are expected over time via the Crisis Concordat Group (work with wider
stakeholders) and as a result of implementation of the Acute Care Pathway Programme.
• Timescales for completion of the Should Do and Must Do actions will be incorporated within the
improvement plans.
Source: NHSI QIG minutes
and StEIS database
67
Content
Exception Reporting
Community Services:
BCH, NSCP and Sirona
Content
68
BCH – Patient Safety Incidents January 2017
The Issue
• The FFT response rates for the Walk in Centre (WIC) (7.5%) remains significantly below the improvement trajectory of 13%.
The FFT for the Urgent Care Centre (12.2%%) has improved and is just below the expected improvement trajectory of 13%.
• Medication incidents continue to occur as a result of human error. No harm was sustained by patients as a result of these
incidents, but similar types/themes have been identified including missed does, syringe drivers issues, controlled drugs and
insulin.
Provider Actions
• BCH are developing an action plan to address the decline in the FFT response rate that includes the use of volunteers
to support collation of the FFT.
• BCH are piloting a new drug chart for community nursing to reduce medication errors. An online Medicines
Management e-learning session has also been developed.
• All staff receive a regular patient safety e-mail disseminating learning from medication incidents to all teams.
• BCH have implemented the EMIS scheduling system.
• BCH plan to address incidents related to the T-Card System through the introduction of mobile working across the
organisation.
Assurance & CCG Response
• BCH have been asked to provide an action plan with expected recovery figures to improve response rates. The
action plan to improve the FFT response rate will be monitored via the IQPM.
• The CCG has sought assurance that action is being taken to reduce the process errors associated with the TCard system.
• BCH have assured the CCG that the level of harm is not rising and that they are confident that the increase in
incidents is a result of improved reporting by staff.
Recovery timescales
Data Source: BCH Quality Report
N/A
69
Content
Sirona - Pressure Ulcers January 2017
The Issue
• The incidence of community acquired grade 2 pressure ulcers continues to increase with 33 reported in January 2017.
• Two grade 3 pressure ulcers were reported in January 2017.
Provider Actions
• Sirona attend the BNSSG-wide Pressure Ulcer Steering Group and are working to reduce the incidence of
pressure ulcers.
• A full Root Cause Analysis (RCA) will be carried out for the two grade 3 pressure ulcers.
Assurance & CCG Response
Sirona Community Acquired Grade 2 Pressure Ulcers August
2016 – January 2017
• The CCG monitors Sirona’s incidence of pressure ulcers
via the Sirona Performance Meetings.
• The CCG attends the BNSSG Pressure Ulcer Steering
Group.
Recovery timescales
Recovery is expected by 31 March 2017.
Data Source: Sirona’s South Gloucestershire
Performance Report
Content
70
Sirona - Thornbury Hospital Cleaning January 2017
The Issue
• The cleaning standard at Thornbury Hospital has improved to 80%; although an improvement this is still below the 95%
target.
Provider Actions
• Sirona have implemented the Cleaning Improvement Action Plan and are monitoring this going forward.
• Sirona’s Head of Service is working with the Ward Manager and Facilities team to ensure further improvement
continues and the 95% target is reached.
Assurance & CCG Response
Thornbury Hospital Cleaning Rates August 2016 – January 2017
• The CCG will continue to monitor Thornbury Hospital’s
cleaning rates via the Quality and Performance meetings.
Recovery timescales
Recovery is expected by 31 March 2017.
Data Source: Sirona’s South Gloucestershire
Performance Report
Content
71
Sirona - Yate Minor Injuries Unit FFT January 2017
The Issue
• The FFT response rate at Yate MlU was 9% in January 2017, continuing below the agreed target of 15% as agreed
between the CCG and Sirona.
Provider Actions
• Sirona continue to work to increase the FFT response rate at Yate MIU.
• FFT cards are given to all MIU attendees upon booking; this commenced on 1 February 2017.
Assurance & CCG Response
FFT Response Rates Yate MIU August 16 – January 17
• The CCG will continue to monitor Yate MIU FFT response
rates via the Quality and Performance meetings.
Recovery timescales
Recovery is expected by 31 March 2017.
Data Source: Sirona’s South Gloucestershire
Performance Report
Content
72
Exception Reporting
Urgent Care:
BrisDoc, SWAST
and Care UK NHS 111
Content
73
SWAST - Performance January 2017
The Issue
• Purple (previously known as Red) performance Trust-wide for SWAST continues to be a challenge in January 2017 (as it is for
other Ambulance services during the winter period).
• Performance pertaining to Purple responses within 8 minutes in the Bristol area is 75.77% in January, which though above
SWAST’s target of 75% is a decrease from the previous month.
• January’s performance of Purple responses within 8 minutes, in the South Gloucestershire area, is 66.67%, which is below
the target of 75% and a noticeable decrease from the previous month.
• January’s performance of Purple responses within 8 minutes, in the North Somerset area, is 79.87%, which is above
SWAST’s target of 75% and a noticeable increase on the previous month.
Provider Actions
• The modelling for the rota review to change the Rapid Response/ Double Crewed Ambulance (RRV/DCA) mix
has been finalised and the plan is to initiate this in April 2017.
• NHS England and Sheffield University convened a second Ambulance Response Programme (ARP) workshop
in January; this smaller workshop built on the work of the previous one and looked at potential future
ambulance clinical quality indicators as well as system metrics. This is expected to be published by the end of
the financial year.
Assurance & CCG Response
• SCWCSU/CCGs continue to review at the bi-monthly IPQMG meetings.
Recovery timescales
Ongoing.
Content
74
SWAST – Handover Delays January 2017
The Issue
• Handover delays continue to be a challenge for SWAST.
• The total handovers taking more than 15 minutes at the Bristol Royal Infirmary in January 2017 was 897, with 177.4 hours
resource lost due to these delays; this is higher than the previous months figures.
• The total handovers taking more than 15 minutes at Southmead Hospital in January 2017 was 960, with 179.7 hours resource
lost due to these delays; this is a deterioration from December’s figures.
• The total handovers taking more than 15 minutes at the Weston General Hospital in January 2017 was 484, with 97.1 hours
resource lost due to these delays. This figure has increased from last month, which reflects the challenging situation at this
hospital currently. However despite the increase in handover numbers the associated time lost did not increase significantly.
Provider Actions
• SWAST, Commissioners and SCWCSU discuss these delays at the IQPMG.
Assurance & CCG Response
• SCWCSU/CCGs continue to review at the bi-monthly IPQMG
meetings.
Recovery timescales
Ongoing.
Content
75
SWAST – Staff Sickness, Turnover and Appraisals
January 2017
The Issue
• Sickness was 6.04% for January 2017 and 5.28% year to date, a slight increase on December‘s figure of 6.11% and 5.04%
year to date.
• Turnover is at 13.17% in January 2017, a marginal decrease on December’s figure of 13.25%.
• To date the percentage of appraisals completed is 72.07% against the target of 85% for the year.
Provider Actions
• SWAST management continue to monitor and manage sickness, the staying well service is supporting those
individuals identified as suffering from muscular-skeletal injury or mental health related illnesses.
• The Trust continues to monitor the declining level of turnover seen over the past few months.
• Following on from previous months there continues to be a significant focus to complete overdue career
conversations. Alternative methods for ensuring these are completed such as the use of overtime are being
considered. There has been a drive in the North Hub to ensure that those which work part-time still receive a
timely appraisal.
Assurance & CCG Response
• SCWCSU/CCGs continue to review at the bi-monthly IPQMG meetings.
Recovery timescales
Ongoing.
Content
76
SWAST – Serious Incident Themes January 2017
The Issue
• Currently identified themes within SWAST are “Spinal management” and “No Clinical Decision in Isolation”, monitoring of
which is ongoing.
• Two potential themes, namely “Staying on the line” and “Hub Resourcing/Audit Prioritisation” are to be discussed with the
Clinical Development Team.
• “Adherence to Non-Conveyance policy” has been noted as a potential theme and SCWCSU are in discussion with the Trust
regarding this.
Provider Actions
• The Trust is currently undertaking it’s first concise RCA investigation after previous agreement with
commissioners.
Assurance & CCG Response
• SCWCSU is to meet with SWAST’s Deputy Clinical Director on 17 March 2017, as
this is the first available date to discuss these issues.
• SCWCSU are organising a meeting at the North Hub to look at the 999 call audit
process; this has been delayed due to the move to St. James North.
Recovery timescales
Ongoing.
Content
77
Care UK NHS 111 – Performance January 2017
The Issue
• Ambulance dispatch rates deteriorated fractionally from 10.3% in December to 10.6% in January (against the 10% target).
• Warm transfer performance is at 40.7%; this is affected by the clinical prioritisation model operated locally which ensures that clinical
resource is prioritised according to patient acuity (ensuring patient safety). However, Care UK NHS 111 continues to perform ahead of
the national average for combined clinical contact (warm transfers plus call backs in 10 minutes) at 82.1%.
• There is a low response rate (8%) from the over 65s to the electronic patient satisfaction survey.
Provider Actions
• The ambulance validation line continues to be operational 7 days a week. Individual ambulance dispatch rate performance is discussed
with staff in one to ones and addressed in staff development plans where appropriate.
• Training sessions have been put in place to develop staff skills in “Probing” relating to the “red triggers” in Pathways to reach safe and
appropriate outcomes for patients.
• Care UK NHS 111 report that clinical training days are in place to improve management of urgent conditions and understanding of
alternative pathways to ED.
• The ED validation line will operate more frequently during peak times in Q4, staffed by agency clinicians. Latest figures suggest that of
those calls validated, circa 70% are redirected to an alternative service.
• Care UK NHS 111 will be sending out a quarterly paper based satisfaction survey to the over 65s to improve response rates from this
group.
Assurance & CCG Response
• The CPNs for ED referrals and ambulance referrals remain open. The associated action plans are monitored monthly at bespoke review
meetings.
• Care UK NHS 111 perform in line with national average for ambulance and ED referral metrics.
• CQUIN payments are adjusted accordingly for the underperformance for ED referrals and ambulance referrals, in line with the contract.
• Commissioners have suggested that Care UK NHS 111 liaises with Healthwatch to obtain an independent review of its services.
Recovery timescales
Care UK NHS 111 is showing positive progress, but there is no definitive timescale for performance
improvement as this is heavily dependent on clinical workforce.
Content
78
Care UK NHS 111 – Workforce January 2017
The Issue
• Health Advisor (HA) staffing levels are good (78.87 WTE) against an establishment of 115 WTE.
• Clinical Advisor (CA) staffing levels remain low, with the Bristol call centre operating at 23.18 WTE against a clinical
establishment of 42.47 WTE. Staffing levels for clinicians remain static despite provider actions to increase applications.
However despite the clinical shortfall, Care UK NHS111 performs well on the NHS England standard for calls transferred
to a CA and the combined clinical contact metrics.
Provider Actions
• A new rota has been implemented with improved work patterns, aimed at making roles more attractive.
• A Recruitment Partner is focusing on South West clinical recruitment, including attendance at recruitment fairs.
• The Care UK Network offers additional resilience i.e. clinicians from other sites are able to handle calls where required
and demand is managed on a real time basis by The Bridge Team (commended by the CQC in their inspection report).
• Home working posts are being advertised nationally.
• The clinical prioritisation model in operation locally ensures that clinical resource is prioritised according to patient acuity.
• A clinical referral bonus is in place.
• Due to the workforce being predominantly part time, the provider is able to flex its existing workforce as appropriate, or
agency staff for clinicians.
Assurance & CCG Response
• Commissioners continue to monitor workforce planning at the monthly IQPMB.
Recovery timescales
There is no specific recovery timescale, but Care UK NHS 111 is working to meet its clinical
establishment as soon as possible.
Content
79
BrisDoc – Performance January 2017
The Issue
• Performance pertaining to clinical advice within 2 hours improved in January 2017 (96%) despite the continued
increase in demand for services during the month. BrisDoc report that safety was maintained and patient satisfaction
remained high.
Provider Actions
BrisDoc have implemented an Escalation Plan to manage periods of increased demand that incorporates:
• Patient safety calling (i.e. by the operational team) to manage patient expectations regarding service demand and
wait time reduces patient call backs to NHS111 chasing a response, and also allows the identification of red flags
for expediting to a clinician if necessary.
• Clinician streaming of cases to ensure prioritisation is appropriate and to re-designate disposition if the patient
requires a face to face appointment.
• Non-clinical call backs to manage failed contacts and to support clinician streaming.
• Remote working on an ad hoc basis in response to demand surge.
Assurance & CCG Response
• BrisDoc performance is monitored through the monthly contract meetings.
Recovery timescales
March 2017.
Data Source: Brisdoc Quality &
Performance Report
Content
80
Patient Advice and
Liaison Service
(PALS)
Content
81
Summary of PALS activity in January 2017 for BNSSG CCGs
In January 2017 a total of 88 new cases were recorded.
BNSSG PALS contacts by type January 2017
16
14
12
10
8
6
4
2
0
Top five areas:
• Acute – an unusual month where clinical treatment was more of an issue than access including advice given on how to complain to Trusts,
requests for help with long waiting lists and poor transfer of care from Southmead to BRI.
• Mental health – 9 out of 15 were people trying to contact IAPT (Improving Access to Psychological Therapies). Others included needing crisis
team contact details, MH advocate not attending meetings and lack of therapy following a therapist’s retirement.
• eReferral (Choose & Book) – mainly South Gloucestershire patients needing to be talked through the process (PALS number not included in
Bristol and North Somerset letters).
• GP services – mainly administration; specifically poor communication with patients and problems with referrals.
• Other – including one distressed person asking for PALS to stop the media reporting such bad news about the NHS all the time as it is making
them ill and increasing their anxiety attacks.
Compliments
4 compliments were received in January; 1 pertained to the care and support given by a GP at Montpelier Health Centre and 3 related UH Bristol
82
including ‘the professional treatment received was exceptional’.
Content
Acute services contact by provider January 2017
10
9
8
7
6
5
4
3
2
1
0
BNSSG PALS contacts January 2017
Out Of
Area/Unknown
9%
North Bristol
University
University
North Bristol
University
NHS Trust Hospitals Bristol Hospitals Bristol NHS Trust Hospitals Bristol
Bristol CCG
Bristol CCG
North Somerset
South
South
CCG
Gloucestershire Gloucestershire
CCG
CCG
Cumulative figures for 2016/17
South
Gloucestershire
CCG
21%
North Somerset
CCG
11%
Bristol CCG
59%
120
100
80
60
40
20
0
Content
83
Serious Incidents
Content
84
BNSSG Serious Incidents Overview - February 2017
January 2017 Summary
•
•
•
•
•
•
•
•
•
•
•
UH Bristol reported 9 SIs.
WAHT reported 11 SIs.
NBT reported 11 SIs.
BCH reported 4 SI.
NSCP reported 3 SIs.
Sirona reported 2 SIs both concerning South Gloucestershire patients.
AWP reported 6 SIs involving 3 Bristol patients, 2 North Somerset patients and a South Gloucestershire patient.
SWAST reported 1 SI concerning a Bristol patient.
St Peter’s Hospice (SPH) reported 1 SI.
BNSSG SIs February 2017
Care UK NHS 111 reported no SIs.
30
28
BrisDoc reported no SIs.
26
24
22
20
18
16
14
12
10
8
6
4
2
0
Themes
Even though 12 Hour Trolley Breaches remain a theme across the BNSSG area, the number of incidents
have been decreasing over the last month, with February’s numbers accounting for 39% of all acute SIs
reported. These incidents involved a total of 31 patients, a 78% drop from last month.
Data Source: STEIS
85
Content
UH Bristol
Summary
Within February 2017, UH Bristol reported 9 SIs. These pertained to 2 pressure ulcer incidents and 7 reported 12 Hour Trolley
Breaches involving 14 patients (see graph to the left below). These incidents concerned 14 Bristol patients, of which 13 were
involved in the reported 12 Hour Trolley Breaches, one patient from South Gloucestershire and one from BaNES (see graph to
the right below). This brings the total number of incidents for the year (from April 1st onwards) to 63 SIs.
10
Child Death
Environmental Incident
Medication Incident
Pressure Ulcer
Sub-optimal care for deteriorating patient
Treatment Delay
Diagnostic Incident
Maternity
Pending Review
Slip, trips, and falls
Surgical/Invasive procedure incident
Trolley breach
18
Bristol CCG
16
South Gloucestershire CCG
North Somerset CCG
14
Other CCGs
12
8
10
6
8
4
6
4
2
2
0
0
Apr May Jun
Jul
Aug
Sep
Oct
Nov Dec
Jan
Feb Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance
In February 2017, UH Bristol had a 100% compliance rate for reporting SIs with all 9 SIs being reported within the expected
timeframe of 2 working days (in accordance to national policy). The Trust also achieved 100% compliance with 72 hour reports
due in February, all being received within the deadline of 3 working days. From the beginning of April 2016 to date, the Trust’s SI
compliance stands at 95% for incident reporting and 77% for 72 hour report submissions.
NB - monthly numbers are small which impacts on percentages.
86
Content
WAHT
Summary
Within February 2017, WAHT reported 11 SIs. These pertained to 3 reported 12 Hour Trolley Breaches (involving 5 patients), 2
pressure ulcers, 2 slips, trips and falls, 1 treatment delay, 1 maternity incident, 1 surgical /invasive procedure and 1 unexpected
injury causing potential harm (see graph to the left below). These incidents concern 12 patients from North Somerset and one
from Somerset (see graph to the right below). This brings the total number of incidents for the year (from April 1st onwards) to
117 SIs.
32
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
Surgical/invasive procedure incident
Abuse/alleged abuse of adult patient by staff
Commissioning incident
Environmental Incident
HCAI/infection control incident
Maternity
Medication Incident
Pressure Ulcer
Slip, trips, and falls
Sub-optimal care for deteriorating patient
Treatment Delay
Trolley breach
Unexpected Death (general)
25
Bristol CCG
23
21
19
South Gloucestershire
CCG
17
15
North Somerset CCG
13
11
Other CCGs
9
7
5
3
1
-1
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance
In February 2017, WAHT had a 100% compliance rate for reporting SIs with all of the 11 SIs being reported within the expected
timeframe of 2 working days (in accordance to national policy). The Trust achieved 60% compliance with 72 hour reports with
only 6 of the 10 due in February being received by their expected deadline of 3 working days. There are 2 outstanding 72 hour
reports due in February. From the beginning of April 2016 to date, the Trust’s SI compliance stands at 95% for incident reporting
and 35% for 72 hour report submissions.
87
Content
NBT
Summary
Within February 2017, NBT reported 11 SIs. These pertained to 2 reported 12 Hour trolley breaches (involving 12 patients), 3
treatment delays, 2 slips, trips and falls incidents, 1 diagnostic incident, 1 medical equipment failure, 1 pressure ulcer and 1
unexpected Injury causing potential (see graph to the left below). These incidents involved 12 patients from South
Gloucestershire, 9 from Bristol, 1 from North Somerset, 1 from Wiltshire and a patient from NEW Devon (see graph to the right
below). This brings the total number of incidents for the year (from April 1st onwards) to 103 SIs.
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Unexpected Injury causing potential harm
Commissioning Incident
Diagnostic Incident
HCAI/Infection Control incident
Maternal Death
Maternity
Medical equipment failure
Medication Incident
Pressure Ulcer
Screening Issue
Slip, trips, and falls
Sub-optimal care for deteriorating patient
Surgical/Invasive procedure incident
20
Bristol CCG
18
South Gloucestershire
CCG
North Somerset CCG
16
14
Other CCGs
12
10
8
6
4
2
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance
In February 2017, NBT had a 91% compliance rate for reporting SIs with 1 of the 11 SIs not being reported within the expected
timeframe of 2 working days (in accordance to national policy). The Trust achieved 50% compliance with 72 hour reports with 4
of the 8 due during February being received by their deadline of 3 working days. From the beginning of April 2016 to date, the
Trust’s SI compliance stands at 84.6% for incident reporting and 57% for 72 hour report submissions.
NB - monthly numbers are small which impacts on percentages.
88
Content
BCH
Summary
BCH reported 4 SIs in February 2017 all of which pertained to pressure ulcers (see graph below). This brings the total number of
incidents for the year (from April 1st onwards) to 36 SIs.
9
Medication Incident
8
7
Sub-optimal care for
deteriorating patient
6
5
Pressure Ulcer
4
3
2
1
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance
In February 2017, BCH had 100% compliance rate for reporting SIs within the expected timeframe of 2 working days (in
accordance to national policy). BCH had 50% compliance for 72 hour reports, with 1 of the 2 due in February not being received
within the deadline. From the beginning of April 2016 to date, BCH’s SI compliance stands at 95% for incident reporting and 74%
for 72 hour report submissions.
NB - monthly numbers are small which impacts on percentages.
89
Content
NSCP
Summary
Within February 2017, NSCP reported 3 SI’s all of which pertained to pressure ulcers (see graph below). This brings the total
number of incidents for the year (from April 1st onwards) to 24 SIs.
6
5
Confidential Information
Leak
Diagnostic incident
4
Medication Incident
Slip, trips, and falls
3
Pressure Ulcer
2
1
0
1
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance
In February 2017, NSCP had a 100% compliance rate for reporting SIs with all SIs being reported within the expected timeframe
of 2 working days (in accordance to national policy). NSCP also achieved 100% compliance with 72 hour reports with all reports
due in February being received within the deadline of 3 working days. From the beginning of April 2016 to date, NSCP’s SI
compliance stands at 63% for both incident reporting and 72 hour report submissions.
NB - monthly numbers are small which impacts on percentages.
90
Content
Sirona
Summary
Within February 2017, Sirona reported 2 SIs both of which concerned South Gloucestershire patients. These pertained to
pressure ulcer incidents (see graph below). This brings the total number of incidents for the year (from April 1st onwards) to 19
SIs.
4
Pressure Ulcer
3
2
1
0
1
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance
In February 2017, Sirona had a 100% compliance rate for reporting SIs with both SIs being reported within the expected
timeframe of 2 working days (in accordance to national policy). Sirona also achieved 100% compliance with 72 hour reports with
all reports due in February being received within the deadline of 3 working days. From the beginning of April 2016 to date,
Sirona’s SI compliance stands at 100% for incident reporting and 90% for 72 hour report submissions.
NB - numbers are small which impacts on percentages.
91
Content
AWP
Summary
Within February 2017, AWP reported 6 SIs relating to BNSSG patients. These pertained to 5 apparent self-harm incidents and a
homicide by an outpatient (see graph to the left below). These incidents concerned 3 Bristol patients, 2 North Somerset patients
and a South Gloucestershire patient (see graph to right below). This brings the total number of incidents affecting BNSSG
patients this year (from April 1st onwards) to 66 SIs.
12
Apparent/actual/suspected self-inflicted harm
Abuse/alleged abuse of adult patient by staff
Disruptive/ aggressive/ violent behaviour meeting SI criteria
Homicide by Outpatient
Medication incident
Pending Review
Slip Trips & Falls
Sub-optimal care of the deteriorating patient
Unexpected Death
11
10
9
8
7
6
10
Bristol CCG
9
South Gloucestershire
CCG
North Somerset CCG
8
7
Other CCG
6
5
5
4
4
3
3
2
2
1
1
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
0
Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan Feb Mar
Compliance
In February 2017, AWP had a 100% compliance rate for reporting SIs with all 8 SIs being reported within the expected timeframe
of 2 working days (in accordance to national policy). The Trust achieved 88% compliance with 72 hour reports with 1 of 8 being
received after their deadline of 3 working days. From the beginning of April 2016 to date, the Trust’s SI compliance stands at
90% for incident reporting and 84% for 72 hour report submissions.
AWP currently have several RCA reports overdue and this is being followed up with both the Trust and Commissioners.
92
Content
SWAST
Summary
Within February 2017, SWAST reported 1 SI relating to the BNSSG locality. This pertained to a treatment delay and concerned a
Bristol patient (see graph to below). The total number of incidents affecting BNSSG patients this year (from April 1st onwards) is
9 SIs.
11
Bristol CCG
10
North Somerset CCG
9
8
South Gloucestershire CCG
7
Other CCG
6
5
4
3
2
1
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Compliance
In February 2017, SWAST achieved 100% compliance rate for reporting SIs with all SI’s being reported within the expected
timeframe of 2 working days (in accordance to national policy). The Trust had 0% compliance with 72 hour reports, with all 6
which were due, not being received within their deadline of 3 working days. From the beginning of April 2016 to date, the Trust’s
SI compliance for incidents stands at 96% for incident reporting and 53% for 72 hour report submissions. An issue was identified
with the Trust’s process for producing 72 hour reports which led to many being received overdue and it is hoped that this has
now been addressed.
NB - numbers are small which impacts on percentages.
93
Content
Other Providers
St Peter’s Hospice (SPH)
SPH reported 1 SI in February 2017. Therefore the total number of incidents, to date, in 2016/17 is 4.
Care UK NHS 111
Care UK NHS 111 have reported no SIs in February 2017. Therefore the total number of incidents, to date, in 2016/17 remains
2.
BrisDoc
BrisDoc have reported no SIs in February 2017. Therefore the total number of incidents, to date, in 2016/17 remains 3.
Content
94
Areas for Future Development
Content
95
•
The content of the BNSSG Quality Report will continue to evolve over the coming
months to include standardised quality measures reflected within the Quality
Schedules for 2017/19 which will allow the opportunity for benchmarking.
•
Going forward the report will include new sections pertaining to AQPs and
Safeguarding and will also explore SI themes. Other possible areas currently being
discussed include the Children’s Community Health Partnership and Care Homes.
•
Consideration is also being given as to how the CCGs can quality assure other
healthcare services pertaining to patients from the BNSSG area who receive care
outside of the locality e.g. RUH.
Content
96
Glossary
•
•
•
•
•
•
•
•
UHB – University Hospitals Bristol NHS Foundation Trust
WAHT – Weston Area Healthcare NHS Trust
NBT – North Bristol NHS Trust
BCH – Bristol Community Health
NSCP – North Somerset Community Partnership
Sirona – South Gloucestershire Community Services
AWP – Avon and Wiltshire Mental Health Partnership
SWAST – South West Ambulance Service NHS Foundation Trust
Content
97
Meeting of Bristol Clinical Commissioning Group
Planning and Performance Committee
To be held on Thursday 16th March 2017
commencing at 10.30am in Jill Shepherd’s Office
Performance Report March 2017
Reporting on January 2017 performance unless stated
Annex item 8
1
Purpose
This paper sets out the CCGs latest performance position. The focus is on the
CCG position, with appropriate provider detail behind it. The purpose is to
provide assurance to the committee that performance is well managed and
provide opportunity to challenge.
2
Report Summary
Performance key messages are given on page 5. Exception reports within the
report focus on underperforming areas, with emphasis on improvement actions.
Note that the position being reported is as up to date as the data available at the
time of writing. It may not always be coterminous with a particular month end
and may result in different reporting periods for different elements of the report.
3
How have service users, carers and local people been involved?
Patients and members of the public have not been involved in this process.
4
Implications on equalities and health inequalities.
Not applicable.
5
Evidence Informed Commissioning
Not applicable.
6
Financial Implications
Financial reporting is presented to the Financial Review Committee (FRC). This
committee will be informed about any relevant financial consequences of
performance and activity. For example, penalties levied on providers for under
performance or cost pressures from increased activity. This will flow through to
and be consistent with what is reported to FRC.
The CCGs financial position is a significant factor in NHS England’s assurance
review of us against the CCG Assessment and Improvement Framework.
7
Legal implications
Not applicable.
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 1 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
8
Risk implications, assessment and mitigation
The corporate risk register captures the risks relating to non-delivery of
performance expectations. This report and processes behind it inform our
assessment of these risks and activate actions to mitigate them.
9
How does this fit with Bristol CCG’s Operational Plan or Strategic
Objectives?
This report supports monitoring the delivery of the CCG 2016/17 plan.
10
Recommendation(s)
The Committee is asked to note and discuss the performance reported and
decide on any action required of staff, or be asked of other groups, to further
inform or improve the position.
Nicola Dunn, Chief Finance Officer (CCG)
Asifa Hojati, Performance Assistant (CCG)
Mark Sims, Contract Business Manager (CCG)
Page 2 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Contents
Page
1
3
5
10
13
26
Section
Cover Sheet
1. NHS Bristol Current CCG Assurance Framework Ratings
2. Performance Key Messages
3. Performance Against Core Standards
4. Exception Reports
5. Activity Review
List of Supporting Annexes – Those not listed for inclusion within the Governing Body
Papers are available on request through [email protected] or in writing to
Bristol CCG, South Plaza, Marlborough Street, Bristol BS1 3NX.
Annex
1
2
Title
CCG Assessment and Improvement
Framework scorecard
Glossary of Terms and Abbreviations
Planning &
Performance

Governing
Body


Page 3 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
1. NHS Bristol Current CCG Assurance Framework Rating
The CCGs assurance rating performance remains consistent with that previously
reported, with no change in rating since the end of 2015/16.
Assurance Framework Area
1.
Better Health
2.
Better Care
3.
Sustainability
4.
Leadership
Overall Rating
Rating
Requires improvement
Requires improvement
Requires improvement
Requires improvement
Requires improvement
2016/17 rating categories are: Outstanding, Good, Requires improvement and Inadequate.
Page 4 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Performance Key Messages
Bristol CCG Overall Position
 Following the sharp fall in December, driven by the large cohort of endoscopy surveillance
patients at NBT, Bristol CCG diagnostics improved in January but remains some way below
the national standard.
 Only one of the 8 cancer standards – Cancer 62 days (screening) was failed in January with
the overall Cancer 62 day standard being met for the third consecutive month. Although UHB
underperformed against the 62 day standard in January, they are no longer reporting
histopathology delays at NBT. A Cancer Alliance wide bid has been submitted to NHS
England of which Bristol is a key constituent. The CCG has been informed that they may
receive funding in relation to the recovery package and risk stratified follow-up, but there will
be additional work required on the current bid and the funding will not be available until later
in 17/19. The CCG is awaiting further information from NHS England.
 Continuing pressure across the BNSSG healthcare system continues to impact other areas
with 12 hour trolley waits increasing significantly again at both UHB and NBT. Ambulance
handover delays also rose at both Trusts but the new SWASFT Category 1 ambulance
performance measure met the 75% standard for the third consecutive month in Bristol. 4 hour
performance rose slightly at UHB but fell at NBT. Weekly BNSSG-wide A&E delivery board
teleconferences are established to monitor the 4 hour performance in an effort to reach 90%
be end of March. Temporary NHSE / NHSI oversight of A&E delivery board has been setup
through an Urgent Care Programme Board, Chief Executive membership.
 RTT performance continues the recent flat, but under performing, trend with UHB meeting
the standard for the third month but offset by NBT issues in MSK and Gynaecology. Contract
management processes and the RTT Delivery Board are working to address these areas.
Bid money from NHS England has been received and will be used immediately to increase
surgical rates at the weekend at NBT and UHB to address performance and backlog.
UH Bristol: There were three 52 week waiters in January. Two were due to patient choice and
the other, in cardiology, resulted from an admin error. However, the RTT 18 week incomplete
standard was met for the third consecutive month with February also expected to achieve
although there is a risk towards the end of April as a result of an increase in the size of the
elective waiting list. Although clearance of the backlog of follow-up patients for specialties with
non-recurrent funding is still behind plan, the list has not increased further and UHB have
assured that they have robust processes in place to identify risk of harm from delays.
January also saw 19 Trolley waits reflecting continued A&E performance below both trajectory
and standard – albeit slightly improved. 2 acute physicians have now started in post in the Acute
Medical Unit. Overall admissions were higher than last year and the greater proportion of
patients over 75 suggests higher acuity leading to more over 14 day stays and Delayed
Discharges. Pressure contributed to the performance of Last Minute cancellations worsening
and there were 4 28-day re-booking failures - above the agreed threshold of 3.
The Trust met 3 of its 6 national cancer standards in January. Cancer 62 day performance for
December dropped back below standard due to an increase in the number of benign skin cancer
cases and the effect of late/incomplete referrals from other providers. Late referrals from NBT,
however, have fallen and the overall performance for the quarter was above the national
average.
Diagnostics was below standard but an improvement on December. Although the routine
echocardiography backlog was addressed in January, patients waiting over 6 weeks for Sleep
Studies increased significantly as a result of capacity lost following the move of the service and
‘snagging’ issues. Sessions were also cancelled to free-up physicians to undertake additional
Page 5 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
ward rounds. Recovery is expected by April with further actions aimed at improving resilience.
Following issue of a Contract Performance Notice, a contract meeting has been held with the
provider to discuss poor performance in the following areas:
 Diagnostics
 Last minute cancellations and 28 days rebooking
 Follow-up waiting list reduction
 Appointment Slot Issues
 A&E 4 hours and ambulance handovers
 62 day cancer
 Referral to Treatment Time
Appropriate plans/trajectories are being put in place
NBT: Diagnostics remained well below the standard, in January, following identification of the
large cohort of endoscopy surveillance patients who had not been previously reported on the
national diagnostics submission. A root cause analysis will be shared through Quality sub-group.
Trolley waits rose from 18 to 29 where continuing 4 hour A&E pressure saw performance
remaining below standard. Despite implementation of the “winter bed” model in November, beds
remain in short supply and high admission rates have required the use of more escalation
capacity leading to high occupancy. Ambulance handover delays rose as a result and there were
two 28 day re-booking delays.
RTT 18 week performance was just under trajectory driven mainly by Trauma and Orthopaedics
and Gynaecology. A CPN was issued for Gynaecology 18 Week RTT on 06/01/17 and RAP
actions are underway. The Trust also failed to achieve the RTT backlog trajectory.
Cancer performance improved in January with the Trust delivering all of its 7 national targets. It
also exceeded the 62 Day standard for Quarter 3. Commissioners have formally lifted CPNs for
cancer 31 and 62 days but will raise one for 2 week waits.
BCH: There were fewer restrictions of service at the Urgent Care Centre in January; but BCH
state that this is due to overstaffing at a level that is not sustainable. However, a business case
for additional staffing for the UCC has not been approved as data showed that there was no
linkage between increased pressure at local EDs and when the UCC had restricted access.
Referrals to the Podiatry service are now within the 10% tolerance level and, whilst still an area
of concern for BCH/commissioners, are no longer classed as a formal “cause for concern”.
However they will continue to be closely monitored.
The Elderly service is predominately for older people who require domiciliary physio or OT. Most
referrals are routine but some are urgent and the case mix has changed over the past twelve
months. The Elderly service RTT <18 week performance is currently 28.2% against 95% target
due to an increase in referrals and changing acuity of caseload leading to increased contacts
required. This is a slight improvement on M9. The service is forecasting a year end breach for
RTT <18 week target which cannot be recovered. The provider’s request for a restriction on
referrals to Elderly service was not supported by the CCG Leadership Group. However, the
Group has asked commissioners to work with BCH to look at appropriate alternatives for routine
referrals into the Elderly service.
The Muscolo-Skeletal physio service is forecast to meet the 95% target month on month but will
not recover YTD target due to the transfer of patients from Sirona in April 2016.
Page 6 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
AWP (Inpatients): Inpatient services continue to perform well against almost all access
indicators. Larch ward continues to facilitate discharge through its step-down function and out of
area bed usage has reduced since Larch became operational. Across the Trust out of area
placements have reduced significantly with only 4 service users currently placed out of Trust.
However, Delayed Transfer of Care rates across the Trust continue to rise with the number of
Bristol CCG DTOCs increasing slightly in January from 12.2% to 13.1% and the total number of
DTOCs on Bristol wards also increasing. The AWP Inpatient Head of Operations continues to
have a weekly conference call with Bristol CCG and BCC to reviews all delays, including
DTOCs. Discharge countdown processes have been implemented on all wards to improve action
allocation within AWP and with partner agencies. Most DTOCs are due to the need for specialist
placement or no provider being identified for social care placements; BCC and the CCG have
agreed to escalate this issue. Bristol CCG and BCC have created a joint role from Better Care
Fund to support improvements in DTOCs, and have created a Project Plan to support this.
Improved action tracking of the DTOC conference call has been implemented to better track
actions, progress and appropriate escalations. Improvements are still required to ensure timely
addressing of actions, particularly from the Local Authority. Information has been requested as
to appropriate targets and timescales for decision making to support action and / or escalation. A
system wide DTOC group has been proposed to be manged through ICQPM and will be taken
forward at the next meeting. Each CCG has been asked to provide a paper to the next ICQPM
which outlines actions being taken to reduce DTOCs.
SWASFT: Trust wide performance for the new Category 1 incident response was below the 75%
target at 71.16%, showing an upward trend from December which was 69.70% and a year to
date overall performance of 70.89%. Overall activity remains under plan, although for December
there has been year on year growth of 2.71% overall.
The provider continues to show improvements in performance and is taking action around
recruitment and retention to improve the resource position. SWASFT is also in the process of
revising operational rotas which will look to better match resource against demand and improve
performance. A programme of fleet investment is intended to address an imbalance between
Rapid Response and transporting needs, which is an identified issue when operating within the
Ambulance Response Programme.
Care UK (111): There was underperformance in January against 60 seconds call answering
(93.9% against 95% standard), ED referrals (7.3% against 5% standard) and ambulance
referrals (10.6% against 10% standard). 60 seconds call answering dropped due to one day of
significant underperformance (2 January), when call volumes significantly outstripped forecast in
the morning period (possibly due to patients not realising that GP practices would be closed as
this was a bank holiday). Although the provider managed to secure an additional 40 hours that
morning, it was insufficient to match demand. If performance on this day was excluded, the
provider would have achieved 95% for the month. Almost all national providers experienced the
same pressures with a subsequent impact on call answering performance.
Strong performance continues in call abandonment (0.9%, ahead of 5% standard), calls
transferred to a clinical advisor (34% against 30% standard), and the combined warm transfer
and call back in 10 minutes measure. This is particularly good given the clinical workforce
shortfall within the service.


Contract Performance Notices and associated Remedial Action Plans remain in place for
ED referrals and ambulance referrals (both CQUINs). The key challenge continues to
relate to workforce, particularly for clinical advisors. Mitigating actions are as follows:
3 Clinical Advisors are currently in training. Clinical staffing levels are at their highest for
12 months.
Page 7 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017





Increasing applications to the service, by attending job fairs, recruiting via agencies. The
provider is now also offering a “referral” bonus for clinical staff.
Continued use of the ambulance validation interception line (exceeding validation target of
50% set by NHS England).
ED referral line continues at peak times. Of those calls validated, circa 70% are diverted
to an alternative service.
Ongoing use of the clinical prioritisation model to ensure the most acutely unwell patients
are managed first, as well as the Bridge which ensures demand is evenly profiled across
the Care UK network to support KPI delivery.
Next Remedial Action Plan review meeting to be held 10 March.
GP Out of Hours: Whilst demand remained high, performance for clinical advice was strong this
month with the KPI for a two hour call back being achieved. This was due to a focus on
designating “advice only” shifts in the clinical rota to improve patient flow and safety.
Performance for Urgent face to face appointments was 88% against a target of 95%, as the
emphasis for performance has been put on the potentially higher risk patient group who are
waiting at home to be called.
Independent Sector: Activity volumes at IS providers are improving following the expected
Christmas drop off. However the Care UK activity still has not risen back up to its previous levels
at April. Revised IMAS models have been received by providers prepared to inform the RTT
Choice project. These were presented at the Trauma & Orthopaedics steering group and will be
discussed further at the next RTT Programme Board. Care UK, Spire, Circle Bath and SSS are
engaging in the project on waiting list transfers out from NBT to help reduce the 18 week wait
patients. The IFR team have undertaken Q2 CBA audits and these have highlighted that there
are some policies in Nuffield Health and Care UK that are not being adhered to. The CCG is
expecting refunds of approximately £45k following these audits.
Community Children’s Health Partnership (lead provider Sirona care and health): The most
recent performance report is for December 2016. However, as most services are reliant on
manual data entry from paper records, there is a time lag in getting accurate data.
Community Children’s Health Partnership - CCG commissioned services
Community Paediatrics wait times show a slight improvement over the year; up to 93.1% in
December, but poor performance in July 2016 means that the year to date, at 91.3%, is below
target.
Physiotherapy performance dipped in December but this may be due to data lag. The year to
date performance is 98.4%. Occupational therapy performance dipped in November and
December, but the year to date performance is on target at 90%. Speech and Language therapy
performance was also poor in November and December and is below target for the year to date
at 84%. An action plan is in place to meet the 18 week target by the end of March.
The did not attend (DNA) rate for all services had improved in November, but dipped again in
December to 6.5% against a target of 6%. Poor performance over the summer months means
that the year to date rate is 6.5%.
The percentage of health contributions to Education Health and Care (EHC) Plans on time is
below target at 81% in the year to date. There have been some IT and administrative issues
contributing to this which are being addressed.
Page 8 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Community Children’s Health Partnership - Public health commissioned services
There have been small improvements in Health Visitor performance with a slight increase
against all main key performance indicators. However overall performance is well below target.
Only 53% of families having their new born visit within 14 days and only 86% ever having a visit.
Only 56% of twelve month reviews were completed on time, although 74% had a visit by 15
months. The proportion of children having a 6-8 week review was better with 81% receiving a
review against a target of 90%. Public Health commissioners are working directly with this
service, which is delivered by Bristol Community Health in Bristol, to develop a recovery plan.
An Action Plan will be required in response to BCH’s CQC Inspection which identified children’s
services as requiring improvement. This is expected by the end of March.
Jointly commissioned services (CCG and Local Authority)
Child and Adolescent Mental Health Service (CAMHS) is showing improvement. The DNA
rate was down to 5% in December against a target of 7.2%, and has been continuously
improving since September. Year to date performance for the number of children having a first
(choice) appointment within 8 weeks is on target at 90%. The percentage having their second
(partnership) appointment within 10 weeks has improved throughout the year and was 100% in
December. Overall performance against the 18 week target was up to 94% in December.
Looked After Children’s Health. The proportion of looked after children with an up to date
health assessment is well below target in Bristol. In December only 69% of eligible children had
an up to date health assessment, against a target of 90%. The provider has completed a
detailed root cause analysis and a recovery plan is in place with monthly review meetings.
Additional clinics have been arranged and all children without an up to date health assessment
have been given an appointment before the end of March. A Contract Performance Notice will
be issued if improvements are not made as a result.
IAPT Recovery Rate: Despite a seasonal drop in December and January, the performance
trend remains upward and on track to achieve the 50% target by the end of Q4.
NHSE Recovery Funding is being used to work with AQP partner providers to support
improvements including marketing and awareness-raising, top-up treatment and changes to
attendance approaches. One provider is trialling “Big White Wall” online therapy and has already
demonstrated an improvement.
The Service Improvement Plan is updated regularly and Recovery is a standing item on the IAPT
Provider Forum agenda. Weekly individual therapist performance figures are also sent to all
providers.
Bristol waiting lists for Step 2 therapies have been reduced to near zero. However, demand for
Step 3 1:1 therapies remains high indicating the high complexity of referrals to this service.
Referrals continue to be gathered from a wide range of the population using web-based
resources such as webinar-based course delivery and on-line course listings. The online therapy
provider, SilverCloud, has been commissioned as a pilot to deliver to clinically suitable
individuals. This launched mid-February and impact is still to be analysed.
Page 9 of 27
2. Performance Against Core Standards (NB: All figures are for Bristol CCG except where noted and where the described
standard is shaded purple)
Cancer Wait Times
Planned Care
NHS Constitution
Standard
RTT:
Incomplete
pathways
52 w waits
admitted
(unadjusted
for choice)
52 w waits
non-admitted
52 w waits
incomplete
Diagnostic 6
week wait
Cancer 2
week – all
Cancer 2
week – breast
symptoms
Cancer 31 day
st
1 treatment
Cancer 31 day
subsequent
treatments –
surgery
Cancer 31 day
subsequent
treatments –
drugs
Cancer 31 day
subsequent
treatments –
Radiotherapy
Cancer 62
days from GP
referral
Cancer 62
days from
referral –
screening
Cancer 62
days from
referral –
consultant
upgrade
Quarter 1
Target
Quarter 2
15/16
Quarter 3
Q1
Apr
May
Jun
Quarter 4
Q2
Jul
Aug
Sep
Q3
Oct
Nov
Dec
Jan
Feb
Q4
YTD
Mar
92%
91.04%
90.76%
90.66%
90.80%
90.80%
90.32%
90.13%
89.99%
89.99%
90.27%
90.38%
90.29%
90.29%
90.62%
90.62%
90.62%
0
27
27
19
20
20
40
37
22
22
29
25
34
34
48
48
48
0
22
20
15
22
22
23
23
18
18
13
18
19
19
19
19
19
0
21
21
18
20
20
17
13
11
11
8
15
16
16
15
15
15
99%
98.78%
98.58%
98.68%
97.88%
97.88%
97.49%
96.15%
95.55%
95.55%
98.12%
97.57%
93.33%
93.33%
95.04%
95.04%
95.04%
93%
94.87%
94.40%
94.61%
93.31%
94.10%
94.56%
89.88%
91.97%
92.07%
93.56%
93.21%
93.57%
93.44%
94.09%
94.09%
93.29%
93%
93.85%
94.23%
97.78%
90.32%
93.71%
96.30%
89.13%
93.62%
93.20%
75.00%
100.00%
90.91%
89.47%
97.06%
97.06%
92.73%
96%
95.63%
96.08%
95.93%
95.00%
95.67%
98.16%
95.74%
98.94%
97.59%
97.59%
97.44%
98.27%
97.75%
98.27%
98.27%
97.17%
94%
94.99%
96.15%
93.02%
96.77%
95.00%
100.00%
94.29%
100.00%
98.29%
100.00%
97.92%
97.56%
98.50%
100.00%
100.00%
97.71%
98%
98.66%
98.18%
100.00%
100.00%
99.33%
98.04%
98.28%
98.15%
98.16%
96.23%
100.00%
100.00%
98.72%
100.00%
100.00%
98.88%
94%
96.09%
98.36%
95.56%
98.25%
97.55%
97.83%
98.39%
95.16%
97.06%
93.65%
98.51%
100.00%
97.22%
94.67%
94.67%
96.94%
85%
81.38%
83.91%
80.91%
81.63%
82.03%
83.33%
85.48%
80.51%
83.14%
83.33%
87.72%
86.32%
85.85%
89.09%
89.09%
84.25%
90%
84.48%
66.67%
37.50%
90.91%
68.18%
81.82%
88.89%
91.67%
87.50%
100.00%
100.00%
100.00%
100.00%
83.33%
83.33%
85.19%
95.48%
96.55%
100.00%
100.00%
98.70%
96.15%
77.78%
93.10%
89.02%
95.65%
97.22%
87.50%
93.41%
94.74%
94.74%
93.68%
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 10 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Cancelled Operations
Ambulance
Urgent Care
NHS Constitution
Standard
4 hour waits in A&E
UHB
4 hour waits in A&E
NBT
Ambulance hand
over delays >30
minutes UHB
Ambulance hand
over delays >30
minutes NBT
Ambulance hand
over delays >60
minutes UHB
Ambulance hand
over delays >60
minutes NBT
12 Hour Trolley
Waits UHB
12 Hour Trolley
Waits NBT
Red Response
CCG
Red Response
SWASFT
Cat 1 Response
CCG
Cat 1 Response
SWASFT
Mixed Sex
Accommodation
breaches (CCG)
Cancelled
Operations not
rebooked within 28
days UHB
Cancelled
Operations not
rebooked within 28
days NBT
Numbers of Urgent
Operations
cancelled for a
second time (CCG)
Care Programme
Approach 7 day
follow up
Quarter 1
Target
Quarter 2
15/16
Quarter 3
Q1
Apr
May
Jun
Quarter 4
Q2
Jul
Aug
Sep
Q3
Oct
Nov
Dec
Jan
Feb
Q4
YTD
Mar
95%
90.43%
87.17%
91.66%
88.99%
89.32%
89.33%
90.01%
87.33%
88.89%
82.94%
78.45%
79.64%
80.35%
80.37%
80.37%
85.57%
95%
84.98%
77.12%
76.16%
82.18%
78.47%
79.42%
78.76%
83.71%
80.62%
76.57%
80.72%
77.95%
78.34%
75.31%
75.31%
78.80%
0
918
53
56
84
193
70
97
115
282
135
110
93
338
122
122
935
0
282
102
118
133
353
93
98
74
265
151
52
67
270
114
114
1002
0
184
9
16
30
55
7
28
25
60
26
9
21
56
16
16
187
0
28
7
4
6
17
1
0
3
4
4
1
7
12
2
2
35
0
12
0
1
0
1
0
0
1
1
2
1
11
14
19
19
35
0
3
2
0
0
2
0
0
1
1
3
0
18
21
29
29
53
75%
73.01%
75.22%
76.74%
75.45%
72.43%
74.32%
70.66%
72.52%
71.43%
71.43%
73.60%
75%
66.75%
69.04%
69.86%
68.96%
65.95%
69.13%
69.83%
68.21%
67.22%
67.22%
68.38%
75%
72.63%
77.35%
78.08%
77.22%
75.77%
75.77%
76.78%
75%
66.56%
72.85%
69.70%
70.76%
71.16%
71.16%
70.89%
0
0
0
0
0
0
0
0
0
0
3
0
3
1
1
4
0
76
23
2
2
27
4
3
0
7
3
6
4
13
4
4
51
0
52
2
2
3
7
3
0
0
3
2
1
2
5
2
2
17
96.19%
Not
measured
for
Months
93.21%
Not
measured
for
Months
95.86%
Not
measured
for
Months
95.73%
Not
measured
for
Months
0
95%
Page 11 of 27
94.95%
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Page 12 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
DTOCs
Mental Health Access Waits
IAPT
HCAI
Other Key
Performance
Indicators
MRSA – number of
cases (CCG)
C Diff – number of
cases (CCG)
Quarter 1
Target
0
Quarter 2
15/16
Quarter 3
Q1
Apr
May
Jun
17
1
2
0
134
8
14
14
65.10%
66.40%
Quarter 4
Q2
Jul
Aug
Sep
3
2
2
2
36
11
16
10
69.40%
68.80%
69.30%
Q3
Oct
Nov
Dec
6
2
3
0
5
37
6
10
8
24
69.40%
70.20%
70.10%
Q4
YTD
2
2
16
13
13
110
Jan
Feb
Mar
Dementia %
Diagnosis Rate
66.6%
Access to
psychological
therapy services
15%
13.44%
16.47%
13.59%
13.50%
14.52%
13.61%
13.31%
12.49%
13.14%
16.16%
17.96%
11.96%
15.36%
14.62%
13.91%
14.26
%
14.33%
Psychological
therapy services
recovery rate
50%
39.36%
49.06%
45.54%
47.76%
47.49%
45.25%
47.52%
44.37%
45.73%
48.89%
51.91%
44.24%
48.46%
45.27%
49.24%
47.05
%
47.18%
95%
98.90%
100.00%
100.00%
99.64%
98.98%
98.99%
100.00%
99.33%
99.77%
99.81%
99.78%
99.79%
99.61%
99.77%
99.68
%
99.60%
95%
99.47%
100.00%
100.00%
99.80%
100.00%
100.00%
100.00%
100.00%
99.89%
100.00%
100.00%
99.96%
100.00%
100.00%
100.0
0%
99.93%
75%
93.41%
94.25%
94.17%
93.95%
93.88%
94.95%
95.00%
94.61%
96.36%
96.93%
96.12%
96.49%
97.28%
97.69%
97.46
%
95.46%
75%
88.77%
96.10%
97.40%
93.74%
97.42%
98.00%
97.86%
97.75%
98.03%
99.01%
99.11%
98.69%
98.18%
98.47%
98.33
%
97.02%
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
#N/A
IAPT % of people
<18 weeks from
referral to entering
treatment against
completed
episodes
IAPT % of people
<18 weeks from
referral first
treatment against
number who enter
treatment
IAPT % of people
<6 weeks from
referral to entering
treatment against
completed
episodes
IAPT % of people
<6 weeks from
referral first
treatment against
number who enter
treatment
*** Delayed
Transfers of Care To Be Added ***
#N/A
#N/A
Page 13 of 27
71.30%
#N/A
3. Exception Reports
Exception reports are provided for the following areas where performance is red
or amber* (under target) for the month of January 2017 (December 2016 for
UHB and NBT Cancer) and for where commissioners have significant concerns.










Referral To Treatment Times Incomplete Pathways
52 Week Waits
Diagnostics
Cancer 62 day from GP Referral
4 Hour Waits in Accident and Emergency (UHB and NBT)
Ambulance Handover Delays >30 Minutes and >60 Minutes
SWAST Category 1 Ambulance Response
Cancelled Operations not Rebooked within 28 Days (UHB and NBT)
12 hour Trolley Waits
IAPT Psychological Therapy Services Recovery Rate
*In absence of national definitions the ‘amber’ threshold is determined as 10% of target
Please note that, whilst cancer data reflects the latest month available, the
associated trust-related commentary reflects the previous month.
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 14 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Referral To Treatment Times Incomplete (92%) (January)
Bristol CCG
90.62%
UHB
92.20%
NBT
86.19%
Bristol CCG
Performance at the end of January improved from 90.29% to 90.62%.
UHB
The 92% national standard was met at the end of January, with reported performance
of 92.2% against the recovery forecast of 92.0% (see Appendix 3). The number of
patients waiting over 40 weeks RTT at month-end decreased in January but remained
high, mainly due to continued theatre capacity pressures in the Division of Women’s &
Children’s, which is expected to improve from April.
NBT
The Trust marginally failed to achieve the RTT trajectory in month with performance of
86.19%. The Trust also failed to achieve the RTT backlog trajectory. Underperformance
was driven mainly by Trauma and Orthopaedics.
Mitigations
Commissioners continue to promote the use of appropriate alternative providers, at
point of referral, through the local choice support centre. In addition, the Bristol referral
service triages referrals for 95% of the population resulting in 9% of referrals being
returned. All orthopaedic referrals are made via the MATS interface service and several
new Individual Funding Request policies, covering orthopaedic work were implemented
on 1st July and further policies in October.
UHB: The recovery plan continues to be implemented and monitored through weekly
escalation meetings with Divisions. Specialty specific actions are also in place. A
BNSSG programme board work plan is in place. The Trust is discussing a strategy for
dermatology for BNSSG with commissioners factoring in the closure of Taunton
service. IMAS capacity and demand modelling re-run is in place and meetings are
being held as part of the annual Operating Plan cycle, with specialties having produced
delivery plans to enable demand to be met.
NBT: Remedial action plans are in place to monitor progress across a number of
specialties who are not meeting the constitutional standards. Thoracic Medicine and
Gynaecology at a specialty level failed to meet their planned incomplete performance
levels. A refreshed plan has been provided for Gynaecology. Progress against the
Elective Intensive Support Team action plan is being monitored via the monthly RTT
General Manager group chaired by the Director of Operations. Key focus areas include
Operational Management/Training, further Capacity & Demand modelling and
improving BI reporting.
Page 15 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
March 2017
Claire Thompson
52 Week Waiters Incomplete Pathways (Limit 0) (January)
Bristol CCG
15
UHB (total)
3
NBT (total)
39
Bristol CCG
The number of 52 week waiters improved slightly in January to 15 compared to 16 in
December.
UHB
There were three over 52-week waiters, two (paediatric) due to patient choice and one
(cardiology) due to an administrative error.
NBT
The Trust continues to meet the trajectories for Neurosurgery and Epilepsy at the end
of December. Orthopaedic Spines performance is failing against recovery trajectory due
to patient choice. The Trust has also reported in month breaches in Orthopaedics (non
Spinal) related to patient choice issues, and is forecasting between 5 -10 per month for
the remainder of the year. RCAs have been completed for all of these breaches.
Mitigations
Commissioners are assured that all long waiting patients on RTT pathway are actively
reviewed in line with a standard operating procedure designed to identify any risk of
harm and expedite treatment of patients if required.
UHB: The Trust is working to reduce non-admitted backlog to mitigate the risk of
conversion to admitted pathways. An additional Medway/System C function is being
tested to mitigate the risk of incorrectly listing patients.
NBT have Remedial Action Plans and recovery trajectories in place for all >52 week
waiters. The Neuro / Epilepsy trajectory has been re profiled; whilst the clearance date
remains unchanged, improvements month on month have been evened out.
Q3 2017/18
Claire Thompson
Page 16 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Diagnostics (99%) (January)
Bristol CCG
95.04%
UHB
98.4%
NBT
88.40%
Bristol CCG
Diagnostic performance improved from 93.33% in December to 95.04% in January.
However, overall Bristol CCG failed to achieve the 99% target.
UHB
Performance against the 99% national standard was 98.4% in January. Although the
backlog of routine echocardiography scans was addressed in January, the number of
patients waiting over 6 weeks for a Sleep Studies test increased significantly. This was
a result of service capacity lost due to the physical move of the service and associated
‘snagging’ issues with the new facility, along with sessions having to be cancelled to
free-up physicians to undertake additional ward rounds. Additional sessions are being
undertaken reduce the number of long waiters.
NBT
The Trust failed to meet its recovery plan; the primary reason was identification of a
large cohort of endoscopy surveillance patients who had not been previously reported
on the national diagnostics submission.
Mitigation
Commissioners have requested further clarity to the reasons behind the backlog of
surveillance patients at NBT. Clarity is also being sought to the length of delays and
whether the Trust is on track with its weekly recovery trajectory. The CCG has been
working closely with both trusts to divert endoscopy referrals to other providers at the
point of referral, and have written to all GPs to request that all suitable patients are
referred to other providers. Commissioners continue to promote the use of alternative
routine endoscopy capacity and the Bristol referral service ensures that appropriate
options are selected. UHB has put a notice on ICE alerting referrers to the capacity
issues and where there is suitable capacity at other providers.
UHB: The Trust is aiming to run additional sessions/increase capacity for sleep studies,
CT cardiac and MRI. It is also trying to increase adult endoscopy capacity through
recruitment, training, WLIs, use of Glanso, and outsourcing of routine work. The action
plan has been refreshed in response to the CPN that was raised.
NBT: The clinical validation of the surveillance patients has now concluded and an RCA
will be shared with the Quality Sub Group. Additional capacity (including the use of
other providers) did not begin as originally planned but the Trust remains confident of
clearing the backlog by the original date of the end of March 2017.
UHB: April 2017/NBT: TBA
Claire Thompson
Page 17 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Cancer 31 Day Surgery (94%) (January)
Bristol CCG
100.00%
UHB
92.86%
NBT
94.19%
Bristol CCG
Bristol CCG met the 94% standard in January with performance of 100.00%
UHB
UHB under achieved against the 94% target in January with performance of 92.86%
NBT
The Trust achieved the 94% standard in January with performance of 94.19%.
Mitigations
Histopathology reporting delays have now largely been addressed. A local CQUIN
came into effect on the 1st October, along with a national policy for ‘automatic’ breach
reallocation of late referrals. Formal reporting changes will be brought in nationally from
2017/18.
UHB: An improvement plan continues to be implemented to minimise avoidable delays.
Recovery Expected: February 2017
Alison Moon
Page 18 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Cancer 62 Day GP Referred (85%) (January)
Bristol CCG
89.09%
UHB
84.66%
NBT
88.79%
Bristol CCG
Bristol CCG met the 85% standard in January with performance of 89.09%.
UHB (December)
December’s performance was 81.5% against the 85% 62-day GP standard, and a
trajectory of 85.1%. Unusually, the 85% standard was not met for internal pathways
(due to delayed diagnostics and lack of surgical capacity) with performance at 82.8%.
Performance continues to be impacted by factors outside of the control of the Trust,
including late referrals and medical deferrals. A CQUIN came into effect on the 1st
October, along with a national policy for ‘automatic’ breach reallocation of late referrals.
Adjusted performance based upon the reallocation rules would have been 84.4%.
NBT (December)
The Trust passed the 62 day national standard for December 2016 with a performance
of 90.2% against the 85%. The Trust also passed Q3 with a performance of 88.56%.
Mitigations
Histopathology reporting delays have now largely been addressed. A local CQUIN
came into effect on the 1st October, along with a national policy for ‘automatic’ breach
reallocation of late referrals. Formal reporting changes will be brought in nationally from
2017/18.
UHB: An improvement plan continues to be implemented to minimise avoidable delays.
This includes a deputy cancer manager now in post, internal KPI monitoring, a new
cancer PTL summary and review of ideal timescales.
NBT: The Trust continues to monitor performance against the new national breach
reallocation guidance which commences from April 2017. If the guidance had been
applied to December’s performance there would have been a decrease in performance
to 90.00%. Applying the BNSSG CQUIN breach reallocation guidance the Trust would
still exceed the national performance standard with a performance of 88.88%.
Commissioners are now considering lifting the Contract Performance Notice following 4
confirmed months of achievement.
Recovery Expected: February 2017
Alison Moon
Page 19 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
A&E 4 Hour Performance (95%) (January)
UHB
80.4%
WAHT
63.69%
NBT
75.31%
Please note that ,whilst the Bristol population is seen at UHB and NBT, Weston is
shown above for comparison
UHB
The 95% national standard was not achieved; trust-level performance improved to
80.4% but was below the in-month trajectory (88.5%). Levels of emergency admissions
via the BRI ED were 3.3% down on the same period last year, although total
emergency admissions into the BRI were up by 4.7%. The number of over 14 day stays
and the number of bed-days consumed by Green to Go (Delayed Discharge) patients
has increased, resulting in a rise in BRI bed occupancy above the 2015/16 seasonal
norm. Actions continue to be taken to manage demand and reduce length of stay.
NBT
Overall January performance against the 4 hour target was 75.31%, with waiting for a
bed being the main cause of breaches, followed by awaiting Emergency Department
(ED) assessment. The ‘winter bed’ model was implemented across the Trust on 24th
November and focus during January has been to continue to embed the revised
systems and processes required to implement the new winter model. Surgical
Assessment and Surgical Short Stay are now embedding new processes and improving
flow. Despite the allocation of additional beds to Medicine as part of the model,
admission rates during January has required more escalation capacity to be available
resulting in the Trust operating at a very high occupancy level. Consequently the Trust
has remained predominately in red and black escalation levels and has impacted
negatively on flow and the delivery of ED targets.
Mitigations
Performance of the BNSSG system is monitored at the Urgent Care Delivery Board,
which also coordinates system wide actions.
UHB: Trust actions from STF plan are monitored at APG. A revised plan following NHSI
“Critical Friend" visit (scheduled for 28th February) will include an estimate of breach
savings for each action. Current actions include: prediction/management of demand,
management of flow, improving communications, admission avoidance and improving
discharges. An action is in place to improve experience for frequent ED attendees.
NBT: The ‘winter bed’ model was implemented across the Trust on 24th November and
focus during January has been to continue to embed the revised systems and
processes required to implement the new winter model. Surgical Assessment and
Surgical Short Stay are now embedding new processes and improving flow.
Recovery: Not in 2016/17
Claire Thompson
Page 20 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Ambulance Handover Delays >30 and >60 Minutes (Limit 0) (January)
UHB
>30 = 122
>60 = 16
WAHT
>30 = 87
>60 = 20
NBT
>30=114
>60=2
UHB
Performance against the >30 mins standard deteriorated in January, with ambulance
handovers >30 minutes reaching 122 compared to 93 in December. However, there
was an improvement for handovers >60 minutes with the Trust reporting 16 compared
to 21 in December.
NBT
The Trust met its Ambulance handover trajectory for >1 hour in January.
Mitigations
Commissioners recognise that the key to the recovery of this standard is successful
implementation of urgent care plans that focus on patient flow throughout the hospital.
SCWCSU is liaising with UHB and SWASFT to fully align reporting of the number of
ambulance handovers.
UHB performance is monitored against an STP trajectory.
Recovery: Not in 2016/17
Claire Thompson
Page 21 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Ambulance Response for January
Following a new code set trial, a new Category 1 response measure was introduced on
the 25th October, replacing the Red Response Category.
New Category 1 Responses (75%) January
SWASFT
71.16%
Bristol CCG
75.77%
SWASFT
Trust wide performance for the new Category 1 incident response was below the 75%
target at 71.16%, showing an upward trend from December which was 69.70% and a
year to date overall performance of 70.89%. Overall activity remains under plan,
although for December there has been year on year growth of 2.71% overall
Bristol CCG
Bristol CCG area met the 75% target, with performance of 75.77% for January. This is
deterioration from December which was 78.08%. Year to date performance is 76.78%
which is above the target. For Bristol CCG area activity was 7.22% under plan and
showed a reduction in year on year activity of 6.59%. Part of this is could be
attributable to profiling across the year but can also be attributable to the commissioner
demand management plans in place.
Mitigation
SWASFT continue to show improvements in performance and are taking actions
around recruitment and retention to improve the resource position
SWASFT are in the process of revising operational rotas which will look to better match
resource against demand and improve performance.
The provider also has a programme of fleet investment to address an imbalance
between Rapid Response and transporting needs which is an identified issue when
operating within the Ambulance Response Programme.
Recovery Expected : TBA
Nicola Dunn
Page 22 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
12 Hour Trolley Waits (Limit 0) (January)
UHB
19
NBT
29
WAHT
70
UHB
UHB reported 19 x 12 hour Trolley breaches in January.
NBT
NBT reported 29 x 12 hour Trolley breaches in January.
Mitigations
Winter pressures across A&E have resulted in a large increase in the number of
breaches at both Trusts.
Breaches trigger production of an incident report to be produced within 72 hours.
Commissioners monitor breaches, for both UHB and NBT, via the respective ICQPMG
and sub groups.
Recovery TBA
Claire Thompson
Page 23 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
Cancelled Operations not Rebooked within 28 Days (Limit 0) (January)
UHB
4
NBT
2
UHB
Four patients cancelled in December were readmitted outside of 28 days. This equates
to 93.1% of cancellations being readmitted within 28 days, which is below the former
national standard of 95%. Emergency pressures continues to be the predominant
cause of cancellations this month, with ward bed availability, emergency patients
needing to be prioritised, and a lack of High Dependency / Intensive Therapy Unit beds
(due to these being occupied by emergency patients), making-up 61% of all
cancellations.
NBT
In month, there were two breaches of the 28 day re -booking target. One breach was in
General Surgery resulting from staff sickness. The other breach was in Urology due to
theatre staffing issues.
Mitigations
Commissioners continue to monitor underperformance at both UHB and NBT via the
ICQPMG and Access performance Groups.
UHB: An action plan to reduce elective cancellations continues to be implemented and
has been refreshed as part of CPN issued
NBT: The Trust’s elective winter plan came into effect on 12th December. This aims to
reduce pressure on the bed base, preventing future cancellations resulting from bed
shortages.
Recovery TBA
Nicola Dunn
Page 24 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
IAPT Psychological Therapy Services Recovery Rate (50%)
Bristol CCG
45.27% (January)
Bristol CCG
Unvalidated data shows Bristol CCG’s IAPT Recovery Rate at December - 44%, Jan 17
- 46%, Feb 17 - 51%.
Mitigations
Bristol’s Recovery Rate continues to be regularly monitored by commissioners and
NHS England. The general trajectory over the past year has been upward and
commissioners remain confident that this will continue and that Bristol will be close to
achieving the 50% target by the end of Q4. The temporary drop in December and
January is seasonal and correlates closely with a higher than average number of DNAs.
NHSE allocated a set sum of Recovery Funding to each CCG, to be used specifically to
support improvements to IAPT recovery in Q4. Bristol commissioners continue to work
in partnership with the Bristol AQP providers to implement the actions in the project
plan. The money is being used to support marketing and awareness-raising among the
general public, additional top-up treatment doses to individuals who are close to
recovery at the end of treatment, system-wide changes to attendance approaches, and
a contribution to one provider who is trialling Big White Wall online therapy with a small
number of clients. This is already demonstrating an improvement.
The IAPT Service Improvement Plan is adapted and updated regularly in partnership
with all providers to ensure that it reflects the current situation. A recovery rate is a
standing item on the IAPT Provider Forum agenda, ensuring that the issue remains live
with providers. Weekly reports on individual therapist recovery figures are also sent to
all providers for discussion in clinical supervision and to support learning.
Reducing waiting times is a key to ensuring that people recover and the recent waiting
list initiative has seen Bristol waiting lists for Step 2 therapies reduce to close to zero.
Unfortunately, the demand for Step 3 1:1 therapies remains high; this is indicative of the
high rate of psychological complexity of referrals to the service.
The service continues to take a proactive approach to gathering referrals from a wider
range of the population of Bristol, using a range of web-based resources such as
webinar-based course delivery, creating a live listing of available courses, and the
online therapy provider, SilverCloud, has been commissioned on a pilot basis to deliver
Page 25 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
online therapies to clinically suitable individuals. This launched mid-February and
impact is still to be analysed.
Some Recovery Achieved and Expected to
continue during Q4 2016/17
Jill Shepherd
Page 26 of 27
Meeting of Bristol CCG Planning and Performance Committee 16th March 2017
5.
Activity Review
Compared with the operational plan submission, in the first nine months of 2016/17,
Bristol CCG has seen reduced levels of activity in referrals, first and follow up
outpatients, and both elective and non-elective admissions. A&E attendances are over
plan.
In outpatients first attendances, although the overall CCG plan is underperforming,
UHB have seen a 4.4% increase when comparing the 2016/17 month 10 position to the
same period in the previous year. NBT have seen a larger increase of around 7.8% in
outpatient firsts in comparison to the same period last year. There has also been a
cumulative fall in independent sector outpatient firsts, although this is primarily at Care
UK.
Outpatient follow-ups have seen an increase of 24.1% at NBT, and a smaller but still
considerable rise at UHB, 6.7%, when comparing months 1 to 10 of 2015/16 and
2016/17. It is likely that data issues arising from NBT’s move to Lorenzo have affected
their 15/16 outpatients follow-up numbers. Overall, independent sector follow-up
appointments have increased by 2.4% when compared to the previous year.
In terms of elective care (including both elective inpatients and day cases), when
comparing the two month 10 positions, UHB have seen a slight -1.9% decrease in
activity. At NBT, there has been an increase of 6.5% in day cases & elective inpatient
care. There has also been a decrease overall in Independent Sector activity, again
primarily at Care UK.
For emergency care, UHB has seen an increase of 1.6% between the first ten months
of 2015/16 and the same period 2016/17, whereas NBT have seen an increase of
8.5%. This may partially be related to the recording of HOT clinics and ambulatory care.
Page 27 of 27
Annex 9 – Glossary of Terms and Abbreviations
A&E
Accident & Emergency
ARP
Ambulance Response Programme
Appointment Slot Issue (ASI)
Where patients cannot book directly into a slot
AWP
Avon and Wiltshire Mental Health Partnership
BCH
Bristol Community Health
“Black” Escalation
A status declared by a Trust indicating that it is experiencing severe and prolonged excess pressure requiring support
from external agencies. Black is the highest state of escalation that can be declared by a Trust and is preceded by Red,
Amber and Green escalation. There are a set of clear criteria to define escalation status and the actions required at
each stage.
BNSSG
Bristol, North Somerset and South Gloucestershire
BNSSSG
Bristol, North Somerset, Somerset and South Gloucestershire
BPCAg
Bristol Primary Care Agreement
CA
Clinical Advisor
Category A "Red 1 Calls"
These are the most time critical calls and cover cardiac arrest patients who are not breathing and do not have a pulse,
and other severe conditions such as airway obstruction. Red 1 patients account for less than 5% of all ambulance calls.
Category A "Red 2 Calls"
Red 2 calls are serious but less immediately time critical and cover conditions such as stroke and fits. These are now
measured in a way which provides the ambulance Trust with up to a minute to establish the nature of the call and
despatch the most appropriate response before the clock starts.
1
CHC
Continuing Healthcare
Clostridium Difficile (C Diff)
Clostridium Difficile (C Diff) is a bacterium that is present naturally in the gut of around 3% of adults and 66% of
children. It does not cause any problems in healthy people. However, some antibiotics that are used to treat other
health conditions can interfere with the balance of good bacteria in the gut. When this happens, C diff bacteria can
multiply and cause symptoms such as diarrhoea and fever.
CPN
Contract Performance Notice
CQC
Care Quality Commission
CQUIN
Commissioning for Quality and Innovation Framework. This is an incentive scheme for providers who are
commissioned through the NHS Standard Contract. The intention of the framework is to secure improvements in quality
of services and better outcomes for patients, whilst also maintaining strong financial management. Providers must
achieve their CQUINs goals in order to receive payment of the CQUINs funds.
CRES
Cash Reduction Efficiency Savings
Data completeness
Complete information reported for patients for whom data was expected.
DEXA scans
DEXA stands for dual energy X-ray absorptiometry. A DEXA scan is used to measure the density of bones.
Echocardiogram
An ultrasound of the heart in which sound waves are used to project images of the different chambers and arteries of
the heart.
E. coli
Escherichia coli, known as E. coli, are bacteria found in the digestive system of many animals, including humans. Most
strains are harmless but some strains can cause serious illness.
ED
Emergency Department
FFT
Friends and Family Test
2
FRC
Financial Review Committee (Governing Body Sub-Committee)
GPSU
GP Support Unit
GPST
GP Support Team
HCAI
Healthcare Associated Infections
HPA
The Health Protection Agency has been established as a non-departmental public body. Its role is to provide an
integrated approach to protecting UK public health through the provision of support and advice to the NHS, local
authorities, emergency services, other Arms Length Bodies, the Department of Health and the Devolved
Administrations.
IST
Intensive Support Team
In-house and Tertiary
referrals
Breaches can be in-house - those treated at the same Trust - so each patient is counted as 1, or tertiary referrals,
accountability will be assigned to both the treating Trust and the Trust where the patient is first seen. This means that if
more than one Trust has been involved in the care pathway of a patient, and that patient then breaches the 62 Day
target, the breach will be shared equally between the two Trusts.
KPI
Key Performance Indicators
Monitor
Monitor is an independent corporate body established under the Health and Social Care (Community Health and
Standards) Act 2003. It regulates NHS foundation trusts, making sure they are well-managed and financially strong so
that they can deliver excellent healthcare for patients.
MRI
Magnetic resonance imaging (MRI). Using an MRI scanner, it is possible to make pictures of almost all the tissue in the
body.
MRSA
Methicillin Resistant Staphylococcus Aureus - a strain of Staphylococcus aureus that has become resistant to the
antibiotic methicillin. The patient is kept in isolation to stop the spread of this infection.
MSA
Mixed Sex Accommodation. Being in mixed sex hospital accommodation can be difficult for some patients for a variety
of personal and cultural reasons. The NHS is working to ensure that all hospitals provide same sex accommodation for
3
all patients.
MSSA
Methicillin Sensitive Staphylococcus Aureus - MRSA and MSSA only differ in their degree of antibiotic resistance: other
than that there is no real difference between them.
NBT
North Bristol Trust
NICE
National Institute of Clinical Excellence
OOH
Out of Hours
ORCP
Operational Resilience Capacity Planning
PDR
Personal Development Review
Polling ranges
Polling ranges relate to what appointments will show on Choose and Book for patients to choose from. For example, if
the trusts set their polling ranges at 5 weeks this means that patients can only choose from appointments over the next
5 weeks.
PTS
Patient Transport Services
QIPP
Quality, Innovation, Productivity and Prevention programme.
RAG
Red, Amber, Green status rating of performance against set thresholds. Red indicates failure against plan, amber
indicates underachievement against plan and green indicates achievement against plan.
RAP
Remedial Action Plan
RCA
Root Cause Analysis.
Referral to Treatment (RTT)
The period from referral to the start of the first treatment.
4
RUH
Royal United Hospitals Bath
SCWCSU
South Central and West Commissioning Support Unit
SFT
Sustainability and Transformation Fund
SI
Serious Incident
SLAM
Service Level Agreement Monitoring
SWASFT
South West Ambulance Service Foundation Trust
UHB
University Hospitals Bristol
VTE
Venous Thrombolysis Embolism
5
Meeting of Bristol Clinical Commissioning Group Governing Body
To be held on Tuesday 28 March 2017
commencing at 13.30pm at the Greenway Centre, Southmead, Bristol
Title: CQC Quality Report on the University Hospitals Bristol NHS
Foundation Trust
Agenda Item: 14 a
1
Purpose
The attached Care Quality Commission (CQC) report was published on 2nd
march 2017 and describes the findings from the announced inspection of the
University Hospitals Bristol NHS Foundation Trust (UHB) services. The attached
report describes the CQC’s judgement of the quality of care at UHB and is based
on a combination of what the CQC found when they inspected, information from
their ‘Intelligent Monitoring’ system, and information given to them from people
who use services, the public and other organisations.
2.
Background
The CQC inspected the UHB main site between 22nd and 24th November 2016
as part of their comprehensive inspection programme for Acute Trusts. They
also followed this with an unannounced visit on 1 December 2016.
This inspection was a follow up to their inspection in September 2014, when the
Trust was rated as ‘requires improvement’ overall. The focus of this inspection
was on those services previously rated as ‘requires improvement’. This
included:
 surgery;
 medical care (including older people’s care);
 outpatients and diagnostic imaging
Inspectors also looked at urgent and emergency care even though this was rated
as ‘good’ in 2014. This was because of the national problems in emergency
departments relating to flow. However, the overall rating from the November
2016 inspection included services rated in the Trust's previous inspection back in
2014.
During the inspection, the CQC visited a range of wards and departments within
the hospital and spoke with clinical and non-clinical staff, patients and relatives.
They held focus groups to meet with groups of staff and managers. Prior to the
inspection, they obtained feedback and overviews of the Trust performance from
local Clinical Commissioning Groups and NHS Improvement.
The CQC reviewed the information that they held on the Trust, including
previous inspection reports and information provided by the Trust prior to their
inspection. They also reviewed feedback people provided via the CQC website.
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 1 of 4
Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP
3.
Key Findings
The CQC noted the actions taken by the Trust to address areas of weakness
identified in the last CQC inspection in 2014 and gave them an overall rating of
‘outstanding’; the only Trust in the country to be assessed as ‘outstanding’ from
a previous rating of ‘requires improvement’. Commendably UHB are one of only
six Acute Trusts nationally to be rated as ‘outstanding and the only in the South
West.
The overall rating for each of the domains is as follows:
Are services safe?
Are services effective?
Are services caring?
Are services responsive?
Are services well-led?
Good
Outstanding
Good
Requires improvement
Outstanding
•

•
•

Overall rating
Outstanding

The inspectors identified a number of areas of outstanding practice, including:

In times of crowding the emergency department was able to call upon preidentified nursing staff from the wards to work in the department. This
enabled nurses to be released to safely manage patients queueing in the
corridor.

New starters in the emergency department received a comprehensive,
structured induction and orientation programme, overseen by a clinical
Nurse Educator and Practice Development Nurse. This provided new staff
with an exceptionally good understanding of their role in the department
and ensured they were able to perform their role safely and effectively.

Staff in the teenagers and young adult cancer service continually
developed the service, and sought funding and support from charities and
organisations, in order to make demonstrable improvements to the quality
of the service and to the lives of patients diagnosed with cancer.

There was a focus on leadership development at all levels in order to
support the culture and development of the Trust.

There was use of innovation and research to improve patient outcomes
and reduce length of stay and the use of a discrete flagging system to
highlight those patients who had additional needs.
However, there were also areas of poor practice where the trust needs to make
improvements. The CQC noted four ‘must do’ actions relating to medicines
storage; medical records storage on wards and outpatients: staff mandatory
training rates and restricting access to non-ionising radiation premises.
The CQC also identified 33 ‘should do’ actions for the Trust to action.
Page 2 of 4
Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP
4
Next Steps and Assurance processes
The CQC will meet with UHB on 13th March to discuss whether to hold a Quality
Summit or to use an alternative forum for discussing the findings in the report.
(The CQC automatically hold a quality summit following a full inspection or
where concerns have been identified in a follow up inspection, but do not do so
for follow up inspections that show improvement).
If a Quality Summit is not held Bristol CCG has offered the CQC to attend a
shadow Joint Commissioning Board (JCB) meeting to give a short presentation
to commissioners on the findings and learning from the report. The CQC has
accepted this offer if this proposal is accepted.
As a response to the CQC report the Trust will be drafting an action plan to
address the 4 ‘must do’ and 33 ‘should do’ actions. Monitoring of the plans will
be via the monthly Quality Sub Group of the Integrated Contract Quality &
Performance Meetings.
5
How have service users, carers and local people been involved?
Service users and stakeholders were involved in the CQC inspection with their
views and comments taken into account to inform the CQC judgements.
6
Implications on equalities and health inequalities.
There are no specific health inequalities issues raised in the paper.
Please indicate below the age group/s covered by the service/affected
by the issue discussed
Children/Young
People
7
X
Adults
X
Financial Implications
There are no financial implications for the CCG.
8
Legal implications
There are no legal issues raised in this paper.
9
Risk implications, assessment and mitigation
The risks in this paper relate to the specific findings in the CQC report about
patient safety and delivery of the services.
10
Recommendation(s)
Page 3 of 4
Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP
The Governing Body is asked to note the CQC findings in the inspection report
published on 2nd March 2017 and agree assurances on compliance with actions
will be monitored through the Quality Sub Group.
Members are also asked to consider the recommendation of the CQC attending
a JCB meeting to present the findings in the UHB inspection report.
Bridget James
Head of Quality
8th March 2017
Alison Moon
Director of Transformation and Quality
8th March 2017
Glossary of terms and abbreviations
CQC
Care Quality Commission
The CQC are an independent regulator of health
and adult social care in England.
They make sure health and social care services
provide people with safe, effective,
compassionate, high-quality care and they
encourage care services to improve.
Page 4 of 4
University Hospitals Bristol NHS Foundation Trust
Univer
University
sity Hospit
Hospitals
als Brist
Bristol
ol
Main Sit
Sitee
Quality Report
Trust Headquarters
Marlborough Street
Bristol
BS1 3NU
Tel: 0117 923 0000
Website: www.uhbristol.nhs.uk
Date of inspection visit: 22 – 24 November 2016 1
December 2016
Date of publication: 02/03/2017
This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found
when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the
public and other organisations.
Ratings
Overall rating for this hospital
Outstanding
–
Urgent and emergency services
Good
–––
Medical care (including older people’s care)
Good
–––
Surgery
Outpatients and diagnostic imaging
1 University Hospitals Bristol Main Site Quality Report 02/03/2017
Outstanding
Good
–
–––
Summary of findings
Letter from the Chief Inspector of Hospitals
We inspected University Hospitals Bristol Main Site as part of our comprehensive inspections programme of all NHS
acute trusts.
The inspection was announced and took place between 22 and 24 November 2016. We also inspected the hospital on
an unannounced basis on 1 December 2016.
We rated the hospital as outstanding overall. The effective and well led key questions were rated as outstanding; safety
and caring was rated as good; and the responsiveness of the hospital was rated as requires improvement.
Our key findings were as follows:
Safe:
• We rated safety in the hospital as good, and found safety was good in all the services we inspected.
• Openness and transparency about safety was embedded in the services we inspected. There was a positive safety
culture with good staff involvement. Learning opportunities were identified and shared with staff within their own
area and across the trust to support improved safety, and led to changes in practice
• When things went wrong patients were provided with a timely apology and support. The majority of staff understood
their responsibilities under the Duty of Candour requirement and could provide examples when they had been used.
• Innovation was encouraged, such as SHINE in the emergency department, which provided staff with a simple
checklist to ensure patient-safety based actions were completed. Since its introduction there had been no incidents
of a deteriorating patient not being identified and then managed.
• Wards and departments appeared visibly clean. A thorough cleaning programme was in place across the hospital
and staff were observed using personal protective equipment to prevent infection. Staff were seen to use hand
sanitising gel prior to providing care and treatment to patients.
• Medicines managed safely and effectively in the services we inspected. Learning was evidenced from incidents
relating to medicines, and medicines administration records were fully completed.
• Nurse and medical staffing levels met national and local guidelines and planned to ensure safe care, and agency staff
were only used when required to cover increased demand and vacancies. There were effective handovers and shift
changes, to ensure staff can manage risks to patients who use services.
• Consultant cover in the emergency department did not meet the 16-hours on-site standard and was reduced
significantly at weekends. However, junior doctors felt well supported and both the local management team and
trust executives were aware of this concern and had actions ongoing to improve the levels of cover.
• Staff understood their safeguarding responsibilities. Staff were aware of local procedures and knew what to do if they
had a concern. In surgery we found examples were staff had taken steps to prevent abuse from occurring and
responding to signs of abuse by working with the safeguarding team and local authority to ensure patients were
protected. There was lack of clarity around the correct processes to safeguard children between the ages of 16 and 18
years in the surgical trauma assessment unit. There were concerns in this unit around the levels of safeguarding
training provided to staff working overnight.
• Staff carried out comprehensive risk assessments for patients and developed management plans to ensure risks to
patients’ safety were monitored and maintained. The World Health Organisation surgical safety checklist was utilised
effectively to keep patients safe. However, the environment for patients on the oncology ward presented a potential
risk to the safety of patients who may be confused or could not maintain their own safety.
• Systems to ensure patients’ information was kept safe were not always implemented. Records were found to not be
stored securely which could cause a potential breach of patients’ confidentiality in the emergency department,
outpatients departments and on medical wards.
2 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summary of findings
• Mandatory training compliance for nursing and medical staff across the services we inspected were below the
hospitals target, including fire, resuscitation and safeguarding training for medical staff. Receptionists in the
emergency department had not received any training or guidance to help them identify potentially seriously unwell
patients.
Effective:
• We rated the effectiveness of services within the hospital as outstanding. Urgent and emergency services were rated
as outstanding, and medical care and surgery were rated as good. We do not currently rate the effectiveness of
outpatients and diagnostic imaging.
• Patients had comprehensive assessments of their needs, which include consideration of clinical needs, including
both mental and physical health and wellbeing, nutrition and hydration needs.
• We found there was good multidisciplinary working and people received care from a range of different staff, teams or
services, in a coordinated way. All relevant staff, teams and services were involved in assessing, planning and
delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and
complexity of people’s needs.
• Patients’ care and treatment was planned in line with current evidence based guidance. Clinical care pathways were
developed in accordance with national guidelines. Trust policies included reference to NICE guidance and other
national strategies. However, the diagnostic imaging service did not always ensure it met best practice clinical
guidance for report turnaround time for medical staff requesting diagnostic imaging to be carried out.
• Patients received care from different teams who worked together to coordinate care. We observed board rounds
taking place on wards, which demonstrated effective multi-disciplinary working. For some wards complex discharges
were daily occurrences. A multidisciplinary audit programme was in place and actively used by staff to encourage
and monitor improved outcomes. There were links with GPs and community providers to ensure safe patient
discharge.
• The hospital achieved good patient outcomes and delivered effective care in the emergency department and
medical wards. A programme of local and national audits was used to monitor care and treatment. Some areas
showed improvements, including the national stroke audit. In outpatient departments clinics were benchmarked
against each other and actions put in place to improve outcomes. Outcomes for people who used the surgical
services were mixed. The trust performed well in the bowel cancer audit and the oesophago-gastric cancer national
audit and had an improving picture for the national emergency laparotomy audit. However, results were not always
in line with the national scores. For example, the trust was performing worse than the national average in some
elements of the hip fracture audit, although, the service provided at this trust was relatively small compared to other
trusts. Despite this, mortality rates were better than the England average in all audits we reviewed.
• Innovative approaches were used to deliver care. This included simple solutions such as a touchscreen guideline
system in the emergency department resuscitation area, and the close working relationships with external partners
to deliver alternative care pathways and admission avoidance programmes. The SHINE patient safety assessment
tool had driven significant improvements and clearly demonstrated improved outcomes.
• Patients’ consent to care and treatment was sought in line with legislation and guidance. Staff had a clear
understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.
• Not all staff had received an appraisal in the last year, with particular low compliance in the ancillary staff group.
Without an appraisal, learning needs may not be identified and a plan put in place to support staff to develop their
practice.
Caring:
• Overall, caring within the hospital was rated as good. Surgery was rated as outstanding for caring and all other
services inspected were rated as good.
3 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summary of findings
• People we spoke with praised the staff for their kindness and compassion. Patients told us they had been treated
with dignity and respect at all times by staff who were respectful and caring.
• Staff often went out of their way to meet the emotional and physical needs of patients. It was clear they had taken the
time to get to know and understand their patients. Staff took the time to ensure patients were comfortable,
responding compassionately to patients in pain or distress and giving reassurance and support.
• We observed doctors and nurses introducing themselves when they met patients and their families for the first time.
Patients in the emergency department were addressed by their preferred name. Patients and those close to them
were treated as partners in their care and supported to make informed decisions about their care and treatment. We
saw examples where relatives and carers were included as part of the care provided for both physical and emotional
wellbeing. In outpatient departments staff talked about patients compassionately with knowledge of their
circumstances and those of their families. Relatives were encouraged to be involved in care as much as they wanted
to be, while patients were encouraged to be as independent as possible.
• We saw staff from all groups assisting patients and others who were confused or lost in the emergency department in
a helpful and supportive manner. One doctor was seen helping a patient to the toilet.
• Staff in the emergency department had received lots of positive feedback about the compassionate care provided in
the form of cards and letters, and these were displayed in the staff room.
• Patients’ privacy and dignity was respected and staff sought permission before carrying out care and treatment in all
the services we inspected. In the emergency department staff used curtains around the bed spaces to provide
privacy when assessing and treating patients, and ensured patients’ dignity was maintained when curtains were
opened. Patients in the corridor, however, did not have the same provision to ensure their privacy. Staff did their best
to ensure confidentiality and privacy in the corridor by keeping conversations as quiet as possible, but because of the
close proximity of other patients and relatives conversations could still be overheard.
Responsive:
• Overall, improvements were required to ensure that services within the hospital were responsive to patients’ needs.
We rated the responsiveness of services within the hospital as requires improvement. Urgent and emergency services
were rated as requires improvement. However, surgical services, medical care and outpatients and diagnostic
imaging were rated as good.
• Access and flow was an issue within the hospital. The hospital was consistently failing to meet the national standard
which requires 95% of patients to be discharged, admitted or transferred within four hours of their arrival at the
emergency department. The emergency department suffered from regular crowding, and this was cited as the
department’s greatest risk. Patients spent longer in the emergency department compared to the England average.
• The emergency department and the trust were working closely with commissioners and partners to address
system-wide flow issues and introduce innovative methods to improve patient flow.
• Waiting times, delays and cancellations were minimal and managed.
• Referral to treatment times for different specialties within the medicine division were not all within the England
standards. Within surgery referral to treatment standards were being met 92% of the time. Where there had been a
slip in performance there were clear actions to address these which had been proven to be effective. In the
outpatients departments the overall referral to treatment standard on average was slightly worse than the national
average.
• Processes to ensure patients who were medically fit to leave the hospital were not always timely. However, in the
majority of cases, reasons for discharge delays were not attributable to the hospital.
• We found that medical and surgical services were planned and delivered in a way that met the needs of local
patients. The hospital offered choice and flexibility to patients and provided continuity of care. New clinics, services
and virtual facilities were implemented, to ensure services met patients’ needs. However, sometimes incurred delays
due to issues elsewhere.
4 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summary of findings
• The medical wards were creative to ensure patient flow through the hospital was maintained and was responsive to
the ever-changing demand. There was a constant oversight by senior staff, of how different departments were
managing flow, to ensure staff across all areas of the hospital prioritised patient safety, whilst maintaining the flow of
patients through the hospital.
• The flow of patients through the medical division was monitored and actions taken to minimise the numbers of
patients being cared for on wards other than those related to their medical condition/specialty. These patients were
known as medical outliers. The hospital ensured outlying patients received the care and input from nursing and
medical staff, relevant to their medical condition/specialty.
• The radiology department was slightly below the national standard of 90% of patients referred by the cancer referral
process to be seen within two weeks. However; the diagnostic and imaging department was above the national
average for the percentage of patients seen within six weeks.
• Patients were not always able to locate the outpatients and diagnostic imaging departments because they were not
clearly signposted. A wide selection of information leaflets were available to patients; however, they were not
available in other languages.
• The parking facilities did not always meet the demand leaving patients unable to find a space in a timely manner.
• There was good support for patients living with dementia or learning difficulties, and translation services were
available for patients whose first language was not English. Reasonable adjustments were made for people living
with dementia or with learning difficulties including use of the ‘this is me’ document and access to activities for
stimulation. There were access to dedicated teams for dementia, learning disabilities and psychology which were
always available.
• In response to the last inspection and feedback from patients, each outpatient department had introduced waiting
time boards which displayed the waiting times for each clinic for that day.
Well led:
• We rated the well led domain as outstanding. Urgent and emergency services and surgery were rated as outstanding;
and medical care and outpatients and diagnostic imaging were rated as good.
• The leadership, governance and culture promoted the delivery of high-quality person centred care. There was a clear
statement of vision and values within the trust which was driven by quality and safety. We found clear statements of
vision and values for medical care, surgery, and outpatients and diagnostic imaging, which were driven by safety and
quality. The strategies and supporting objectives were stretching, challenging and innovative whilst remaining
achievable. The emergency department strategy had not yet been drafted and agreed, although there were
programmes of work underway which showed progress towards achieving the department’s vision.
• Staff understood the vision and strategy and their role in in delivering it. They were proud to work for the hospital and
patient focused. Staff demonstrated a kind culture, both to patients and relatives, and to each other.
• Governance structures were complex to follow. However, the board and other levels of governance within the
hospital functioned effectively and interacted well. Staff told us their responsibilities were clear and quality,
performance and risks were understood and managed. Risks were escalated when needed and the information
communicated to the hospital board flowed well. Processes were in place to monitor, address and manage current
and future risk. Performance issues and concerns were escalated to the relevant committees and board. There was a
continued focus and drive to improve safety and quality through excellent governance and leadership.
• Comprehensive and successful leadership strategies were in place to ensure delivery and to develop the desired
culture and to motivate staff to succeed. Leaders understood the challenges to good quality care within and outside
the organisation, and there were collaborative relationships with stakeholders.
• Staff felt leadership was good and divisional lead staff were accessible. Staff told us they felt supported and heard,
and there was a collective culture of openness to drive quality and improvement. Leaders and staff demonstrated the
participation and involvement of patients who used the service was important to them.
5 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summary of findings
• Staff were proud of the organisation as a place to work and spoke highly of the culture. There were high levels of
constructive engagement with staff. Where there had been a poor culture identified innovative and effective actions
were put into place to resolve them.
• Innovative approaches were encouraged and supported, and these had a clear focus on patient safety, quality and
performance, from staff led forums to improve the efficiency of work streams to research in pioneering research
techniques. Changes were monitored effectively to evidence the improvements to patient care the changes had.
• Leaders demonstrated a drive for continuous learning and improvement through the ongoing evaluation and
monitoring of the service and by delivering projects and innovative developments aligned to this.
• The management and governance of current performance of staff mandatory training did not ensure all staff were
fully training. For medical staff, this included fire, safeguarding and resuscitation training.
• The medical division had recognised a risk in the acute oncology service at night, concerning both staffing levels and
a lack of suitably skilled triage staff. However, sufficient action was required to minimise the risk to patients in both
the service provision and staffing provision.
We saw several areas of outstanding practice including:
• In times of crowding the emergency department was able to call upon pre-identified nursing staff from the wards to
work in the department. This enabled nurses to be released to safely manage patients queueing in the corridor.
• The audit programme in the emergency department was comprehensive, all-inclusive and had a clear patient safety
and quality focus.
• New starters in the emergency department received a comprehensive, structured induction and orientation
programme, overseen by a clinical nurse educator and practice development nurse. This provided new staff with an
exceptionally good understanding of their role in the department and ensured they were able to perform their role
safely and effectively.
• In the emergency department the commitment from all staff to cleaning equipment was commendable.
• The comprehensive register of equipment in the emergency department and associated competencies were
exceptional.
• Staff in the teenagers and young adult cancer service continually developed the service, and sought funding and
support from charities and organisations, in order to make demonstrable improvements to the quality of the service
and to the lives of patients diagnosed with cancer. They had worked collaboratively on a number of initiatives. One
such project spanned a five year period ending May 2015 for which some of the initiatives were ongoing. The project
involved input from patients, their families and social networks, and healthcare professionals involved in their care. It
focused on key areas which included: psychological support, physical wellbeing, work/employment, and the needs
of those in a patients’ network.
• The use of technology and engagement techniques to have a positive influence on the culture of an area within the
hospital. There were clear defined improvements in the last 12 months in Hey Groves Theatres.
• The governance processes within the division to ensure risks and performance were managed.
• The challenging objectives in the strategy and how they are used to proactively develop the quality and the safety of
the service.
• The use of innovation and research to improve patient outcomes and reduce length of stay. The use of a discrete
flagging system to highlight those patients who had additional needs. In particular those patients who were diabetic
or required transport to ensure they were offered food and drink.
• The introduction of IMAS modelling in radiology to assess and meet future demand and capacity.
• The use of in-house staff to maintain and repair radiology equipment to reduce equipment down time and expenses.
• The introduction of a drop in chest pain clinic to improve patient attendance.
However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust
must:
6 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summary of findings
• Ensure all medicines are stored correctly in medical wards, particularly those which were observed in dirty utility
rooms.
• Ensure records in the medical wards and in outpatient departments are stored securely to prevent unauthorised
access and to protect patient confidentiality.
• Ensure all staff are up to date with mandatory training.
• Ensure non-ionising radiation premises in particular Magnetic Resonance Imaging (MRI) scanners restrict access.
In addition the trust should:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Ensure chemicals are stored securely at all times in the emergency department and on medical wards.
Ensure checks of the equipment in the emergency department’s resuscitation area are recorded consistently.
Ensure patients in the emergency department have access to call bells at all times.
Ensure reception staff are able to recognise patients who attend the emergency department with serious conditions
and need urgent referral to the triage nurse and provide a formalised process for summoning help.
Continue working towards providing 16-hours on-site consultant cover in the emergency department, and increase
consultant cover at the weekend.
Ensure the emergency department is accessible to wheelchair users and the layout of the reception desk allows staff
to interact with wheelchair users whilst sat at the desk.
Ensure the emergency department develops and formalises its vision and strategy.
Ensure staff in the emergency department are up-to-date with their mandatory training, including safeguarding
adults and children.
Work with commissioners and the local mental health service provider to ensure mental health patients arriving at
the emergency department receive the care they require in a timely manner.
Ensure all staff working in the emergency department and medical staff receive an annual appraisal.
Ensure clear signage and equipment is in place for staff, patients and visitors to wash their hands when entering a
medical ward area.
Ensure the environment in the oncology department and ward keeps patients safe and comfortable, especially for
patients who may be confused or cannot maintain their own safety.
Ensure access to the staff room on the medical assessment does not allow access to unauthorised people.
Take remedial maintenance action to ensure the heating system on ward D703 maintains a suitable and safe
temperature for staff and patients.
Ensure staff have a greater understanding and awareness of the intercom system on the Hepatology ward, to ensure
safe and prompt access to the ward and confidentiality of patient information.
Ensure medical doctors’ inductions are undertaken in scheduled blocks and planned so doctors do not start work on
the wards without an induction.
Ensure clear signage and equipment is in place on medical wards to advise staff, patients and visitors to wash their
hands when entering a ward area.
Ensure delays in the provision of take home medicines do not delay patients.
Ensure medical records are legibly and fully completed. This includes patient risk assessments.
Audit records in the cardiac catheter laboratory to ensure they are fully complaint with the World Health Organisation
surgical safety checklist for all surgical procedures.
Address the risk in the acute oncology service where patients may be placed at risk by reduced staffing levels at night
due to admissions of emergency oncology patients. There should be suitably skilled staff in place at night to ensure
safe triage advice is given to patients accessing the emergency oncology service. Whilst the trust recognised these
risks, sufficient action should be taken to minimise the risk to patients in both the service provision and staffing
provision.
Ensure pain audits are established to monitor if pain was managed effectively for patients with an ability to express
their pain.
7 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summary of findings
• Continue to monitor staff’s use of the Abbey Pain Scale to ensure patients with cognitive impairment in the
specialised services division have an effective tool to assess their pain needs.
• Continue to ensure all efforts be made to maintain flow through the hospital and patients be nursed on the correct
wards to meet their needs.
• Reduce the risk on the hepatology ward in relation to lone working practices, when accompanying patients off the
ward at night to smoke.
• Improve the level of safeguarding training for staff working overnight in the surgical trauma assessment unit.
• Improve compliance for mandatory training in surgical areas.
• Improve patient outcomes to bring them in line with the national average for the hip fracture audit and improve the
National Emergency Laparotomy Audit.
• Ensure patients within all of the diagnostic imaging waiting rooms can be monitored by staff.
• Monitor the World Health Organisation (WHO) Surgical Safety Checklist is always used in the appropriate area as a
checklist when carrying out non-surgical interventional radiology.
• Provide leaflets within outpatient departments are available in different languages
• Check local and national diagnostic reference levels (DRLs) are on display as stated in Regulation 4(3)(c) of IR(ME)R
2000 and IR(ME) amendment regulations 2006 and 2011.
• Make improvements on the follow up backlog waiting list to meet people’s needs and minimise risk and harm caused
to patients through excessive waits on follow up of outpatient appointments and the reporting of images.
Professor Sir Mike Richards
Chief Inspector of Hospitals
8 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summaryoffindings
Summary of findings
Our judgements about each of the main services
Service
Urgent and
emergency
services
Rating
Good
–––
9 University Hospitals Bristol Main Site Quality Report 02/03/2017
Why have we given this rating?
We rated this service as good because:
• There was a multidisciplinary audit programme in
place which was actively used by staff to encourage
and monitor improved outcomes.
• Innovative approaches were being used to deliver
quality care. In particular a new patient safety
assessment tool, known as SHINE, had driven
significant improvements and clearly demonstrated
improved outcomes.
• There was a strong multidisciplinary approach to
patient care and this included staff within and
external to the department, including partner
organisations.
• There was a real focus on staff learning and
development. Staff were supported and sponsored
by the department and the trust to complete
additional relevant qualifications.
• Staff demonstrated a clear understanding of consent
and best interest decision practices and records
evidenced these were being followed.
• There was a continued focus and drive to improve
safety and quality through excellent governance and
leadership.
• Leaders were respected by their teams and truly
encouraged a supportive, open and honest culture
amongst all staff.
• Innovative approaches were encouraged and
supported, and these had a clear focus on patient
safety, quality and performance.
• There was an extremely positive safety culture, with
all staff taking an interest and personal responsibility
with regard to patient safety.
• Learning opportunities were identified and these
were actively shared with staff to support improved
safety. The use of simulation training to further
embed learning was an excellent tool.
• Medicines were managed safely and securely.
Incidents relating to double administrations had led
to new stickers being implemented to highlight
pre-hospital medicines administration to staff.
Summaryoffindings
Summary of findings
• Nursing staffing levels met national guidelines and
additional nurses were called upon from the wards to
support the department in times of crowding.
• People were treated with dignity and respect and
staff were mindful of confidentiality and privacy.
• Staff took time to ensure patients and their relatives
understood their care, diagnosis and treatment plans.
• The emergency department and the trust were
working closely with commissioners and partners to
address system-wide flow issues and introduce
innovative methods to improve patient flow.
However:
• The trust was consistently failing to meet the national
standard which requires 95% of patients to be
discharged, admitted or transferred within four hours
of their arrival at the emergency department.
• The emergency department suffered from regular
crowding, and this was cited as the department’s
greatest risk. This was on the corporate risk register.
• Wheelchair users and patients with mental health
conditions were not having their needs met.
• Patient privacy and confidentiality could not be
maintained in the corridor when the department was
crowded.
• Not all staff had received an appraisal in the last year,
with particular low compliance in the ancillary staff
group.
• Consultant cover did not meet the 16-hours on-site
standard and was reduced significantly at weekends.
However, junior doctors felt well supported and both
the local management team and trust executives
were aware of this concern and had actions ongoing
to improve the levels of cover.
• Receptionists did not receive any training or guidance
to help them identify potentially seriously unwell
patients and there was no formalised procedure for
calling for help in the event of a patient deteriorating
in the waiting room. However, while this presented a
risk to patients awaiting triage, no incidents of harm
had been reported.
10 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summaryoffindings
Summary of findings
Medical care
(including
older
people’s
care)
Good
–––
We rated this service as good because:
11 University Hospitals Bristol Main Site Quality Report 02/03/2017
• There was a good incident reporting culture and staff
were encouraged to report incidents. Learning from
incidents had led to changes in ward practice.
• Safety was monitored and actions taken to improve
safety.
• Staffing levels were in line with the hospital’s staffing
measurement tools.
• Feedback from patients and those close to them was
positive. Patients’ emotional and social needs were
valued and this was demonstrated in the way staff
cared for patients.
• The service was flexible and creative to ensure flow
was maintained. The systems put in place to support
the patients on outlying wards ensured they were
seen by the right medical team every day, and their
care was always overseen by the medical team.
• Work had taken place to deliver services that met the
needs of patients living with dementia.
• Patients’ care and treatment was planned in line with
current evidence based guidance.
• Patients had comprehensive assessments of their
needs. Patients had their pain assessed regularly and
managed promptly. Their nutrition and hydration was
assessed and monitored.
• A programme of local and national audits was used
to monitor care and treatment was being provided in
accordance with national guidelines. Some areas
showed improvement, including the national stroke
audit.
• Learning needs of staff were identified and training
put in place to meet those needs.
• Patients received care from different teams who
worked together to coordinate care. There were links
with GP’s and community providers to ensure safe
patient discharge.
• When patients who needed specialist community
support were discharged, effective links were made
with community services.
• Whilst care was provided seven days a week, ward
rounds by medical staff did not take place every day.
However, access to medical care was always
available.
• Discharge delays, transfers and bed moves were all
monitored to ensure they did not negatively impact
on patients.
Summaryoffindings
Summary of findings
• Complaints were handled in accordance with trust
policy, and improvements were made in response to
complaints.
• There was a clear, overarching statement of vision
and values for the medicine service, which was driven
by safety and quality. Staff understood the vision and
strategy and their role in in delivering it.
• Risks were escalated when needed and the
information communicated to the hospital board
flowed well. Processes were in place to monitor,
address and manage current and future risk.
• Leaders understood the challenges to good quality
care within and outside the organisation, and there
were collaborative relationships with stakeholders.
• Staff felt leadership was good and divisional lead staff
were accessible. Leaders and staff demonstrated the
involvement of people who used the service was
important to them.
• The hospital had forged strong links and worked
closely with the voluntary sector.
• Leaders demonstrated a drive for continuous learning
and improvement through the ongoing evaluation
and monitoring of the service and by delivering
projects and innovative developments.
However:
• Systems were not always reliable to keep patients’
information safe. Records were consistently seen to
not be stored securely.
• Not all medical staff had completed mandatory
training in line with the trust’s targets.
• Doctor induction was undertaken in scheduled
blocks. Should doctors start work in between those
blocks, they may work for a period of time without
induction.
• There were gaps in information being monitored in
specific areas of care, such as pain audits to establish
if pain was managed effectively. The cardiac catheter
laboratory used a World Health Organisation surgical
safety checklist for all surgical procedures. However,
these records were not audited to ensure they were
all fully completed.
• Not all staff had received an appraisal in the last year.
Without an appraisal, learning needs may not be
identified and a plan put in place to support staff to
develop their practice.
12 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summaryoffindings
Summary of findings
• The management of risk did not protect staff on the
hepatology ward. This related specifically to lone
working practices when accompanying patients off
the ward at night who wanted to smoke.
• The division had recognised a risk in the acute
oncology service at night, concerning both staffing
levels and a lack of suitably skilled triage staff.
However, further action was required to minimise the
risk to patients in both the service provision and
staffing provision.
Surgery
Outstanding
–
We rated this service as outstanding because:
• There was a good culture of incident identification,
reporting, investigation, and sharing of learning
throughout the surgical division. There were many
examples shared with inspectors of learning from
incidents both in their own area and from the wider
trust.
• Staffing levels were good with only occasional use of
agency staff. Where there were shortages of staff there
was a quick response to rectify this. This resulted in
safe staff management and handover from staff to
manage risks.
• Risks were managed and responded to effectively
both on the wards and in theatre. Learning from a
never event was fully integrated into the surgical
safety checklist. On the wards we saw comprehensive
risk assessments, which included physical and
mental health, to ensure the safe care and treatment
of patients.
• Staff worked effectively together as a
multidisciplinary team and worked together in a
coordinated way for the patients best interests. This
included working between teams and services.
• Mortality rates were consistently better than the
national average in all the audits we looked at.
• Feedback from patients and their families was almost
entirely positive. Patients we met spoke positively of
the service they received and of the compassion,
kindness and caring of all staff. Staff ensured patients
experienced dignified and respectful care.
• Although slightly limited, reasonable adjustments
were made for patients living with dementia or with
learning difficulties including use of the ‘this is me’
document and patient access to activities.
13 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summaryoffindings
Summary of findings
• Leadership in the trusts surgical services was
enthusiastic and staff were motivated to succeed. A
strong governance structure aided managers to
proactively review performance and risks and were
reviewed to reflect best practice.
• We saw an innovate method of engaging staff through
the use of the ‘Happy App’ and proactive engagement
with staff. We found because of this the culture of
engagement had developed to be positive. Staff were
proud to work at the hospital.
However:
• Not all staff within the surgical service had received
recent mandatory training to keep patients safe.
There were a number of staff who had not completed
all of the required training for resuscitation,
safeguarding, fire, manual handling and infection
control.
• The service was planned and delivered in a way
which met patient’s needs. However, some patients
had long waiting times to have their surgical
procedure due to a high level of medical outliers on
surgical wards and staff shortages in some
specialties. This was particularly apparent in the cleft
palate service and the dental service.
Outpatients
and
diagnostic
imaging
Good
–––
We rated this service to be good because:
14 University Hospitals Bristol Main Site Quality Report 02/03/2017
• There was a good incident reporting culture and
openness and transparency were encouraged.
Lessons learnt were shared in both outpatients and
diagnostic imaging to make sure action was taken to
improve not just the affected service.
• There were clearly defined systems and processes to
keep people safe and safeguarded from abuse. All
staff we spoke with had a good awareness of
safeguarding legislation and what to do if they had
any concerns.
• People’s care and treatment in both outpatients and
diagnostic imaging was planned and delivered in line
with current evidence based guidance, standards,
best practice and legislation. We saw evidence of
audit to ensure that practice was monitored ensuring
consistency
Summaryoffindings
Summary of findings
• Feedback from patients and relatives had been
consistently positive. They praised the way the staff
really understood their needs and involved their
family in their care. Patients were treated as
individuals.
• We found although people were waiting too long for
appointments, there were innovative approaches to
the appointment booking systems and the
management of the capacity and demand of
outpatient’s and diagnostic imaging clinics.
• In response to the last inspection and feedback from
patients, each outpatient department had introduced
waiting time boards which displayed the waiting
times for each clinic for that day.
• Services were planned and delivered in a way that
met the needs of the local population and took into
account patient choice.
• There was a clear statement of vision and values,
driven by quality and safety. It was translated into a
credible strategy for outpatients with defined
objectives that were regularly reviewed and relevant.
• Staff and patients were engaged in how care was
delivered. Staff felt as if they were active contributors
to how the service was developed.
However:
• Some medical records were not being stored securely
in outpatient departments.
• There was a backlog of appointments and high levels
of referrals meaning people were not able to access
the services for assessment, diagnosis or treatment
when they needed.
• We found doors to the MRI scanners were unlocked
and were accessible to patients in the main waiting
area.
15 University Hospitals Bristol Main Site Quality Report 02/03/2017
Univer
University
sity Hospit
Hospitals
als Brist
Bristol
ol
Main Sit
Sitee
Detailed findings
Services we looked at
Urgent & emergency services; Medical care (including older people’s care); Surgery; Outpatients &
Diagnostic Imaging
16 University Hospitals Bristol Main Site Quality Report 02/03/2017
Detailed findings
Contents
Detailed findings from this inspection
Page
Background to University Hospitals Bristol Main Site
17
Our inspection team
18
How we carried out this inspection
18
Facts and data about University Hospitals Bristol Main Site
18
Our ratings for this hospital
19
Findings by main service
20
132
Action we have told the provider to take
Background to University Hospitals Bristol Main Site
University Hospitals Bristol NHS Foundation Trust
comprises eight hospitals and is one of the largest NHS
trusts in the country. It is an acute teaching trust and
became a foundation trust in June 2008.
proportion of children living in households with
long-term unemployment. There were significant
variations in levels of deprivation within the city of Bristol
and there were areas of prosperity within the city and the
immediate surrounding area. Census information
showed that 16% of Bristol’s population was non-white,
with 6% declaring their ethnic origin as Black, 5.5% as
Asian and 3.6% as mixed race.
The trust had 899 beds and employed 7,745 full time
equivalent staff. In the financial year 2015/16, the trust
had an income of £599.2 million and costs of £596.7
million, meaning it had a surplus of £3.5million for the
financial year. This was the 13th successive year of
reported surplus for the trust. The trust predicted it
would have a surplus of £16million in 2016/17.
This inspection was a follow up to our inspection in
September 2014, when the trust was rated as requires
improvement overall. We focused this inspection on
services rated as requires improvement: surgery; medical
care; and outpatients and diagnostics. We also inspected
urgent and emergency care, although it was rated as
good in the inspection in 2014, because national
problems in accident and emergency departments and
frequent ambulance queues at the Bristol Royal Infirmary
were a cause for concern. We inspected the following
hospitals as part of this inspection:
The trust provided services to three distinct populations.
Acute and emergency services were provided to the local
population of around 450,000 in south and central Bristol.
Specialist regional services were provided across the
region from Cornwall to Gloucestershire. Specialist
services were also provided across the whole of the South
West, South Wales and beyond.
The 2015 Indices of Deprivation showed that Bristol was
the 77th most deprived local authority out of 326 local
authorities. Life expectancy for men, at 78.4 years, was
slightly lower than the England average of 79.5 years. Life
expectancy for women, at 82.9 years, was very slightly
lower than the England average of 83.2 years. Bristol was
significantly worse than the England average for the
proportion of children living in poverty, levels of violent
crime, and educational attainment. However, Bristol was
better than the national average for England for the
•
•
•
•
•
17 University Hospitals Bristol Main Site Quality Report 02/03/2017
Bristol Royal Infirmary;
Bristol Heart Institute;
Bristol Oncology and Haematology Centre;
Bristol Eye Hospital;
University of Bristol School of Oral & Dental Sciences.
Our inspection was carried out in two parts: the
announced visit, which took place on 22, 23, and 24
November 2016; and the unannounced visit, which took
place on 1 December 2016.
Detailed findings
Our inspection team
Our inspection team was led by:
Chair: Andrew Welch, Medical Director, Newcastle Upon
Tyne Hospitals NHS Foundation Trust
Head of Hospital Inspections: Mary Cridge, Care
Quality Commission
The team included CQC inspectors and a variety of
specialists including: accident and emergency nurse;
accident and emergency doctor; medical nurse team
leader; medical doctor; theatre nurse specialist, surgical
doctor; surgery nurse team leader; medicine nurse;
outpatients nurse team leader; radiographer; two experts
by experience and a board level director.
How we carried out this inspection
We carried out the announced part of our inspection
between 22 and 24 November 2016 and returned to visit
some wards and departments unannounced on 1
December 2016.
During the inspection we visited a range of wards and
departments within the hospital and spoke with clinical
and non-clinical staff, patients, and relatives. We held
focus groups to meet with groups of staff and managers.
Prior to the inspection we obtained feedback and
overviews of the trust performance from local Clinical
Commissioning Groups and NHS Improvement.
We reviewed the information that we held on the trust,
including previous inspection reports and information
provided by the trust prior to our inspection. We also
reviewed feedback people provided via the CQC website.
Facts and data about University Hospitals Bristol Main Site
University Hospitals Bristol NHS Foundation Trust
comprises eight hospitals and is one of the largest NHS
trusts in the country. It is an acute teaching trust and
became a foundation trust in June 2008.
The trust had 899 beds and employed 7,745 full time
equivalent staff. In the financial year 2015/16, the trust
had an income of £599.2 million and costs of £596.7
million, meaning it had a surplus of £3.5million for the
financial year. This was the 13th successive year of
reported surplus for the trust. The trust predicted it
would have a surplus of £16million in 2016/17.
The trust provided services to three distinct populations.
Acute and emergency services were provided to the local
population of around 450,000 in south and central Bristol.
Specialist regional services were provided across the
region from Cornwall to Gloucestershire, into South Wales
and beyond.
Between August 2015 and August 2016 there were
129,694 attendances at the emergency department.
18 University Hospitals Bristol Main Site Quality Report 02/03/2017
Between September 2015 and August 2016 there were
139,486 inpatient admissions, and between July 2015 and
June 2016 there were 712,591 outpatient appointments.
The trust had a stable board, with the most recent
executive appointments being the director of strategy
and transformation in 2016. The chief executive had been
in post since 2010. The eight non-executive directors had
also been appointed with most having been in post for at
least three years. At the time of our inspection the chief
executive was leading the work for the Bristol, North
Somerset and South Gloucestershire Sustainability and
Transformation Plan.
Inspection History:
This is the twelfth inspection of the trust since it was
registered with the commission in 2010. In September
2014 we carried out an announced comprehensive review
of the trust and all locations, and closed down all
outstanding compliance actions. We rated the trust as
requires improvement overall. Urgent and emergency
Detailed findings
care, critical care, maternity and family planning, services
for children and young people, and end of life care were
all rated as good. Medical care, surgery, and outpatients
and diagnostics were rated as requires improvement.
Previous inspections include:
• January 2014: Dementia themed inspection
• November 2013: Responsive inspection at the Bristol
Royal Hospital for Children
• April 2013: Follow up inspection
• September 2012: Responsive inspection
• May 2012: Responsive inspection
• March 2012: Special review of termination of pregnancy
procedures at the Central Health Clinic
Our ratings for this hospital
Our ratings for this hospital are:
Safe
Effective
Urgent and emergency
services
Good
Medical care
Good
Good
Surgery
Good
Good
Outpatients and
diagnostic imaging
Good
Not rated
Overall
Good
Caring
Responsive
Good
Requires
improvement
Good
Good
Well-led
Overall
Good
Good
Good
Good
Good
Good
Good
Good
Good
Requires
improvement
19 University Hospitals Bristol Main Site Quality Report 02/03/2017
Urgentandemergencyservices
Urgent and emergency services
Safe
Effective
Caring
Responsive
Well-led
Overall
Information about the service
University Hospitals Bristol NHS Foundation Trust had
three emergency departments providing urgent and
emergency care for people in central, south and
north-west Bristol. These were the Bristol Royal Infirmary,
Bristol Royal Hospital for Children, and Bristol Eye
Hospital. In 2015/16 the three emergency departments
saw 127,570 patients. This averaged 2,453 attendances a
week, or 350 attendances a day.
We last inspected the urgent and emergency services
provided by the hospital trust in September 2014. At that
inspection we visited all three emergency departments
and rated the service as good overall, with
responsiveness being rated as requiring improvement
and effectiveness not being rated.
For this inspection we reviewed and rated all five
domains, but only visited the Bristol Royal Infirmary.
The emergency department at the Bristol Royal Infirmary
included a resuscitation area with six patient spaces, a
major injury and illness area with 11 patient bed spaces, a
minor injury and illness area with seven assessment and
treatment cubicles, and an observation unit with eight
patient bed spaces. The department was a trauma unit.
This meant the unit could treat trauma patients, but
would transfer major trauma cases to the local major
trauma centre.
Between April and August 2016 the Bristol Royal Infirmary
emergency department had seen 26,070 patients,
averaging 1,303 attendances a week, or 186 attendances
a day.
20 University Hospitals Bristol Main Site Quality Report 02/03/2017
Good
Outstanding
–––
–
Good
–––
Requires improvement
–––
Outstanding
Good
–
–––
We inspected the emergency department as part of an
announced follow-up inspection on 22, 23 and 24
November 2016. We also carried out an unannounced
inspection on 1 December 2016.
Urgentandemergencyservices
Urgent and emergency services
Summary of findings
We rated this service as good because:
• There was a multidisciplinary audit programme in
place which was actively used by staff to encourage
and monitor improved outcomes.
• Innovative approaches were being used to deliver
quality care. In particular a new patient safety
assessment tool, known as SHINE, had driven
significant improvements and clearly demonstrated
improved outcomes.
• There was a strong multidisciplinary approach to
patient care and this included staff within and
external to the department, including partner
organisations.
• There was a real focus on staff learning and
development. Staff were supported and sponsored
by the department and the trust to complete
additional relevant qualifications.
• Staff demonstrated a clear understanding of consent
and best interest decision practices and records
evidenced these were being followed.
• There was a continued focus and drive to improve
safety and quality through excellent governance and
leadership.
• Leaders were respected by their teams and truly
encouraged a supportive, open and honest culture
amongst all staff.
• Innovative approaches were encouraged and
supported, and these had a clear focus on patient
safety, quality and performance.
• There was an extremely positive safety culture, with
all staff taking an interest and personal responsibility
with regard to patient safety.
• Learning opportunities were identified and these
were actively shared with staff to support improved
safety. The use of simulation training to further
embed learning was an excellent tool.
• Medicines were managed safely and securely.
Incidents relating to double administrations had led
to new stickers being implemented to highlight
pre-hospital medicines administration to staff.
• Nursing staffing levels met national guidelines and
additional nurses were called upon from the wards
to support the department in times of crowding.
21 University Hospitals Bristol Main Site Quality Report 02/03/2017
• People were treated with dignity and respect and
staff were mindful of confidentiality and privacy.
• Staff took time to ensure patients and their relatives
understood their care, diagnosis and treatment
plans.
• The emergency department and the trust were
working closely with commissioners and partners to
address system-wide flow issues and introduce
innovative methods to improve patient flow.
However:
• The trust was consistently failing to meet the
national standard which requires 95% of patients to
be discharged, admitted or transferred within four
hours of their arrival at the emergency department.
• The emergency department suffered from regular
crowding, and this was cited as the department’s
greatest risk. This was on the corporate risk register.
• Wheelchair users and patients with mental health
conditions were not having their needs met.
• Patient privacy and confidentiality could not be
maintained in the corridor when the department was
crowded.
• Not all staff had received an appraisal in the last year,
with particular low compliance in the ancillary staff
group.
• Consultant cover did not meet the 16-hours on-site
standard and was reduced significantly at weekends.
However, junior doctors felt well supported and both
the local management team and trust executives
were aware of this concern and had actions ongoing
to improve the levels of cover.
• Receptionists did not receive any training or
guidance to help them identify potentially seriously
unwell patients and there was no formalised
procedure for calling for help in the event of a patient
deteriorating in the waiting room. However, while
this presented a risk to patients awaiting triage, no
incidents of harm had been reported.
Urgentandemergencyservices
Urgent and emergency services
although junior doctors felt well-supported. However,
there had been no reported harm to patients and there
was senior management and executive visibility of this
with actions ongoing to improve the levels of cover.
Are urgent and emergency services safe?
Good
–––
We rated safe as good because:
• There was an extremely positive safety culture, with staff
taking an interest and personal responsibility with
regard to patient safety.
• Staff were genuinely open, honest and transparent and
actively reported incidents as an active tool for learning
and improvement.
• Learning opportunities were identified and these were
actively shared with staff to support improved safety.
The use of simulation training to further embed learning
was an excellent tool.
• Innovation was encouraged and the delivery of the
SHINE patient safety assessment tool had delivered
excellent results.
• A thorough cleaning programme was in place and
records confirmed this was being completed.
• Although crowding was an issue and ambulance
patients often had to queue in a corridor, this was being
actively managed in a way that kept patients safe with
additional staff being allocated and the use of a patient
safety checklist.
• Patients arriving in the department were assessed and
monitored effectively. Those arriving by ambulance
were assessed swiftly within five minutes of arrival. The
majority of self-presenting patients (those not arriving
by ambulance) were assessed within 30 minutes of
arrival.
• Medicines were managed safely and securely. Incidents
relating to double administrations had led to new
stickers being implemented to highlight pre-hospital
medicines administration to staff.
• Staff understood their safeguarding responsibilities and
actively reported concerns.
• Nursing staffing levels met national guidelines and
additional nurses were called upon from the wards to
support the department in times of crowding.
However:
• Mandatory training compliance within the nursing and
medical staffing groups was below target for all topics.
• Consultant cover did not meet the 16-hours on-site
standard and was reduced significantly at weekends,
Incidents
• There was a positive reporting and safety culture. All
staff we spoke with were aware of their responsibility to
report incidents and valued this as an opportunity to
learn and improve. This was evidenced in the types and
numbers of incidents reported. The department was the
highest reporting area in the trust, with a large number
of near misses and minor incidents being report.
• In the 2015/16 safety culture survey the department
scored extremely well, with a number of responses
performing higher than the trust overall.
• Incidents were reported on an electronic system, which
staff told us was simple to use. All staff had access to this
system.
• We reviewed a large number of reported incidents and
saw evidence these were investigated and fed back to
staff. Learning points were identified and shared
throughout the department, and the wider hospital
where required.
• There had been no never events reported in the
emergency department between October 2015 and
November 2016. Never events are serious incidents that
are wholly preventable, where guidance or safety
recommendations that provide strong systemic
protective barriers are available at a national level, and
should have been implemented by all healthcare
providers.
• There had been three serious incidents in the
emergency department between August 2015 and
September 2016. We reviewed the investigations for all
three incidents and found thorough investigations had
been completed, involving both internal and external
multidisciplinary teams where necessary. The
investigations clearly identified where learning was
possible and the action plans reflected the actions
needed to address these opportunities. Actions
included teaching sessions for staff and simulation
training.
• There were a number of systems to ensure learning from
incidents was shared throughout the department. Daily
safety briefings provided immediate opportunities to
share safety learning with staff. Minutes of governance
and staff meetings demonstrated learning from
22 University Hospitals Bristol Main Site Quality Report 02/03/2017
Urgentandemergencyservices
Urgent and emergency services
incidents had been discussed, and these minutes were
circulated to staff who were not in attendance.
Simulation training was used as another tool to share
learning and embed practice following more complex or
serious incidents.
• Mortality and morbidity meetings were held quarterly to
ensure there were sufficient numbers of cases to
discuss. The meetings were consultant-led and usually
just involved staff from the department, but where other
specialties had input with the patient’s care these
reviews were jointly held. The meetings were open to all
staff working in the department, but as is usual in
emergency departments the core attendees were
middle-grade doctors and consultants. The meetings
were well documented and minutes were circulated to
staff.
Duty of candour
• Regulation 20 of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014 was introduced
in November 2014. This Regulation requires a provider
to be open and transparent with a patient or other
relevant person when things go wrong in relation to
their care and the patient suffers harm or could suffer
harm which falls into defined thresholds.
• All staff we spoke with had a good understanding of the
duty of candour and some were able to give examples
of when they had fulfilled the requirements of the
Regulation.
• We reviewed several examples where patients had
suffered moderate or serious harm and found evidence
that duty of candour had been followed. We saw
support had been given to patients and their families,
explanations and apologies were provided and
recorded, and investigation findings were shared once
completed.
Safety thermometer
• The safety thermometer is used nationally to record
patient harm and to provide immediate information and
analysis for teams to monitor their delivery of harm-free
care. Data collection takes place on one day each
month. It is therefore only a snapshot of a single-day’s
performance.
• There were no reported pressure ulcers, falls with harm
or catheter-acquired urinary tract infections between
September 2015 and November 2016.
Cleanliness, infection control and hygiene
• Cleanliness, infection control and hygiene were very
good throughout the emergency department.
• The department had clear and detailed cleaning work
schedules with tasks broken down into time slots. The
work schedules were comprehensive and included the
cleaning of all surfaces, floors, bed spaces, bed rails,
toilets and bins. Check sheets were signed once
cleaning had been finished, and we saw these were
complete and up-to-date.
• The department was visibly clean and the patients we
spoke with told us they thought the department was
very clean.
• We observed cleaning to be thorough, with staff moving
objects so they could clean behind and underneath
them. Hard-to-reach areas were not overlooked, and
staff had the equipment to reach difficult areas, for
example curtain rails and high ledges.
• All staff took responsibility for ensuring the cleanliness
of the department, regardless of their role or grade. We
saw nursing staff, doctors and consultants cleaning
equipment they had used.
• There was good access to alcohol hand gel throughout
the department.
• There had been no cases of methicillin-resistant or
methicillin-susceptible Staphylococcus aureus (MRSA
and MSSA), or Clostridium difficile (C. diff) in the last six
months.
• We observed one patient with a potentially contagious
infection being provided with a mask to prevent the
airborne spread. The patient required admitting to the
hospital and isolation facilities were being arranged.
• All staff were bare below the elbows and regularly used
alcohol hand gel to reduce the risk of cross-infection.
However, staff rarely used soap and water to clean their
hands before or after patient contacts. Internal hand
hygiene audits for September and October 2016 showed
only 66% compliance. Data was not provided for the
preceding months. Increased awareness of hand
hygiene procedures was highlighted on an infection
control noticeboard.
Environment and equipment
• Equipment was serviced and checked in accordance
with manufacturers’ and local requirements. All the
equipment we checked in the department had stickers
confirming the last and next inspection or service date
23 University Hospitals Bristol Main Site Quality Report 02/03/2017
Urgentandemergencyservices
Urgent and emergency services
•
•
•
•
•
•
•
and these were all up-to-date. Portable appliance
testing stickers also showed all the equipment had been
tested in the last year. We also received a spreadsheet of
all the equipment in the department, along with the
next service schedule date. All items of equipment in the
department were up-to-date.
Staff had easy access to equipment and we found
storage and labelling made it easy for staff to identify
and obtain the equipment they needed.
We found the sluices were clean, tidy and
well-organised. Items marked as being clean were
checked and found to be visibly clean. There were
clearly identifiable domestic and clinical waste disposal
facilities, and we found these were being used
appropriately.
The department had a dedicated mental health
assessment room, which met the required standards.
There was good access and egress, furniture was
appropriate and an alarm system was installed.
Although the majors area did not have an emergency
resuscitation trolley, we were assured equipment was
readily available in the resuscitation area which had
access directly from majors. Managers and staff
described the actions they would take in the event of a
cardiac arrest in majors, with the patient being taken
straight into the resuscitation area. In the event the
resuscitation area was full, a patient could generally be
moved out of resuscitation to make space. Alternatively,
a cardiac arrest patient could be temporarily
accommodated centrally in the resuscitation area. As a
final option, a spare defibrillator normally used to
accompany critically unwell patients from resuscitation
to other areas of the hospital could be easily moved into
a majors' cubicle. There had been formal risk
assessment of this position.
The hospital had a helipad on the roof so air
ambulances were able to land. There was good access
from the helipad to the emergency department.
X-ray and computed tomography (CT) was located
adjacent to the department. This meant patients could
be transported quickly to these areas.
Ambulances had direct access to the emergency
department from a covered drop-off area. Doors directly
into the resuscitation area were located opposite the
ambulance entrance, which reduced delay when
critically unwell patients arrived.
• Patients in the waiting room could be seen from the
reception desk. However, a number of the seating
positions faced away from the desk so staff might not
have been able to see a patient deteriorating.
• Resuscitation equipment checks were not always being
recorded. While we found the emergency resuscitation
trolley in the observation unit had daily checks recorded
for the past three months, checks in the resuscitation
area were inconsistently recorded. Although we
observed checks were being carried out, staff did not
always record these. In the five weeks leading up to our
inspection checks had not been recorded on 13 days,
although staff told us the equipment was checked daily.
• In the observation unit there were two bed spaces
without fixed monitoring equipment. Although two
portable machines were available, these were
frequently in use in the corridor due to crowding in the
department. While observations were still possible
using equipment in the other bed spaces, it did mean
on occasions these were delayed. This was recognised
as a risk in the department with the lack of monitoring
equipment being placed on the department risk register
in April 2016. A capital bid for more equipment was
planned for 2017.
• Chemicals were not always stored securely. On the first
day of our inspection we found chlorine tablets on top
of a cupboard in an unlocked sluice. We also found a
bottle of toilet bleach in an unlocked cupboard in the
relatives’ room. We raised this with senior staff and
found these had been removed on the second day of
our inspection.
• The department was frequently crowded, with patients
being held in a corridor until space became available in
majors. We found this to be a regular occurrence during
our inspection and were told by staff patients queued
almost every day.
Medicines
• Medicines were managed in a way that kept people safe.
Medicines were stored in locked cupboards in a locked
room, accessible only with a swipe card. Keys to the
medicine cupboards were stored in a separate locked
safe so they could be accessed when needed.
Intravenous fluids were also stored within this locked
room.
24 University Hospitals Bristol Main Site Quality Report 02/03/2017
Urgentandemergencyservices
Urgent and emergency services
• Controlled drugs were stored securely and only
authorised staff were able to access them. The
controlled drugs registers were up-to-date and regular
checks were recorded in all but one case.
• Allergies were recorded clearly on patient records and
prescription charts in all but two of the 18 records we
reviewed.
• Refrigerator temperatures were all within range and we
saw daily checks were being recorded.
• Stickers were being introduced to improve patient
safety. Following a number of incidents where
medicines had been administered twice, usually
following patient admission by ambulance, new stickers
had been introduced to reduce errors. These stickers
were placed on the front of patients’ records to alert
staff that medicines had been given by the ambulance
crew prior to the patient arriving at hospital.
• There were clear disposal and destruction processes in
place for wasted or out-of-date medicines. Facilities for
the disposal of wasted medicines were available in the
department, while destruction could be arranged
through the pharmacy.
• We found a number of patient group directives in the
minors area had been printed but were out-of-date. All
the up-to-date directives were available on the trust
intranet system. We highlighted this to staff and found
the following day the printed directives had been
removed.
Records
• Patient care records were well completed. We reviewed
a total of 18 records and found in all but two records the
notes were legible, complete, signed, timed and dated.
We found all records had risk assessments and
management plans completed and these were easily
identifiable. While records were not stored securely in
majors, the filing system used was located by the nurse
in charge’s station and this area was away from the
patient areas and always observed. In the observation
unit care records were stored securely in the enclosed
nurses’ station.
• The department used paper care records, which were
scanned into an electronic system at a later date.
• Do not attempt resuscitation orders, when completed or
handed over on the patient’s arrival, were stored at the
front of care records so they could be quickly located
and referred to in the event of a cardiac arrest.
• Internal records audits showed variable compliance
between November 2015 and October 2016. For
example, in November 2015 no ECGs had been labelled
correctly, while in four other months all had been
labelled correctly. The year-to-date compliance was
89.7%, which was an improved position from 79.2% the
previous year. Another indicator was the name and
designation of the staff member completing the notes
being written in full. In January 2016 no records audited
had this completed, although in five other months all
the records audited had this detail. The year-to-date
position was 72% of records contained this detail.
Safeguarding
• Most clinical staff working in the emergency department
were up-to-date with level two adult safeguarding
training. Within the nursing staff group, 96% of those
staff required to complete this training had done so.
Within the medical staff group, 74% of those staff
required to complete this training had done so. The
trust target was 90%.
• Not all clinical staff in the emergency department had
completed children’s safeguarding training. Against a
target of 90%, only 56% of nursing staff and only 43% of
medical staff had completed level three children’s
safeguarding training. Although the children’s
emergency department was completely separate, staff
in the adult emergency department still came into
contact with children who had come in with an adult
and therefore should have received some form of
children’s safeguarding training.
• Staff were aware of their safeguarding responsibilities
and knew the processes to follow in the event of a
safeguarding concern being identified. All the staff we
spoke with were able to talk through the process of
reporting a safeguarding concern, and could show us
where to find help and guidance to support them. They
were able to tell us about the different types of abuse
and knew how to manage incidents or concerns or
about female genital mutilation.
• We saw a laminated flowchart in majors outlining the
safeguarding process, and a dedicated area on the
trust’s intranet provided additional information and
contact details for the safeguarding leads.
• Concern forms had been introduced and were well used
by staff where concerns were identified that may not fit
strictly into safeguarding criteria but required a
multi-agency review. These were sent to the trust’s
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safeguarding team and regular review meetings took
place with other agencies, including the local authority,
where further actions to address any concerns were
agreed.
Mandatory training
• Mandatory training compliance did not meet the trust
target. The trust had a target of 90% compliance for all
mandatory training, but within the medical and nursing
staff groups in the emergency department no topic met
this target. Compliance ranged from 37% (information
governance) to 78% (conflict resolution awareness,
conflict resolution training, and equality and diversity).
• Mandatory training was monitored centrally by the
trust’s training centre and monthly updates were
received by the department’s clinical nurse educator.
The clinical nurse educator then identified those who
needed to complete any statutory and mandatory
training and updated a list in the staff room.
• Staff told us they found accessing mandatory training
difficult because they were often too busy on a shift to
be released. Since the one-day training had been
stopped in preference of separate e-learning modules,
staff told us they had found it more difficult to be
released to complete it. Staff were able to complete the
training in their own time, but this was discouraged by
the department and the trust because it was a
work-based activity and staff needed time to rest away
from work.
• Training in the identification and management of sepsis
was included in the induction of all new staff. This
included familiarising staff with the trust’s policies and
processes.
Assessing and responding to patient risk
• Patients in the emergency department were kept safe
through the use of observation tools. Having recognised
the impact of crowding in the department on patient
safety, and particularly the increased risk for patients
waiting in the corridor, a research project was
undertaken which resulted in the introduction of a new
patient safety checklist. The SHINE project was
introduced by the department in November 2014 and
provided staff with a simple checklist to ensure
patient-safety based actions were completed. Since its
introduction there had been no incidents of a
deteriorating patient not being identified and then
managed.
• In every record we looked at in majors, minors,
resuscitation and the observation unit we found the
patients had all had observations completed and
documented on an hourly basis. An early warning score
system was being used, and since the introduction of
SHINE the recording of an early warning score had
increased from 51% to 82%.
• Patients arriving by ambulance were assessed promptly.
The department performed better than the England
average in the 12-month period between October 2015
and September 2016. During this period the average
time from arrival to initial assessment was five minutes.
The national average was six minutes. During our
inspection we found even when the department was
crowded and patients were queuing in the corridor,
initial assessments were completed without delay to
ensure patients were safe.
• Risk assessments were used routinely throughout the
department and included mental health, pressure areas,
venous thromboembolism (VTE) and sepsis. We saw
these used in care records to assess patient risks and
create management plans to reduce those risks.
• Patients requiring diagnostics, or who were awaiting
results of diagnostic tests, out of the department were
escorted when necessary. The department had written
criteria identifying the patients who required an escort.
These included patients who were immobilised or had
increased early warning scores. We observed all the
patients fitting the criteria during our inspection were
accompanied.
• Patients with suspected sepsis were identified and
treated early through the use of a sepsis screening tool
and treatment pathway. Patients with suspected sepsis
were identified on the majors whiteboard with a ‘sepsis’
magnet so all staff were aware and able to take
proactive action to manage them. We observed three
patients who had presented with symptoms suggesting
they may have sepsis and found in each case the
screening tool and treatment pathway had been
completed.
• A dedicated mental health assessment matrix was being
used to risk assess patients presenting with mental
health conditions. Depending on the risk, actions to take
were highlighted to staff so patients could be managed
safely.
• Patients who arrived at the department having made
their own way presented to a reception desk in a main
waiting room. Receptionists took patients’ basic details,
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including what was wrong, and entered these on a
computer system. A triage nurse was then able to see
the details and would call patients through in order of
their arrival. However, if the triage nurse saw any
potential ‘red flags’, for example chest pain, they could
reprioritise the waiting queue. Receptionists were not
trained to recognise serious concerns or ‘red flags’ and
were not provided with any guidance to help them
recognise patients who were potentially seriously
unwell or at risk of deterioration. However, all the
receptionists we spoke with said they used their
common sense and would call for help if they were
concerned about a patient. Receptionists did not have a
formal process for summoning help in the event of a
patient deteriorating in the waiting room. They told us
they would shout to the triage nurse in the next room, or
through to minors if the triage nurse was not there.
However, while this presented a risk to patients awaiting
triage, no incidents of harm had been reported.
• Patients who arrived at the department having made
their own way were not always assessed promptly.
Between November 2015 and October 2016 the average
time from arrival to assessment was 27 minutes. The
longest average wait time was 33 minutes in October
2016. Only 38% of patients who were not brought to the
department by ambulance were assessed within 15
minutes, and only 66% of patients were assessed within
30 minutes and 91% within 60 minutes. This area of
performance had been identified in a departmental
team meeting but actions to understand and address
the issues had not been identified. However, there was
no evidence of patient harm as a result of delayed
triage.
• On the first day of our inspection we observed ten
patients in minors waiting for triage. Between 2.20pm
and 4pm all ten patients we observed had to wait longer
than the 15 minute standard for time to initial
assessment. The average triage time for these patients
was 26 minutes. On the second day of our inspection we
reviewed eight records and found one did not have a
triage time recorded and of the other seven only two
had been triaged within 15 minutes.
• We found patient call bells were not being made
accessible to all patients in majors. Although staff had
good visibility into most cubicles, they were not being
observed at all times. We highlighted this concern on
our first day and found action had been taken to resolve
the issue on our second day. We also found all patients
had access to a call bell on our unannounced
inspection.
Nursing staffing
• The emergency department used a scoring system for
acuity and dependency. The tool was used daily to
review staffing levels based on the needs of the patients
in the department. Advanced staffing levels were
planned using historical data, including attendance
numbers, acuity and dependency.
• Staffing levels met national guidance and kept patients
safe, although staffing in minors was highlighted by staff
as a concern because of timeliness of assessments and
the impact on patient experience. On every shift it was
planned there would be one band seven or band six
senior shift coordinator, two band five registered nurses
in the observation unit looking after up to eight patients,
two band five registered nurses in minors, three band
five registered nurses in majors looking after up to 11
patients and either two or three band five registered
nurses in resuscitation looking after up to six patients.
During the day at least one unregistered nursing
assistant provided additional cover, while at night there
were at least two. Emergency nurse practitioners also
worked in the department covering the full 24-hour
period.
• During times of crowding, additional nursing cover
could be requested from the wider hospital to release
emergency department staff to look after patients in the
corridor. We saw this system working well and patients
told us they felt safe. However, some nursing staff from
the wider hospital told us they were sometimes
allocated to the corridor, which they felt uncomfortable
with because they were not from an emergency
department background.
• At the time of our inspection there were 2.7 whole time
equivalent registered nurse vacancies at band seven,
with interviews planned in December 2016. There were
also two band six registered nurse vacancies. Band five
registered nurses had been over-recruited to help
manage the impact of staff turnover within this staffing
group. There were an additional five whole time
equivalent band five registered nurses. We did not see
this have any adverse impact during the inspection, and
staff told us the skill mix and staff numbers were ok.
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• Data provided by the trust showed between May and
August 2016 all shifts were fully staffed, with some
months having increased staffing numbers.
• Between September 2015 and August 2016 the bank
and agency usage rate was 11.7% in the emergency
department. The department was working hard to
reduce its agency spend and used bank staff in
preference of agency staff as often as possible. These
bank staff were trust employees and were familiar with
the department so it was believed to be safer, as well as
more economical.
• A structured handover process between shifts ensured
patients were kept safe. The oncoming nurse in charge
received a handover from the off-going nurse in charge.
Every patient in majors and the observation unit were
discussed in turn, covering what the patient presented
with and the plan for their assessment and/or
treatment. When the matron was on duty they also
attended the handover but were able to leave and
accept ambulance patients so the nurses in charge
could continue the handover. Once the patients had
been discussed, the ‘ABC of handover in the ED’ was
followed which covered various areas of the
department, including bed availability and breaches,
colleagues (sickness, issues), deaths, disasters,
deserters, drug charts, discharge summaries, equipment
issues, friends and family test completion and gaining
knowledge (any teaching or training needed).
• The nursing staff meanwhile took individual handovers
for the patients they would be looking after. These
handovers were also well structured and included
discussion about social considerations, medicines,
pressure areas, observations, the patient’s presenting
complaint and any blood results. Once the handovers
had been completed the nurse in charge then delivered
a safety briefing to each nurse in turn.
• All new staff had a comprehensive induction process.
This included a three-day induction followed by a
two-week supernumerary period. The programme
included assessing patients, meeting all the specialist
nurses, handovers, orientation and equipment
familiarisation. One new starter who had been through
this process told us they felt much safer knowing the
induction process had been so comprehensive. Staff
supporting the department from other areas of the
hospital received basic familiarisation and guidance
from the nurse in charge.
Medical staffing
• Medical cover generally kept patients safe, but
consultant cover was recorded as a risk in the
department, particularly at weekends.
• Medical cover Monday to Thursday was provided by two
consultants during the day and two consultants in the
evening, one of whom was on-call overnight. On Fridays
this reduced to one consultant on the evening shift and
at weekends there was just one consultant covering the
department. Middle-grade and junior doctors worked a
variety of shifts covering the whole 24-hour period and a
minimum of an ST4 was on duty in the department at all
times.
• Consultants were not planned to provide a minimum of
16-hours on site cover. During the week consultant
cover was provided 8am to 10.30pm, although we were
told they usually worked until midnight. After 10.30pm a
consultant was on-call. At weekends consultant cover
was only provided 8am to 5pm, with the remaining
hours being covered on an on-call basis.
• Overnight on Monday to Thursday there were two
middle-grade doctors on duty providing medical cover
for the department, and on Fridays, Saturdays and
Sundays this was increased to three. Junior doctor cover
mirrored the middle-grade cover overnight.
• The department had completed a benchmarking
exercise and identified they had fewer consultants when
compared with other departments locally. It was
recognised they were unable to meet 16-hours of
planned consultant presence, and the weekend was
highlighted as a particular risk. We were told a business
case was being put together to request additional
funding so medical cover could be strengthened.
• Military doctors worked in the department on a
supernumerary basis and we were told this worked well.
However, it was felt by department managers if these
military doctors were not available the department
would struggle to provide adequate medical cover.
• Between September 2015 and August 2016 the bank
and locum usage rate was 3.3% in the emergency
department.
• We observed a medical handover and found it to be
comprehensive. We observed excellent communication
between the whole medical team at the handover, with
each doctor taking the time to handover their patient in
detail with others clearly listening. Patient safety
considerations were highlighted and the opportunity to
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have a quick learning discussion was maximised. In the
same way as the nursing handover, the medical team
finally completed the ‘ABC of handover in the ED’. The
handover was also attended by the nurse in charge,
psychiatric liaison and representatives from a partner
organisation providing the REACT service.
•
Major incident awareness and training
• The trust had major incident and business continuity
plans in place. These were readily accessible and
included action cards relevant to the emergency
department. Most staff we spoke with were aware of the
major incident arrangements and knew how to access
the action cards and major incident equipment.
• An emergency decontamination tent was stored outside
the department and could be erected in the event of an
incident requiring patients to be decontaminated.
• Security were based in the department out-of-hours.
In-hours, we were told security staff were very
responsive if needed. Reception staff told us they
received verbal abuse on a daily basis and reported this
in most instances. They told us they were
well-supported by security and emergency department
staff and managers in these circumstances.
•
•
•
Are urgent and emergency services
effective?
(for example, treatment is effective)
Outstanding
benchmarking and peer review. A thorough
multidisciplinary audit programme was in place and
actively used by staff to encourage and monitor
improved outcomes.
The continuing development of staff skills, competence
and knowledge was recognised as being integral to
ensuring high quality care. There was a clear focus on
staff learning and development, with staff being
supported and sponsored by the department and the
trust to complete additional relevant qualifications.
Staff delivered strong multidisciplinary working both
within the department, and with staff from other
departments or organisations.
There was a truly holistic approach to planning people’s
discharge or transfer to other services, and this was
done at the earliest stage. Staff from two external
agencies worked proactively within the department to
support discharges with increased social care provision,
and to provide a ‘virtual ward’ to allow patients to be
cared for at home. Staff in the department worked
closely with these teams and engaged with them
promptly after a patient had been assessed.
Staff demonstrated a clear understanding of consent
and best interest decision practices and records
evidenced these were being followed. Consent practices
ensured people were involved in making decisions
about their care and treatment.
However:
–
• Not all staff had received an appraisal in the last year,
with particular low compliance in the ancillary staff
group.
We rated effective as outstanding because:
• The safe use of innovative approaches to care and how
care was delivered was actively encouraged. This
included simple solutions, such as a touchscreen
guideline system in the resuscitation area, and the close
working relationships with external partners to deliver
alternative care pathways and admission avoidance
programmes. The SHINE patient safety assessment tool
had driven significant improvements and clearly
demonstrated improved outcomes.
• All staff were actively engaged in activities to monitor
and improve quality and outcomes, including
Evidence-based care and treatment
• The emergency department used a combination of
National Institute for Health and Care Excellence (NICE)
and Royal College of Emergency Medicine (RCEM)
guidelines to determine the treatment that was
provided. Guidance was regularly discussed at team
meetings, and regular audits were completed and
learning opportunities shared with staff.
• A range of clinical care pathways and proformas had
been developed in accordance with national guidelines.
These included treatment of stroke, sepsis, asthma,
fractured neck of femur (broken hips), acute coronary
syndrome, diabetic ketoacidosis, upper gastrointestinal
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bleed, suspected pulmonary embolism and mental
health problems. We found these were understood by
staff and were being used effectively to manage
patients’ care.
• Following the introduction of the SHINE patient safety
assessment tool compliance with the evidence-based
sepsis pathway had increased from 93% to 95%. An
increase in compliance with the evidence-based stroke
pathway was also seen, rising from 86% to 97%. For
patients with a fractured neck of femur, evidence-based
pathway completion increased from 92% to 97%.
• A programme of multidisciplinary audits was used to
check care and treatment was being provided in
accordance with national guidelines. Where
performance could be improved action plans were
completed and learning was shared with staff. Further
audits were then completed to check performance had
improved. For example, in February and March 2016 an
audit was completed against the NICE guideline CG176
for head injuries. The audit identified poor performance
in documentation of a cervical spine assessment,
computed tomography (CT) reporting times and the
provision of written head injury advice. A poster was
devised that reminded staff of the guidelines, showed
the audit findings and the actions being taken to
improve performance. A further audit was completed in
June 2016 and showed an increase in performance. We
saw similar audit posters covering the recording of
referral discussions and management advice for
patients with an intracerebral haemorrhage, reviewing
blood culture sampling, and cervical spine imaging.
Pain relief
• Patients had their pain assessed and managed
promptly. In all the records we reviewed all patients had
an early pain score recorded and timely administration
of pain relief where required.
• All patients we spoke with were comfortable and told us
they had been asked if they were in any pain and offered
pain relief.
Nutrition and hydration
• Following assessment of a patient, intravenous fluids
were prescribed and administered when clinically
indicated.
• We observed nurses, healthcare assistants and
members of the catering team providing water, hot
drinks and snacks for patients. Before offering any food
to patients, staff checked with the nurse and doctor,
where appropriate, to check the patient was able to eat
and drink.
• Patients we spoke with told us they had been offered
drinks and snacks where appropriate.
Patient outcomes
• The department had taken part in a number of national
audits since 2014, including the Royal College of
Emergency Medicine 2014/15 audit for assessing
cognitive impairment in older people, and mental
health in the emergency department 2014/15 audit.
• In the cognitive impairment audit the department
scored in the upper quartile compared to other
hospitals for two measures, in line with the England
average for three measures and in the lower quartile for
one measure (having an early warning score
documented). Since the introduction of the SHINE
patient safety checklist early warning scores were
routinely documented for all patients, and this was
evident during our inspection.
• In the mental health audit, the department scored in the
upper quartile for two measures, compared equally with
the England average for four measures, and was in the
lower quartile for two measures (provisional diagnosis
documented and assessed by a mental health
practitioner within one hour). Although the trust had
increased psychiatric liaison provision, this standard
remained poor. However, mental health services were
provided by an external provider and the trust was
working closely with them and commissioners to try
and improve the service response time.
• Other national audits had taken place since 2013,
including the Royal College of Emergency Medicine 2013
consultant sign-off audit, paracetamol overdose 2013/
14 audit and severe sepsis and septic shock audit 2013/
14. In the absence of formal Royal College of Emergency
Medicine re-audits, the department had proactively
re-audited their performance following action plans
being completed and these demonstrated outcomes
were being improved.
• Following all audits, clear action plans were put in place
to increase performance where needed, and re-audits
had either taken place or were planned. Where re-audits
had taken place there was a demonstrable
improvement in performance. For example, the correct
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•
•
•
•
•
assessment of risk, appropriate blood tests being sent
and use of a departmental flowchart to assess the need
for blood thinners in venous thromboembolism in lower
limb immobilisation.
Additional local audits included asthma management
and seizures. Again, where standards were not being
met there were clear recommendations and action
plans produced to improve performance in those areas,
including re-audits in the future and these were showing
improvements were being made.
Audit meetings were held to discuss the progress of
audits and present audit results and recommendations
once completed. These meetings were recorded and
minutes were circulated to staff.
The department was about to start a project with
pre-hospital partners, including the ambulance service
and GPs, to help further improve patient outcomes. The
pre-hospital partners had agreed to trial an early
warning score system so differences pre-hospital, on
arrival and during assessment, observation and
treatment could be compared and considered.
Following the introduction of the SHINE patient safety
checklist, improvements in pathway compliance had
been seen in a number of areas. This in turn promoted
improved patient outcomes.
Unplanned re-attendance rates between October 2015
and September 2016 were about 8%. This was higher
(worse) than the national standard of 5%, but similar to
the England average of 7.5%.
•
•
•
•
Competent staff
• New starters in the department received a structured
induction and orientation programme, overseen by a
clinical nurse educator and practice development nurse.
For nursing staff there were two routes, depending on
whether or not they had previous emergency
department or critical care experience. Both routes
included a period of two weeks supernumerary practice,
including either one-to-one resuscitation experience
and the first of a two-part induction, or both parts of the
induction. Further development goals included 1:1 shifts
with the practice development nurse, resuscitation
training and triage training.
• Other external and internal courses were also available,
including point of care simulation, human factors
•
•
•
•
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training, male catheterisation, trauma immediate life
support, advanced life support, advanced trauma life
support observer, minor injury and illness, and
plastering.
Staff were supported by their managers and the trust to
attend additional courses. Study leave could be
approved for 75% of the study time needed, with staff
completing the other 25% in their own time. The
department had six staff on the principles of emergency
care course at a local university, and planned to allow
more to complete this when further opportunities arose.
A further two members of staff, both assistant
practitioners, were also being sponsored by the trust to
complete their training to become registered nurses.
This required two years study at university.
Student nurses received a one-day induction and were
allocated mentors who they worked with in a
supervised, supernumerary capacity.
The department employed a clinical nurse educator for
15 hours-a-week. Although they would have liked more
hours to deliver more education, the benefit of just
15-hours was being noticed by staff who felt
well-supported with their ongoing development.
Additionally, a practice development nurse worked one
shift a week, with a focus on training and support on the
‘shop floor’.
There was protected teaching time for the emergency
nurse practitioners every Tuesday for one hour. The
sessions frequently had guest speakers from other
specialties and the time was also used to discuss
complex or particularly interesting cases.
Middle-grade doctors had four hours protected teaching
time every Wednesday afternoon. The sessions covered
safety updates, including learning from incidents. The
staff we spoke with valued this highly.
Medical staff also had the opportunity to attend annual
practical procedures training and this was run jointly
with another local hospital. Doctors told us they felt well
supported by a positive culture of education and
teaching.
A comprehensive register of the equipment used in the
department was held by the clinical nurse educator. We
reviewed the log and saw staff were signed off as being
competent on each piece of equipment before they
were permitted to use it unsupervised.
Not all staff in the emergency department had received
an appraisal in the last year. In the year 2015/16 only
78% of staff had received an appraisal, against a trust
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target of 85%. Administrative and clerical staff had the
highest compliance at 94%, while 81% of nursing staff,
75% of medical staff and only 29% of ancillary staff had
received an appraisal. We were told by department
managers the biggest difficulty with completing
appraisals was releasing staff from the department to
attend. Managers told us they were working hard to
release staff for their appraisals, prioritising quieter
times in the department, but due to demand were still
finding this difficult.
Multidisciplinary working
• Effective multidisciplinary working was evident in the
emergency department. We observed all staff across all
grades, functions and departments working
exceptionally well together. Communication, support
and challenge were encouraged by excellent
relationships between everyone. In one example we
observed a nurse constructively challenging a doctor
about the prescription of medicines for a patient. The
two members of staff discussed the options together
and reached agreement about the diagnosis and
treatment plan before the medicines were prescribed
and administered.
• All the ambulance staff we spoke with told us they had
really good working relationships with the emergency
department staff. They told us they were listened to at
handover and felt valued and respected as part of the
emergency team by all the emergency department staff.
• The department was working closely with two external
organisations who were based within the hospital. The
trust had contracted with a third party organisation to
provide a ‘virtual ward’ by providing medical and
nursing care in a patient’s home wherever possible, and
REACT reviewed social care packages and arrangements
to help facilitate discharges of patients to their home
rather than having to be admitted to a hospital bed. We
saw excellent working relationships between the
external and internal staff, with a clear focus on working
together to achieve the best outcome for the patient.
• While timely access to the external mental health
provision was difficult, we observed good relationships
when staff did arrive in the department. Additionally,
increased numbers of psychiatric liaison nurses had
improved communication and support for the
department.
Seven-day services
• Imaging services were available 24-hours-a-day,
seven-days-a-week. These were located next to the
department and staff told us they were able access the
service in a timely way. Once completed, emergency
department staff were able to view the images on the
department’s computers, prior to a formal report being
received. We were told there was sometimes a short
delay in the report arriving, but staff felt this was
minimal. Out-of-hours reporting was completed
remotely by telemedicine. Staff told us this service
worked well and provided timely reporting and
discussion.
• Consultants provided cover 24-hours-a-day, seven
days-a-week. This was either on site or on-call. Junior
and middle-grade doctors told us the consultants were
always accessible and gave them good support. They
said consultants were always willing to come in if they
were on-call, even if this was not specifically requested.
Access to information
• Information needed to deliver effective care and
treatment was well organised and accessible. Treatment
protocols and guidelines were either included in
proformas or easily accessible from the trust’s intranet
site.
• In the resuscitation area four bays had been fitted with
touchscreen monitors allowed staff to immediately
access emergency guidelines, protocols and medicines.
This had been developed internally by one of the
consultants and was well-utilised by staff in emergency
situations.
• The trust used a computer system to enter patient
details and allow internal tracking. In the emergency
department this computer system displayed the various
performance times for patients in the department,
allowing easy identification of patients who had been in
the department a long time and needed actions to be
taken. This system could also be viewed by the clinical
site and bed management team and helped with
planning beds.
• Additionally, the computer system displayed warning
flags to highlight to staff patients who may need extra
support, for example patients with learning disabilities
or who may require language translation services. These
flags also alerted specialist teams in the hospital who
would make contact with the department to provide
any additional support needed.
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• Notes for patients who were admitted or transferred
travelled with the patient and were handed over to staff
at the destination to ensure continuity of care and
access to the history of their time on the emergency
department.
• Discharge letters were sent to GPs daily and included
relevant and pertinent information for their attention.
Consent, Mental Capacity Act and Deprivation of
Liberty Safeguards
• Staff had an excellent understanding of the Mental
Capacity Act 2005, Deprivation of Liberty Safeguards and
consent. All staff we spoke with were able to clearly
communicate their responsibilities. In all the records we
reviewed we observed consent had been obtained and
recorded where appropriate, and where consent was
refused this was clearly documented, along with
confirmation the patient had the capacity to make that
decision.
• The trust’s intranet site had a section dedicated to the
Mental Capacity Act and provided staff with easy access
to policies and guidance. Best interest discussion
paperwork could be printed directly from the intranet
site and provided a clear template for staff to record
best interest discussions and decisions.
• For patients who required emergency decisions to be
made for them, for example patients who were
unconscious, staff made decisions in the patient’s best
interest and clearly documented these in the patient’s
records.
Are urgent and emergency services
caring?
Good
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We rated caring as good because:
• People were treated with dignity and respect and staff
were mindful of confidentiality and privacy.
• Care was delivered compassionately by all staff and at
all times.
• Staff took time to ensure patients and their relatives
understood their care, diagnosis and treatment plans.
• Patients and their relatives received emotional support.
However:
• Patient privacy and confidentiality could not be
maintained in the corridor when the department was
crowded.
• Between September 2015 and August 2016 the
department scored lower (worse) than the England
average in the NHS Friends and Family Test.
Compassionate care
• People we spoke with praised the staff for their kindness
and compassion. Patients told us they had been treated
with dignity and respect at all times.
• Staff took the time to ensure patients were comfortable,
responding compassionately to patients in pain or
distress and giving reassurance and support.
• We observed doctors and nurses introducing
themselves when they met patients and their families
for the first time. All patients were addressed by their
preferred name.
• The department had received lots of positive feedback
about the compassionate care provided in the form of
cards and letters, and these were displayed in the staff
room.
• We saw staff from all groups assisting patients and
others who were confused or lost in the department in a
helpful and supportive manner. One doctor was seen
helping a patient to the toilet.
• Privacy in the reception area had been considered and
an auditory barrier had been built in front of the
reception desk to prevent other people in the waiting
room being able to hear what was being said.
• Staff used curtains around the bed spaces to provide
privacy when assessing and treating patients, and
ensured patients’ dignity was maintained when curtains
were opened.
• Patients in the corridor, however, did not have the same
provision to ensure their privacy. Staff did their best to
ensure confidentiality and privacy in the corridor by
keeping conversations as quiet as possible, but because
of the close proximity of other patients and relatives
conversations could still be overheard.
• Between September 2015 and August 2016 the
department scored lower (worse) than the England
average in the NHS Friends and Family Test. The
percentage of patients who said they would
recommend the department ranged from 71% in March
2016 to 80% in August 2016. The national average across
the same period ranged from 83% to 88%.
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Understanding and involvement of patients and
those close to them
• Most patients and their relatives received regular
communications and were kept informed about their
care, treatment and condition. Staff made sure patients
and relatives understood the assessments being done
and the likely diagnosis and treatment plan. Patients
and relatives were given opportunities to ask questions
and staff gave them time to do this.
• However, one patient and their relatives told us they
would have liked more communication while they were
waiting for further examinations to be completed. They
told us this was taking a long time and they didn’t feel
updated.
• We observed one doctor taking a medical history from a
patient and explaining the tests they were going to carry
out. The consultation was undertaken in an unhurried
and sensitive manner and everything was explained to
the patient in a way they could understand.
• We also observed nursing staff taking time to read
through and explain patient information leaflets to
ensure patients understood what they needed to do
before they were discharged.
Emotional support
• Emotional support was provided to patients and
relatives. On two occasions we saw families of patients
being cared for in the resuscitation area being given
emotional support by nursing staff. Both families were
made comfortable in the relatives’ room to provide
some privacy and the nurses took time to talk with them
and help them understand what was happening. The
families were given regular updates and the nurses
regularly checked on their welfare. On another occasion
we saw a distressed patient being comforted by a
nursing assistant.
Are urgent and emergency services
responsive to people’s needs?
(for example, to feedback?)
Requires improvement
–––
We rated responsive as requires improvement because:
• The trust was consistently failing to meet the national
standard which requires 95% of patients to be
discharged, admitted or transferred within four hours of
their arrival at the emergency department.
• The emergency department suffered from regular
crowding, and this was cited as the department’s
greatest risk. This was on the corporate risk register.
• Wheelchair users and patients with mental health
conditions were not having their needs met.
• Patients spent longer in the emergency department
compared to the England average.
• The percentage of patients waiting between four and 12
hours from the decision to admit until being admitted
varied, but was regularly higher (worse) than the
England average.
• Patients with mental health conditions were not
formally assessed and found the most suitable
treatment pathway in a timely manner, although this
service was provided by an external provider.
However:
• The emergency department and the trust were working
closely with commissioners and partners to address
system-wide flow issues and introduce innovative
methods to improve patient flow.
• There was good support for patients living with
dementia or learning difficulties, and translation
services were available for patients whose first language
was not English.
• The trust escalation policy provided good support to the
emergency department at times of increased pressure.
Service planning and delivery to meet the needs of
local people
• The emergency department and the trust were working
closely with commissioners and other partners to
identify system-wide strategies to improve patient flow.
Projects were ongoing included the ‘virtual ward’ and
REACT social care service, both of which were helping
with admission avoidance.
• The department saw a high number of patients with
mental health conditions, and drug or alcohol abuse. An
eight-bedded observation unit allowed patients who
required ongoing monitoring for up to 24 hours to be
admitted without using a hospital bed. Although a large
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number of patients with mental health conditions were
admitted to the observation unit, it was also able to
accommodate other patients who required less than 24
hours of observation, treatment or diagnostic tests.
There was a mental health assessment room in the
observation unit that was appropriately designed and
allowed a private and safe area for mental health
assessments to take place.
The waiting room was adequately sized to
accommodate the numbers of patients and their
relatives or friends most of the time. However, when it
was busy people did have to stand.
A project was well underway to improve signage and
patient information throughout the emergency
department. This project had been undertaken with the
Design Council and installation was due to be
completed in December 2016.
An emergency nurse practitioner-led ‘see and treat’
service ran in minors between 8am and 2am. This
service was designed to help reduce some of the
demand by promptly identifying patients who could be
seen, assessed, treated and discharged relatively
quickly.
A GP-led support unit was available at the hospital and
the department was able to refer one patient an hour to
help reduce demand in minors. Staff wanted to increase
the number of referrals they could make to further help
manage demand, telling us they believed they could
refer up to four appropriate patients an hour if this was
agreed. This was still under discussion at the time of our
inspection.
A relatives’ room was provided in the majors’ area so
relatives and friends of patients had somewhere quiet to
sit and make drinks. However, some of the furniture in
the room was damaged and some relatives told us it
wasn’t very inviting.
All the patients and relatives we spoke with either in the
waiting room or in minors were concerned there was no
information about current waiting times. They told us
they could see patients coming back from seeing a
doctor but there was then a long delay before the next
patient was called through, even though the waiting
room was not busy. Managers told us they hoped the
Design Council project would help to address this by
providing more information about the different stages in
the patient journey through minors.
• The needs of patients in wheelchairs were not being
met. Although access to the department’s main
entrance was straightforward through the use of a lift or
an automatic door at the drop-off point, once at the
door to the waiting room it was difficult for wheelchair
users to gain access. The door was relatively heavy and
was not automatic.
• Additionally, although the reception desk had a lowered
section to accommodate wheelchair users, large
computer monitors obstructed the view. Staff therefore
had to stand and look down at wheelchair users while
trying to enter details into the computer system.
• The needs of patients with mental health conditions
were also not being met. The department’s risk register
carried a risk from April 2012 that mental health patients
presenting to the department were “at risk of increased
harm” due to excessive waits for assessment. We found
this was still the case, although the hours of the
psychiatric liaison service had been increased. The
mental health assessment provision was provided by an
external provider and the trust was trying to resolve
longstanding issues with the responsiveness of the
service, but no improvements had yet to be seen. During
our inspection we observed two patients in the
department for over 12 hours because they were
awaiting mental health assessments. Not only did this
impact on capacity in the emergency department, it
also led to increased stress and anxiety for these
patients.
• We spoke with the father of one patient who had been
in the waiting room for over nine hours because a
mental health practitioner had yet to arrive and assess
the patient. They had arrived in the department at 2am
and were becoming increasingly uncomfortable and
tired.
• Another patient was admitted having taken an
overdose. They arrived in the department at 10.30pm
and were subsequently admitted to the observation
unit to await assessment by a mental health
practitioner. A mental health consultant reviewed the
patient over 12 hours later at 11.15am and agreed the
patient would need an assessment under the Mental
Health Act 1983. The patient then left the department
and took a further overdose before being returned to
the department by the police at 2.25pm. The patient
was placed under temporary detention under Section
Meeting people’s individual needs
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5(2) of the Mental Health Act 1983 at 3pm to prevent
them from harming themselves again. The patient was
finally assessed and placed under section at 4.30pm, 18
hours after they had first been admitted.
Multiple information leaflets were available, but these
were all provided in English. Although other formats
were offered, including braille, large print or email, there
was no provision of leaflets in other languages.
Leaflets available included head injury advice and how
to treat your injured ankle (the two most common
leaflets handed out), services to help you (including
counselling, mental health and psychiatric services,
housing and money problems, alcohol and drug
problems, women’s services, and refugee action), and
what to expect from services for patients living with
dementia.
The observation unit had separate male and female
toilets and showers, with disabled facilities.
Water was available in various places throughout the
department, and the relatives’ room had provisions for
people to make themselves cups of tea and coffee.
Patients with dementia were highlighted on the majors’
whiteboard with a forget-me-not sticker. A booklet
called ‘All about me’ was available and patients or
someone close to them were asked to complete
information about them to help staff meet their
individual needs. This included the patient’s preferred
name, any communication difficulties or preferences,
how their mobility was, and what food and drink they
liked and disliked.
A learning difficulty team was available to support
patients in the department if needed. An alert could be
placed on the computer system by staff and this
automatically flagged up to the learning disability team.
A nurse from the team would then make contact with
the department and could provide any support or
guidance needed. If necessary, a team member would
attend the department to give additional support.
Staff were able to access interpreters for patients whose
first language was not English. This could be arranged
through an external company over the telephone. A
computer alert was created so all staff could see
interpreters were needed, and in the event of the patient
coming back to the hospital this flag would be
immediately available for staff to see.
Access and flow
• The emergency department was consistently failing to
meet the national standard requiring 95% of patients to
be discharged, admitted or transferred within four hours
of arrival. Between November 2015 and October 2016
the department failed to meet the standard in any
month, with performance ranging from 73% in October
2016 to 89% in November 2015. Performance against
this standard showed a trend of decline between
October 2015 and March 2016. Performance then
improved, however remained below the standard each
month up to October 2016. Nationally, emergency
departments are struggling to meet this standard, with
the national average performance over the same period
ranging between 87% and 93%. However, with the
exception of May 2016, this emergency department was
also performing below (worse than) the national
average.
• The percentage of patients waiting between four and 12
hours from the decision to admit until being admitted
increased sharply from 11% in December 2015 to 27% in
January 2016. Performance stayed high until May 2016
where it fell back to 7%. Rates then fluctuated around
the England average until September 2016, before rising
in October 2016 to 25%.
• Patients spent longer in the emergency department
compared to the England average. Between July 2015
and June 2016 the average total time in the department
for admitted patients ranged from 140 to 165 minutes.
The England average over the same period was
between 130 and 155 minutes. We were told this was
due to the flow issues through the hospital.
• There were 275 ambulance handover delays over 60
minutes between September 2015 and August 2016.
Performance was variable throughout this period and
ranged from 13 delays in October 2015 to 31 delays in
December 2015.
• Between August 2015 and July 2016, 16 patients waited
more than 12 hours from the decision to admit until
being admitted.
• We were told by managers and staff that crowding was
the biggest risk to the department, although patient
safety was being well-mitigated. Crowding in the
department was on the corporate risk register.
• Staff and managers told us increasing demand was
causing issues with higher numbers of attendances, and
at times this was being exacerbated by the medical and
surgical take. When patients who were being admitted
to medical or surgical wards in a planned,
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non-emergency capacity did not have a bed to go to,
they were managed in the emergency department until
a bed became available. We reviewed the numbers of
medical and surgical expected patients coming through
the department and found 736 medical patients and
633 surgical patients had been through the emergency
department between April and October 2016. The
numbers of medical patients had increased by 207 on
the same period in the previous year, but the numbers
of surgical patients had decreased by 327. This showed
the overall numbers coming through the department
remained similar compared to last year.
Managers and staff also highlighted difficulties with
discharging patients from hospital back into the
community and the impact this was having on patient
flow through the hospital. This then had a cumulative
impact in the department and contributed further to
crowding.
The department was trying a number of approaches to
help manage the situation, and was being supported by
the trust to do so. For example, patient flow
coordinators worked in majors 24 hours-a-day, seven
days-a-week to help with oversight of flow through the
department. The team had been nominated for an
internal recognising success award and had been
recognised as “an important part of the administrative
cog that keeps this busy department moving.”
Another approach was the collaboration with a third
party provider to provide a ‘virtual ward’. This started in
July 2016. At the time of our inspection the service had
capacity for 25 patients (with 16 patients using the
service), although this capacity was planned to increase
to 35 in December and to 50 in 2017. The third party
provider team worked closely with the emergency
department to identify and assess patients who could
be transferred to the service for ongoing care in the
community rather than on a ward. This promoted faster
discharge from the department, and also kept hospital
beds free.
Another partner was providing a service called REACT.
Again, the service’s staff worked closely with the
emergency department to identify and engage with
patients who could be discharged home but required
additional social care provision to facilitate this.
A pilot was also due to start in December 2016 to help
manage the medically expected patients in a better way.
This would see nurses from the emergency department
staff the ambulatory care unit, so medically expected
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patients who do not require a bed could be observed
and monitored while a bed is found for them. Staff in the
emergency department told us they would not want to
staff this permanently because they were not
emergency patients, but recognised the need to
complete a trial and support a hospital-wide approach
to managing patient flow.
Patients usually received treatment within one hour of
arrival at the emergency department. The Royal College
of Emergency Medicine recommends the time patients
should wait between arrival and treatment is no more
than one hour. In the 12 months between October 2015
and September 2016 this standard was met in nine
months. Performance against this standard showed a
stable trend, generally better than the standard.
The department performed better than the England
average for the percentage of patients who left the
department before they were seen. Between July 2015
and June 2016 the emergency department performed
consistently in this area, with between 2% and 2.7% of
patients leaving before they were seen. The England
average was between 2.7% and 3.6% over the same
period.
Operational grip meetings took place in the department
twice a day and were attended by the clinical site
managers from medicine and surgery, plus the lead for
the day, the emergency department nurse in charge,
ambulatory care senior nurse, medical admissions unit
senior nurse, and the matron from the older person’s
unit. At the meeting the trust’s escalation status was
confirmed, and bed pressures, expected transfers and
admissions, and staffing were all discussed.
Additionally, cover staff for the corridor were planned in
advance so help could be called quickly when needed.
The trust had a well-written escalation policy with good
support mechanisms from across the trust. Staff told us
they thought the escalation processes worked, but
believed there were issues with being on red (high
escalation) or black (critical escalation) for long periods
because this not sustainable and the efficiency of the
system decreased over longer periods.
Learning from complaints and concerns
• Complaints were handled in accordance with trust
policy. If a patient or relative wanted to make a
complaint staff initially tried to resolve the concerns
locally. However, if this was not possible and they
wanted to make a formal complaint they were directed
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to the patient support and complaints team.
Information about the patient support and complaints
team was available in leaflet form and was displayed in
the waiting room.
• Between February and August 2016 there were 57
complaints about the emergency department. This
equated to 11% of all complaints received relating to
the Bristol Royal Infirmary. It took an average of 35.2
days for the trust to investigate and close these
complaints. The trust had a standard timescale of 30
days for complaint resolution, however, where
necessary longer timescales were agreed with the
complainant depending on the complexity of the issues.
• Formal complaints were investigated by senior staff in
the emergency department. Staff involved were
included in the investigation process and given support
where necessary.
• Learning from complaints was discussed at governance
meetings, team meetings and, if safety related, during
safety briefings.
Are urgent and emergency services
well-led?
Outstanding
–
We rated well-led as outstanding because:
• Leaders had an inspiring shared purpose and strived to
deliver and motivate staff to succeed. There was a
continued focus and drive from the leadership team to
improve safety and quality.
• Staff satisfaction across all groups was high and staff
were proud to work in the department.
• Staff spoke of a highly supportive and open safety
culture. They were encouraged to raise concerns to
identify learning opportunities and felt safe in doing so.
• There was strong collaboration and support across all
functions and staff groups, with a common focus on
improving the quality of care and people’s experiences.
A strong audit programme had a safety and
performance focus, and all staff were involved with the
programme. Junior doctors were allocated audits when
they started in the department.
• The overarching governance framework was very strong
and was led by a consultant with an excellent
understanding of governance processes.
• Innovative approaches were encouraged and
supported, and these had a clear focus on patient
safety, quality and performance.
However:
• A departmental strategy had not yet been drafted and
agreed, although this was a deliberate decision by the
new clinical lead to allow time for staff and senior
leadership engagement. The development of this
strategy was planned to be clearly aligned with the trust
quality strategy, published in July 2016, and to ensure
the engagement of staff within the department.
Vision and strategy for this service
• There was a clear vision for the continued development
of the department, however this was not yet written
down. Managers and staff were able to communicate
their vision to us, telling us the department wanted to
continue its improvement of safe, quality care delivered
in a timely manner.
• A local strategy for achieving the vision had not been
produced or finalised. However, there was work ongoing
to ensure that this was aligned with the trust quality
strategy, published in July 2016, which set out the
expected quality standards within the trust as well as
associated behaviours which were in line with the trust
values. There was agreement from all that this would
have a heavy focus on staffing, particularly within the
medical group, and continued engagement with
partners. Staff engagement was seen as essential in the
development of the strategy. There had been a number
of innovative projects in place as part of this
development including SHINE, REACT, a virtual ward and
improved signage throughout the department.
• The clinical lead for the department had only been in
post since September 2016 and had therefore not yet
‘put pen to paper’. This had been a deliberate decision
because they did not want to produce a new strategy
quickly, without taking staff and trust priorities into
consideration. They explained their intention was to
draft a new vision and strategy in the new year following
a senior management team away day. They told us this
would allow the vision and strategy not only to meet the
needs and desires of the department, but also the
agreed direction of the trust. The full development of
the vision and strategy would have staff input to ensure
it also reflected their views and had their support.
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Governance, risk management and quality
measurement
• There was a strong governance framework which was
focused on supporting the delivery of safe, quality care.
There were clear reporting structures from the
department into the division and up to the board, and
vice-versa.
• A departmental clinical lead for governance had been
appointed who oversaw both governance arrangements
and audit activity. This consultant had a strong
understanding of governance and ensured all aspects of
quality, safety, performance and finance were being
considered.
• Fortnightly team and management meetings were
well-structured. Standing agendas included
performance, staffing, safety, governance, trust issues,
complaints and clinical incidents, teaching and training.
Minutes of the meetings were kept and detailed the
discussions that had taken place.
• Regular mortality and morbidity meetings were also
held and discussions were again well-documented in
meeting minutes. Learning opportunities were
identified and plans made to ensure staff received
additional teaching and support as needed.
• A strong audit programme had been introduced and the
areas of work had a strong focus on patient safety.
Learning from clinical incidents was used to help
develop some of the audit work. When middle-grade
doctors started in the department they were tasked with
an audit each in their first week. These were agreed and
overseen by a lead consultant, and all relevant staff
were involved. This included nursing, medical,
administrative and support staff. Following the
identification of a need to audit, the audit was
allocated, designed and agreed. Once an audit had
been completed the results, conclusions and
recommendations were presented at a dedicated audit
meeting. Actions were agreed to meet the
recommendations and action plans put in place.
Actions included changes to practice, administrative
support (for example stickers on notes), teaching, and
information posters, and usually involved a re-audit to
check improvements were being made.
• The department had a local risk register, which was
reviewed by the governance lead and matrons on a
quarterly basis, or sooner if something had significantly
changed. The risks recorded on the register reflected the
concerns staff and managers told us about. A divisional
and trust risk register were also used so higher risk
concerns could be reviewed at a more senior level in the
trust. This was a score-based system and escalation was
made by the management team as required.
• A sepsis lead had been appointed but they had started a
new job. A new sepsis lead was due to be appointed in
January 2016. There was evidence sepsis was a focus in
the department, with a sepsis audit having been
completed and information posters and teaching
sessions taking place to raise awareness and increase
performance.
Leadership of service
• The emergency department had an energetic, cohesive
and well-motivated leadership team. The leadership
team were highly visible in the department and regularly
worked clinically. There was a clear focus from the team
to deliver excellent, high quality and safe care. They all
demonstrated the skills, knowledge, integrity and
experience needed for their roles.
• The department’s clinical lead had only been in post in
that role for three months, but was an experienced
member of the emergency department consultant
team. They were supported by a stable nursing
leadership team and together they were providing
outstanding leadership.
• Staff told us they trusted the leadership team and found
them supportive and approachable. They told us they
were supported to report incidents to ensure learning
could be identified and patient safety improved. They
felt they could do this without fear of repercussion, and
felt they would be listened to and supported through
any investigations.
• All staff fulfilling a leadership role, including consultants
and nurses in charge of the department, provided
excellent support to their teams on a ‘day-to-day’ basis.
We received lots of positive feedback from staff.
Comments included: “The best managers I’ve ever had
are here” and “I feel well-supported by my managers.”
• Although the local leadership was excellent, some staff
told us they didn’t feel well supported by the divisional
management team. They didn’t feel the divisional
managers engaged fully with the department. However,
everyone told us there was excellent support and
engagement from the executive team, including the
chief executive.
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Culture within the service
• Staff told us they really enjoyed working in the
emergency department. They felt respected and valued.
Team work and a supportive, open culture were cited by
many staff as one of the best things about working in
the department, and this was clearly visible throughout
our inspection. Morale was generally good despite high
demand and crowding. Staff felt leaders recognised the
pressures they faced and took a genuine interest in staff
wellbeing.
• There was a culture of openness and honesty. Staff told
us they felt able to raise concerns and believed they
would be listened to and supported. They said this was
the case across all staff groups and grades.
• Although reception staff and patient flow coordinators
were not under the direct management of the
department, they were well integrated and told us they
were made to feel part of the team. They said staff were
supportive of them and included them in team
activities.
• A number of staff told us this was the best emergency
department they had worked in, and put this down to
the positive culture and teamwork, encouraged by the
leadership.
Public engagement
• The emergency department engaged with patients in a
number of ways. The main method of patient
engagement was through the NHS friends and family
test. Methods of collecting responses included touch
screen surveys in the observation unit and waiting
room, text messaging and postcards.
• During project work, patients were engaged and asked
for their input where necessary. For example, during the
SHINE patient safety assessment tool project patients
were asked what they felt was important to them while
in the department. Feedback about access to food and
water and contact with relatives were subsequently
included in the final checklist.
• Aside from the Friends and Family Test, the department
had attempted to run its own regular patient survey but
they had received such a low response rate it was
discontinued.
Staff engagement
• There were some formalised staff engagement
programmes, for example drop-in sessions and exit
interviews, but staff told us they could give open and
honest feedback to managers at all times. Staff felt ideas
and concerns were listened to and taken forward where
possible.
• The trust also encouraged staff to complete the annual
staff survey and we saw action plans had been written
to address areas where improvements could be made.
Innovation, improvement and sustainability
• A number of innovative projects had been completed by
the department to help improve patient care and the
sustainability of the department.
• The SHINE patient safety assessment tool had come
about following a research programme supported by
the Health Foundation. This work had resulted in a
patient safety checklist and its benefits to patient safety
and experience are well-documented throughout this
report. The project was nominated for two 2 Nursing
Times awards and the checklist was being shared with
and used by five other emergency departments in the
region.
• Collaboration with external partners to help improve
patient flow included the ‘virtual ward’ and REACT
services. Both services looked to provide support to
patients in the community so hospital beds could be
released. We were told the virtual ward had just hit the
200 patient milestone, saving the hospital 2,000 bed
days.
• A multidisciplinary and high impact users group had
been established to help review and support some of
the most frequent attenders to the emergency
department. The group worked to develop personalised
care plans for these patients to improve their health
outcomes and link them with community services
relevant to their complex health care needs.
• Having recognised the high levels of abuse to staff in the
waiting room and the lack of information about how the
emergency department worked, a project with the
Design Council was nearing completion. New signage
had been designed to make it clearer to patients how
each step of the journey through the department
worked and what they could expect. This was due for
completion in December 2016.
• A touchscreen system in the resuscitation area had been
designed by one of the consultants in the emergency
department to make emergency protocols and
40 University Hospitals Bristol Main Site Quality Report 02/03/2017
Urgentandemergencyservices
Urgent and emergency services
guidelines readily available in a simple and fast way.
Staff were able to see these at the bedside and they
could be used to support timely treatment pathways in
fast-moving emergency situations.
• The department used simulation training to embed
learning from incidents.
41 University Hospitals Bristol Main Site Quality Report 02/03/2017
Medicalcare
Medical care (including older people’s care)
Safe
Good
–––
Effective
Good
–––
Caring
Good
–––
Responsive
Good
–––
Well-led
Good
–––
Overall
Good
–––
Information about the service
We inspected the medical division of University Hospitals
Bristol services at University Hospitals Bristol Main Site
(Bristol Royal Infirmary, Bristol Haematology and
Oncology Centre and the Bristol Heart Institute).
The medical care service at University Hospitals Bristol
Main Site provides care and treatment for Cardiology,
Dermatology, General Medicine, Geriatric Medicine,
Hepatology, Haematology, Oncology, Respiratory
Medicine, Rheumatology and Stroke Medicine. There
were 361 medical inpatient beds and 71 day-case beds
located across 16 wards. There were nine medical wards,
a medical assessment unit and discharge lounge in the
Bristol Royal Infirmary. The Bristol Heart Institute which is
part of the hospital had one ward for medical patients,
one ward for cardiology patients, another ward for
cardiology and cardiac surgical patients and a coronary
care unit. The Bristol haematology and Oncology centre
(also part of the hospital) has an oncology day unit, one
clinical oncology ward with teenagers and young adults
facilities, an acute oncology assessment area, a clinical
haematology ward and a haematology day unit and
assessment area.
In July 2016 in medical services there were 346 nursing
whole time equivalent (WTE) staff employed and 205
other clinical WTE staff. The trust had 36,206 medical
admissions between September 2015 and August 2016.
Emergency admissions accounted for 21,231 (59%) and
14,975 (41%) were elective. The most three common
42 University Hospitals Bristol Main Site Quality Report 02/03/2017
departments patients were admitted to were
Gastroenterology, with a total of 6,251 (42%), followed by
3,160 (21%) for Cardiology and 2,274 (15%) for
Dermatology.
Within Bristol Royal Infirmary, we visited 12 wards and
departments including the medical assessment unit
(MAU), medical wards, hepatology ward, respiratory
wards including the higher care respiratory ward and
elderly care wards including the elderly care assessment
ward. We also visited the ambulatory care unit, stroke
unit, discharge lounge and cardiac catheter laboratory.
Our visits included the Bristol Heart Institute which had
one ward for medical patients, a cardiology ward, a
further ward for both cardiology and cardiac surgical
patients, a cardiac catheter laboratory and a coronary
care unit. We also visited the Bristol Haematology and
Oncology Centre with the oncology day unit, one
oncology ward, which included a teenage and young
adult facility, an acute oncology assessment area, a
clinical haematology ward and a haematology day unit
and assessment area.
We spoke with 35 members of staff, including nurses,
doctors, pharmacists, therapists, administrators and
hotel staff. We spoke with 30 patients and seven relatives.
We reviewed 29 sets of patients’ notes to identify the care
being provided. Both prior to and after the inspection we
reviewed information from the trust.
Medicalcare
Medical care (including older people’s care)
Summary of findings
We rated this service as good because:
• Medical and nursing staff told us there was a good
incident reporting culture and they were actively
encouraged to record incidents onto the electronic
incident reporting system. Staff told us learning from
incidents had led to changes in ward practice, such
as an initiative to reduce patient falls. We saw
evidence of duty of candour being understood and
followed by staff members with a particular example
of the trust policy being followed during this
inspection.
• Safety was monitored and actions taken to improve
safety. Staff created a system to ensure changes in
patients’ treatments and medicines were noted by
staff and acted upon. The implementation of a
‘bicycle light’ system in the medical assessment unit
ensured safety systems were strengthened, by
prompting action from staff when patients’
medicines were prescribed.
• Staffing rotas demonstrated staffing levels were in
line with the hospitals staffing measurement tools,
with agency staff used when required to cover
increased demand and vacancies. Staff told us they
considered staffing levels to be safe.
• Feedback from patients and those close to them was
positive. Patients were treated by kind, caring staff
who were respectful and considerate. Patients’
privacy and dignity was respected and staff sought
permission before carrying out care and treatment.
Patients’ emotional and social needs were valued
and this was demonstrated in the way staff cared for
patients, and in patient feedback.
• Staff often went out of their way to meet the
emotional and physical needs of patients. It was
clear they had taken the time to get to know and
understand patients as individuals.
• The systems of escalation to ensure a constant flow
of patients through the hospital were responsive to
the ever changing demand. The service delivered
was flexible and creative to ensure flow was
maintained. During times when high numbers of
medical patients were being admitted, the flow of
patients through the medical division was monitored
to minimise the numbers of patients who were
43 University Hospitals Bristol Main Site Quality Report 02/03/2017
•
•
•
•
•
•
•
admitted to non-medical wards. These patients were
known as medical outliers. The systems put in place
to support the patients on outlying wards ensured
they were seen by the right medical team every day,
and their care was always overseen by the medical
team.
Services were planned and delivered in a way that
met patients’ needs, which included during times of
increased demand. These included services such as
the ambulatory care unit, a nurse-led clinic for
transient ischaemic attack (stroke) and a virtual
ward.
The trust ensured it provided services to support
patients’ physical and psychological needs. Work
had taken place to deliver services that meet the
needs of patients living with dementia.
Patients’ care and treatment was planned in line with
current evidence based guidance. Clinical care
pathways and trust policies were developed in
accordance with national guidelines and strategies.
Patients mostly had comprehensive assessments of
their needs. Patients had their pain assessed
regularly and managed promptly. Their nutrition and
hydration was assessed and monitored.
The hospital achieved good patient outcomes and
delivered effective care. A programme of local and
national audits were used to monitor care and
treatment was being provided in accordance with
national guidelines. Some areas showed
improvement, including the national stroke audit.
Learning needs of staff were identified and training
put in place to meet those needs. Practice education
facilitators were available to support staff and
specialist nursing teams provided individual and
group teaching for areas identified as needing extra
support.
Patients received care from different teams who
worked together to coordinate care. Multidisciplinary
working was evident in all areas of the hospital. For
some wards, complex discharges were daily
occurrences and we observed board rounds taking
place on wards, which demonstrated effective
multi-disciplinary working. There were links with GPs
and community providers to ensure safe patient
discharge.
Medicalcare
Medical care (including older people’s care)
• Staff had access to patient information to deliver
effective care and treatment. When patients who
needed specialist community support were
discharged, effective links were made with
community services.
• Whilst care was provided seven days a week, ward
rounds by medical staff did not take place every day.
However, access to medical care was always
available. Nurse specialists were available between
five and seven days a week.
• Patients consent to care and treatment was sought in
line with legislation and guidance. Staff had a clear
understanding of the Mental Capacity Act 2005,
Deprivation of Liberty Safeguards and patient
consent.
• Discharge delays, transfers and bed moves were all
monitored to ensure they did not negatively impact
on patients.
• Complaints were handled in accordance with trust
policy, and improvements were made in response to
complaints.
• There was a clear, overarching statement of vision
and values for the medicine service, which was
driven by safety and quality. The medicine division
and specialised services divisions’ vision and
strategies were developed within the context of this.
Staff understood the vision and strategy and their
role in delivering it. They were proud to work for the
hospital and were patient focused. Staff
demonstrated a kind culture, both to patients and
relatives, and to each other.
• Governance structures were complex to follow.
However, the board and other levels of governance
within the medical division functioned effectively
and interacted well. Staff assured us risk was
escalated when needed and the information
communicated to the hospital board flowed well.
Processes were in place to monitor, address and
manage current and future risk. Performance issues
and concerns were escalated to the relevant
committees and the board.
• Leaders understood the challenges to good quality
care within and outside the organisation, and there
were collaborative relationships with stakeholders.
• Staff felt leadership was good and divisional lead
staff were accessible. Staff told us they felt supported
44 University Hospitals Bristol Main Site Quality Report 02/03/2017
and heard, and there was a collective culture of
openness to drive quality and improvement. Leaders
and staff demonstrated the participation and
involvement of people who used the service was
important to them.
• The hospital had forged strong links and worked
closely with the voluntary sector.
• Leaders demonstrated a drive for continuous
learning and improvement through the ongoing
evaluation and monitoring of the service and by
delivering projects and innovative developments
aligned to this.
However:
• Systems were not always reliable to keep patients’
information safe. Records were not consistently
stored securely. This could cause a potential breach
of patients’ confidentiality.
• Not all medical staff received mandatory training in
line with the trust’s targets.
• Doctor induction was undertaken in scheduled
blocks. Should doctors start work in between those
blocks, they may work for a period of time without
induction. This meant no fire training had taken
place and should an incident occur, may place both
staff and patients at risk.
• There were gaps in information being monitored in
specific areas of care. For example, there were no
pain audits to establish if pain was managed
effectively for patients with an ability to express their
pain. The cardiac catheter laboratory used a World
Health Organisation surgical safety checklist for all
surgical procedures. However, these records were
not audited to ensure they were all fully completed.
• Not all staff had received an appraisal in the last year.
Without an appraisal, learning needs may not be
identified and a plan put in place to support staff to
develop their practice.
• The management of risk did not protect staff on the
hepatology ward. Senior staff were aware of risks for
patients and staff but did not put the required
processes in place to mitigate the risk and ensure
safety. This related specifically lone working practices
Medicalcare
Medical care (including older people’s care)
when accompanying patients off the ward at night
who wanted to smoke. We raised this with the trust
who agreed to implement a process to ensure this
risk was reduced.
• The division had recognised a risk in the acute
oncology service at night, concerning both staffing
levels and a lack of suitably skilled triage staff.
However, further action was required to minimise the
risk to patients in both the service provision and
staffing provision.
Are medical care services safe?
Good
–––
We rated safe as good because:
• Nursing and medical staff felt there was a good incident
reporting culture and they were actively encouraged to
complete electronic incident reports. Staff told us
learning from incidents had led to changes in ward
practice.
• The duty of candour was understood by staff. When
things went wrong, patients were provided with a timely
apology and support. Openness and transparency
about safety was encouraged.
• Safety data was monitored and incidents were
investigated fully to enable risks to be identified and to
provide an accurate picture of safety.
• Staff implemented safety systems such as a ‘bicycle
light’ system in the medical assessment unit which
ensured medicines changes happened promptly to
ensure safety systems were strengthened.
• Staff took a proactive approach to safeguarding and
were aware of local safeguarding procedures.
• We observed and patients told us wards and
departments appeared visibly clean. Staff were seen to
use personal protective equipment that prevented
infection.
• Medicines such as controlled drugs and refrigerated
medicines were stored appropriately. We saw evidence
which showed medicines errors were audited and
incidents and themes were visible at board level.
Learning from incidents was identified. Medicines
administration records were well completed.
• Staff in most areas completed comprehensive risk
assessments for patients and developed management
plans to ensure risks to patients’ safety were monitored
and maintained. Risk assessment processes were
monitored and we saw evidence learning from audit
was implemented.
• Staffing rotas demonstrated staffing levels were in line
with the hospitals staffing measurement tool, with
agency staff used when required to cover increased
demand and vacancies. Staff told us they considered
staffing levels to be safe.
• Medical staffing levels and skill mix were well planned
and ensured safe care at all times.
45 University Hospitals Bristol Main Site Quality Report 02/03/2017
Medicalcare
Medical care (including older people’s care)
However:
• Systems to ensure patients’ information was kept safe
were not always implemented. Records were found to
not be stored securely in a quarter of the places we
visited which could cause a potential breach of patients’
confidentiality.
• Not all staff received mandatory training in line with
trust policy. Shortfalls were seen in training levels for
medical staff.
• There were gaps in the monitoring of surgical checklists
and in auditing pain management. The cardiac catheter
laboratory used a World Health Organisation surgical
safety checklist for all surgical procedures. The records
were not audited to ensure they were all fully
completed.
• Doctor induction was undertaken in scheduled blocks.
Should doctors start work in between those blocks, they
may work for a period of time without induction. For
those staff, this meant no fire training had taken place
and should an incident occur, may place both staff and
patients at risk.
•
•
Incidents
• Incidents were reported by staff with lessons learnt and
improvements made when things went wrong. Nursing
and medical staff told us there was a good incident
reporting culture and they were actively encouraged to
complete electronic incident reports. Staff we spoke
with were aware of their responsibility to report
incidents and received learning from incident
investigation.
• The trust policy set out the procedures for managing
incidents. Staff told us the policy was accessible and
they understood and followed it. Staff understood the
root cause analysis process of investigation and their
roles and responsibilities in carrying out this type of
investigation.
• Senior nurses had oversight of incidents and
investigated any concerns. When staff reported an
incident on the electronic incident recording system,
they received an email acknowledging and thanking
them. Once an investigation was complete, staff
received a report of any actions or outcomes associated
with the incident.
• Incidents were investigated and learning from them
shared. We reviewed a large number of staff reported
•
•
•
46 University Hospitals Bristol Main Site Quality Report 02/03/2017
incident data prior to the inspection. We saw incidents
were investigated and learning fed back to staff in the
medicine division, and to the wider hospital, when
applicable.
Learning from incidents led to changes in practice. For
example, staff break patterns were changed as a result
of learning from incidents related to medicines
administration. The changes ensured a nurse assistant
was present during drug rounds. This meant a nurse
assistant was always available to attend to patients’
care needs and prevent interruptions to staff
administering medicines, in order to reduce the
likelihood of errors. On cardiology wards, we heard how
learning from two root cause analysis (RCA)
investigations was implemented on the wards to
improve patient safety. One had resulted in a falls
protocol being placed in every bay.
Learning from incidents was shared with the wider
hospital through the safety briefing. This was a staff
discussion at each hand over which enabled immediate
dissemination of information and learning. For example,
following an investigation into a fall, we saw a record
that the outcome was shared with the ward. As a result
of this incident a poster was laminated and put in the
toilets to remind staff of preventative actions they could
take. Staff told us they considered patient safety had
improved as the briefing system had evolved.
The hospital reported 12 serious incidents in medical
services between October 2015 and September 2016
which met the reporting criteria set by NHS England. Of
these, the most common type of incident reported was
slips, trips, or falls (10 incidents). There was also one
pressure ulcer and one further incident pending review.
In order to drive quality and safety improvements across
the division, senior divisional managers told us learning
from incidents such as pressure ulcers, falls and serious
incidents were shared through the quality and
outcomes group or by the head of nursing for the
division. Staff confirmed this information was passed to
them and we saw handover sheets and briefing notes
which confirmed this.
Mortality and morbidity meetings took place for most
areas of the hospital. The minutes were recorded and
learning shared with wider management groups,
including the clinical governance and risk management
meetings.
Duty of Candour
Medicalcare
Medical care (including older people’s care)
• Regulation 20 of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014 is a regulation
which was introduced in November 2014. This
Regulation requires the trust to notifying the relevant
person that an incident has occurred, provide
reasonable support to the relevant person in relation to
the incident and offer an apology.
• The trust policy ‘Staff Support and Being Open Policy
(Duty of Candour)’ updated June 2016 provided staff
with information for undertaking their duty of candour.
• We spoke to 20 staff in various roles who all
demonstrated an understanding of the duty of candour.
We were given an example of a recent event which had
triggered an investigation and an immediate use of the
duty of candour. The trust’s 72 hour report form and
root cause analysis investigation form contained a
prompt for staff to complete initial duty of candour
where necessary. We saw staff were following the policy,
by meeting with family for further discussion of the
incident and to provide an apology.
• Medical staff had a separate induction programme with
a patient safety session, which contained the same
content for duty of candour as for other clinical staff.
Duty of candour training formed part of the induction
training for nursing staff.
Safety thermometer
• The NHS Safety Thermometer is a local improvement
tool for measuring, monitoring and analysing patient
harm and ‘harm free’ care. Data collected on a monthly
basis provides immediate information and analysis to
teams to monitor their performance in delivering harm
free care.
• Each ward collected data in line with the patient safety
thermometer methodology and displayed the results on
a notice board called ‘how are we doing’. For example in
October 2016 the medical assessment unit had
achieved 99.2% hand hygiene compliance and recorded
eight falls.
• Data from the Patient Safety Thermometer showed the
trust reported 4 pressure ulcers, 7 falls with harm and 20
catheter urinary tract infections between November
2015 and November 2016. Rates of incidents across all
three areas declined during this period.
• There was a recognised risk that venous
thromboembolism (VTE) may not be recorded correctly
and so patients may be at a higher risk. The trust risk
register recorded that VTE risk assessment compliance
had decreased from 99% in the first six months of 2015
to 97% in January 2016. The risk register also recorded
evidence that the process for data entry for VTE risk
assessment completion by non-clinical staff may have
resulted in unreliable compliance information. We
looked at VTE assessment within patients’ records and
saw they were all fully completed.
Cleanliness, infection control and hygiene
• There were systems and processes to reduce and
control the risk of cross infection. All wards and
departments we visited appeared visibly clean and
cleaning staff were seen throughout the hospital
managing the cleaning rotas.
• Ward staff in all areas we visited wore the correct
uniform and used personal protective equipment,
gloves and aprons as needed. Staff followed the
hospital policy of being bare below the elbow.
• However, hand hygiene practice was not consistent
across all wards. On a small number of wards staff did
not adhere to policy for hand hygiene. We observed
some wards did not have clear hand wash signage and
available hand gel. On ward A400 we observed 15
hospital staff enter the ward, only four used the
antibacterial hand gel prior to entry. Ward A525 did not
have hand gel available on entry to the ward. Ward A528
did not have any signage to inform the general public
about the importance of hand washing before entering
the ward. Other wards had hand gel available and we
observed staff cleaned their hands on entry to the ward.
• Wards maintained cleaning audits which were displayed
at ward entrances. Scores were high with an overall
compliance percentage score. For example, in October
2016 ward 808 achieved 98% and ward 528 achieved
96%. We observed cleaning staff were thorough and
worked throughout the day to maintain cleanliness.
• There had been no cases of methicillin-resistant
Staphylococcus aureus (MRSA) bacteraemia associated
with care and treatment of patients at the trust since
August 2015.
• There was an average of three cases of Clostridium
difficile per month reported over the previous 13
months ending November 2016. The trend shown a
decline in reported cases over this period and was in
line with the England average.
• All staff received mandatory and ongoing updates on
infection prevention and control. Other ad hoc and
47 University Hospitals Bristol Main Site Quality Report 02/03/2017
Medicalcare
Medical care (including older people’s care)
targeted training sessions were held. For example, an
infection prevention and control study was held in July
2016 in the dental hospital for trust staff. The theme of
the study day was ‘back to basics’.
• Quality assurance audits were undertaken on an ad hoc
basis and were facilitated by the infection prevention
and control team. The audits observed staff and their
practice. All areas that were audited had their results fed
back to the nurse in charge at the time of audit,
followed by an email to the ward manager, matron and
head of nursing. The most common themes were
inappropriate use of personal protective equipment, the
doors on the isolation room not being kept shut, and
signs on doors to identify isolation rooms not
completed. Staff were informed and any teaching
required was immediately instigated. Areas of audit for
July and August 2016 included specialist medical wards
and wards providing care to older people.
• We saw when side rooms were used for the isolation of
patients with an infection, systems were in place to
inform staff of what level of protection and isolation was
required to maintain safe hygiene practices.
•
•
Environment and equipment
• Access to equipment and facilities kept patients safe.
Staff had easy access to equipment and we saw
equipment had been serviced and labels applied to
identify when servicing was next due.
• Resuscitation trolleys in all areas we visited were seen to
be checked daily and all equipment serviced within the
timescales required. In the cardiac catheter lab, staff
had used a highlighter to mark the ‘use by’ date on
equipment, which made it easier to see and ensured
items were replaced in a timely way.
• We reviewed the maintenance records of equipment in
the medical division and saw some equipment due for
annual service in 2012 and 2013 had not been recorded
as completed, despite a maintenance schedule noting a
frequency of every 12 months. This equipment included
two syringe drivers and an infusion pump. We looked at
equipment maintenance and service stickers attached
to all equipment as we inspected, and all equipment we
saw was in date. We did not see any drivers and pumps
out of date.
• The call bell system on ward 515, the stroke ward, did
not function correctly. When pressed by a patient the
call bell rang quietly but did not show on the digital
display screen to inform nurses where assistance was
•
•
•
48 University Hospitals Bristol Main Site Quality Report 02/03/2017
needed. The bay was identified from the nurse’s station
but not which patient and so may delay the nursing staff
identifying which patient needed assistance. Nurses
could see the call bell light at each bay entrance.
Maintenance staff were aware of the issue but we were
told by the nursing staff the issue was too expensive to
repair.
Staff on cardiology ward 705 told us there was a
shortage of cardiac monitoring equipment for which a
capital bid had previously been rejected. Whilst this did
not make the ward unsafe, there were occasions when
equipment had to be borrowed from other wards. The
monitors for this equipment were linked to the ward
from which they were borrowed. Staff from the other
ward would alert staff if an alarm sounded. This
equipment did not provide a print out of the heart
rhythm.
On the coronary care unit, the information technology
system connected directly to ambulances so staff could
see the ECG (electrocardiogram) results for patients in
an ambulance on the way to hospital. An ECG is the
heart trace used to assess the hearts rhythm and
electrical activity, particularly during a suspected heart
attack. Being able to see the ECG whilst the patient was
on route to the hospital helped staff to make more
informed decisions and gain faster access to the right
care and treatment.
The environment and facilities on most wards in the
hospital were well maintained. However, the decor on
the oncology ward was in need of refurbishment and
staff told us they had raised this at a divisional level. We
were told this was one of the few wards in the hospital
that had not received any level of refurbishment since it
was built.
The cardiology and coronary care units were well laid
out. There were specialised rooms and equipment in
the haematology and oncology wards to deliver safe
care and treatment, such as treatments rooms that
required clean air ventilation, to reduce the risk to
patients with compromised immunity. These rooms had
a side room for staff to change into protective
equipment and staff, including cleaning staff, had a clear
understanding of the protective equipment needed.
Staff raised concerns about the lack of space in the
haematology day unit and assessment area (D701)
where levels of planned and unplanned patient care
needs fluctuated. On occasion, this meant patients
Medicalcare
Medical care (including older people’s care)
•
•
•
•
•
•
would choose to stand in the corridors whilst waiting for
treatment. They were reluctant to sit in the busy waiting
room due to risk of infection and low immune system
suppression as a result of their treatment.
Whilst the design and maintenance of facilities on the
whole kept people safe, there were some areas of risk
identified in relation to access to two wards which may
have compromised patient safety.
Concerns were raised by staff on ward D703 about the
heating system as the temperature fluctuated and both
staff and patients often felt too hot or too cold. Staff on
the ward were unable to adjust the heating controls and
had reported the issue to the maintenance helpdesk but
a response to this had been slow and had not resolved
the problem. This could have impacted upon the health
of both patients and staff.
The environment for patients on the oncology ward did
not ensure patient safety for patients who may be
confused or could not maintain their own safety. At the
end of the ward was a door to a staircase which would
be used by staff and was accessed by pressing a button
on the wall, no other security was in place. The staircase
was out of sight but easily accessible. We alerted staff to
this risk.
Access to the hepatology ward was controlled by use of
an intercom system. The intercom system was not fully
understood by staff and this impacted on people trying
to get into the ward causing delays and confusion to
those waiting outside the ward. We attempted multiple
times to access the ward, and as part of the process
were able to hear nurse’s conversations on the ward. We
asked staff about the system. It appeared the telephone
intercom handle had not fully connected and so
allowed us to hear ward conversations at the nurse’s
station. This may breach patient confidentiality as
nursing staff used this area to discuss patient care.
The staff room on the medical assessment unit was not
secure and could allow access to unauthorised people.
The door was secured by a key pad, but the key pad was
not operating to prevent access and the door could be
pushed open. No lock was in place to ensure the
security of staff bags and belongings. Hot water from a
boiler was accessible in the same staff room, which
placed confused patients on the medical assessment
unit at risk.
Substances which could be harmful to health if ingested
were not always stored safely. The storage of chlorine
tablets in ward unlocked sluices on the medical
assessment unit, wards A808, A805 and
hepatology,D202 and C805 meant they were accessible
to patients who may be confused and could be
ingested. We informed the trust of this risk at the end of
the announced inspection. We returned on 1st
December 2016 as part of our unannounced inspection
and found the storage had not been improved and the
chemicals were still accessible. For example we saw on
the medical assessment unit in an unlocked stock
cupboard which was opposite patient side rooms, 36
tubs of chlorine tablets, each of which contained 150
tablets. We also saw when the chlorine tablets had been
diluted into a water coloured solution they were
labelled with the name of the product but no
instructions not to be ingested.
• The hepatology ward had a sign advising staff ‘Actichlor
tablets were to be kept in the cupboard in the sluice - no
need to lock in the cupboard/sluice’. Staff were unclear
why they were advised to do this. However, the staff on
duty recognised the risk this presented to patients on
the ward, such as those who were confused and were
withdrawing from alcohol, by having access to
unmarked fluids in unlocked rooms. We raised the risk
with staff.
Medicines
• Medicines were managed in a way that kept patients
safe across medical services, with most medicines
stored securely.
• Some wards had ‘pods’ by each bed which stored
patients’ medicines which nurses assisted patients to
administer when needed.
• Medicines administration records were seen to be well
completed and recorded patients allergies. Medicines
which were needed ‘as required’ were recorded clearly
with instructions for staff about doses and range of
administration.
• Controlled drugs were stored securely. The controlled
drugs registers were up-to-date and the access to the
cupboard keys was only by authorised staff. On the
stroke unit, five sets of keys were available and staff
recorded for each day who had held all of the keys
during each shift. This provided a clear audit trail of
which staff had access to which medicines.
• We saw medicine fridge temperatures were monitored
on each ward and all were within the expected range.
On ward D703 the medicines fridge had broken and staff
were using a backup fridge.
49 University Hospitals Bristol Main Site Quality Report 02/03/2017
Medicalcare
Medical care (including older people’s care)
• Medicines were available to enable staff to treat patients
with a diabetic hypoglycaemic event quickly. They were
stored in ‘hypo boxes’ which were located in the locked
clean utility rooms on the wards.
• Following a staff suggestion a system was implemented
on the medical assessment unit to inform staff of
changes to medicines and treatment. This was because
doctors made changes to patients’ medicines and
treatments, and staff were sometimes not aware of
these changes. This had led to delays in treatment. In
order to alert staff to a change, bicycle lights were fitted
to notes boxes outside each bay. When the doctor made
changes they put notes in the boxes and switched on
the red flashing light. Staff responded to the light and
acted on the changes. Staff told us this had been
successful in reducing the number of missed
treatments.
• However, on the higher care respiratory ward and ward
A605 medicines such as creams, gels, enemas and
suppositories were kept in the sluice. These medicines
were not named as prescribed for a specific patient and
were kept as stock in a dirty utility room instead of a
clean area. The rooms were accessible without a lock,
the creams were not stored in a locked cupboard and
the rooms’ temperature was not controlled or
monitored. This meant they were not kept in an area
free of contamination, or was tamper-proof, or stored at
a temperature which was essential to ensure the
medicine remained effective.
• We saw evidence which showed medicines errors were
audited and incidents and themes were visible at a
board level. Lessons from incidents were identified and
learning shared.
• The highest number of incidents reported trust-wide
were associated with medicines. The level of incidents
had been relatively stable between December 2015 and
March 2016.
• Medicine errors related to diabetes, including
hypoglycaemic events, were not directly reported to the
diabetic specialist nurse team at the time of the
incident, to identify if further training was needed.
Those incidents were reviewed by the medicine steering
group from which the diabetes specialist nurses
received the information and took any required action.
Should there be any immediate concerns; the diabetes
specialist nurses were informed.
• Some nursing staff had training to prescribe medicines
as part of their specialist training. For example, the
specialist stroke nurses were qualified nurse prescribers
which enabled treatment to progress quickly.
• Patient group directives are a legal framework
developed to allow some health care professionals to
prescribe or administer medicines without the need for
a doctor or pharmacist. The trust’s patient group
directive for first dose of antibiotic initiative allowed
nurses to administer the first dose of antibiotics in
neutropenic patients. This was in line with a protocol
validated by clinicians, pharmacists and
microbiologists. The trust told us this reduced the
crucial door to needle time in this emergency setting, as
per National Institute for Health and Care Excellence
(NICE) recommendations, improving outcomes in
patients.
• A patient group directive was also developed for first
dose analgesia (pain medicines), which allowed nurses
to administer first dose of diamorphine to patients
presenting in acute sickle crisis, based on a protocol
developed by clinicians, nurses, pharmacists and
palliative care team. This improved patient care and
helped achieve the NICE recommendation of '30 mins to
first dose analgesia in sickle painful crisis'.
• As part of a wider pharmacist role linked to the falls
work being undertaken by the trust, the lead pharmacist
was involved in medicine reviews of patients who had
fallen. The information gathered from these reviews fed
into e-learning for prescribing.
• There was a pharmacist allocated to the discharge
lounge. Take home medicines were pre-arranged on the
ward but on some occasions extra pharmacy support
was needed. The lounge staff used a pharmacy tracker
on the computer to follow up discharge medicines. The
discharge lounges had medicines kept in a locked
cupboard behind the nurses’ station and had a
minimum stock level. There was no resus trolley
available in the discharge lounge but an emergency box
was in place containing emergency drugs. Suction,
oxygen and observation equipment were in the
discharge lounge, as well as a panic button to alert staff
in an emergency.
• We saw some delays in the process for the delivery of
discharge medicines and medicines administration
records. In the higher respiratory ward, three patents
were waiting for the delivery of medicines and their
medicine charts before they could be discharged. The
50 University Hospitals Bristol Main Site Quality Report 02/03/2017
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Medical care (including older people’s care)
medicines had been prepared by the pharmacy but
were delayed in being returned to the ward by the
pharmacy porter. The porter had a delivery route which
took considerable time. The patients had been waiting
in excess of four hours. The turnaround times for take
home medicines were audited. For September 2016 the
average time was 81 minutes. Whilst this was within the
trust target, the delay appeared to be with the delivery
process and not the administration of the medicines.
• Processes for medicines management and delivery on
the chemotherapy day unit were reviewed in 2016 as
part of the chemotherapy day unit transformation
project. Consultants were involved in work to reduce
prescription queries and improve administration
processes through a series of education sessions. The
work involved administrative, nursing and pharmacy
staffing to review and learn from individual cases.
Ongoing auditing of prescribing queries was taking
place, in order to tailor specific learning sessions.
• There were disposal and destruction processes in place
for wasted or out-of-date medicines on each ward.
Wasted medicines were disposed of on each ward and
destruction could be arranged through the pharmacy.
Records
• Patients’ individual care records were not consistently
stored and managed in a way kept patients safe.
• The completion of patient records varied between
departments. Some were well completed, for example
the stroke unit. However some records did not have risk
assessments fully completed and were not fully legible.
• We looked at 26 patient records. Records were divided
into two sets for each patient, one set contained the
doctor’s notes, therapist input and details of all
investigations and the second set remained with the
patient and included observation records, care plans
and risk assessments. The records varied in their
standard of completion. We saw some medical staff
writing was not clear.
• We looked at risk assessments which were undertaken
for each patient and were recorded in a risk assessment
booklet. These included risks relating to food and fluid
intake, VTE and environmental risks. We saw these
assessments were not consistently completed for each
patient, with four out of 26 booklets being partially
completed, with no explanation as to why some risks
were not assessed.
• Records were not stored securely on all wards. On four
out of 16 wards (ward C808, the medical assessment
unit, the higher care respiratory ward and the stroke
ward) notes trolleys were in place but were not locked
when left unobserved. There were unsecure records left
waiting for collection on desks, in boxes and all were
accessible to the public or patients on the ward.
• On Ward D703 the patient records trolley lock had been
broken for two weeks. On ward C805 a trolley containing
patient records was left open in a bay without a member
of staff present and a computer monitor was left
unattended which had patient data that was visible.
This monitor was quickly closed down by a member of
staff who returned promptly to the bay.
Safeguarding
• Whilst there were reliable systems in place to monitor
safeguarding processes within the hospital, and staff we
spoke with knew how to raise and recognise and report
safeguarding concerns, mandatory safeguarding
training levels were not being met. The trust set a target
of 90% for completion of safeguarding training which
they had not met. Medical staff at the hospital were
reported to have undertaken two safeguarding courses
and training completion was less than 90% of target for
both courses.
• Staff we spoke with were able to explain fully their
responsibilities when identifying safeguarding risks and
felt supported to raise any safeguarding issues.
Dementia training was now included in the safeguarding
training for all staff.
• The trust safeguarding activity and arrangements were
monitored by the trust’s safeguarding steering group. It
was chaired by the chief nurse and included senior
divisional representation. The group reported to the
clinical quality group, which in turn reported to the
quality and outcomes committee and subsequently to
the trust board, to ensure they were aware and updated
with any safeguarding issues.
• Staff received training in female genital mutilation to
ensure actions were taken to support those patients.
Further literature was also available in the staff rooms of
some wards to support patients and staff.
51 University Hospitals Bristol Main Site Quality Report 02/03/2017
Mandatory training
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Medical care (including older people’s care)
• A programme of mandatory training was provided for all
staff. The trust set a target of 90% for completion of
mandatory training which they had not met in all areas
including fire safety, safeguarding and resuscitation.
• Training completion rates as of the 1 May 2016, for
medical and dental staff, were below the 90% target for
conflict resolution awareness (72%), infection control
(64%), information governance (39%) and manual
handling (57%), resuscitation 73%, fire 84%,
safeguarding level 3 65%.
• For nursing and midwifery staff, training completion
rates were above the 90% target for conflict resolution
awareness (99%) and infection control (95%), but below
the 90% target for information governance (75%) and
manual handling (87%).
• Reasons given by staff for lack of completion of
mandatory training were attributed to them being
provided with little study time, wards being busy or
training which should have been provided on induction
was not received.
• Nurses could see their training status via an electronic
system which had a traffic light to alert staff to
approaching lapses in validity. The senior sister received
updates of these dates and emailed staff to prompt
them to update their training. Staff told us they were
allocated an extra 12.5 hours per year to maintain their
mandatory training. Should they not complete all areas
of mandatory training, they would lose the 12.5 hours
from their annual leave
• Training was noted on the risk register to be an area of
moderate risk. The trust-wide risk register identified a
risk of not providing resuscitation training to the most
appropriate staff within the trust, leading to a
resuscitation skill gap for clinical staff. The risk was
assessed as low risk but also noted in February 2016 to
require further work to ensure all staff were suitably
trained. Basic life support training was provided as part
of the trust induction and a review of who had
completed advanced life support training was taking
place across the division. Divisional management for the
hospital informed us compliance with resuscitation
training was at 80% at the time of the inspection. They
reported compliance had improved since this training
was added to the staff induction training programme,
and ongoing training was being delivered to ensure all
staff were suitably trained. The level of training was
monitored but no date was available for when full
compliance would be met.
• Fire training was also not fully completed by all medical
and nursing staff. This meant not all staff both during
the day and overnight had completed either face to face
or e-learning fire training.
• The system in place noted in the first year of
employment, face to face fire training was needed. In
the second and third year, online training was
undertaken, and in the fourth year, face to face training
was required. The staff training matrix provided by the
trust noted more nursing staff had received fire training
to a greater extent than medical staff. Some medical
staff had very low achievement levels. For example,
medical staff on the older persons’ ward had a
completed fire safety training level of 43% and general
medicine medical staff 20%. Medical staff in respiratory
medicine achieved 40% compliance, and hepatology
medical staff 25%.
• Essential ‘specific to role’ training was which was
deemed by the hospital, as essential to staff at a
departmental and/or individual role basis. The trust was
aware it did not have a system of centrally recording,
identifying, or governing all of this training. This
presented a risk to patient and staff safety, as there may
be untrained staff working at the trust. We spoke with
specialist nurses who advised us they did provide
specialist support training to staff, when it was identified
as needed.
Assessing and responding to patient risk
• Staff carried out comprehensive risk assessments for
patients and developed management plans to ensure
risks to patients’ safety were monitored and maintained.
• A system of national early warning scores (NEWS) was
used in the hospital to alert staff to the deteriorating
patient. The National Early Warning Scores (NEWS) was
implemented in 2015. This is a nationally recognised
scoring system allocated to physiological
measurements. We looked at 20 NEWS charts and saw
NEWS were correctly calculated and the escalation
process correctly followed. All resuscitation training had
been amended to include more focus on early warning
scores.
• The scores alerted the nursing staff when there was a
need to escalate a deteriorating or unwell patient to the
medical team. We saw when a patient’s observations
highlighted deterioration in their physical condition; the
nursing staff had consistently and responded to these
scores.
52 University Hospitals Bristol Main Site Quality Report 02/03/2017
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• The trust risk register identified the risk of patients
coming to harm or having sub-optimal outcomes due to
the failure of clinicians to recognise and respond to
deterioration. As of 07/12 2016 this was identified as a
moderate risk with actions ongoing.
• The trust undertook an audit of NEWS in September
2016 to monitor its use. The medicine division audit
included 11 wards and consisted of 55 patient charts.
One of the recommendations of the completed report
was training and education focused on correct
escalation (when and to whom to escalate), and a
further refocus on maintaining competence by
conducting manual observations once a day in general
ward areas.
• The auditing of NEWS was reviewed at clinical
governance meetings. In the November 2016 clinical
governance meeting minutes for the haematology and
oncology department noted two incidents where
elevated NEWS scores were not responded to. This was
flagged as a divisional risk. A simulation training
package was being developed and it was raised as an
action that further training needed to be rolled out to
staff, as part of the trusts ongoing training programme in
NEWS.
• The trust had a sepsis audit and work stream to improve
the prompt recognition and treatment of sepsis and
reduce the incidence of deteriorating patients due to
sepsis.
• A sepsis screening tool was in place as part of the NEWS
record. There was no specific sepsis lead role identified
but training was provided to all medical and nursing
staff to raise awareness of sepsis. Through the staff
safety bulletin, all staff were reminded to follow the
NEWS escalation process and ensure sepsis treatment
was started within one hour.
• In the medical assessment unit most patients were seen
and assessed by a relevant consultant within 12 hours of
admission. If patients were considered high risk they
would be seen by one of the medical doctors on the unit
and a consultant if needed. The timescale to be seen by
a doctor from GP referral was two hours, to be seen by a
member of the medical admissions team. If a patient
was unwell or scored highly on the early warning scores,
nursing staff would consult with medical staff, or
medical staff from the admissions team (known as the
‘take team’) and discharge team, to ensure the patient
was seen urgently.
• Patients suffering from neutropenic sepsis were
admitted directly onto the acute oncology ward at any
time during the day or night if they became ill. These
were patients receiving treatment for cancer, who were
at increased risk of an infection due to their treatment. A
four bedded bay, part of ward D603, was allocated for
neutropenic sepsis patients and for patients
experiencing serious side effects of treatment that had
been delivered in oncology or haematology. These
acute oncology patients accessed care through a triage
process by calling a designated phone line.
• The stroke pathway had been developed to ensure
patients who had suffered a stroke were seen
immediately by appropriate staff, and treatment
commenced promptly after arriving at the hospital.
Specialist stroke nurses were available to attend the
emergency department and stay with the patient to
ensure they were continually monitored.
• Ward A525 was a higher care ward caring for patients
with increased respiratory needs, such as those
requiring non-invasive ventilation. This ward was
previously the intensive care ward and so was laid out in
single bays with some side rooms. The area was divided
into male and female areas but mixed sex breaches had
taken place when higher care needs had been provided.
On these occasions apologies were made to patients for
toilet and bathroom access. Staffing levels were
calculated to manage up to eight patients with
increased needs and still have sufficient staff available
for the remainder of the ward. Staff were confident the
staffing levels were safe and enabled two patients to
one nurse when patients were classed as a category two
level of higher care. There were sufficient staff available
to cover all breaks and the supervisory sister was also
available to support staff as needed during the day. We
visited the ward at night, when staff assured us the
staffing levels remained safe.
• Non-invasive ventilation (NIV) is the administration of
ventilator support without using an invasive artificial
airway. This was well managed at the hospital to ensure
patients only received this treatment with correct
support. NIV was managed by consultants and patients
were moved from their place of care to ward A525 if NIV
was needed. This was to ensure staff with the right skills
were providing this specialised level of care. Systems
were in place to ensure those staff were made aware of
any patients needing NIV and prevent the risk of this
being provided elsewhere in the hospital.
53 University Hospitals Bristol Main Site Quality Report 02/03/2017
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• On every board round we saw staff reviewed patients’
risk assessments such as falls, nutrition, and mental
capacity and these were reviewed and adjusted as the
patients’ condition changed. Staff used specific,
recognised icons against the name of each patient,
which alerted staff to a specific risk. For example, the
icons identified a patient at risk of falls, with specific
nutritional needs or patients who were living with
dementia. The system was ticked when a referral had
been made to a specialist team, for example specialist
respiratory nurse or to the therapy team. Risks were also
recorded in each patient’s notes and were completed to
a varied level.
• Should a patient within the medical division have a
cardiac arrest, staff would commence resuscitation and
also call the ‘crash team’ to provide resuscitation
assistance. The medical assessment unit had four high
visibility beds with monitoring available and portable
monitors for other beds, to ensure ongoing monitoring
of the patients’ condition.
• Divisional managers informed us some ward layouts
were changed to make them safer and enable better
monitoring of patients, in order to identify changes in
their condition. For example, in order to reduce violence
and aggression on the hepatology ward, patients were
now in one, two or four bed bays which provided a
quieter and calmer environment. This ward had
challenging and complex patients. We saw a health care
assistant (HCA) escorting two patients from the ward
who were in wheelchairs, to take them to the smoking
area at night. One of these patients was verbally
aggressive and challenging. The smoking area was unlit
and was away from the hospital entrance. This situation
deteriorated and help was needed to support the HCA. A
second nurse from the ward eventually came to help the
HCA. The trust told us the action the division would take
would be to review and record a written risk assessment
for accompanying patients outside, which assessed
both staff and patient safety.
• The cardiac catheter laboratory used a World Health
Organisation surgical safety checklist for all surgical
procedures. We were unable to see any procedures but
staff told us the records were not audited to ensure they
were all fully completed. However, this did not provide
assurance that safety checks were well implemented.
• We looked at ward staffing rotas and saw staffing levels
were in line with the hospitals staffing measurement
tool, with agency staff used when required to cover
increased demand and vacancies. Staff told us they
considered staffing levels to be safe with rare gaps in
staff rotas when cover was attempted but not managed.
• Staffing levels were set across the hospital by the chief
nurse and reviewed annually at a divisional level. Senior
nurses used the safer care tool to record acuity and
dependency. Scoring was recorded daily. The results
were matched against the funded establishments and
the staffing tool used from the Department of Health
report, to ensure staffing was appropriate. Senior
nursing staff met regularly to discuss staffing and skill
mix.
• As a minimum, wards were staffed at a ratio of one
nurse to every six patients during the day and one to
eight at night. However, these ratios differed across the
different wards within the hospital, based on standards
specific to the patient group. On each ward we visited
staffing levels met the dependency of patients and the
acuity tool used, often using several bank and agency
staff.
• In haematology an independent staffing review was
carried out in 2014 by a nurse in a comparable service.
The ward was staffed to match these recommendations
• Duty matrons worked between 8am and 6pm and
reviewed staffing and acuity. During the evening, the site
team were responsible for this role. An escalation
process was established for when extra staff were
required.
• Seven whole-time equivalent nursing assistants were
recruited to form an enhanced supervision team. This
team provided one to one care for patients living with
dementia, or to patients under a deprivation of liberty
safeguard. These were patients who needed extra care
and supervision and this provided extra assurance
about their safety. Ward staff told us, when available;
these staff were a great support.
• In July 2016 the hospital reported a vacancy rate of 9.3%
in medicine for nursing. Vacancy rates for trained nurses
varied within the medicine department. The stroke and
respiratory wards had the highest rate of whole time
vacancies with seven staff needed, as opposed to the
higher care ward, which had two vacancies.
Nursing staffing
54 University Hospitals Bristol Main Site Quality Report 02/03/2017
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• The hospital had a sickness rate of 5.7% in medicine for
nursing staff. The NHS published data which showed the
latest national average sickness rate for January to
March 2016, was 4.37%.
• In July 2016 the hospital had a turnover rate of 14.1% in
medicine for nursing staff and a bank and agency usage
rate of 13.4% in medical care.
• Staffing levels varied depended on the specialty area.
Staffing in the coronary care unit, the medical
assessment unit and the respiratory higher care ward
was planned using an acuity and dependency tool
which reflected the higher level of patient complexity on
these ward. Staffing was set at one trained nurse to two
patients during the day and one trained nurse to two or
three patients at night due to the high dependency
nature of the units. Staff were expected to complete a
red flag incident form for lower than expected staffing.
• Nurse staffing in the teenagers and young adults ward (a
five bed inpatient ward for cancer patients) was staffed
at a ratio of one nurse to every two patients in the day
and one to every three patients at night. This took into
account the paediatric patients staffing requirements
and was reviewed daily by senior nurses. Staff
recruitment and retention on this ward was a focus for
divisional managers and matrons, as there had been
difficulties in maintaining staff on this ward.
• Staff from medical wards could be called upon to work
in the emergency department (ED). The staffing levels
on medical wards could change depending on demand
in ED. If there was an increase in patients in ED which
exceeded three patients to one staff member, an
escalation alert was noted in the bed capacity meeting.
This led to the staffing levels on all wards being
reviewed to establish which ward had capacity to loan a
nurse to ED for a two hour block of time. The risks to
ward patients were assessed and wards nominated to
release staff. Should the ward then have a surge of
demand, the staff member would have to be released
back to the ward. Staff told us whilst they did not have
any specific training for this role, they felt the ED
department supported them. We received a varied
response from staff to this staffing protocol, but there
was a general acceptance of this practice. Some staff
told us it gave them a wider knowledge of the hospital
and awareness of the pressures in ED.
• For all staff working on the bank, agency or in a locum
role, an orientation checklist was used to enable staff to
•
•
•
•
55 University Hospitals Bristol Main Site Quality Report 02/03/2017
familiarise themselves with the allocated work area.
Staff were required to sign and date the form when
completed to provide an audit trail of checks
completed.
Some wards and departments expressed concerns
about staffing levels and skills. Nurses conveyed
increasing concerns about the growing number of
referrals into the haematology and oncology wards,
where there was a higher number of more junior nursing
staff. Whilst staffing levels matched planned levels, the
unpredictability of workload and acuity of patients
could vary. Fluctuations in demand occurred when
patients required urgent access to care during the day
or out of hours, accessed care through the acute
haematology and oncology services. Urgent access and
advice could be sought by telephone. Staff raised
concerns this phone line was only covered by one band
five nurse at night and weekends, but was manned by a
nurse practitioner during the day. These concerns
related to the risk of poor advice might be given and
were listed on the risk register. We were told an incident
occurred a few weeks prior to the inspection, where
nurse staffing ratios on the oncology ward dropped
below planned levels, as two acute oncology patients
were admitted into this area of the ward. This left the
main inpatient ward working on a ratio of one nurse to
every twelve patients instead of one nurse to eight
patients at night. This was escalated by staff, who
confirmed staffing of the acute service was being looked
at as part of operational planning for the future.
On oncology and haematology wards senior nursing
staff had encouraged staff to report incidents in relation
to concerns about the staffing of the acute oncology
service out of hours. Some senior nurses were
concerned there had been a level of acceptance of
incidents by staff, which may have led to staff being less
likely to report incidents related to insufficient staffing
levels. This was being reviewed by senior nursing staff.
Staff we spoke with on cardiology wards C705 and C805
told us while staffing levels matched the planned
establishment; it was difficult to leave the ward to
attend training sessions. Some senior sisters on the
ward often had to step in to help on wards, which meant
they were no longer supernumerary and could not carry
out management duties during those times.
Staff on ward C705, a mixed cardiac surgery and
cardiology ward, often cared for a small number of
patients post cardiac surgery. Senior nursing staff said
Medicalcare
Medical care (including older people’s care)
they felt able to challenge cardiac surgery management,
if they felt skill mix and/or patient dependency
compromised patient safety, and on occasions had
done so. These wards worked together to ensure wards
were staffed safely during sickness or staff absences.
• In the cardiac catheter laboratory the cardiac catheter
laboratory manager was a committee member for a
national cardiac intervention authority, which advised
on staffing levels. Staffing levels in the department were
set using these guidelines.
• Arrangements for handovers and shift changes kept
patients safe. We observed staff handovers which were
clear and concise. On the medical assessment unit,
information was recorded about each patient on a
handover sheet. These were passed on from night staff
to day staff and then stored safely for any further
reference.
• Health care assistants explained trained nurse vacancies
were covered by bank and agency staff, but generally,
healthcare assistant duties which needed to be filled
were left vacant, causing increased pressure on other
ward staff. Staff also told us about an inequity in rota
planning, in that some staff had set shifts and other staff
had to work around them. They felt this left some staff
disadvantaged.
Medical staffing
• Arrangements for medical staffing kept patients safe. In
June 2016, the proportion of consultant grade staff at
the trust was higher than the England average. The
proportion of junior (foundation year 1-2) staff working
at the hospital was lower than the England average.
• Medical staff told us there were no problems accessing
senior staff and consultants. Junior medical staff
confirmed there was good middle grade doctor support
and felt there were good opportunities for doctors
including performing local audits, and care of the
elderly education. They told us there were good
relationships with other medical teams; an example
given was of a particularly good relationship with the
psychiatric and care of the elderly teams.
• Some medical staff we spoke with on cardiology wards
felt junior doctors sometimes struggled to meet the
demands of the busy ward, and cross covered different
wards, which impacted upon time to access training.
However, consultants were called upon to carry out
ward rounds if necessary.
• On elderly care wards divisional managers confirmed
there were no major concerns related to medical
staffing. However they had experienced long term
sickness with consultant and specialist registrar grades
and had mitigated this by employing locum staff.
• In July 2016 the hospital reported a vacancy rate of 5.2%
for medical staff, and a turnover rate in medical care of
4.8% for medical staff.
• In July 2016, the hospital reported a sickness rate of
0.7% for medical staff, and between September 2015
and August 2016 a bank and locum usage rate of 1.3%.
• Doctor induction was undertaken in scheduled blocks.
Should doctors start work in between those blocks, they
may work for a period of time without induction. We
saw this had taken place for one doctor. This meant no
fire training had taken place and should an incident
occur may place both staff and patients at risk.
• There were consultants trained in general medicine
available at all times. On the medical assessment unit
there were three consultants. The acute medical
consultant had responsibility for 20 patients, the
gastroenterology consultant for six patients and the
respiratory consultant for six respiratory patients, plus
their ward specialty areas. There was a ‘take’ consultant
who admitted patients referred from the emergency
department and GPs. Their time on the medical
assessment unit varied depending on activity. The on
call consultant went home overnight, to be called in as
needed. On the medical assessment unit there was also
one ward registrar and one ‘take’ registrar (the registrar
responsible for admitting patients) and a team of senior
house officers (SHOs).
• The weekend medical team on the medical assessment
unit included the ‘take’ consultant on duty, who
admitted patients. Patients who needed review over the
weekend were always highlighted to the registrar to be
seen and, if needed, the on call consultant could be
called in. Weekend cover was provided by the physician
of the day between 8am and 9pm, two registrars (one
‘take’ and cover) and one discharge registrar. There were
no formal ward rounds at the weekend, only those
patients new to the ward were seen. Two ward cover
SHOs and two ward cover junior doctors were available
at weekends.
• There was a seven day consultant delivered service for
endoscopy provided by nine consultant
gastroenterologist physicians (mix of hepatologists,
gastroenterologists and a medical endoscopist).
56 University Hospitals Bristol Main Site Quality Report 02/03/2017
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• Consultants and junior staff started work with a
handover at 8am and allocated patients to their
specialties and doctors. From 5pm one registrar took
charge of the medical cover, one registrar admitted
patients and one SHO and one junior doctor covered
the medical wards, with the exception of cardiology.
One registrar was responsible for medical cover until
7pm. The junior doctor and SHOs were responsible for
examining and taking patient histories for new patients.
They told us they had good numbers of staff to meet the
workload. At 9:30pm, there was a handover to the night
staff which was run by the clinical site manager. The
consultants usually remained on the medical
assessment unit until 9pm and were then on call.
Major incident awareness and training
• The trust had major incident and business continuity
plans. The trust-wide risk register acknowledged the risk
to trust business and operations resulting from adverse
weather conditions such as ice and snow, and the
pressure put on services by large gathering of people
based events. The trust had incident response and mass
casualty plans in place. The local council informed the
hospital about events planned for the year to enable the
hospital management to plan staffing to support an
increase in demand.
• Staff had an awareness of what action to take if a major
incident took place and explained that, whilst they had
not been part of any planned training, they were
confident senior staff would provide guidance. The trust
shared a presentation from August 2016 which
highlighted winter preparations. This looked at
escalation procedures to meet increased winter
demand, which included learning from the previous
year, and plans for times of increased demand.
Are medical care services effective?
Good
• Patients received a comprehensive assessment of their
needs and had their pain assessed regularly and
managed promptly.
• Patients’ nutrition and hydration needs were assessed
and actions put in place to ensure this was managed
effectively.
• The medical division achieved good patient outcomes
and delivered effective care. A programme of local and
national audits was used to monitor care and
treatment. Some areas showed improvements,
including the national stroke audit.
• The learning needs of staff were identified and training
put in place to meet those needs. Practice education
facilitators were available to support staff and specialist
nursing teams provided individual and group teaching
for areas identified as needing extra support.
• Patients received care from different teams who worked
together to coordinate care. Multidisciplinary working
was evident in all areas of the hospital. We observed
board rounds taking place on wards, which
demonstrated effective multi-disciplinary working. For
some wards complex discharges were daily occurrences.
There were links with GPs and community providers to
ensure safe patient discharge.
• Staff had access to information about their patients to
deliver effective care and treatment. Staff worked
cohesively to assess and plan ongoing care and
treatment and to ensure safe discharge arrangements
were made for patients.
• Whilst care was provided seven days a week, ward
rounds by medical staff did not take place every day.
However, access to medical care was always available.
Nurse specialists were available between five and seven
days a week.
• Patients’ consent to care and treatment was sought in
line with legislation and guidance. Staff had a clear
understanding of the Mental Capacity Act 2005,
Deprivation of Liberty Safeguards and patient consent.
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We rated effective as good because:
• Patients’ care and treatment was planned in line with
current evidence based guidance. Clinical care
pathways were developed in accordance with national
guidelines. Trust policies included reference to NICE
guidance and other national strategies.
However:
• There were no hospital-wide pain audits to assess if pain
was managed effectively for patients who were able to
express their level of pain.
• Not all staff had received an appraisal in the last year.
Without an appraisal, learning needs may not be
identified and a plan put in place to support staff to
develop their practice.
57 University Hospitals Bristol Main Site Quality Report 02/03/2017
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Medical care (including older people’s care)
Evidence-based care and treatment
• The trusts policies and services were developed to
reflect best practice and evidence-based guidelines. The
hospital developed clinical care pathways in accordance
with national guidelines. This ensured patients received
the most effective treatments, in a timely way, from the
most appropriate teams.
• Policies included reference to National Institute for
Health and Care Excellence (NICE) guidance, for
example the hospital policy for transfer of patients both
internally and externally to other locations, referenced
the NICE guidance Acutely Ill Patients in Hospital July
2007 and the south-west dementia partnership hospital
standards in dementia care. This outlined clear roles,
responsibilities and processes to ensure patients were
safely and effectively moved between teams, both
within and outside of the hospital. The National
Dementia Strategy (2009) was used to develop the falls
management policy, to ensure national policy and
recommendations were implemented, avoidable falls
and harm were reduced, and to promote a consistent
approach to falls management across the hospital.
• The trust identified falls prevention as a priority area in
2016 and had instigated a programme in response,
called ‘Eyes on Legs’. The concept was devised by a ward
sister and matron following a serious patient fall. They
identified falls prevention had not previously been given
sufficient priority by the ward’s multi-disciplinary teams.
Following this, the ‘Eyes on Legs’ campaign was rolled
out across the hospital. The concept was to ensure all
staff, regardless of their role, understood the message
that falls prevention was everyone’s responsibility.
• Staff from the teenagers and young adult ward used
best practice guidelines to ensure patients achieved the
most effective outcomes. Care delivered to young
patients followed guidelines such as the NICE improving
outcomes guidance for children and young people with
cancer.
• Stroke pathways were in place to support patients to
access the right services and effective treatment at the
earliest point of admission, in line with NICE guidelines
for the management of stroke and transient ischaemic
attack. This meant specialist nurses and nursing staff
were available at all times to undertake thrombolisation
(the breakdown of a blood clot) and bring the patient
from the emergency department to the ward.
• The hospital provided a medical ambulatory care unit
which included a GP support unit to provide direct
advice and support to primary care patients. The aim of
the ambulatory care unit was to reduce unnecessary
admissions and alleviate pressure on the emergency
department and medical assessment unit. The
ambulatory care unit lead nurse was keen to develop
the service to provide a wider scope of service for
patients.
• Patients were admitted to the medical assessment unit
from the emergency department via ambulatory care or
directly from GP referral. Those patients admitted
directly from their GP were triaged on the medical
assessment unit and directed to the correct admission
or discharge pathway. The length of stay on the medical
assessment unit was an average of between 24 and 48
hours. Some patients were held on the medical
assessment unit if their safety was risk assessed, and it
was considered the best place for them to remain until a
ward bed was available.
• A range of specialist nurses provided specialist care and
treatment to medical inpatients, education to
healthcare professionals in the community and primary
care, and to outpatients following their stay in hospital.
For example, cardiology specialist nurses and outreach
services such as the arrhythmia specialist nurse service,
was implemented in line with the National Service
Framework for coronary heart disease. The service
helped to ensure patients were identified early when
diagnosed in the community or in hospital, and by
working to educate clinicians in primary care, to ensure
patients were treated in line with relevant clinical
guidelines.
• Enhanced supervision teams were established in the
hospital to support wards and staff with patients with
extra needs during the day. Plans were in place to
extend the provision of this service at night. Their role
included taking patients to the dementia café, activity
clubs and supporting activities on the ward. They were
allocated where a need was identified and were not
counted as part of the ward staffing level. Usually three
of these staff worked each day, this included night shifts.
They carried a bleep to ensure they were used where
needed.
• Trust protocols were available to staff via the intranet to
support their practice. Staff told us they knew where to
58 University Hospitals Bristol Main Site Quality Report 02/03/2017
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Medical care (including older people’s care)
access this information and were able to show us. These
were also available on each ward in paper copy. Doctors
told us there was good access to local guidelines
including antibiotic guidelines.
• Staff said they received regular updates with new
policies and guidelines. They were notified by email
from senior staff within the trust, through team
meetings, or during daily safety briefings on the wards.
At team meetings staff told us clinical nurse specialists
provided up to date advice and guidance about care,
treatment, and changes to ways of working.
Pain relief
• Patients had their pain assessed regularly and managed
promptly. In 20 records we saw patients had a pain
score recorded and there was evidence of timely
administration of pain relief when required. Pain
assessments had been calculated correctly and
medicines charts reflected action taken to address any
pain levels found. Further monitoring recorded if those
actions had been effective and any changes needed.
• We spoke with seven patients who confirmed their pain
had been well managed and they were comfortable.
• Pain was also well managed on the oncology and
haematology wards. We saw patients had access to a
variety of pain medicines and eight patients across
these wards told us their pain was well managed.
• Two pain scoring systems were used. A system was in
place for patients who had the cognitive ability to tell
staff about their pain. For those patients who did not
have the cognitive ability, the Abbey pain score was
used. This included a range of means to assess patients’
pain levels for example facial expression. The national
early warning score charts recorded which system of
pain assessment had been used, and pain scores were
included in the overall scoring system to identify patient
deterioration.
• Pain audits were carried out across the medicine wards
but these were focused on patients who were not able
to say they were in pain. The use of the Abbey pain scale
was audited by dementia leads each month and
feedback provided to wards. The Abbey pain scale was
used to assess pain levels for patients with cognitive
impairment. The September 2016 dementia report
showed a RAG (red, amber, green) rating of green in the
Bristol Royal Infirmary during May 2016, July 2016 and
August 2016. The average score showed staff assessed
pain using the scale for 76% of patients during this time.
In specialised services, (the Bristol Heart Institute and
the Bristol Haematology and Oncology Centre) the
report showed audit scores for use of the Abbey Pain
Scale were poor. Staff training sessions were
implemented to ensure all staff were competent to use
the scale. The report noted September 2016 data
showed signs of improvement. There were no pain
audits for patients who were able to verbally express
their pain to establish if pain was also managed
effectively for this patient group.
Nutrition and hydration
• The malnutrition universal screening tool (MUST) was
used to calculated and record patients’ nutritional risk.
Patients’ records showed these were correctly
calculated and actions put in place to support each
patient’s hydration and nutrition. For example, when a
patient had been assessed as at risk of dehydration, it
was recorded on their prescription chart ‘offer me a
drink’ with the amount and frequency, to ensure
sufficient fluid was offered and recorded.
• The patients view on the hospital food was varied. Some
patients felt the portion size and menu choice was
sufficient. Others felt the portions were too small and
did not meet their needs. We observed an evening meal
being served and patients being asked if they wanted
more or less food served. Patients told us they could
access food late in the evening as staff would get them a
sandwich. Staff told us they could ring the kitchen if
needed for alternatives.
• Speech and language therapists were available between
8am and 5pm Monday to Friday to carry out a swallow
assessment on all stroke patients. Should the
assessment be needed out of those hours, nursing staff
on the stroke ward were trained by the speech and
language therapists to complete the assessments to
prevent a delay in patients receiving the most
appropriate and safe food and drink.
Patient outcomes
• The outcomes of patients’ care were routinely collected
and monitored to measure the effectiveness of care and
treatment. The hospital took part in national audit
programmes and also established local audits.
• The hospital took part in the quarterly Sentinel Stroke
National Audit programme (SSNAP). This aimed to
improve the quality of stroke care by auditing stroke
services against evidence-based standards, and
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•
•
•
•
•
national and local benchmarks. On a scale of A-E, where
A is best, the trust achieved a score of C in the audit
(April 2016 to June 2016), which was an improvement of
one grade over the score in the previous audits. All
patient centred performance measures were the same
or better when compared to the previous quarter, with
seven of the 11 indicators showing improvement
compared to the previous quarter. Team centred
performance was similarly good with improvements
seen for six of the 11 indicators and no indicators
showing worse performance in the latest quarter.
The hospital results in the 2014/15 heart failure audit
were better than the England and Wales average for all
of the four standards relating to in-hospital care.
However, results were worse than the England and
Wales average for three of the seven standards relating
to discharge. Divisional managers informed us that in
order to address this, additional nurses and consultants
had now been employed.
The hospital took part in the 2015 National Diabetes
Inpatient Audit. They scored better than the England
average in six areas and worse than the England average
in 11 areas. The diabetes specialist nurses produced an
end of year report for 2015/2016. This included progress
with inpatient care and completed actions from the
2015 report. For example, one area which had not
scored well was foot assessments, and the end of year
report recorded progress with foot care pathways being
employed on the wards.
The trust took part in the 2013/14 Myocardial Ischaemia
National Audit Project (MINAP) and scored better than
the England average for all of the three metrics. This was
the most recent MINAP audit, for which scores in 2013/
14, showed an improvement over the previous year.
There had been an improvement in the number of
patients receiving antibiotics within one hour of arrival,
for patients undergoing chemotherapy who presented
with potential neutropenic sepsis. These were patients
whose immune systems were compromised due to their
treatment. Between July to November 2016 (5 months)
95% (19 out of 20) patients received antibiotics within
one hour of presentation of symptoms, whereas
between November 2013 and April 2014 the rate was
54%.
The trust told us its primary percutaneous coronary
intervention (PCI) programme offered extensive services
to patients across the region. This is an urgent
procedure carried out when patients present with
•
•
•
•
•
60 University Hospitals Bristol Main Site Quality Report 02/03/2017
symptoms of a heart attack. Part of this PCI programme
involved coronary intervention in patients suffering out
of hospital cardiac arrests, who had been resuscitated.
This involved cooperative working between cardiology
and the general intensive care unit. Senior nursing staff
informed us outcomes compared favourably with
national and international benchmarking, but did not
have access to data.
The trust participated in the 2015 Lung Cancer Audit and
the proportion of patients seen by a cancer nurse
specialist was 95.3%, which was better than the audit
minimum standard of 80%, and was an increase on the
previous year’s score of 76%.
Outcomes for cancer patients on the teenage and young
adults ward were measured through qualitative data,
which looked at compliance with medicines and
treatment. Compliance for teenagers and young adults
undergoing cancer treatment is known to be
challenging due to a wide range of age, psychological
and social reasons specific to young people. Both
qualitative and quantitative data showed demonstrable
improvements to patient outcomes across a range of
areas, of both the physical and psychological health of
patients.
Between March 2015 and February 2016, patients at the
hospital had a higher than expected risk of readmission
for elective gastroenterology and both elective and
non-elective cardiology. Patients had a lower than
expected risk for general medicine (elective and
non-elective).
The hospital provided a dedicated service for patients
with heart conditionsacross Bristol and the South West.
Divisional managers informed us the cardiology risk of
re-admission was attributed to both the complexity of
the patient group (which they deemed more complex
than the national average), to the complexity of patients
being referred from other centres across the region, in
part, due to the strength of the specialist nursing team
within the hospital.
Local audits monitored a wide range of processes and
outcomes such as: documentation, chest x-rays,
requests for acute medical admissions at the hospital,
elderly discharge summary standards, and unplanned
admissions from home to hospital. These showed a
good level of outcomes and compliance.
Medicalcare
Medical care (including older people’s care)
• Falls management was audited regularly and actions
produced as a result. The data showed whilst the
number of falls per month varied and was seen to have
increased in October 2016, the number of falls resulting
in harm had fallen from March 2016 to October 2016.
Competent staff
• An appraisal was used to identify learning needs, and a
plan put in place to support staff to develop their
practice. A high level of staff had received an appraisal in
the last year. In the year 2015/16, 82% of staff within the
hospital had received an appraisal. However, the trust’s
target was 85%. Nursing staff appraisal levels were at
88%, medical staff 72%, and allied health professional
appraisals at 86%.
• Staff told us they were provided with training to deliver
effective care in their roles. There were a range of
specialised staff across the hospital who worked closely
with ward staff to meet their learning needs and
improve competencies. Many staff had developed skills
in a range of areas, such as dementia, falls, and infection
prevention and control.
• Practice education facilitators were available to support
staff and specialist nursing teams provided individual
and group teaching for areas identified as needing extra
support. For example, practice education facilitators
worked seven days a week in haematology and
oncology to support staff with learning and competency
development. Nursing staff often took on link roles
where they took the lead on their ward in some of these
areas. They were provided with extra training and could
support other nurses on their ward
• The diabetic specialist nurses, the respiratory specialist
nurses and stroke specialist nurse all provided training.
A number of cardiac specialist nurses including
arrhythmia, heart failure and acute coronary syndrome
provided outreach care to patients across the hospital
and on cardiology wards. Other specialist nurses
included tissue viability, learning difficulties, dementia
and wound care.
• A number of staff we spoke with said they had been
given opportunities to develop their skills and practice.
They had accessed courses other than mandatory
training, in order to enhance their skills or for personal
development. Other staff felt funding was limited or
gaining agreement for time off the ward was difficult to
achieve. Some staff told us they had taken annual leave
in order to access further training.
• Staff in the cardiac catheter laboratories received
simulation training to practice resuscitation of patients,
as patients receiving treatment and assessments there
were generally at higher risk. The training also aimed to
enhance communication skills within the team and
incorporated human factors training.
• Staff on cardiology ward C705 (which provided care to a
small number of cardiac surgery patients) were rotated
onto the cardiac surgery ward for periods of six to nine
months in order to ensure staff were competent to
deliver effective patient care.
• The oncology and haematology service provided new
staff with a supervision period lasting three months,
along with a chemotherapy workbook to complete. New
staff’s competencies were then assessed to ensure their
practice was safe. Registered nurses working on the
oncology ward were provided with annual
chemotherapy training together with a workbook to
complete. There were additional competency training
sessions, such as blood transfusion competencies. We
reviewed a register of staff’s chemotherapy
competencies and could see all staff had attended a
chemotherapy workshop, and there were good levels of
compliance for staff who had attended a chemotherapy
update in 2016.
• A quality improvement lead for foundation doctors
provided support for doctors in training. Mentors who
had been through the programme provided support to
medical staff. Junior doctors were increasingly
attending dementia cafés twice per month in order to
improve their knowledge and skills to manage patients
living with dementia.
Multidisciplinary working
• Effective multidisciplinary working was evident in all
areas of the medical and specialist services we
inspected. We observed board rounds taking place on
wards which demonstrated multi-disciplinary working.
This was an opportunity for a multidisciplinary team
discussion about each patient’s treatment, which was
recorded in patients’ notes and updated on the wards’
white boards. The board rounds also included
community services who were actively involved in
discharge planning. For some wards the discharge of
patients with multiple medical conditions and complex
care needs were daily occurrences. There were good
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•
•
•
•
•
links with GPs and community providers to ensure safe
patient discharge. In each discussion about the patient
it was clear which consultant or team had overall
responsibility for the patient’s care.
Multidisciplinary team meetings took place on all wards
and we saw they were a forum for discussion and
decision making of the patients care and treatment
plans. On the stroke ward, in addition to the
multidisciplinary meeting, there was also a stroke
operations meeting to discuss any multidisciplinary
concerns, or if patients were being cared for on an
alternative ward.
We observed a haematology weekly, multidisciplinary
grand round, which was a paper based review of
patients on the ward. We saw input from a wide range of
healthcare professionals which included nursing and
medical staff, and specialists from other services,
including a consultant transplant specialist, palliative
care and a clinical nurse specialist.
On cardiology wards we noted allied health
professional, social workers, pharmacy, dietetics, ward
clerks and nursing assistants were often not present. On
one cardiology ward we were informed social workers
were available by phone. However, staff told us there
had been a shortage of social workers and it was
sometimes difficult to access them.
Staff told us a three-times-a-day; multi-professional
board rounds were conducted to progress patients’ care
and ensure safe and supported discharge. This included
partnership working with Bristol Community Health
rapid response team to facilitate early supported
discharge for Bristol patients who were medically stable
but required up to five days’ further nursing/
occupational therapy/physiotherapy support to provide
a safe discharge. The older persons’ mental health
specialist nurse was included in this board round.
We reviewed patients’ notes and saw evidence of
multidisciplinary team working. For example, in one
oncology patients’ record we saw evidence of input
from physiotherapists, dieticians, occupational therapy,
speech and language, and medical and nursing input
from other departments due to the patients’ co-existing
health conditions. We reviewed a further set of notes
which showed multidisciplinary working between
medical, nursing and allied health professional staff. A
further set of notes we looked at recorded input from a
dietician, physiotherapist, occupational therapist, pain
support services, stroke nurse and nursing and medical
staff.
Seven-day services
• Whilst care was provided seven days a week, ward
rounds by medical staff did not take place every day.
Ward rounds took place each day Monday to Friday. All
patients had a clinical assessment once admitted to the
medical assessment unit by a consultant or registrar.
This was undertaken within 12 hours.
• Medical staff could be accessed to ensure patients could
be discharged at the weekend if needed. Medical cover
was provided per specialty area between 8am and 5pm.
After 5pm cover was provided by medical staff whose
role it was to admit patients onto the medical and
stroke wards.
• An on-call stroke physician was available through the
South West Stroke Network rota after 5pm and before
8am and during weekends. This service covered a wide
region which included Bristol, Gloucester, Swindon,
Taunton, Yeovil and Salisbury.
• A consultant and registrar worked on cardiology wards
at the weekend and were initially based in the coronary
care unit to carry out a board round, then went to the
acute medical unit or the emergency department to
review patients due to be admitted to the hospital .
• Nurse specialists were available between five and seven
days a week to provide specialist input to patient care.
• In 2014 a six day diabetes service was instigated which
integrated inpatient and outpatient work. A new
consultant had recently been appointed. Diabetic nurse
specialists rotated working to include Saturdays. A
telephone line was available for staff to leave messages
and request a call back. Out of hours guidelines on the
management of diabetic patients were available for all
staff to access on the hospital’s intranet. Out of hours
generally meant after 5pm and before 8am and at
weekends.
• The heart failure nursing outreach team carried out
three rounds per week within the medicine division. The
purpose of this was to increase access to care for
patients with heart failure and to reduce the
readmission rate.
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Medical care (including older people’s care)
• Ward staff had access to mental health services for
patients with physical and mental health needs.
Telephone referrals could be made and the dementia
lead nurse was available to help staff with the referral
process.
• The specialist nurse stroke team were available seven
days a week. Occupational and physiotherapists worked
a six day week with the stroke service. For the medical
wards, physiotherapists were available between 8am
and 4:30pm Monday to Saturday, with Saturday being a
reduced staffing level. Overnight there was access to an
on call physiotherapist who could be called into the
hospital. On a Sunday between 8:30am and 4:30pm the
higher respiratory areas had access to a physiotherapist.
• The tissue viability nurses worked a five day week but
had a support line where patients could leave messages
and they would respond when on duty.
• The specialist respiratory service worked Monday to
Friday, with a seven day service for patients with chronic
obstructive pulmonary disease (COPD), provided in
conjunction with the community health COPD team.
• Day case care and treatment was provided on the
haematology day unit every day except for Saturdays.
• The medical ambulatory care unit was open from 8am
to 8pm on Monday to Friday and admitted patients from
the emergency department, GP referral and ambulance
services, directly to the unit. They were supported by the
medical staff from the emergency department.
• The general pharmacy closed at 6pm and an on call
pharmacist was available until 8am when it reopened.
Access to information
• Staff had access to patient information to deliver
effective care and treatment. Discharge letters were
started well in advance of discharge and were
completed by both the consultant and nursing staff. The
letters were stored on the ward computer; they were
comprehensive and accessible to staff to contribute to.
This included pharmacy staff to record the take home
medicines.
• When patients who needed specialist community
support were discharged, the links were made with
community services. For example, a patients needing
diabetic follow up would have a GP discharge letter and
a follow up referral to community diabetic services,
depending on geographical location.
• When patients moved between teams and services
within the hospital notes did not travel with the patient.
This meant it was not always easy to gain access to care
records in a timely way. A variety of nursing and
administrative staff told us they spent a lot of time
chasing and collecting patient notes. Administrative
staff mainly worked during daytime between 8am and
5pm, which meant patient records required by nursing
staff at weekends had to be collected from other parts
of the hospital. This meant staff temporarily leaving the
ward and therefore reducing staffing levels during that
time period. Administrative staff also had to leave
positions unmanned whilst going to other buildings in
the hospital to collect patients’ notes.
• When a child’s care transitioned from the children’s
hospital to the care of the teenager and young adult
ward, information was shared between professionals
who were involved in their care. Healthcare
professionals and patients met with staff on the teenage
and young adult unit to discuss and plan their care,
during the transition period.
Consent, Mental Capacity Act and Deprivation of
Liberty Safeguards
• Patients’ consent to care and treatment was sought in
line with legislation and guidance. Staff had a clear
understanding of the Mental Capacity Act 2005,
Deprivation of Liberty Safeguards and patient consent.
• In the 29 records we reviewed we observed consent had
been obtained and recorded in each case and where
consent was refused or not able to be provided this was
clearly documented. We observed staff and saw they
asked for consent before undertaking any actions.
• The trust undertook an audit of clinical consent in
September 2016 with the aim of determining whether
consent for treatment was being obtained according to
trust policy. The results showed areas for improvement.
A sample of 123 patients undergoing operations or
procedures in January 2016 was used across five areas/
specialties within the trust. These areas included
medicine, cardiology, oncology and haematology. There
were 11 objectives and the results showed whilst
medicine, cardiology and haematology scored well in
many areas, there was room for improvement in some
areas. These included ‘the risks of the procedure/course
of treatment will be recorded on the consent form’. Staff
told us an action plan was being put into place to
address the shortfalls.
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• The trust reported that Mental Capacity Act 2005 and
Deprivation of Liberty Safeguard training was fully
incorporated into safeguarding training undertaken by
staff.
• We spoke with staff on wards including A400, C808 and
the higher care respiratory ward, who described the
local process for making a Deprivation of Liberty
Safeguards application and were clear about their
responsibility towards the patient.
• We reviewed 26 sets of notes and looked specifically at
five sets of notes to review how do not attempt
cardiopulmonary resuscitation (DNACPR)
documentation was recorded. We saw the records
included who the decision had been discussed with, the
reason for the decision, their comments and any plans
for review of the document. The document was signed
and dated by the doctor and included their grade. No
junior doctors had signed the forms seen.
Are medical care services caring?
Good
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We rated caring as good because:
• Feedback from patients and those close to them was
positive. Patients were treated by kind, caring staff who
were respectful and considerate.
• Patients’ privacy and dignity was respected and staff
sought permission before carrying out care and
treatment.
• Staff often went out of their way to meet the emotional
and physical needs of patients. It was clear they had
taken the time to get to know and understand their
patients.
• Patients and those close to them were treated as
partners in their care and supported to make informed
decisions about their care and treatment.
• Staff were without exception courteous and helpful.
• Patients’ emotional and social needs were valued and
this was demonstrated in the way staff cared for patients
and in patient feedback.
Compassionate care
• We observed staff took the time to interact with patients
and those close to them in a respectful and considerate
way. We heard of and saw many examples of staff
delivering compassionate care and treating patients
with kindness, dignity and respect.
• We spoke with 30 patients who were all positive about
the care and compassionate treatment they had
received from staff. We saw care provided to both
patients, and their relatives and carers, which
demonstrated staff, understood their patients’ needs.
They were always kind, thoughtful and polite. Patients
made comments such as: “I don’t know anywhere else
in the world I would get this care and treatment”; “staff
always have a smile”; “staff could not have been more
helpful”; and “care has been first class”.
• Patients on the oncology ward felt their care needs were
met and spoke highly of the staff who were described as
caring and kind. One patient said, “I receive what
everyone deserves”. Another patient receiving
chemotherapy described the service they had received
as “faultless”.
• We supplied the hospital with comment cards several
weeks prior to the inspection, so patients and those
close to them could tell us about their experiences of
care at the service. We received 80 comment cards and
found the feedback about care they received was very
positive. Comments included: “All staff (doctors, nurses
and cleaning staff) were very kind and polite and did
everything you needed”; “My needs have been
responded to very well and quickly, from needs such as
needing painkillers to needing a hair dryer!”; and “They
[staff] have spent the relevant time listening to my
needs and requirements and gone ‘the extra mile’.”
• We observed staff speaking to patients by bending
down to their level, making eye contact and referring to
them with preferred names and with references that
demonstrated they had taken time to get to know the
patient.
• The NHS Friends and Family Test was created to help
service providers and commissioners understand
whether their patients were happy with the service
provided, or where improvements were needed. The
Friends and Family Test response rate for medical care
at the hospital was 50%, which was better than the
England average of 25%. Between November 2015 and
October 2016, over 90% of patients who had received
care at the hospital would recommend the service to
friends or family. However, on older people’s wards A518
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and A528 less than 90% of patients in at least four out of
the last six months would recommend the service. On
older people’s ward C808, only 73% of patients would
recommend the service to friends and family in October
2016.
We observed staff respected patients’ confidentiality,
privacy and dignity by ensuring toilet doors and curtains
were always pulled closed and by knocking or seeking
permission before entering. Voices were lowered when
confidential or personal information was being
discussed. Staff told us and patient feedback confirmed
patients’ dignity was respected. One patient who had
been treated at the hospital for a number of years
stated, “the staff have continued to deliver remarkable
care, and an unfailing recognition of my dignity and
shown sincere respect. I consider myself exceedingly
fortunate to experience the NHS care and treatment.
This is true of consultants, registrars as well as the
nurses.”
Staff told us they understood and respected patients’
personal, cultural, social and religious needs and took
these into account. We saw care records recorded any
personal, cultural or religious preferences to ensure staff
could respect them.
The cancer patient experience survey had rated the trust
lower than the national average. Divisional managers
told us the trust had engaged in working with a buddy
hospital in order to learn from them and improve the
cancer patient experience.
When patients experienced physical pain, discomfort or
emotional distress, we saw staff responded with
kindness and compassion in a timely way. Patients said
their needs were responded to in time and with good
care.
We heard of examples where staff often went out of their
way to care for patients in the hospital to meet both
their physical and emotional needs. Staff in one area of
the hospital tracked down a patient’s relatives and
facilitated a reunion. The patient expressed how happy
this had made them. The same nurse held their hand
when the patient later passed away. Staff on the
oncology ward told us staff of all grades had gone out of
their way to care for patients, often carrying out errands
and tasks for the patient in their own time. We heard
particular examples of this in relation to terminally ill
patients.
We saw numerous instances when hospital staff in the
corridors were stopped by patients and relatives to ask
for directions or assistance. Staff were without
exception, courteous and helpful. We were particularly
impressed by porters and cleaning staff who were
extremely helpful to relatives and patients. We saw one
of these staff escort two relatives to where they needed
to be. They did this in a friendly and inclusive manner
that was considerate of their walking pace, which put
them at ease.
Understanding and involvement of patients and
those close to them
• Staff showed an encouraging, supportive and sensitive
attitude to patients and those close to them. Patients
told us they felt involved in the decisions about their
care, and relatives told us they were kept informed and
updated with any changes to their relatives care.
• The family of a patient in the hospital commented about
their experience of bringing a relative to the hospital for
treatment and stated, “From the beginning she (the
patient) was treated with total dignity and respect as
were we as relatives. All the staff without exception have
been friendly, extremely helpful and have kept us
informed of what is going on at all times. It is such a
pleasure to deal with such caring wonderful people. This
hospital is first class.”
• Staff in the teenagers and young adults ward worked
closely with patients, their carers, families and social
network, to provide ongoing support to patients and
those close to them.
• We observed staff worked collaboratively with patients
and carers and encouraged their involvement. For
example, nursing staff on the oncology and
haematology wards described their awareness of how a
diagnosis affected those close to the patient and how
important it was to support the friends and families.
• Relatives told us visiting times were flexible to meet the
needs of family members and their working lives. We
visited in the evening and saw some relatives were able
to visit later. We also overheard a telephone
conversation where staff were helpful in enabling a
relative from further afield to visit outside of normal
visiting times.
Emotional support
• A hospital chaplain visited the wards once or twice a
week to provide emotional support to patients and their
relatives.
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• We spoke with a patient and family who told us how the
staff had tried to ensure they were treated by the same
medical team as their admission several years earlier, in
order to provide consistency of care.
• Clinical nurse specialists were available across the
hospital. We saw the specialist staff working on all wards
and records confirmed their ongoing input in patients’
care, which included emotional support for their clinical
specialties. For example, a tumour clinical nurse
specialist provided emotional support and advice to
patients and families.
• In the oncology and haematology department patients
and families had access to a range of services to help
them to manage the emotional impact of their care and
treatment. The cancer information and support centre
sign posted patients to the support they could access
both within and outside of the hospital, which included
from volunteers and charities. Staff told us they would
refer patients here for further emotional support where
appropriate. Psychological and palliative care services
were available for patients to access.
• Staff empowered patients to manage their own health,
care and wellbeing to maximise their independence.
Feedback from patients and observations of care,
showed how staff taught patients to manage their care
in their own homes, for activities such as dressing and
bathing themselves, or in changing wound dressings.
• Staff in the cardiac catheter laboratories worked closely
with patients and carers to educate them about their
diagnosis. They described to us how they used images
of cardiac vessels displayed during procedures, to
inform them about their condition, where appropriate.
• Staff in the teenagers and young adults’ area clearly
articulated their understanding of the needs of young
people using the service, who were faced with cancer at
a critical stage in their life. This included patients’
physical, emotional, educational, social, sexual and
employment development. A range of and initiatives
were in place, to support patients’ varying needs.
Support included, counselling and psychological care,
along with a range of social activities both in and off the
ward, such as cake baking, arts and crafts, and music
events. Door labels were used so patients could make
clear if they wanted to be left to sleep until their chosen
time. This helped patients to regain an element of
control over their disease and feel empowered to make
decisions about their care.
Are medical care services responsive?
Good
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We rated responsive as good because:
• Services were planned and delivered in a way that met
the needs of local patients. The hospital offered choice
and flexibility to patients and provided continuity of
care. New clinics, services and virtual facilities were
implemented, to ensure services met patients’ needs.
• The service delivered was creative to ensure patient flow
through the hospital was maintained and was
responsive to the ever-changing demand. There was a
constant oversight by senior staff, of how different
departments were managing flow, to ensure staff across
all areas of the hospital prioritised patient safety, whilst
maintaining the flow of patients through the hospital.
• The flow of patients through the medical division was
monitored and actions taken to minimise the numbers
of patients being cared for on wards other than those
related to their medical condition or specialty. These
patients were known as medical outliers. The hospital
ensured outlying patients received the care and input
from nursing and medical staff, relevant to their medical
condition or specialty.
• Transferring patents out of hours was avoided.
Transfers, whenever possible, took place between 8am
and 8pm to avoid disruption to patients and maintain
safe staffing levels. Discharge delays, transfers and bed
moves were all monitored to ensure they did not impact
negatively on patients’ care and treatment.
• Access to care was managed to take account of people’s
specific care needs, including those with urgent care
needs.
• Complaints were handled in accordance with trust
policy and improvements were made in response to
complaints.
However:
• Processes to ensure patients who were medically fit to
leave the hospital were not always effective. However, in
the majority of cases, reasons for discharge delays were
not attributable to the hospital.
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• Referral to treatment times for different specialties
including within the medicine division were not all
within the national standard. The referral to treatment
time for cardiology patients was worse than the England
average.
Service planning and delivery to meet the needs of
local people
• Services were planned and delivered to ensure flexibility
and choice so patients received care in an appropriate
setting. Ambulatory care pathways were in place to
enable patients to avoid admission to the hospital
where appropriate. A scoring system was used to guide
staff when assessing patients, where the higher the
score meant patients were more suitable and
appropriate to be sent home. The unit used a three
track triage process to categorise patients for a, same
day admission, future admission, or ‘bring back for a
clinic’, category. The ambulatory care clinic had seen an
increase in gastroenterology patients which was now
50% of their work.
• Endoscopy services were run through theatres. To cope
with increasing levels of demand, four gastroenterology
beds were allocated on the respiratory higher care bay.
These beds were under the care of the gastroenterology
consultant and endoscopies were undertaken with
recovery on that ward. A higher care bed was
maintained to provide access to care for these
emergency patients. Staff on the respiratory ward told
us they would sometimes assist with the endoscopies,
as they had received training to do so.
• Services provided were reflective of the needs of the
local population, ensured choice and continuity of care.
The trust contracted with a third party company to
provide a virtual ward to support patients to receive
treatment at home, whilst still being under the
supervision of the hospital. This service managed up to
19 patients in their own homes. Treatments included
intravenous antibiotics and patients were visited by the
staff to provide care and support where appropriate.
The service was implemented to reduce avoidable
admissions. Should the patient deteriorate, they were
transferred directly to the medical assessment unit, and
did not have to wait to be seen in the emergency
department.
• The hospital implemented a nurse-led transient
ischaemic attack (stroke) clinic on the stroke ward. This
service enabled patients to be treated without
admission. Should an admission to the hospital be
considered, they could be seen by a doctor at the clinic.
The nurse saw up to nine patients at each weekday
clinic. The clinic did not operate during weekends.
• Staff told us about the dementia café which was held
twice a month, and both patients and their carers were
encouraged to attend. The café provided access to
games and memory tools but also offered a social
environment for patients and carers to meet and share
experiences. We saw on ward C808 activities were
provided to support patients living with dementia.
Activities and entertainment were also provided on the
ward.
• Information about the needs of teenagers and young
adults were collected during project work and through
ongoing feedback from patients and those close to
them. It was used to inform the design and
redevelopment of the teenage and young adult area,
which underwent refurbishment in 2014. Subsequent
project work and ongoing feedback enabled the service
to continue to develop, reflecting the needs of the
teenagers and young people using the service.
Access and flow
• The service delivered was flexible and creative to ensure
flow was maintained. Since the inspection in 2014,
divisional managers had focussed on improving patient
flow and discharge, by working more closely with
community based care to access beds within the
community, and through initiatives to treat patients at
home where possible using a virtual ward or the SAFER
patient flow bundles. These were guidelines the hospital
implemented which ensured patients were reviewed by
a consultant earlier in the day, with a focus on discharge
and overcoming any barriers to this, early on in the
patients’ stay.
• The trust anticipated receiving around 45 medical
admissions each day. This level could vary and on the
first day of our inspection there were 52 medical
admissions. We saw that whilst this day and the
following day were very busy, flow was maintained by a
process of evaluation and prioritisation. There was a
constant oversight of how other departments were
managing flow and looking at the hospital in a wider
context, to ensure staff across all areas of the hospital
prioritised patient safety, whilst maintaining the flow of
patients through the hospital.
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• The trust had an escalation plan which was last
reviewed in November 2015. This plan was drawn up to
ensure any patient coming into the trust, could access
safe care, in a timely way. The objective of the
escalation plan was to maintain the hospital at ‘green’
escalation status (low levels of pressure), with no
obstructions to patient flow. The actions outlined at
‘amber’, were designed to return the situation to ‘green’
and prevent deterioration to ‘red’ escalation at which
point patient flow would be compromised. We observed
the escalation plan being used with the trust being in
‘red’ status during the inspection. We observed the plan
being followed and the status fluctuating, as staff
implemented the escalation process.
• There were a series of meetings throughout the day to
identify issues with capacity and flow, escalation,
discharge planning and breaches. These meetings
included staffing levels to ensure sufficient staff with the
right skills were in place to meet ward demand. Should
flow become a problem, extra meetings were put in
place to keep a close eye on any changes required to
manage patient flow.
• An escalation ward was available should an increased
bed capacity be urgently needed. Managers had not
requested for this ward to be opened during the
inspection, as it was not considered to be needed, but
we observed the ward not be in a state of preparedness
should it be needed urgently. We discussed this with
senior staff who addressed this.
• The medical assessment unit had a treatment room,
which was used for patients when additional beds were
needed. The room was often temporarily used in this
way but was not entirely suitable. No toilet facilities
were available and so only patients who were mobile
could use this. The use of this room also prevented the
ward using the treatment room for its designated
purpose. The regularity of its use was not recorded;
however staff told us it was used regularly when there
was increased patient demand.
• Data provided showed in the 12 months prior to our
inspection, medical bed occupancy ran at 98%. When
occupancy runs above 85% there is an increased risk to
patients. On occasions where ward occupancy levels
were high, patients were admitted to wards which were
not identified for their medical condition/specialty.
These patients were known as medical outliers. The
hospital ensured outlying patients received the care and
input from nursing and medical staff. This ensured
patients’ care was not negatively affected by being on
an outlying ward.
• From July 2016 to October 2016 there had been 105
days when patients were not in the correct department
in oncology, 284 in cardiac services and 725 in medicine.
Divisional managers told us there was a reduction in the
number of medical outliers compared to the previous
year, and attributed part of this to the changes that were
made to its bed base model. For example, ward A605
was changed from a surgical ward to become a medical
ward.
• On day one of our inspection there were 13 outlying
patients. After a busy night of admissions, on day two
this had increased to 21 outlying patients. The outlying
patients were recorded on a board in the bed site office
and on the electronic information system. We visited
five outlying patients on their wards and reviewed their
records. We saw they had been visited each day by a
medical doctor, with the exception of the weekends,
when a weekend plan was recorded. Staff explained the
system in place to contact the appropriate medical
doctor for each patient. They told us the system worked
effectively, and records confirmed in one instance when
staff were concerned about a patient’s deteriorating
condition, they had called the medical doctor who had
attended promptly. Divisional managers told us if
oncology or haematology patients did have to be
admitted on outlying wards, they were risk assessed so
only clinically stable patients would be selected.
• The hospital and ward ensured outlying patients
received care and input from suitably skilled nursing
and medical staff. For example, on cardiology wards,
senior nursing staff said staffing, skill mix and patient
acuity would be considered before taking on any
outlying patients. They said they were able to challenge
any decisions to ensure wards were safe, and gave
examples of two occasions where they had not agreed
to accept outlying patients onto the ward.
• Between April 2015 and March 2016 the average length
of stay for medical elective patients at the hospital was
three days, which was lower than the England average
of 3.9 days. For medical non-elective patients, the
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average length of stay was 8.2 days, which was worse
than the England average of 6.6 days. All delays were
monitored and audited to look for any reasons or trends
the trust could use for improvement.
Discharge delays, transfers and bed moves were all
monitored to ensure they did not negatively impact on
patients. The trust aimed to discharge or transfer
patients earlier in the day and so started discharge
planning as soon as possible. Of the patients
discharged, 29% left the hospital between 7am and
12pm.
The processes in place to ensure discharge from
hospital for those patients medically fit to leave were
not always effective. However, in the majority of cases
the reasons for the delays were not attributable to the
hospital. Some patients experienced a delay in
discharge as they were waiting for services to be put in
place to support them at home or in the community;
these services were outside of the hospital’s control.
The reasons for delayed discharges were audited by the
trust. In the year from August 2015 to August 2016 there
were between 33 and 60 patients per day awaiting
discharge each month. The reasons for delay included
the agreement of funding for care in the community,
patients waiting residential and nursing home
placement, patients awaiting non acute beds in local
hospitals, and access to homecare packages. There
were also delays caused by the process of families
viewing and selecting residential and nursing homes, as
well as patients awaiting access to assessment and
re-ablement services. Of the delays recorded by the
trust and provided to us, we could only identify seven
which were a result of the hospital’s processes. These
were due to delays in decisions being made by
multi-disciplinary care.
At the time of our inspection there were delays in
transfers of care or discharge for 70 patients who were
deemed medically fit for discharge. The hospital
provided a discharge ward where 18 beds were
occupied by patients who were ready to be discharged,
but were awaiting packages of care. There were a further
11 patients waiting on other wards for a bed on this
discharge ward. Of these 18 patients on the ward, 12
were waiting for nursing/residential home placements,
six were awaiting packages of care, and three were also
waiting funding. None were delayed as a result of the
hospital’s processes.
• The remaining 41 patients fit for discharge were located
across the hospital. Their location and status for
discharge was monitored by the bed management
team, to ensure the discharge process remained
ongoing.
• The trust continually monitored patient discharge data
to highlight any ways that discharge and transfer could
be made more efficient. Work to reduce
delayeddischarges continued as part of the emergency
access community wide resilience plan.
• The medical division used the hospital discharge lounge
to support earlier discharge from the wards and
appeared well used. There were between 25 and 30
patients per day who were discharged from the hospital
through the discharge lounge, with an average length of
stay in the lounge of around three hours. The lounge
was open from Monday to Friday from 8am to 8pm and
had a set of criteria for its use. There was no facility for
patients to lie down if needed. If there was any
deterioration in a patients’ condition, the patient would
be returned to the ward. Discharge lounge staff could
decline a patient transfer if they felt the discharge
lounge was not a suitable environment for that patient.
The lounge was staffed by a trained nurse and a health
care assistant. They were also supported by volunteer
staff. Hot meals and sandwiches were available
throughout the day.
• Transferring patents out of hours was avoided.
Transfers, whenever possible, took place between 8am
and 8pm to avoid disruption to patients and maintain
safe staffing levels. Although the trust did not advocate
the transfer of patients between wards out of hours,
there were occasions when this was unavoidable, and
patient transfers and discharges at night did take place.
If an out of hours transfer was required, a criterion must
have been met. Staff had a duty to report out of hours
transfers of patients with a learning disability or
dementia.
• There were systems in place to monitor the number of
times a patient had to move ward, with actions
implemented to try to reduce the number of times
patients were moved. Between August 2015 and July
2016, 31% of patients did not move wards during their
admission, and 69% moved once or more. The highest
amount of bed moves at night within the medical
division was on ward A400, the older person’s
assessment unit, which had between 14 and 28 moves
per month over the last six months. Staff told us this was
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because it was an assessment unit and not intended for
inpatient stay. The bed management team monitored
the number of moves and considered this when making
decisions to move patients. The bed management team
told us they tried wherever possible, to avoid
unnecessary moves.
The trust told us there had been no mixed sex breaches
on any wards within the trust. Staff told us mixed sex
breaches did occur, but had agreed timescales with the
local commissioners to ensure when they occurred, they
were afforded time to reorganise and move patients.
Not all patients had timely access to initial assessment,
diagnosis or urgent treatment due to increasing
demand on the service, particularly in cardiology.
Rheumatology exceeded the national standard.
Thoracic medicine, geriatric medicine and
gastroenterology almost met the national standard.
Specialties such as dermatology, cardiology and general
medicine did not always meet the national standard.
This meant that patients were not always seen within
the 18 week referral to treatment standards.
The referral to treatment time for cardiology patients
was significantly worse than the national standard.
Divisional managers told us cardiology referral to
treatment times were improving. The percentage of
cardiology patients receiving treatment within 18 weeks
between November 2015 and October 2016 was 61.9%.
This was below the England average of 85.3%. Delays
were attributed to a shortage of cardiology physiologists
and to increasing demand for the service at a local and
regional level, in particular for cardiac ablation services.
Divisional managers reported difficulties with access to
services across the south-west and with service
commissioning. We were told the 92% standard would
be met within the two months following our inspection,
based on the trend at the time.
The medical division had plans in place to minimise the
time people had to wait for their treatment or care. For
example, in dermatology as a result of rising demand in
the service a system wide strategy was in development.
This was being overseen by NHS Improvement, clinical
commissioning groups and the trust. Another example
is in haematology where plans were in place to increase
the number of beds by the beginning of 2017. Although
performing better than the England average, plans were
in place to increase capacity to further mitigate the risks
associated with demand.
• In order to manage capacity, a fourth catheter
laboratory opened in July 2016, with plans being
discussed for a fifth catheter laboratory. The service
extended its working day to offer increased sessions.
Due to recruitment issues with cardiac physiologists
there had been a focus on the development of existing
staff in order to manage capacity internally.
• In the cardiac catheter laboratories, a project was
underway to ensure all sessions were “starting on time”.
This ensured four extra patients per day received their
intervention and as such had increased capacity. Due to
the increasing levels of demand, and issues with the
recruitment of cardiac physiologists, risks flagged by
senior staff from the cardiac catheter laboratory related
to capacity within the service. The hospital had focused
on recruitment and on ways in which the department
could increase capacity, both in recent times and in the
future to ensure its service provision met the demand.
Senior staff within the department and at a divisional
level confirmed plans were being discussed to expand
the service further, to meet current and predicted
demand. Whilst some referral to treatment standards
currently exceeded the 18 week wait, we were informed
urgent patients were prioritised and were being seen
within days.
• Access to care was managed to take account of any
specific and urgent care needs. For example, the
hospital was part of a city-wide cancer performance
improvement plan and had worked on access to
services. A pathway mapping exercise was completed
whereby any breaches in standards were examined, and
actions taken to implement learning.
• The hospital provided an outreach service for acute
heart failure patients. This meant patients with heart
failure, who were being treated for other conditions on
medical wards, received care and treatment for this
condition. Staff were focused on meeting their care
needs and ensured patients received the input required
from allied health professionals, such as occupational or
physiotherapists, dieticians and social care input.
Meeting people’s individual needs
• The hospital took account of patients’ specific needs.
Translation services were available on each ward with
the use of a language telephone service and a translator
could be requested. Interpreters could be booked to
visit the ward. Staff confirmed this had happened and
had been successful. Family members were only used
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for translation if the issue was non-medical. We saw one
patient for whom English was not their first language.
The patient had a long treatment plan and had received
numerous interpreters at the hospital, to support in
understanding their care plan. The patient was happy
with their care and treatment.
All of the wards had accessible information leaflets in
different languages for patients to access regarding a
variety of medical conditions. We saw signage in
multiple languages and large print to ensure patients
could access the information they needed.
The needs of different patients were considered when
planning and delivering services and work had taken
place to deliver a dementia considered service. A visual
identification system was used for patients with a
cognitive impairment - a forget me not flower. This
highlighted the need for staff to adapt their
communication strategies and approaches to providing
care. The "All About Me" document was given to patients
and/or their carer to complete, to help staff provide as
individualised care as possible.
There was a dementia strategy implementation group
who formulated an action plan to develop the dementia
provision. The trust had a named consultant geriatrician
who was the lead for dementia and delirium. There was
a lead dementia practitioner in post together with a
dementia nurse practitioner and support worker. The
team was notified of admissions via the clinical alert
system. Referrals were made by agencies: for example,
the dementia well-being service, safeguarding team and
the later life mental health team.
The monthly audit for caring for patients with a
cognitive impairment care plan was introduced in 2014.
The medicine division was consistently compliant: the
numbers of patients with this care plan were
significantly higher than the other divisions, which
demonstrated the medicine division understood the
importance of delivering care for these patients.
The clinical alert system was used for patients with a
learning disability, Parkinson’s disease and known
carers. This meant teams and services were alerted
when these patients were admitted to, or attended the
hospital. This ensured the hospital provided timely
access to additional specialist support, review and
services.
Individual care needs and adjustments were put in
place. When individuals with learning disabilities were
referred to the learning disabilities team by carers or
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external providers (local authority), the learning
disability team was able to support pre-planned
admissions and make reasonable adjustments
according to identified needs.
For patients who were visually impaired individual care
needs and adjustments were put in place which
included adjusted cutlery, non-slip plates, assistance
with meal times and assistance with menu selection.
It was common for patients who were hard of hearing to
be put in a side room upon request, so they could have
their radio/TV on at a raised volume without upsetting
the other patients. The trust has been signed up to the
‘Deaf Health charter’ for the previous 18 years. This
charter details best practice standards which were used
to guide the practice standards and work of the link
nurses. We did not see this in practice but staff were
clear that support and assistance was available for
patients who were hard of hearing.
A new lounge was provided for patients undergoing
treatment in the cardiac catheter laboratories. Staff felt
this made patients more comfortable and helped
patients living with dementia to remain calm and
comfortable. There was seating, a fridge, a drinks
machine, a television, books and games available.
For patients with bariatric needs equipment was
available on request. The medical assessment unit had
bariatric equipment and could request a hoist. Staff on
the elderly care ward confirmed that should specific
hoist and stand aid equipment be needed, this was
accessed through the equipment store and
physiotherapy teams.
Most areas of the hospital were accessible for patients
with limited mobility or who used mobility aids.
Disabled toilets were available for patients and visitors.
Wards had access to single rooms which staff told us
they moved patients to where appropriate, to ensure
they were able to meet patients’ specific needs.
For those patients who were homeless and rough
sleeping, if staff considered them to be at risk due to
their health on discharge, staff would contact the social
worker on call or contact the local hostel to ensure
patient safety.
Patients’ spiritual and religious needs were provided for.
Staff knew how to contact the appropriate chaplaincy
lead. There was a multi faith prayer room available in
the hospital. The chapel in the hospital building was
closed in July 2016 for ongoing refurbishment work, but
an alternative room was provided.
Medicalcare
Medical care (including older people’s care)
• The trust appointed a wellbeing coordinator in the
teenager and young adult ward and developed the
concept of a “wellbeing pathway”. This integrated a
holistic needs assessment at diagnosis and during
treatment, with an end of treatment reassessment and
ongoing support during the “living with and beyond
cancer” phase of care. This approach meant young
people with cancer had their complex, physical and
emotional needs individually assessed and support and
resources were offered for longer term
self-management.
• The cancer support service provided a friendly,
confidential service where patients affected by cancer
could talk to someone in person or on the telephone.
Other services and workshops available provided
practical guidance with tying headscarves, hats and
wigs, as well as make up workshops and massage or
creative writing.
• Some patients told us sometimes they had little to
entertain themselves with, as not all patients had access
to TV and Wi-Fi. This varied from ward to ward. Some
patients had access to free television and radio systems,
and books which included books in large print. A day
room was available on wards with access to water.
These rooms were also used for private conversations.
• Patients told us when they used the call bell staff came
quickly. The hospital monitored patient satisfaction
which included monitoring call bell response times. We
observed when call bells were rang, staff responded
promptly.
Learning from complaints and concerns
• Complaints were handled in accordance with trust
policy. Between February 2016 and August 2016 there
were 96 complaints about medical care provision at the
hospital. This was by division, the highest amount of
complaints across all divisions in the hospital. The
hospital took an average of 24.7 days to investigate and
close these complaints. Timescales for resolution of
complaints was 30 working days according to the
hospitals policy, and were confirmed as part of
individual local resolution plans. We reviewed the
complaints information and saw there was a range of
themes which included attitude and communication by
staff, cancelled appointments and delays for treatment.
For each complaint there was a description and action,
with a resulting outcome recorded.
• Patients told us they felt comfortable to raise a
complaint with staff, or would contact the hospital
following discharge.
• Staff told us that on receipt of any complaint, they
would endeavour to resolve it on the ward, but would
also provide patients with information on how to
formalise their complaint.
• Notice boards on wards displayed examples of how they
had responded to patient complaints or concerns. For
example, on the coronary care unit, staff took action to
reduce the level of machinery noise on the ward in
response to a complaint.
Are medical care services well-led?
Good
–––
We rated well-led as good because:
• There was a clear, overarching statement of vision and
values for the medicine service, which was driven by
safety and quality. The medicine division and
specialised services divisions’ vision and strategies were
developed within the context of this. Staff understood
the vision and strategy and their role in in delivering it.
They were proud to work for the hospital and patient
focused. Staff demonstrated a kind culture, both to
patients and relatives, and to each other.
• Governance structures were complex to follow.
However, the board and other levels of governance
within the hospital functioned effectively and interacted
well. Staff assured us risk was escalated when needed
and the information communicated to the hospital
board flowed well. Processes were in place to monitor,
address and manage current and future risk.
Performance issues and concerns were escalated to the
relevant committees and board.
• Leaders understood the challenges to good quality care
within and outside the organisation, and there were
collaborative relationships with stakeholders.
• Staff felt leadership was good and divisional lead staff
were accessible. Staff told us they felt supported and
heard, and there was a collective culture of openness to
drive quality and improvement. Leaders and staff
demonstrated the participation and involvement of
patients who used the service was important to them.
72 University Hospitals Bristol Main Site Quality Report 02/03/2017
Medicalcare
Medical care (including older people’s care)
• The hospital had forged strong links and worked closely
with the voluntary sector. There were over 400
volunteers assisting at the hospital.
• Leaders demonstrated a drive for continuous learning
and improvement through the ongoing evaluation and
monitoring of the service and by delivering projects and
innovative developments aligned to this.
However:
• The management of risk did not protect staff on the
hepatology ward. Senior staff were aware of risks for
patients and staff when accompanying patients off the
ward at night who wanted to smoke, but had not put the
required processes in place to mitigate the risk and
ensure safety.
• The management and governance of current
performance of staff mandatory training did not ensure
all staff were fully training. For medical staff, this
included fire, safeguarding and resuscitation training.
• The division had recognised a risk in the acute oncology
service at night, concerning both staffing levels and a
lack of suitably skilled triage staff. However, sufficient
action was required to minimise the risk to patients in
both the service provision and staffing provision.
• Divisional managers articulated the haematology and
oncology strategy was focused on the capacity and
capability to cope with increasing demand, through the
number of beds, staffing and skill mix. They aimed to
expand the research element through clinical trials to
ensure access and use of the best medicines and
treatments, being a regional centre. Additionally, the
vision was to improve patient experience through the
refurbishment of the oncology ward environment and
by working with a buddy hospital.
• The vision for cardiology services was to expand the
service, offer new innovative treatments and technology
and to play a constructive role in cardiology service
development and sustainability within the region.
• Staff we spoke with across all areas of the hospital
demonstrated their understanding of the trust’s vision
and strategy. Staff were aware of ways in which the
service aimed to achieve the vision, drive quality, safety
and patient experience.
• The organisation proactively engaged and involved staff
in the strategic development of the service. Staff told us
their views were considered and staff embraced change
in order to improve patient care.
Governance, risk management and quality
measurement
Vision and strategy for this service
• The trust had developed a quality strategy for 20162020 for the overarching medical service, which
incorporated medicine and the specialised services
divisions. Specialised services included cardiology at
the Bristol Heart Institute (BHI), and oncology and
haematology at the Bristol Haematology and Oncology
Centre (BHOC). Strategic development focused on
working collaboratively with stakeholders to deliver of
high quality local, regional and tertiary services, to
develop and expand specialist services, and to deliver
excellent care with compassion.
• The purpose of the quality strategy was to articulate the
trust ambitions for quality in a way that was meaningful.
It served as a statement of intent that patients, carers,
staff, commissioners and other stakeholders could use
and to hold the trust board to account, for the delivery
of high quality services. Whilst specialised services had
their own strategies and key priorities, they were set in
the context of the overall medical service strategy.
Divisional managers reported there was consistency
between the clinical divisions within the medical
service, and the trust’s strategy.
• Governance structures were complex to follow.
However, the board and other levels of governance
within the medicine and specialised services divisions
functioned effectively and interacted well.
• The divisional management of both the medicine and
specialised services divisions varied in their
construction and had different governance pathways.
Within medicine services, both the medicine and
specialised services divisions reported to a divisional
level board. This board reported to the divisional
directors, clinical chair and to the senior leadership
team at trust board level. Whilst it was difficult to
understand how the services were aligned, staff did not
raise concerns in relation to this. However, we were told
proposals for changes to this were made to the board in
the month prior to the inspection, which had not at that
time been approved.
• Governance frameworks and management systems
were reviewed and evaluated regularly. The trust
commissioned an independent review of governance
which included the medicine division. This report
recognised governance for elective and non-elective
73 University Hospitals Bristol Main Site Quality Report 02/03/2017
Medicalcare
Medical care (including older people’s care)
•
•
•
•
care was difficult to follow. During the inspection, we
recognised because there were several specialties, all
with their own governance arrangements, it was
complex and sometimes difficult to review as a whole.
However, we found there were effective governance
frameworks in place overall, which supported the
delivery of the strategy and good quality care.
Information travelled from ward to divisional and trust
boards, and back again. Risks were identified and plans
put in place to address those risks. Staff felt confident to
raise risks and received learning from wider trust issues.
The medicine division floor to board tool was put in
place to enable front line ward and departmental issues
to be raised. Ward sisters/managers reported the
quality, safety and experience of their patients to the
divisional board, and upwards to the trust board. The
tool was laid out using the CQC Fundamental Standards
and replaced the previous outcome based framework
used.
There were comprehensive assurance systems, which
measured quality, effectiveness, safety and risk. The
trust undertook a patient safety and clinical risk report
quarterly. This identified issues arising from patient
safety incidents reported during the quarter, and
provided an analysis by harm, risk and cause. The
quarter’s data was placed in context with previous
quarters to identify trends. Divisional managers told us
they reviewed quality and safety performance regularly
and reviewed and set priorities for their respective
services each year.
Governance arrangements supported quality and safety
across all areas of the division. For example, specialised
services provided by the Bristol Haematology and
Oncology Centre and the Bristol Heart Institute each had
levels of clinical and information governance that
flowed across the two sites. Matrons across all areas of
the hospital met monthly and shared ideas across the
divisions. Initiatives were instigated and rolled out
hospital wide, such as mini teaching sessions for staff
with a focus on improving quality of care and patient
safety. There was a focus on nutrition in the month of
September 2016 and on cognitive impairment during
October 2016.
There were separate, specialised services and medicine
divisional, clinical governance and risk management
meetings which fed into the divisional and trust boards.
We saw risks were reviewed monthly, and included
investigations of serious incidents and route cause
•
•
•
•
•
74 University Hospitals Bristol Main Site Quality Report 02/03/2017
investigations. This meant any risks of concern could be
flagged to the divisional and trust board and addressed
at monthly management meetings and shared across
the hospital.
The risk registers for the hospital were extensive and it
was clear to follow how risks were being reviewed and
managed. Staff took action to improve performance as a
result, and risks within the hospital matched those
highlighted on the division’s risk registers. For example,
the trust wide risk register noted a risk of information
governance breaches, leading to a breach in patient
confidentiality. There was a risk staff who had not
undertaken information governance electronic learning
training may not be fully aware of their responsibilities
under the Data Protection Act. This was rated as a
moderate risk and actions were put in place to address
this, such as distributing messages to raise awareness of
training through payslips, and to monitor the monthly
uptake of e-learning to improve compliance rates.
Through effective governance review processes, staff felt
the board executives had an improved understanding of
falls, and had both questioned data and presented
challenges. There was an executive lead for falls in
place. A focus on falls management was developed with
a falls lead and falls champions in all areas of the
hospital. Staff received further education and training in
falls to ensure skills were orientated to this and
awareness increased.
Staff in the cardiac catheter laboratory used a World
Health Organisation (WHO) surgical safety checklist for
all surgical procedures. The WHO surgical safety
checklist aims to decrease errors and adverse events,
and increase teamwork and communication in surgery.
However, we identified a gap in monitoring that this was
implemented. Staff told us checklist records were not
audited to ensure they were all fully completed.
Since our last inspection in 2014, managers within the
medicine division said the flow of patients through the
hospital remained a risk, but felt this was being well
mitigated. Concern remained in relation to capacity in
the community, which impacted upon their ability to
discharge patients from the hospital. As such, work was
being undertaken to address this externally, with
stakeholders in primary and social care and strategic
health improvement plans within the south-west region.
Divisional managers told us ward layouts were changed
in order to make them safer. For example, in order to
reduce violence and aggression in hepatology, patients
Medicalcare
Medical care (including older people’s care)
were placed in one, two or four bedded bays, which
provided a quieter and calmer environment. However,
we visited this ward at night during the unannounced
inspection and did not find it to be calm or quiet. We
also identified concerns about the management of risk
on the hepatology ward in relation to lone working
practices when accompanying patients off the ward at
night who wanted to smoke. We raised this with the
trust who agreed to implement a process written risk
assessments to assure this risk was reduced.
• The trust risk register recorded a moderate risk of
medicines errors because of the risk of the medicines
policy not being understood. A medicine safety officer
sub group reviewed medicines errors. This audit
reviewed themes and identified learning. All of the
reports went to the quality and safety group for their
review.
• Management and staff were aware of the risk of the
increasing demand for haematology, which was said to
be reflective of the national picture. Plans were in place
to increase the number of available beds in order to
address this. Staff turnover and skill mix in haematology
was identified as a risk and was being addressed
through recent recruitment initiatives. We were told they
were on target to reach full capacity by the beginning of
2017. This would also permit the three, currently
unfunded beds on this ward to be opened permanently,
as per the operational plan. The divisional managers
also reported a plan was in place to address the skill mix
in haematology.
• At the time of the inspection, there were concerns raised
by a number of senior staff on the oncology and
haematology wards relating to staffing and skill mix at
night for acute oncology patients. We were provided
with assurance that a plan to address concerns about
the skill mix of nursing staff at night was being
considered. The increased demand seen in the month
prior to the inspection was being discussed at ward
level, and by senior nursing staff within clinical
governance and risk meetings, at the time of the
inspection. This provided further assurance the risk was
being mitigated. We reviewed the November 2016
clinical governance meeting minutes and saw these
issues were being reviewed and monitored closely, and
consideration was being given as to whether the risk
related to service provision and or staffing provision.
Work on staffing recruitment and retention on the
teenagers and young adults’ oncology area was also
ongoing.
• Managers and senior staff both demonstrated and told
us they understood the challenges to delivering high
quality care. Actions within and outside the organisation
were taken to address them. For example, in the
teenagers and young adults ward, there were clear,
collaborative relationships with other acute trusts
within the region and with national and regional
charitable organisations, in order to drive the quality of
the service and patient and carer experience.
Leadership of service
• Staff felt leadership was good and divisional lead staff
were accessible. Staff told us they felt supported and
heard, and there was a collective culture of openness to
drive quality and improvement.
• Staff knew who their leaders were within the division.
Not all staff were aware of the executive team but said
they received weekly emails from executive staff which
contained updates about the wider hospital. New staff
told us the chief executive was present during part of
their induction, where staff were able to ask questions.
• A matron and head of nursing told us on alternate
Tuesdays, they worked on the wards in a clinical role.
We asked staff from a number of wards, but none were
able to confirm having seen this.
• Matrons and ward managers spoke positively about
leadership of the trust and felt supported and listened
to. They told us divisional managers were visible and
approachable.
• We spoke with junior nursing staff and student nurses
who told us they felt supported by senior staff. We were
given examples when work on wards was stressful,
senior staff had supported the junior staff.
• We saw and staff told us, leaders encouraged
appreciative, supportive relationships among staff. For
example, on the oncology ward, senior nurses were
seen to be very supportive of staff during times of
emotional distress caused by the death of a patient.
They continually checked on staff throughout the day
and ensured they took breaks, or were offered the
opportunity to seek support if needed. Some staff had
taken temporary career breaks and worked in other
areas of the hospital, before returning to work on these
wards a year or so later.
75 University Hospitals Bristol Main Site Quality Report 02/03/2017
Medicalcare
Medical care (including older people’s care)
• There were strong social networks between younger
staff in oncology and haematology which senior staff
encouraged, as they recognised the importance of the
support this provided, particularly during times of
emotional distress due to the nature of the disease area.
Culture within the service
• The culture within the hospital was focused on the
needs and experiences of those who used the service
and those close to them. We found staff were proud to
work at the hospital and we saw staff demonstrate a
kindness culture, both to patients and relatives but also
to each other. We saw staff across all departments
worked together to encompass the values of the
hospital.
• Staff spoke of an open culture which was focused on
delivering safety and quality. They felt success was
celebrated at all levels.
• There was a culture of supporting staff and focusing on
staff’s wellbeing. Staff were able to access psychological
support where needed. This was an initiative that was
introduced as a result of feedback from a staff
champions meeting. In the cardiac catheter laboratory,
some staff practiced Tai Chi prior to a shift, led by a
member of staff on the unit. Mindfulness sessions were
available to staff in the BHOC. Mindfulness practices are
described as a way of paying attention to, and seeing
clearly what is happening around us, and promotes
wellbeing.
• We were told by some junior doctors they needed a
greater consistency of junior doctor cover to enable a
sustainable service. They felt this would enable
improved learning opportunities for junior doctors.
• However, there were some concerns raised about
development and training opportunities. Several band
two and three staff explained they did not feel there was
a development strategy for them. The band two staff felt
there was a lack development potential to progress to
band three. Nursing staff told us training in general was
not given sufficient priority to ensure it was completed
as required. Staff felt other pressures impacted upon
their time allocated for such training, which in turn, gave
line managers cause to raise completion rates with
them.
• There was a strong ethos of teamwork and staff felt very
well supported. Staff were very complimentary about
line managers and the leadership within the divisions.
Public engagement
• The hospital had forged strong links and worked closely
with the voluntary sector. There were many examples of
where patients, carers and charities had worked with
the hospital to raise fund to improve services.
• The hospital had in excess of 400 volunteers who
medical and nursing staff told us went ‘above and
beyond’ to help staff and patients. There was a range of
volunteers across the hospital from people who took
trolleys from ward to ward selling snacks and
confectionary, to those who offered emotional support
to patients and families. We observed volunteers on
medical wards and in the discharge lounge. They
provided conversation and support to patients and staff
told us they were a valuable asset to the hospital.
• Leaders and staff demonstrated the participation and
involvement of patients who used the service was
important to them. Patients were encouraged to raise
concerns with staff when they occurred, and to
complete the friends and family survey to ensure they
gathered the views of those who used the service. We
saw on wards across the hospital, display boards which
showed results from the friends and family test. Staff
told us they encouraged patients to complete these or
to provide feedback that would be listened to. We saw
examples around the hospital where feedback had been
provided and action taken, using the ‘you said, we did’
format adopted by many NHS hospitals nationally.
• The stroke specialist nursing team had provided
teaching into the community. They had spoken with
neighbourhood watch groups, police and had spoken
on the local radio to provide learning about the stroke
services.
• The hospital rolled out initiatives to engage young
patients with health conditions, such as congenital
heart disease. Young patients on the teenagers and
young adults’ oncology ward were engaged in the
development of services to improve care and adherence
to treatment whilst on the ward. Projects included social
media and IT, to work collaboratively to develop the
content, design and functionality of an on-line
emotional support website and an IT-based holistic,
needs assessment tool.
Staff engagement
• The trust demonstrated it valued and encouraged staff
to raise concerns. A ‘Happy App’ was developed
76 University Hospitals Bristol Main Site Quality Report 02/03/2017
Medicalcare
Medical care (including older people’s care)
•
•
•
•
•
•
whereby staff flagged and recorded any issues or
comments on an electronic tablet device, in order for
senior staff to respond. However, for this initiative, the
staff’s view of the ‘Happy App’ varied, with some liking
the ability to record a concern or comment. Some staff
told us they felt this was not always effective and a face
to face meeting would have been better. We noted the
‘Happy App’ comments on some wards were mostly red,
an indicator of a negative comment.
Staff had recently all received a small, laminated card
advising them of uniform protocol and the guidelines
for wearing staff uniform. Staff told us their views on this
card varied with some staff feeling this was an
unnecessary expenditure.
A staff suggestion box had been added on ward A605,
for staff to place comments in. We did not find any
comments at that time.
The hospital produced a ‘Voices’ magazine, for its staff
and the December 2015 copy included the recognising
success awards. Members of the medical and
specialised services division were recognised. Amongst
those receiving recognition were nurse specialists, the
trust falls steering group, the cardiac catheter
laboratories team and the older persons assessment
unit.
The trust recognised individual departments through a
nomination and award scheme. For example, staff in the
cardiac catheter laboratories had won ‘team of the year’
in 2016 for embodying the values of the trust. Matron for
the cardiac catheter laboratory spoke incredibly highly
about the teamwork, skills and commitment of staff
within the department.
In May 2016 the assessment medical unit won a nursing
and midwifery award for sustained standards of care
delivery during a structural and staff change.
We saw on ward C808 student nurses had a notice
board with details of mentoring. Some student nurses
had written cards of thanks to staff for their time on the
ward. These cards were extremely complimentary about
the support they had received from the ward staff.
Innovation, improvement and sustainability
•
•
•
•
•
•
• Leaders demonstrated a drive for continuous learning
and improvement through the ongoing evaluation and
monitoring of the service and by delivering projects and
77 University Hospitals Bristol Main Site Quality Report 02/03/2017
developments aligned to this. We heard many examples
from managers and staff that innovation was
encouraged. There were a wide number of innovations
and initiatives within the hospital.
The ‘Eyes on Legs’ project was implemented and
training for staff was being delivered in relation to falls
management. It was introduced into all mandatory
training. The ‘Eyes on Legs’ project worked on the
principle that everybody was responsible to drive
accident prevention.
The trust told us they had been piloting the use of iPads
for patients living with dementia. Staff were trained by a
group called ‘Alive’ to understand how to use them with
patients.
There were plans in place to ensure the sustainability of
high quality services to patients locally and within the
wider region. An arrhythmia nurse-led outreach service
into the emergency department and medical
assessment unit was planned to start in the New Year
(2017).
Two cardiologists were employed by the Bristol Heart
Institute as part of a team of three consultants at a local
district general hospital. This ensured a more locally
accessible service was provided to the wider population
within the region.
Patients on the teenage and young adults cancer ward
were provided with access to an IT-based integrated
assessment map, to capture the patients’ needs across
ten different domains of a young person’s life, at the
time of transition between child and adult services. It
helped staff and patients to identify and discuss
individualised needs, plan how these could be
addressed and evaluate how these were being met. The
teenage and young adults Cancer South West Integrated
Assessment Map (IAM) Portal Project used a novel
method of undertaking a holistic needs assessment,
considering all aspects of the patients’ complex needs.
This was made accessible to patients via a website and
more recently, through the development of an app for
use with mobile devices.
Staff in the teenagers and young adult cancer service
continually developed the service and sought funding
and support from charities and organisations, in order
to make demonstrable improvements to the quality of
the service and to the lives of patients diagnosed with
cancer. They had worked collaboratively on a number of
initiatives. One such project spanned a five year period
ending May 2015 for which some of the initiatives were
Medicalcare
Medical care (including older people’s care)
ongoing. The project involved input from patients, their
families and social networks, and healthcare
professionals involved in their care. It focused on key
areas which included: psychological support, physical
wellbeing, work/employment, and the needs of those in
a patients’ network.
• Rapid access care of the elderly clinics were established
as a way of avoiding admissions to hospital where
possible. Divisional leaders informed us they planned to
increase this service. However, further recruitment of
consultants would be required to enable this to happen.
• The trust launched a virtual ward service with a third
party provider in July 2016. The virtual ward specialised
in caring for acute patients in their own home through a
virtual ward model. The service was available over 24
hours 365 days of the year. It provided patients with the
same high-quality level of safe and professional care
they would receive in hospital, delivered in the comfort
of their own home or place of residence. Since the
launch, 113 patients had been cared for within the
service consuming 827 bed-days (until end September
2016). The virtual ward had been increasing their virtual
in-patient capacity over the last 3 months and at the
time of the inspection, were caring for approximately 20
patients at a time, in their own home environment. At
present they could accept up to 25 patients. By January
2017, it was planned that the virtual ward would care for
up to 35 patients at a time with the virtual ward model.
• A number of new, innovative cardiology procedures
were made available to patients at the hospital. For
example, in 2015, the Bristol Heart Institute secured
funding to offer a procedure to patients suffering from
breathlessness and tiredness, due a leak in their mitral
heart valve. The procedure was offered to seriously ill
patients for whom open heart surgery would have
proved high risk, due to co-existing health conditions.
The unit was one of three hospitals selected to offer the
procedure through NHS England’s commissioning
through evaluation programme.
• The trust implemented new technology in the oncology
centre called the Icon Gamma Knife, in July 2015. This
permitted the staff to develop innovative new treatment
techniques for patients with a variety of conditions. The
trust told us the technology meant patients received
safer, effective treatment, with fewer side effects or the
need for supplementary medicines, than traditional
treatments. For those who were in a palliative phase of
life, it achieved tumour control without neurosurgery.
The trust was the first in the UK to use this regime. For
patients with benign tumours adjacent to critical
organs, the team were the first in the world to develop a
technique, where treatment resulted in a clinically and
statistically significant reduction in the normal brain
being treated. It was believed the technique should
reduce the risk of side effects in later life, whilst
maintaining at least equivalent tumour control.
• The trust informed us more than 100 patients with
advanced prostate cancer were treated with a
pioneering radium treatment for advanced prostate
cancer, which extended life expectancy. They were one
of the first in the country to use the treatment, which
treated prostate cancer with bony metastases
(secondary malignant growths in bone). Staff injected
patients with the treatment, which delivered radiation,
provided pain relief and extended life expectancy. Men
received six injections in total, every four weeks, which
took only a few minutes to administer, and had minimal
side effects. The Bristol Haematology and Oncology
Centre was one of the first centres to start offering this
treatment regularly on the NHS starting in February
2014, following a successful trial. The team had helped
14 other centres across the country establish this
service. This method allowed for patients to receive
prompt care and a reduced number of hospital visits.
78 University Hospitals Bristol Main Site Quality Report 02/03/2017
Surgery
Surgery
Safe
Good
–––
Effective
Good
–––
Caring
Outstanding
Responsive
–––
Well-led
Outstanding
–
Overall
Outstanding
–
Information about the service
Surgery services at University Hospitals Bristol NHS
Foundation Trust were delivered from five of the seven
hospitals which make up University Hospitals Bristol main
site. These were:
•
•
•
•
•
Good
–
The Bristol Royal Infirmary
The Bristol Heart Institute
The Bristol Eye Hospital
University of Bristol School of Oral & Dental Sciences
St Michael’s Hospital
Adult theatres and recovery, known as Hey Groves, were
based in the Bristol Royal Infirmary and included ten
theatres and nine recovery beds. The Bristol Heart Institute
was co-located within The Bristol Royal Infirmary and
utilises the Hey Groves theatres. The Queens Day Unit was
also within the Bristol Royal Infirmary and included two
theatres and four recovery beds. Endoscopy was
co-located within the Queens Day Unit and included four
rooms and two second stage recovery areas (male and
female). In the Bristol Royal Infirmary there were 6 wards
and 147 beds. In addition, there were 8 chairs on STAU for
ambulatory attendances. The Bristol Eye Hospital had four
theatres and three recovery beds and two wards with 28
beds. Eleven of these beds were inpatient beds (on
Gloucester Ward) with the remaining 17 on a day case
ward. The University of Bristol School of Oral & Dental
Sciences had one day case theatre and four day case beds.
Surgery services were also provided at St Michael’s Hospital
(on the Bristol Royal Infirmary main site) and South Bristol
Community Hospital. In St Michael’s Hospital three theatres
were dedicated to gynaecological surgical procedures and
two were dedicated to obstetric surgical procedures. At
South Bristol Community Hospital there were two day case
theatres and an endoscopy service. However, we did not
inspect these services during this inspection.
Adult surgery was based within the Surgical Head & Neck
division and was divided into eight services. These were
anaesthetics, dental, ear nose and throat & thoracic, eye,
gastrointestinal, intensive care, theatres, and trauma and
orthopaedics). Although critical care was within the
Surgical Head & Neck division we did not inspect this
service during this inspection. Cardiac services were based
within the specialised services division.
During the reporting period (April 2015 to March 2016) there
were a total of 27,751 surgical spells across the whole of the
trust. There were 23,769 surgical spells for the areas we
inspected.
During the last inspection visit between 10 September 2014
and 12 September 2014 and unannounced inspection on
21 September 2014 we rated surgical services as requires
improvement for safe, effective, responsive and well led,
with caring being rated as good. Compliance actions were
issued based on breaches found of the Health and Social
Care Act 2008 (Regulated Activities) Regulations 2010.
Breaches in the regulations included regulation 9 (for
discharge planning), regulation 13 (for medicines
management), regulation 14 (for meeting patients
nutritional needs), regulation 17 (for patients staying
overnight in recovery without adequate privacy and
dignity), and regulation 22 (for insufficient staffing),
79 University Hospitals Bristol Main Site Quality Report 02/03/2017
Surgery
Surgery
During our announced inspection between 22 November
2016 and 24 November 2016, we visited the University of
Bristol School of Oral & Dental Sciences and two wards at
the Bristol Eye Hospital. At the Bristol Royal Infirmary we
visited the Hey Groves and Queens Day Unit theatres
(including endoscopy) and their recovery areas. We visited
five wards in the Bristol Royal Infirmary, the discharge
lounge, the surgical and trauma assessment unit and two
wards in the Bristol Heart Institute.
We spoke 67 staff, 30 patients and their relatives and
looked in nine sets of patient records. We performed an
unannounced inspection in the evening of 1 December
2016 and revisited a ward and revisited the surgical trauma
assessment unit. During this time, we spoke with an
additional four members of staff and four patients.
80 University Hospitals Bristol Main Site Quality Report 02/03/2017
Summary of findings
We rated surgery services as outstanding because:
• There was a good culture of incident identification,
reporting, investigation, and sharing of learning
throughout the surgical division. There were many
examples shared with inspectors of learning from
incidents both in their own area and from the wider
trust.
• Staffing levels were good with only occasional use of
agency staff. Where there were shortages of staff
there was a quick response to rectify this. This
resulted in safe staff management and handover
from staff to manage risks.
• Risks were managed and responded to effectively
both on the wards and in theatre. We saw examples
of the World Health Organisation surgical safety
checklist being utilised effectively to keep patients
safe. Learning from a never event was fully integrated
into the surgical safety checklist. On the wards we
saw comprehensive risk assessments, which
included physical and mental health, to ensure the
safe care and treatment of patients.
• Mortality rates were better than the England
average. Patient outcomes were recorded and
audited. For example, the trust performed well on
the bowel cancer audit, and there was demonstrable
improvement in the national emergency laparotomy
audit.
• Staff worked effectively together as a
multidisciplinary team and worked together in a
coordinated way for the patients best interests. This
included working between teams and services.
• Feedback from patients and their families was
consistently very positive. Patients we met spoke
positively of the service they received and of the
compassion, kindness and caring of all staff. Staff
ensured patients experienced dignified and
respectful care. Relative of patients were fully
involved in patient care and the staff ensured that
strong relationships were built to ensure a high
quality of care.
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• Friends and family results were always positive and
response rates were better than the national
average. We saw many examples of person-centred
care which had a positive impact on patients’
wellbeing.
• Although slightly limited, reasonable adjustments
were made for patients living with dementia or with
learning difficulties including use of the ‘this is me’
document and patient access to activities.
• Leadership in the trusts surgical services was
enthusiastic and staff were motivated to succeed. We
found the strategy for the division was clear and had
supporting objectives which were challenging,
supportive and innovative. A strong governance
structure aided managers to proactively review
performance and risks and were reviewed to reflect
best practice.
• We saw an innovate method of engaging staff
through the use of the ‘Happy App’ and proactive
engagement with staff. We found because of this the
culture of engagement had developed to be positive.
Staff were proud to work at the hospital.
However:
• Not all staff within the surgical service had received
recent mandatory training to keep patients safe.
There were a number of staff who had not completed
all of the required training for resuscitation,
safeguarding, fire, manual handling and infection
control.
• Outcomes could have been improved for the
national hip audit. However, the service provided at
this trust was relatively small compared to other
trusts of a similar size.
• The service was planned and delivered in a way
which met patient’s needs. However, some patients
had long waiting times to have their surgical
procedure. This was particularly apparent in the cleft
palate service and the dental service.
Are surgery services safe?
Good
–––
We rated this service as good for safe because:
• Safety performance showed a good track record and
steady improvements. When something went wrong
there were thorough investigations were carried out.
Lessons were learnt and communicated widely to staff,
to support improvement in other areas as well as
services which were directly affected.
• When something did go wrong patients received a
sincere and timely apology in line with duty of candour
regardless of meeting the duty of candour threshold.
This was recorded in patient records.
• There were clearly defined systems, processes and
standard operating procedures to keep patients safe
and safeguarded from abuse. We were given multiple
examples by staff where they had taken steps to prevent
abuse from occurring, and responding to any signs or
allegations of abuse and worked with the safeguarding
team and the local authority to ensure patients were
protected.
• Staffing levels and skill mix were planned, implemented
and reviewed to keep patients safe at all times. The use
of bank and agency staff was low. Any staff shortages
were responded to quickly and adequately. There were
effective handovers and shift changes, to ensure staff
can manage risks to patients who use services.
• Patient records showed risks to patients were assessed,
monitored and managed on a day to day basis,
including the identification of deteriorating health. We
saw good use of the World Health Organizations safer
surgery checklist. We found staff were fully engaged with
this and it was conducted appropriately.
• Standards of cleanliness and hygiene were well
maintained. Wards were visibly clean and there were
records to evidence regular cleaning and
decontamination.
However:
• Not all staff had received up to date training in all safety
systems. Compliance rates for mandatory training were
below the trust’s 90% target for medics and dentists and
administrative staff. However, nursing and allied health
professional staff were above the target.
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Incidents
• Staff understood their responsibilities to raise concerns,
to record safety incidents, concerns and near misses
and report them. All staff we spoke with were clear
about the processes involved when reporting an
incident and were confident to do so. Between
September 2015 and August 2016 there had been an
increase in the number of incidents reported (from 6.5
incidents per 100 patients to 7 incidents per 100
patients) and a decrease in the number of serious
incidents reported. This indicated an improving safety
reporting culture.
• The safety performance over time was good and
surgical services performed well compared to similar
services in other trusts. Between October 2015 and
September 2016 there was one incident classified as a
never event. Never events are serious incidents that are
wholly preventable, where guidance or safety
recommendations that provide strong systematic
protective barriers are available at a national level, and
should have been implemented. A specimen meant for
transfer to histology was left in a patient in a bag. The
route cause analysis and learning from the never event
were ongoing at the time of our inspection. Immediate
additional safety checking systems were implemented
and integrated into the World Health Organisation safer
surgery checklist to ensure all histology samples were
removed from theatre prior to finishing the operation.
• In accordance with the Serious Incident Framework
2015, surgical services reported nine serious incidents,
which met the reporting criteria set by NHS England
between October 2015 and September 2016. Of these
the most common type of incident reported was
sub-optimal care of a deteriorating patient, falls,
surgical incidents, pressure ulcer, and diagnostic
incidents. In response to the increased incidents in the
care of the deteriorating patient, a project team was put
together to investigate, the results of which highlighted
further training was required. During the inspection we
saw scheduled training sessions for staff to attend.
• When things went wrong, thorough investigations were
carried out in a timely way and all relevant staff and
patients were involved in the investigation. Between
April 2016 and August 2016 there had been two serious
incidents reported. Both of these had a 72 hour
investigation report and a root cause analysis
completed within the correct timescale. Examples of
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82 University Hospitals Bristol Main Site Quality Report 02/03/2017
root cause analysis seen were completed to a high
standard. There were comprehensive action plans
which included immediate and medium term
recommendations. Recommended learning was
identified and disseminated as identified.
Some incidents occurred on the wards had a post
incident debriefing known as a ‘SWARM’. A SWARM was
initiated as soon as possible after an adverse or
undesirable event has occurred. This allowed staff to
discuss the issues and to share immediate learning and
would be used in conjunction with the trust incident
reporting policy.
Lessons were learnt and action was taken as a result of
investigations. In theatres changes had been made to
insulin packs as a result of the learning identified
following the investigation of a near miss (a near miss is
an incident which was picked up before harm was
caused). This included storing insulin packs in theatre
fridges along with a laminated information sheet and
guidelines for drawing up the insulin. Departmental
training and a trust-wide safety bulletin was also put in
place.
Learning was shared to make sure action was taken to
improve safety beyond the effected team or service.
Staff we spoke with said they received feedback and
individual learning from incidents. Minutes of local team
meetings demonstrated sharing of learning between
departments and services. These were supported by
using posters and newsletters. ‘Learning after Significant
Event Recommendations’ (LASER) leaflets were in
circulation and were displayed on ward notice boards.
Examples of these included an incident involving an air
embolism and an incident involving the non-detection
of raised blood ketones. These leaflets had information
on the patient story, learning from the root cause
analysis and a list of recommendations. Other leaflets
included the ‘Governance Grapevine’, which was
released monthly within the division and shared
divisional wide messages on incidents.
Learning sessions were also put in place on wards to
reinforce the lessons learnt from incidents and to give
staff the opportunity to ask questions.
Staff gave us multiple examples of learning from
incidents and how practice had changed on their own
ward, and in the wider directorate.
Multi-professional surgical mortality and morbidity
reviews were held regularly. Learning was shared at
these meetings and was then disseminated through
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clinical educational sessions and team meetings. We
saw multiple examples where the learning taken had fed
into service improvement, including changes to
processes. Where concerns were raised investigations
were carried out to improve the service. For example, as
a result of mortality data around the fractured neck of
femur service The British Orthopaedic Association was
asked to review the data and produce
recommendations.
Duty of Candour
• Regulation 20 of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014 is a regulation
which was introduced in November 2014. This
Regulation requires the trust to be open and
transparent with a patient when things go wrong in
relation to their care and the patient suffers harm or
could suffer harm which falls into defined thresholds.
Staff at all levels in the service had a good
understanding of the duty of candour and could
describe when it would be used.
• Incident reports seen showed adherence to the duty of
candour regulation, including processes and evidenced
written apologies. There was a check list within the root
cause analysis process which ensured the duty of
candour was considered. This had to be completed
within ten days of the reported incident to ensure the
patient and family were involved and apologised to at
the earliest opportunity. We saw evidence this was used
effectively.
Safety thermometer
• The NHS patient safety thermometer is used to record
the prevalence of patient harms at ward level, and to
provide immediate information and analysis for
frontline teams to monitor their performance in
delivering harm free care. Data collection took place on
one day each month.
• Between September 2015 and September 2016 the
division reported six pressure ulcers, one fall with harm,
and five urinary tract infections. Learning had been
identified for all three measures and was shared across
the whole division to promote awareness and reduce
occurrences with other patients. For example, to raise
awareness of pressure sores, a designated lead had
been introduced into ward areas. This individual had
introduced training for staff in the detection of a
potential pressure ulcer, made learning from pressure
ulcers visible to all staff, and worked towards “changing
the mind-set of the nursing staff”.
• National Institute of Health and Care Excellence quality
standard 3 statements 1 and 3 state all patients upon
admission should receive an assessment for the risk of
venous thromboembolism and bleeding and should
then be reassessed within 24 hours. The divisional
quality scorecard between April 2016 and August 2016
showed 99.2 percent of patients received care met these
standards.
Cleanliness, infection control and hygiene
• Standards of cleanliness and hygiene were well
maintained. There were cleaning rotas and signing
sheets in the wards for the cleaning of equipment
including the resuscitation trolley and drip bag stands.
We also found bathroom and toilet cleaning records
were on display, as were tap flushing records. In
endoscopy we found there was a recovery work area
cleaning checklist which was signed on a daily basis. We
found in ward and theatre areas that they were all
physically clean and tidy. Equipment we checked was
also physically clean. However, we found the Queens
day unit and the endoscopy suite shared a dirty utility
room where clean equipment was stored. There was an
increased risk of contaminating equipment due to the
presence of bodily fluid coming into this area for
disposal.
• There were reliable systems in place to prevent and
protect patients from a healthcare-associated infection.
We saw an example on the surgical trauma assessment
unit where a patient was quickly moved from a bay to a
side room when they found inconclusive results to a
methicillin-resistant Staphylococcus aureus swab. We
found on all of the wards we visited there were sufficient
side rooms to manage the needs of patients requiring
isolation. We found staff were always wearing personal
protective equipment when entering the room and
disposed of it immediately when leaving. However,
some staff told inspectors they sometimes didn’t see
doctors wearing personal protective equipment when
going into side rooms.
• Trust policies on hand washing and infection prevention
and control were not always followed. The National
Institute of Clinical Excellence Quality Standard 61
Statement 3 states ‘people should receive healthcare
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from healthcare workers who decontaminate their
hands immediately before and after every episode of
direct contact or care’. Observations made on ward A700
showed out of ten opportunities to gel hands only three
staff done so which increased the risk of spreading
infections. However, this was not reflected in the
surgical services hand hygiene audits which were
completed on a monthly basis. Results were positive
year on year and did not drop below 97%. We also found
on ward A700 and A800 hand gel was not always located
at the entrances which discouraged visitors from gelling
when entering the ward. We also found there were no
information displayed to visitors to highlight the
importance of decontaminating their hands to reduce
the spread of infection. Staff on a cardiac ward
explained to inspectors additional training had been
introduced when their scores dropped slightly which
included training sessions with the infection control
specialist nurse and sessions with a glow box.
• The rate of infection was similar to the England average.
There were no methicillin-resistant Staphylococcus
aureus bloodstream cases and only four cases of
Clostridium difficile and four cases of
methicillin-sensitive Staphylococcus aureus between
April 2016 and August 2016.
• We found in theatres that processes to decontaminate
patients and staff pre and post operatively to reduce the
risks of surgical site infection were in line with the
National Institute of Clinical Excellence clinical guidance
74. This included the showering, hair removal,
appropriate uniform for staff and theatre ware for
patients, nasal decontamination, bowel preparation,
removal of jewellery, and the management of staff
leaving the operating theatre, sterilisation and skin
preparation. Surgical services submitted data to public
health England for the surveillance of surgical site
infections. Between April 2015 and March 2016 of the 33
hip replacement operations and 90 reduction of long
bone fracture operations done of them had surgical site
infections. Of the 199 repair of neck of femur operations
done only two had a surgical site infection (one percent)
which was comparable to the England average.
• The trust managed and decontaminated reusable
medical devices in line with national guidance which
resulted in the sterile services department gaining
International Organization for Standardization
accreditation. There were clear processes in place to
ensure there was separation and tracking of sterile and
non-sterile equipment. Of the 12,000 items of medical
equipment that were decontaminated each month by
the SSD only two items within a three month period
were returned due to the instrumentation being
unsterile (broken packs) and four were returned due to a
hair or suture being on the instrument set. Where items
were found to be unsterile they could be tracked back to
the individual who packed it to ensure learning was
supported.
Environment and equipment
• The design, maintenance and use of the facilities and
premises kept people safe. All areas inspectors visited
were well maintained and tidy.
• The maintenance and use of equipment kept people
safe. Resuscitation equipment was always available in
ward environments. We checked eight pieces of
equipment in the main theatres, endoscopy and in the
queens day unit and they all had up to date service
stickers. Equipment was managed by a central team.
Staff we spoke with in theatres described to us how they
would report faulty equipment and when this happened
it was dealt with quickly by the Medical Equipment
Management Organisation. Staff reported any faulty
equipment via the electronic reporting system and all
the staff we spoke with were confident in how to
complete this process.
• We checked three resuscitation trolleys during the
inspection and two resuscitation trolleys during the
unannounced inspection. The resuscitation equipment
and trolleys were visibly clean and free from dust. There
was evidence of daily and weekly checking of the
equipment on the trolleys and the trolleys were sealed
with tags to show they had not been tampered with
since these checks. The queens day unit audit data from
June to November 2016 showed poor compliance with
daily checking and was rated uncompliant by the trust
however, when we reviewed one months of recorded
checks all were completed, signed and dated. This was
evidence of learning and improved practice. We
reviewed the daily equipment checklists in the Queens
day unit and saw one month’s checks were fully
completed and signed for. The list included checking
expiry dates of emergency drugs, calibration of the
blood sugar monitor, and re stocking of essential items.
• Trust policy stated the anaesthetic equipment should
be checked daily and recorded in a log book. We
checked the log book in Hey Groves theatre 5 which was
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started on 4 July 2016, nine signatures were missing. We
could not find the log book in theatre 7 and reported
this to the theatre staff. The log book in day theatres had
too many signatures missing to count. We escalated this
to the theatre manager who assured us that the daily
equipment checks were always completed but staff
often forgot to sign that they were completed.
• Arrangements for managing waste and clinical
specimens mostly kept people safe. The wards,
pre-admission area and theatres had suitable quantities
of properly assembled sharps bins in use and stored for
replacement. We found these bins were not overfilled
and closed when in use. However, we saw one sharps
bin in the surgical trauma assessment unit during our
unannounced inspection which was filled above the fill
line as a syringe was sticking out of the top.
Medicines
• Arrangements for medicines management kept people
safe on the majority of the ward and theatre areas we
visited. Controlled drugs (CDs) were stored, prepared
and disposed of in line with the Safer Management of
Controlled Drugs Regulations. Intravenous fluids were
stored safely and trained nurses held keys to all drugs
trolleys and cupboards. However, we saw eye drops had
been left on an open shelf on an inpatient ward in the
eye hospital. These could have been tampered with or
removed by an unauthorised person. The stationary
books used to order, return or distribute CDs were
stored securely, access was restricted and they were
kept in a locked cupboard. We checked a number of
stocks and the registers and found them to be accurate.
Apart from one missing signature, all CD books had two
signatures to ensure safe removal and administration of
a CD; the missing signature was escalated to the
matron.
• Of the six medicines trolleys we looked at we found they
were all securely locked and attached to the wall via a
wire to prevent removal.
• The ordering, receipt, storage, administration and
disposal of controlled drugs were in accordance with
the Misuse of Drugs Act 1971 and its associated
regulations.
• There were manageable levels of stocks to prevent
medicines going out of date and reducing the risk of
errors.
• We checked a number of medicine fridge temperatures
on several wards and two of the theatre areas and saw
they were all recorded and within the correct range
(between 2°C and 8°). We asked staff what they would
do if the temperature was outside of the correct range,
and they told us they would escalate this to the
pharmacy department and the nurse in charge.
• Hypoglycaemic boxes were provided on the wards and
were easily accessible in case of a diabetic
hypoglycaemic emergency. The boxes we saw all had
clear guidance of what to do in such an emergency and
all were fully stocked.
Records
• We looked at seven patient records in different wards in
surgical services. Of the seven individual care records we
looked in we found they were written and managed in a
way that kept people safe (including ensuring people’s
records were accurate, complete, legible, and up to
date) which was in line with the records management
code of practice for health and social care. All
documentation reviewed was signed, dated, legible,
with clear communication from the nurses, consultants
and allied health practitioners. On A700 they were
piloting integrated medical and nursing records and
found this was working effectively. Staff said it improved
multidisciplinary working between professionals and
ensured all staff were fully informed when managing
patient care.
• We looked at the records for two patients who were due
to be discharged. When a patient was due to be
discharged we found all relevant documentation was
filled in and ready for ongoing care including
information on medicines, surgical intervention and
care requirements and access to a telephone number
for concerns.
• We looked in two pre operation assessment records and
found they were also written and managed in a way that
kept people safe. We found the records to be accurate,
complete, legible and up to date and included all
relevant information from the anaesthetist and
consultant which was in line with the records
management code of practice for health and social care.
• We found records were mostly held securely in lockable
records trolleys. However, in the Queens day unit and
the surgical and trauma assessment unit these trolleys
were not available. These records could have been
tampered with or removed without authorisation.
• Additional information on wards was displayed on white
boards. This showed the patients name, risk of falls
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status, pressure care status, cognitive status, therapy
status, and when their next consultant review was. All
patients signed a consent form to say they were happy
for this information to be displayed. Although the board
looked busy all staff we spoke with were familiar with
how it worked and the information it displayed. These
boards were used and updated as part of the morning
safety brief and ward board rounds.
Safeguarding
• The trust safeguarding policies described the definition
of abuse and who might be at risk. These policies were
easily accessible on the trusts intranet pages along with
information provided by the trusts safeguarding team
(including contact details and phone numbers). Despite
the levels of safeguarding training people understood
their responsibilities and adhered to safeguarding
policies and procedures.
• The staff working in surgical services generally
understood their responsibilities to safeguard adults
and children despite training levels being below the
trusts 90% target. At June 2016 only 67% of medical and
dental staff had completed level two adults and level
two children’s safeguarding training. The percentage of
nurses who completed level two adults safeguarding
training was 95% which was better than the trusts 90%
target. However, level three was only 75%. Although
near the trusts 90% target only 89% of nurses had
completed safeguarding level two training. Despite this
we were given multiple examples of where safeguarding
referrals had been made based on allegations of abuse.
We were also given examples about where parents with
children under the age of 18 had to stay in overnight and
ensuring referrals were made to ensure the child’s
safety. We observed care on the surgical trauma
assessment unit where members of the public were
refused access to a patient due to an alert being raised
and the hospital informed. Staff on wards told us they
regularly received feedback from the safeguarding team
when they made a referral.
Mandatory training
• Most nursing staff received effective mandatory training
in the safety systems, process and practices which kept
people safe. In October 2016 92.6% of nursing staff
within surgical services had received all the appropriate
training compared to a 90% trust target. Conflict
awareness training rates were 98%, conflict resolution
training rates were 97%, equality and diversity training
rates were 98%, infection prevention and control
training rates were 95%, medicines management
training rates were 95% and patient safety training rates
were 93%. However, information governance training
rates were 78% and manual handling training rates were
88%. In line with the National Institute of Clinical
Excellence guideline 51 training had been rolled out to
nursing staff for the recognition, diagnosis and early
management of sepsis. Staff we spoke with had received
training in the application of the sepsis protocol and
could direct inspectors to the sepsis management
policy.
• All health care professionals received effective
mandatory training in the safety systems, process and
practices which kept people safe. In October 2016 95%
of health care professionals within surgical services had
received all the appropriate training compared to a 90%
target. Conflict resolution awareness training and
equality and diversity training rates were 100%, conflict
resolution training and infection prevention and control
training were at 97%, and information governance,
manual handling training and patient safety training
were at 90%.
• Not all medical and dental staff had received effective
mandatory training in the safety systems, process and
practices which kept people safe. In October 2016 65%
of medical and dental staff within surgical services had
received all the appropriate training compared to a 90%
trust target. Conflict awareness training rates were 75%,
conflict resolution training rates were 68%, equality and
diversity training rates were 76%, infection prevention
and control training rates were 66%, information
governance rates were 38%, manual handling rates
were 59%, medicines management training rates were
65% and patient safety training rates were 64%. This
means doctors and dentists were not suitable equipped
to keep patients safe.
• Not all administrative and clerical staff received effective
mandatory training in the safety systems, process and
practices which kept people safe. In October 2016 85%
of administrative and clerical staff within surgical
services had received all the appropriate training
compared to a 90% target. Conflict resolution and
awareness training rates were 96% and equality and
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diversity training rates were 97% which were above the
trusts target. However, infection prevention and control
rates were 87%, information governance rates were
59%, and manual handling rates were 88%.
Assessing and responding to patient risk
• Comprehensive risk assessments were carried out for
patients who use surgical services. Risk management
plans were developed in line with national guidance
and risks generally managed positively. Patients had risk
assessments carried out during their pre-admission
appointment which included assessments for falls and
malnutrition universal screening tool and venous
thromboembolism as per National Institute of Clinical
Excellence quality standard 3. Of the seven records we
looked in on wards we found actions resulting from risks
assessments were all completed and reassessed on an
ongoing basis in line with trust protocol. Additional
risks, such as allergies were identified during admission
and patients would have a different colour identification
wristband to raise awareness of this to staff.
• Staff identified and responded to changing risks to
patients who use surgical services. There was a hospital
wide standardised approach to the detection of the
deteriorating patient with a clearly documented
escalation response, in line with the National Patient
Safety Agency guidelines. The national early warning
scores were used within the hospital. Records were in
place for each patient and were completed and
calculated in all of the records we saw.
• National early warning scores scoring was audited on a
monthly basis and identified 76% compliance in
recording and escalating of the deteriorating patient
between April and October 2016 which was a decline of
results from a previous year. This was a decline in
compliance from April 2015 to March 2016. An
investigation conducted before the inspection
highlighted what the issues were and an action plan
was put into place to feedback results to all staff across
the trust, continue with individual ward monthly audits
and conduct teaching for all staff.
• Doctors we spoke with were positive about how
national early warning scores were being used
effectively on the wards. Training in how to use national
early warning scores was part of nurse induction and
ongoing essential learning and ensured staff escalated
and responded appropriately. Nurses we spoke with
said they could easily contact a doctor of necessary. We
were given examples where if a score changes a doctor
attends within 15 minutes. If necessary the consultant
can be called and they will also be there quickly.
• In all operations we observed, the National Patient
Safety Agency five steps to safer surgery were being
followed as part of the World Health Organisation (WHO)
surgical safety checklist. This included a surgical
briefing, signing in, time out, signing out and debriefing.
The briefing was an opportunity for the operating or
interventional team to share information about patients
and discuss potential and actual safety issues before
the theatre list takes place. Staff present included
theatre nurses, operational departmental practitioners,
anaesthetists, surgeons, specialist registrars and scrub
nurses. We saw how the team planned the mornings
theatre sessions, discussed specific equipment that may
be required and had updates from surgeons and
anaesthetists regarding complex patients with
comorbidities. The WHO surgical checklist formed part
of a procedure carried out to scrutinise all safety
elements of a patient’s operation. This included,
checking the correct patient, the correct operating site,
consent had been given, and all the staff were clear in
their roles and responsibilities. The hospital was
committed to ensuring all surgical procedures
completed the surgical safety checklist. The hospital
monitored audit data over the 12 months prior to our
inspection, which showed the theatre department were
99.6% compliant with the WHO surgical safety checklist.
One member of staff we spoke with said there had been
“a massive culture change” around the checklist and
they felt they had “the freedom to speak up without
repercussions”.
• The dental hospital had adapted its checklist in
response to historic never events. There were
standardised procedures across this and other
departments in the trust and we saw how the nursing
staff were empowered to facilitate the checklist and
every member of the team was fully engaged in the
process.
• The hospital had a National Safety Standards for
Invasive Procedures (NatSSIPs) workgroup in order to
streamline practice across the hospital. NatSSIPs
provide a framework for the production of Local Safety
Standards for Invasive Procedures (LocSSIPs), which
were embedded.
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• There was a clear triage process in place for patients
who went directly to the surgical trauma assessment
unit. This occurred when GP practices directly referred
patients. We saw an example where a patient was seen
for an initial nursing assessment within 15 minutes of
their arrival. This included a full set of clinical
observations, documentation of their relevant past
medical history and a pain assessment score. We also
found there was a clear risk assessment process for
medical patients coming from the medical admissions
unit onto the surgical trauma assessment unit. During
the unannounced inspection we observed a nurse
individually assessing a patient who was being
transferred from the medical assessment unit and
challenged records and assessments in line with the
hospitals bed management standard operating
procedure.
Nursing staffing
• Staffing levels and skill mix were planned and reviewed
so people recieved safe care and treatment at all times,
in line with trust policy. Acuity and dependency were
reviewed on a daily basis and staffing was adjusted to
meet the demands on the wards. Bed meetings were
held at 8:30am and 2:30pm on a daily basis to assess
bed flow and staffing in the hospital.
• We found staffing levels were good and actual staffing
figures matched those planned. We found where risks
were greater staffing levels were increased to match this
need. For example on an orthopaedic ward we found
additional staffing were available to care for patients
living with dementia. On another ward we found that
where a patient required one-to-one care additional
staffing was available to meet these care needs. We
looked at shift fill rates surgical services in October 2016
and found that of the seven surgical wards the fill rate
was above 100% for all wards apart from The Bristol Eye
Hospital where fill rates were 98%. Some wards had
significantly higher fill rates than others with Ward A602
having a fill rate of 117% and ward A604 having a fill rate
of 113%.
• Use of bank staff and agency staff were low, with bank
staffing levels remaining consistently below 5% and
agency staffing levels remaining consistently below 2%
between September 2015 and August 2016. Overtime of
staff was constantly below 1% of staffing expenditure
during the same period of time.
• Sickness rates between April 2016 and August 2016 were
4%. However, the trust identified turnover was a risk
with the average turnover between April 2016 to
September 2016 being 14%. This was lower than the
England average.
• Arrangements for handover and shift changes ensured
people were kept safe. We saw a system of staff
handover in the surgical trauma assessment unit
whereby staff spent time studying the handover sheet,
then had a patient inclusive bedside handover, followed
by a whole team discussion of patients and safety
briefing. During this handover patient charts, ongoing
investigations, risk assessments, consent, and discharge
were all discussed. We saw staff were engaging with
patients during this process. A handover checklist was in
use between theatre and recovery staff which had been
introduced since the last inspection. Staff were given
time to complete this and staff we spoke with had found
the handover had significantly improved.
• We found arrangements for shift changes ensured
people were kept safe. During shift changes bedside
handovers were completed which were inclusive of the
patient going through updates for the day, and nutrition
and hydration status. After a bedside handover a team
safety brief was conducted where all patients were
discussed again as a whole team and discussed
discharge arrangements, and risk statuses.
Surgical staffing
• Surgical services had a planned medical staffing level of
505 whole time equivalents (the number of people
working full time employed by the trust. As of June 2016
vacancy rates for surgical services were 4.2% with a
turnover rate of 39.5% and a sickness rate of 0.7% which
was in line with the England average. The use of bank
and locum staff was 1.9% which was lower than then
England average. In September 2016, the proportion of
consultant staff reported to be working at the trust were
about the same as the England average and the
proportion of junior (foundation year 1-2) staff was
lower than the England average.
• Staff we spoke with said there was adequate consultant
presence at the weekends within surgical services. We
spoke with consultants and anaesthetists who
commented that work had been done to improve the
fractured neck of femur pathway to ensure lists were
running seven days a week with very few gaps in the
rotas.
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• Medical staff were not undertaking twice daily ward
rounds. However, risks involved were being proactively
mitigated to ensure safety to patients. Consultant ward
rounds were done every Tuesday, Thursday, Friday,
Saturday and Sunday. Patients had a consultant review
each day in the afternoon. Registrar ward rounds were
held on a daily basis with input from consultants if
necessary.
• Anaesthetists reported frustrations when predicted staff
vacancies were not recruited into in a timely manner.
Staff reported to us when they identified future staffing
shortfalls such as retirement, they were not able to start
the recruitment process early enough to mitigate the
staff shortage.
Major incident awareness and training
• Potential risks were taken into account when planning
services such as the impact of adverse weather or
disruption to staffing. Surgical services had a business
continuity plan which detailed actions that should be
taken in response to various extreme circumstances.
Risks to the service, such as power disruption in
theatres, were on the surgical services risk register.
• There were arrangements in place to respond to
emergencies and major incidents. We saw the trusts
major incident, escalation and extreme escalation plans
which detailed actions which should be taken within
surgical services during times of extreme pressure upon
the service. Action cards were used to ensure
responsibilities were understood and processes were
followed. Actions, such as the cancellation of elective
lists and the reallocation of staff were appropriate for
the level of risk to the service. Staff we spoke with
understood their responsibilities within the major
incident plan and discussed the importance of using
action cards. Many staff could describe the process
involved for the opening of the 21’st bed in ITU and the
impact that would have on the rest of the hospital as
described in an escalation standard operating
procedure.
Are surgery services effective?
Good
We rated effective as good because:
–––
• Patients had comprehensive assessments of their
needs, which include consideration of clinical needs,
including both mental and physical health and
wellbeing, nutrition and hydration needs.
• Pain relief, nutrition and hydration were managed well.
There were clear pathways for managing pain which
were in line with evidence based practice. People had
their nutritional and hydration needs fully assessed and
met in line with best practice. Patients we spoke with
were positive about the quality of care received.
• Staff were qualified and had the skills they need to carry
out their roles effectively and in line with best practice.
Staff were supported to deliver effective care and
treatment, including through meaningful and timely
supervision and appraisal. Through this the learning
needs of staff were identified and training was put in
place to meet them. Staff were supported to maintain
and further develop their professional skills and
experience.
• We found there was good multidisciplinary working and
people received care from a range of different staff,
teams or services, in a coordinated way. All relevant
staff, teams and services are involved in assessing,
planning and delivering people’s care and treatment.
Staff worked collaboratively to understand and meet the
range and complexity of people’s needs.
• Mortality rates in the trust were good. Rates of mortality
for the national hip fracture audit, bowel cancer audit
and the national oesophhago-gastric cancer audit were
better than the national average. Outcomes for people
who used the services were in general good for example
in bowel cancer audit and the oesophago-gastric cancer
national audit and had an improving picture for the
national emergency laparotomy audit.
However:
• The trust was performing worse than the national
average in some elements of the hip fracture audit.
However, the service provided at this trust was relatively
small compared to other trusts.
• Appraisal rates could have been improved. The trust
had a target of 85% completion of appraisals but only
77% of staff in the surgical division had received this.
Administration staff had the lowest rates with only a
66% completion rate.
Evidence-based care and treatment
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• Relevant and current evidence based guidance;
standards, best practice and legislation were identified
and used to develop the service through various
steering groups within the Surgery, Head & Neck
division. Examples of these steering groups included the
nutrition and hydration steering group which had
developed standard operating procedures in line with
best practice and guidance for ‘cancelled operations/
procedures and nutritional needs’, and nil by mouth
patients. Another example included the tissue viability
group which used best practice and guidance to
develop processes to prevent pressure sores, with a
focus on medical equipment such as oxygen masks and
nasal tubes. Product trials were underway at the time of
the inspection for alternative products to further relieve
pressure in these areas. A working group for
anaesthetists used best practice guidelines and results
from the hip fracture audit to introduce new
anaesthesia guidelines. Also the introduction of an
improved block anaesthetic system to enhance
post-operative analgesia for limb surgery and
introduced a wound catheter and elastomeric pump
service which, based on an audit of 225 cases, has
improved the overall length of stay of patients by three
days.
• Patients had their needs assessed and their care
planned and delivered in line with evidence based,
guidance, standards, and best practice. Care plans, risk
assessments, food charts, blood sugar monitoring, fluid
charts, observation charts, drug charts and signature
sheets were all standardised throughout the trust and
were developed in line with best practice
recommendations and guidance.
• Staff described the ‘Sepsis Six’ pathway for identifying
and treating sepsis, in line with National Institute for
Health and Care Excellence (NICE) guidance (NG 51).
Clinical staff were trained in the identification and rapid
treatment of sepsis and this was also included in the
nurse’s induction study days.
• In order to streamline practice across the trust National
Safety Standards for Invasive Procedures (NatSSIPs) for
specimen checking was in the process of being
implemented and posters were printed and ready to be
displayed. NatSSIPs provide a framework for the
production of Local Safety Standards for Invasive
Procedures.
• The pre-op assessment area made good use of
technology to improve its effectiveness. Video recording
of assessments had also been introduced for high risk
patients to allow them to use this information alongside
data collected in the clinic. Also, some patients had their
clinics held remotely though video link which has
significantly reduced the waiting times for patients.
Pain relief
• Surgical services had pathways and guidance in place to
ensure people had pain relief and improvements were
being made based on evidence based practice and
guidance. Many guidelines on pain management had
been introduced since the last inspection. These
included ‘intrathecal spinal anaesthesia – management
for adult inpatients’; ‘Local anaesthetic infiltration via
elastomeric pumps’; ‘insertion and management of
wound infiltration catheters and elastomeric pumps’;
‘ketamine infusion for pain relief in adults’; ‘Analgesic
prescribing for in-patients with acute pain and illicit
opioid dependency’. This ensured pain pathways were
being followed.
• Audit work had highlighted how patients who had
sustained rib fractures were at higher risks of developing
complications (such as chest infections) due to poor
pain management restricting breathing. A new
algorithm and guidelines on managing these patients
has been disseminated and will be re-audited. A sticker
had also been introduced as part of the patient records
to identify patients during ward rounds to ensure follow
up of pain medication. A weekend handover sheet was
also introduced to ensure effective transfer of
information between teams.
• Every patient we spoke to told us they had been given
adequate pain relief. Patients told us when they
required extra pain relief the nurses responded to call
bells efficiently and administered the medication swiftly.
Nutrition and hydration
• Patients' nutritional needs were assessed and met using
a 72 hour food chart review. This documented a
patient’s intake over the course of 72 hours which was
then rated to see if any action was required. We looked
in seven sets of patient notes and found they were all
completed with actions of continuing assessments, no
assessments needed, or intervention needed. This was
audited on a monthly basis and between April 2016 and
August 2016 these charts were completed 91.4% of the
time.
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• Pre-operative comfort rounds were used in the
pre-operative areas to ensure patients were adequately
hydrated while waiting for their surgery. A ‘Comfort
Round’ would take place on an hourly basis and
patients would be offered a drink of water or a clear
carbohydrate drink they would also have their
temperature checked. There were criteria for patients
who would be considered high risk who would have a
greater level of monitoring.
• We spoke with 23 patients on the wards and in the
discharge lounge, all except one patient reported the
choice and standard of food was good. One of the
patients on the ward had been in the hospital for
approximately three weeks and although had been on a
soft diet reported the food was still excellent. Another
patient we spoke with who had been on a restricted diet
felt it had been managed well and one other patient
told us how he had received a diet specific to his
religious needs.
• A new breakfast service format was trialled on one of the
wards. The aim was to provide staff with a structured ‘all
hands on deck’ plan with who does what, when and
how. As this ensured a more efficient and timely service
it was implemented on other wards around the trust.
Patient outcomes
• Surgical staff regularly reviewed the effectiveness of care
and treatment through local audit and national audit.
• There was very little orthopaedic work carried out at the
trust with a majority of this patient group being treated
at another NHS trust in the city. Therefore, the numbers
of people that the hip fracture audit relates to is
relatively small. The hip fracture audit looks at key parts
of a patient’s journey after receiving a hip fracture and
analysis its timeliness due to the importance of getting
surgery within 36 hours of arrival to the emergency
department. The mortality rates for the audit were
better than the England average and were better in the
2015 audit than in the 2014 audit. However, the
proportion of patients having surgery within 36 hours
was only 74% in the 2015 audit, which is worse than the
national standard of 85%. The percentage of patients
receiving an orthogeriatrician assessment within 72
hours was only 94.1% compared to a national standard
of 100%. It was identified in the 2015 audit just under
5% of patients developed a pressure ulcer which puts
the trust in the worst 25% of all trusts for this measure.
In addition, length of stay was reported as 25.5 days,
which puts the trust in the worst 25% of all trusts for this
measure. Although the audit was only completed on a
yearly basis it was measured internally on a monthly
basis. Performance in July 2016 was improved but only
slightly. The reasons given for these results were
displayed in an action plan which stated that during
busy times, for example when two fractured neck of
femurs are admitted on the same day, it can be difficult
to ensure surgery within 36 hours alongside other
urgent surgery targets. In addition, due to the lack of
orthogeriatrician cover over weekends and annual
leave, along with significant long term sickness other
measures of the audit were difficult to achieve. Work
was underway to change the working model for this
specialty and funding had been agreed to increase
orthogeriatrician staffing.
• In the 2015 Bowel Cancer Audit, 63% of patients
undergoing a major resection had a post-operative
length of stay greater than five days. This was better
than the national aggregate of 69% and worse than
2014 data. The 90-day and two year post-operative
mortality rate (risk adjusted) for patients undergoing
bowel resection had been within the expected ranges
for 2014 and 2015 as had the 90 day readmission rates.
Temporary stoma rate for the trust was higher than
expected. The trust had 188 operations and a case
ascertainment rate of 120% which was good when
compared to other hospitals.
• In the 2015 Oesophago-Gastric Cancer National Audit
(OGCNCA), the age and sex adjusted proportion of
patients diagnosed after an emergency admission was
5.3%. This placed the trust within the middle 50% of all
trusts for this measure. The 90-day post-operative
mortality rate was 3.8%, within the expected range. The
2014 rate was 4.9%. The proportion of patients treated
with curative intent in the Strategic Clinical Network was
36.7%, in line with the national aggregate. This metric is
defined at strategic clinical network level; the network
can represent several cancer units and specialist
centres; the result can therefore be used as a marker for
the effectiveness of care at network level; better
co-operation between hospitals within a network would
be expected to produce better results
• When comparing the 2014, 2015 and 2016 National
Emergency Laparotomy Audit (NELA) there had been
improvements made year on year. Of the six measures
the trust performed better than the national average for
three of them. These included appropriate
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documentation, access to theatres, and for mortality
rate. The trust performed significantly worse than the
national average for the percentage of operations where
a consultant anaesthetist and surgeon present. The
national average was 74% of operations with the trust
only achieving this in 35% of operations. Improvements
were being made and as a result of the NELA audit
results the introduction of ‘boarding cards’ has
improved communication between teams and
facilitated timely transfer the appropriate pathways
• In the Patient Reporting Outcomes Measures (PROMS)
from April 2015 to March 2016, the two indicators
relating to Groin Hernia showed more patients’ health
improving and fewer patients’ health worsening than
the England averages. No other outcome data was
provided by the trust.
• Emergency re-admission rates were low with the only
1.75% of patients returning to hospital between April
2016 and August 2016. This is improved from 2.82% of
patients returning to hospital between April 2015 and
March 2016.
Competent staff
• Between April 2015 and March 2016, 77% of staff within
surgical services had received an appraisal compared to
a trust target of 85%. Medical staff had a completion rate
of 72%, nursing staff had a completion rate of 86%,
nurses banded two to four had a completion rate of
85%, allied health professionals had a completion rate
of 78% and all other staff had a completion rate of 66%.
• Staff had the right qualifications, skills and knowledge
and experience to do their jobs. There were clear
competency frameworks training plans for staff working
on the wards. We saw a training matrix for one of the
wards which clearly demonstrated the essential training
specific to roles and who had completed it. Training
included venepuncture, cannulation, catheterisation,
medical gasses, and tissue viability. There was a clear
competency process for nurses working in Queens Day
Unit to ensure suitable levels of knowledge and skills to
ensure safe recovery of a patient post procedure. This
included the preparation, understanding of procedures,
handover, and risk assessments as well as a reflective
piece of work which was signed by an assessor. There
were also clear preceptorship and induction processes
in place which had clear aims and objectives which
needed to be signed off by an assessor before being
deemed competent.
• The trust had an effective staff induction programme.
We saw a two day induction programme for new nurses
called the Adult nurse - ward survival guide. The
itinerary covered topics such as infection control, sepsis
6 pathway, blood glucose testing, risk assessments and
incident reporting. We spoke with a staff nurse who had
been in post for a year and we were told the trust had
provided an induction programme and four weeks
supernumerary and the nurse told us this had been
sufficient a period of time. We spoke with a newly
appointed staff nurse in theatres and we told the
induction to the unit was at that time going well. The
nurse was given a work book and was visited weekly by
the practice facilitator to check on progress. As the nurse
had not been theatre trained, they were offered a three
month supernumerary period. Another newly qualifies
nurse said additional training provided was good and
ensured they were trained to manage tasks on the ward
such as cannulation and wound dressing.
• The surgical directorate had employed a practice
education nurse facilitator. This role encompassed
working across all of the wards to support newly
qualified and new staff to the trust. The role had a dual
purpose, to increase ward competence and support
managers with the compliance of their team’s essential
training. This individual also spent time with all nurses
in their preceptorship and acts as a mentor. They also
spend a shift with them to observe their practice and
give constructive feedback on how they could improve.
• However, we spoke with one first year doctor who said
they felt limited in what work they were doing. We were
told there was limited additional training
post-graduation and the scope of practice for doctors
was limited.
Multidisciplinary working
• All necessary staff, including those from different teams
and services were involved in the assessing, planning
and delivery of patients care and treatment. Board
rounds were held on a daily basis and involved the
medical, nursing and therapies staff. These managed
the ongoing risks around patient care and discussed
ongoing discharge as a team. Within this discussion
current condition (such as falls, pressure ulcer risk, and
cognition) were discussed and actions planned for care.
We found these discussions were meaningful and
inclusive of all staff. We found actions were clear and
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•
•
•
•
everyone left these meetings knowing what actions
needed completing. Another example was the inclusion
of a thoracic consultant in a patient handover from the
emergency department to the ward.
Staff on the cardiac wards were positive about access to
additional services. For example, tissue viability services
were available on the same day as referral improving the
outcome of the patients. We were also told specialist
nurses can attend the ward quickly when required,
particularly for upper and lower gastrointestinal care.
The service ensured arrangements for discharge were
considered prior to elective surgery taking place. We
found discharge was discussed with patients on
admission onto the wards and updated on a daily basis
during the ward handovers. However, we found
discharge was being hampered by issues within the
wider health system. In October 2016 there were four
new delayed patients equalling 56 delayed bed days
with the reasons being social care funding issues, social
care assessment delays, and waiting for a community
rehabilitation bed.
When people are discharged from the service this was
done at an appropriate time of day and was only done
when ongoing care was in place. Between April 2016
and August 2016, 30% of patients were discharged
between 7am and 12 noon and only 3% of patients were
discharged out of hours. Only 12% of patients were
discharged to the discharge lounge, the remaining
patients were discharged either to their home or to an
ongoing place of care. The trust recognised
performance on this measure had remained consistent
and additional actions, such as deep dives into patient
discharges and exploring an additional target of ‘before
4pm’ could be introduced to allow the trust better
insight into the data.
Technology was being used to improve the effectiveness
of the multidisciplinary team decision making process.
Video clinics were being held so doctors could remotely
be part of the process at other acute hospitals.
Seven-day services
• Services were provided out of hours and weekends and
this included pharmacy, physiotherapy and imaging
services. Out of hours access to a pharmacist was
managed by an on call system and staff we spoke with
reported this system worked well.
• Consultant, registrar, senior house officers (doctors
employed full time at the trust who are not undertaking
further education) and junior doctor cover was provided
24 hours a day seven days a week.
• For trauma and orthopaedics consultants were onsite
between 8am and 8pm daily (to attend the 8am trauma
meeting, perform ward rounds, clinics, administration,
and trauma lists as per job plans) with on-call
consultant cover provided between 8pm and 8am.
Additional consultant ward rounds were conducted in
accordance with individual job plans. Registrars were
onsite between 8am and 8pm to attend the 8am trauma
meeting, ward rounds, clinics, and to assist with trauma
lists. These doctors held the on-call bleep and there was
the possibility they could be called to the emergency
departments or onto wards. Between 8pm and 8am
registrars were on call and contactable via the on call
bleep. Between 8am and 8pm senior house officer
doctors were available between 8am and 8pm and
attended the ward round then be on call for the
emergency department, the surgical and trauma
assessment unit and for the surgical wards. Between
8pm and 9am senior house officers were on call for the
whole site and at weekends would be allocated to
wards on each day.
• For thoracic surgery, consultants were on site between
8am and 8pm and on call from home between 8pm and
8am. During the day workload involved clinics and
elective surgical lists with emergency surgical work
being covered as necessary. All available consultants, as
well as on-call consultants, would do a morning ward
round every day, including weekends. Registrar and
junior doctor cover was managed separately by
cardiothoracic specialist services.
• For ear, nose and throat consultants were available
between 8am and 8pm and ran a rota being on call a
week at a time. Consultants were not on site at weekend
but were available on call as required. Registrars worked
on site between 8am and 8pm and were available on
call between 5pm and 8am. However, these doctors
provided cover to four acute trusts in the region. At
weekends a registrar was on call between 9am and 1pm
with a second registrar being contactable at the first
registrar’s instruction. Senior house offers were onsite
working 12 hour shifts 24 hours a day seven days a
week.
• For anaesthesia consultants were on site between 8am
and 6pm Monday to Friday with a trauma consultant
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and an aesthetic ophthalmic consultant between 8am
and 6pm on Saturdays and Sundays. Specialty doctors
were available on call for anaesthetic emergency cover
24 hours a day seven days a week.
• For general surgery consultants were on site between
8am and 6pm with on call from home overnight.
Additional consultants were on site to ensure ward
rounds were completed. There were specialist doctors
on call 24 hours a day seven days a week with additional
consultant on call cover for oesophagogastric and
hepatobilliary patients.
• For cardiac cover junior, registrar, fellow, and senior
house officer doctors were on site 24 hours a day seven
days a week and operated daily. Cardiac surgery,
cardiac anaesthesia and intensive care consultants were
on site daily and available on call overnight. All
consultants on call needed to live within 30 minutes to
ensure emergency cover was available.
Access to information
• All information needed to deliver effective care and
treatment was available to relevant staff in a timely and
accessible way including access to risk assessments,
care plans, case notes and test results. This access was
maintained when transferring patients between
services. For example, we saw examples of effective
handover between the emergency department and
wards.
• We saw discharges were coordinated in line with the
Nation Institute of Clinical Excellence Quality Standard
15 Statement 12 in that patients experienced care
between services in a coordinated way. We looked at
several discharge summaries and found they were
complete and comprehensive.
• Where necessary patients who attended the
pre-admission clinic (PAC) were given leaflets on
smoking cessation, weight management and alcohol
intake. Patients whose planned operations required an
admission to the high dependency or intensive care unit
were given information leaflets about these areas and
were offered a chance to visit the department prior to
their admission. Other leaflets that were available
during the PAC explained the discharge lounge, pressure
ulcer prevention and venous thrombus embolism
prevention.
• The Summary Care Record (SCR) is a secure national
electronic record, which is a programme dedicated to
using technology to support better information sharing
between local health and social care organisations. Staff
at the PAC could access this record called Connecting
Care, which enabled them to have information on for
example, any medications, allergies, recent
appointments and diagnoses that a patient may have
had. This record was also available for GPs to access and
allowed information to be shared quickly and safely.
Consent, Mental Capacity Act and Deprivation of
Liberty Safeguards
• Patient consent was sought. Patients we met all said
they had signed consent forms following a discussion
with the doctor. They had been given the opportunity to
ask questions and told the advantages and risks of the
process they were about to undergo. For some
procedures, such as taking blood samples or general
tests, specific written consent was not required.
However, patients would be required to give implied or
verbal consent. Those patients we asked said they were
always asked for their permission by staff before any
procedure.
• The trust reported that Mental Capacity Act and
Deprivation of Liberty Safeguards training was fully
incorporated into safeguarding training undertaken by
staff. Staff we spoke with understood the relevant
consent and decision making requirements of
legislation and guidance including the Mental Capacity
Act 2005. Staff could give us examples of when the act
would be used and in what capacity and the processes
Are surgery services caring?
Outstanding
–
We rated caring as outstanding because:
• We spoke with 30 patients during this inspection on all
of the wards and theatres we visited. We also received
large numbers of comment cards about the service.
Feedback from patients and those close to them were
continually very positive about the way staff treated
people with no negative comments. We were given
multiple examples where staff had gone the extra mile
and where care received exceeded patient’s
expectations. People were always treated with privacy,
dignity, respect and kindness.
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• Comments made were consistently positive and
supportive towards patient centred care. There was a
strong patient centred culture and relationships
between staff, patients, and their relatives were strong,
caring and supportive.
• Friends and Family test results in the surgical division
were better than the rest of the trust and had a higher
response rate than the England average.
• People were involved as partners in their care and were
supported with making decisions. We were given
examples where relatives and carers were included as
part of the care provided for both physical and
emotional wellbeing. We received a plethora of
examples where carers and relatives were involved in
patient care and where emotional support had been
given. People’s individual preferences were reflected in
how care was delivered.
• Peoples emotional and social needed were valued by
staff and were embedded in their care and treatment.
We were given multiple examples where emotional
support was provided which had a positive impact on
the patients’ health and wellbeing.
Compassionate care
• We found staff took the time to interact with people who
use the service and those close to them in a respectful
and considerate manner. We observed examples of care
where this was taking place which had a positive impact
on the patient. One example of this was when two
surgeons went to the discharge lounge to say goodbye
to a patient and to answer any final questions they had.
We observed this to be good support for the patient and
put them at ease for their onward journey from hospital.
Patients on wards we spoke with were consistently
positive about how staff interacted with them. One
patient said “I would be happy for any one of my family
to be treated on this ward”, another said “the staff have
been brilliant and very caring. I have no complaints at
all”.
• Patients we spoke with said they made sure people’s
privacy and dignity were always respected, including
during physical or intimate care. We spoke with six
patients in the discharge lounge who were consistently
complimentary about the care they received. They all
said they were treated with privacy and dignity during
their entire stay at the hospital. One patient we spoke
with said “I have been treated really well by all. I was
always treated with dignity, compassion and respect”,
another said “staff have been really good to me. I have
been treated with privacy, dignity and respect”. When we
were on the surgical wards we saw good examples of
care which respected people’s privacy and dignity. When
physical or intimate care was required curtains were
always fully closed to ensure privacy and when staff
either entered or left the bay or room they always
ensure they done so carefully so as not to compromise
privacy. In theatres we saw that at all times patients
dignity was preserved by making sure patients were
covered up during their procedure. When patients
arrived in theatre they were warmly welcomed by the
staff who were attentive to their needs. We saw
examples of staff making meaningful conversation with
patients and putting them at ease. One patient told us
they felt they were well respected by staff. We were given
an example of how they got to know her better upheld
their personal preference to have female staff helping
them get changed. Patients on wards said “the staff
have been excellent. I am in here quite a lot and the staff
know me really well” another said “I have been treated
really well by everyone on the ward”.
• The Friends and Family Test (FFT) is a nationally
recognised tool used to help service providers and
commissioners understand if their patients are happy
with the service provided, or where improvement is
needed. FFT response rates for the Surgical Head & Neck
division were 39% which was better than the England
average of 29% between September 2015 and August
2016. Response rates for the Bristol Royal Infirmary were
43%. The average score for the division was 97.5% which
was better than the rest of the trust. Additionally to this
assessment staff were asked to complete a patient
survey which was analysed on a monthly basis based on
patient experience and kindness and understanding.
The division consistent performed very well when
comparing the patient experience in surgery with the
rest of the trust”. The trust participated in Public Health
England Surveillance and the Patient Led Assessment of
the Care Environment (PLACE). The assessments
involved local people known as patient assessors,
assessing how the environment supported the provision
of clinical care. The trust scored above the national
England average for privacy, dignity and wellbeing.
• We found during the inspection call bells were always
responded to quickly on the wards regardless of how
busy they were. One patient we spoke with said “when I
used the call bell nurses came really quickly to manage
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my pain. I was treated really well in that regard”. Other
patients were positive about how quickly pain was
managed on the wards saying they always quickly
received medication when they asked for it to make
them feel comfortable. However, one patient we spoke
with on a ward said on one occasion they had to wait
ten minutes for their call bell to be answered. We
observed examples of staff responding well to patients
in distress. One example was with a patient who was
using a walking stick to get out of the ward upon
discharge. A student nurse saw this, recognised they
were finding walking difficult, and asked if they wanted
a wheelchair, they then escorted them to the discharge
lounge.
• There were limited opportunity in the wards to make
hospital feel ‘normal’ to patients. There was no access
to day rooms which meant patients had to either eat in
bed or in their chairs. Although patients we spoke with
said they understood this and felt well informed as to
the reasons why. Dietary requirement were also
explained well as described by one patient who said “I
am on a liquid diet because of my operation but had
this explained to me well. It isn’t an ideal situation but I
am being helped through it”. Another patient said “I am
on a restrictive diet but myself and my family have been
informed as to why this is happening and how long it
will be for”. Staff on wards were given protected time to
help with meal times. We saw good practice where staff
were helping patient to eat their meals and sat with
them during this.
• In the surgical trauma assessment unit there was a
seated area with eight chairs and one cubicle. This
cubicle had a curtain across to ensure dignity was
preserved. We found that despite the curtain
conversations between staff and patients could be
overheard which compromised confidentiality. For
example we heard a patient in distress who has having
blood tests taken which was making the patients in the
seated area feel uncomfortable. One patient we spoke
with said “this is a bit impersonal being able to hear
others conversations”.
Understanding and involvement of patients and those
close to them
• Staff communicated with people so they understood
their care, treatment or condition. Patient we spoke with
said they were informed about their care and that their
relatives were included in discussions. One patient said
“they always keep me informed about the care I receive”.
Another patient described their disabled spouse was
not able to visit regularly so had daily phone calls with
the staff to ensure they had an update on the patients
care. A patient said “this has gone a long way to making
my partner feel better during this worrying time”.
Another patient described how they were making
adjustments to ensure their blind sister was informed of
their care throughout their visit. The patient said they
were relieved and happy they were being informed.
• Staff we spoke with gave us examples of when they had
to deliver bad news to a patient and ensured this was
done in a confidential environment giving them as
much time as necessary to ask questions. We also saw
an example in theatres of staff having a discussion
about how they were going to make adjustments to
communicate with someone who had their operation
cancelled due to anxiety to ensure they supported the
patient as much as possible during their care and
treatment.
Emotional support
• Staff understood the impact person centred care had on
the wellbeing of the patient and those close to them
both emotionally and socially. We were given multiple
examples of how care had been given in ways to
alleviate anxieties and concerns. We observed on
multiple occasions on wards where care had been
delivered in a way which supported positive wellbeing
both in hospital and for their onward journey out of
hospital. For example, discussions about discharge were
given in a supportive and reassuring way, and where
there had been delays in discharge patients were given
time with nurses to discuss concerns and worries. Staff
could describe the importance of offering emotional
support and could give examples of the positive impact
it had on patients. Patients we spoke with on the wards
all reported how they had been supported emotionally
during their inpatient stay. One patient told us he “has
had an exceptional experience” and told us of a specific
nurse who was particularly good and “got him through
the first three days.
• Patients and their relatives and carers were given timely
support and information to cope emotionally with their
care, treatment or condition. We were given an example
of good patient care where they were given a tour of the
intensive care unit prior to their operation so they knew
the environment they will be in better. This relieved
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anxieties of both the patient and their relative who
attended this. Another example we saw in theatres
where a patient was anxious about their operation. The
nurses rang the patient and supported appropriately to
attend and successfully have her operation.
• People were enabled to have contact with those close
to them and to link with social networks or communities
in a variety of ways. All patients were given access to
Wi-Fi to enable them to access the internet and were
given opportunities to use telephones to contact
friends, relatives or carers. We also found although
visiting times were set to ensure uninterrupted periods
of the day and night they could be flexed to meet the
needs of the patients or their relatives. One patient we
spoke with described how their anxiety was reduced as
their partner was allowed to stay later in the evening
when they had their operation.
Are surgery services responsive?
Good
–––
We rated responsive as good because:
• Services are planned and delivered in a way that meets
the needs of the local population. The importance of
flexibility, choice and continuity of care is reflected in
the services. Care and treatment was coordinated with
other services and other providers. However, sometimes
incurred delays due to issues elsewhere.
• People could generally access the right care at the right
time. Access to care is managed to take account of
people’s needs, including those with urgent needs. RTT
standards were being met 92% of the time. Where there
had been a slip in performance there were clear actions
to address these which had been proven to be effective.
• Although slightly limited, reasonable adjustments were
made for people living with dementia or with learning
difficulties including use of the ‘this is me’ document
and access to activities for stimulation. There were
access to dedicated teams for dementia, learning
disabilities and psychology which were always available.
Patients we spoke with were mostly happy with the
attentiveness of the staff allowing their needs to be met.
• Waiting times, delays and cancellations were minimal
and managed well.
However:
• We found due to flow issues some specialties were not
seeing patients in an appropriate time frame. For
example, not all endoscopy patients were seen within 7
days of referral, only 77% of cleft palate patients had
their surgery within the national standard, and 89% of
dental patients were seen within the national standard.
Service planning and delivery to meet the needs of
local people
• We found at the time of the inspection there were very
few surgical outliers and historically was regularly
performing better than the trusts surgical outlier targets.
In July 2016 there were a total of 199 bed days spent
outlying which was slightly worse than a 190 bed days
target. In July 2016 other divisions spent 285 bed days
outlying in surgical areas, with 256 of these being
medical patients. The site team actively allowed surgical
patients to outlie to The Bristol Eye Hospital, escalation
wards, Queens Day Unit, and the physiotherapy gym to
allow medical outliers to remain on the main hospital
site as their consultants were not able to accommodate
review elsewhere.
• Recovery and Day Surgery areas were not used as often
to accommodate patients overnight as they were during
the last inspection. Between September 2015 and
August 2016 the recovery area had been used 75 times,
and the day surgery area had been used 161 times. Staff
we spoke with in recovery said that it was regularly used
but for no more than two patients. The trust had a
number of mechanisms in place to mitigate against the
use of these areas overnight and a system of patient
flow management with reviews of capacity, demand
and Trust/system escalation at four scheduled meetings
each day. These were supported by clear actions and
escalation triggers set out in the Trust’s Adult Escalation
and Extreme Escalation Policies. The vast majority of
use of recovery overnight was for patients requiring high
dependency unit care, where surgery had proceeded on
the basis of bed availability that later reduced due to
unexpected circumstances. This then had an impact on
the following day’s elective surgery capacity.
• Theatre utilisation at Bristol Royal Infirmary ranged from
58.3% to 91.8% during the period May 2016 to July 2016.
When we discussed this with managers there were clear
and reasonable reasons as to why theatres were not
being used and we found they were being utilised fully
with the staffing and bed base available.
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Access and flow
• Most people had timely access to initial assessment,
diagnosis and urgent treatment. Referral to Treatment
(RTT) timeliness was monitored on a weekly basis in the
Surgical, Head & Neck division which was reported to
the trust board on a monthly basis. Each subspecialty
within the directorate reported to a RTT lead who held
them to account for actions against an action plan and
discussed individual patients who were waiting longer
than 18 weeks with consultants to ensure the patients at
highest risk were seen first. Between September 2015
and August 2016 the trust had continually been above
the England average for RTT times. Overall the RTT
standards were met 92% of the time in October 2016.
Where there had been a slip in performance there were
clear actions to address these which had been proven to
be effective. For example, in dental services in October
2016 the RTT standard was met only 89% of the time
due to staffing issues. This was recognised by the trust
and more than ten dentists had been employed by the
service and were due to start shortly after the
inspection. Another example was in the Cleft service
which, due to one member of staff leaving, had a
performance rate of 77%. This was recognised by the
trust and work was being done to upskill clinical nurse
specialists to ensure the standard was met.
• There were continual capacity issues in Endoscopy
resulting in many patients not being seen within 7 days
of referral. Despite having a waiting list a recovery plan
has been verified by JAG (Joint Advisory Group) and the
trust maintained accreditation. Although performance
had been gradually improving only 72% of patients were
being seen within the timeframe (against a standard of
90%) which had affected the trusts ability to oblige to
two week cancer wait standards. There was a shortfall of
5.3 lists per week on endoscopy with a significant
backlog. The division has been training an endoscopy
nurse practitioner to increase capacity and by
outsourcing to another provider which was working
long term with the trust to reduce the backlog and
manage ongoing capacity issues. It was noted in an
action plan there was a significant element of patient
choice with patients not being able to attend within
seven days of referral. Diagnostic six week waits in
Endoscopy with performance being a little short of 99%
which was also due to limited capacity in the unit.
• The cancer waiting list was well managed in the Surgical
Head & Neck division. The trust was on average meeting
the 96% standard for 31 day diagnosis to first definitive
treatment cancer pathways. In July 2016 there were
three breaches, none of which were fully attributable to
the hospital. For 62 day urgent referral to treatment time
standard the trust performance was mixed. In July 2016
performance was 73.3% and August 2016 performance
was 84.8%. In September 2016 only eight patients
breached the standard with a majority of these being
unavoidable due to patient choice.
• Care and treatment was cancelled or delayed only when
absolutely necessary. Between July 2014 and June 2016
cancelled operations for elective admissions remained
slightly higher than the national average, but remained
consistently between 0.8-1.3% of patients. In July 2016
35 out of 2,498 procedures were cancelled on the day,
totalling 1.4% of patients against a 0.8% target. Out of
these 12 were cancelled due to no ward beds being
available and six were cancelled due to intensive care
unit/ high dependency unit beds being available. Four
patients were cancelled due to other clinically urgent
patients being prioritised, four due to late starts or lists
over-running, five due to the surgeon or anaesthetist not
being available, two were due to equipment failure and
one was due to an administration error. An action plan
recognised the division had experienced continuing
pressures due high emergency take and long periods
with lots of medical outliers on wards. There were also
some periods of time where acuity in the Intensive Care
Unit caused elective cancellations. People were
supported to access care and treatment again within 28
days as far as possible. For the period of April 2016 to
June 2016, very small numbers of patients were not
treated within 28 days. For example, in July 2016 only
two patients did not get rebooked within 28 days.
• During our inspection, we saw how efficiently the
emergency theatre worked with the wards to identify
the golden patient. This was a pre-selected patient who
was allocated first on the morning’s theatre list who had
a clear surgical plan in place and had already been
reviewed by the anaesthetist. This enabled the case to
start on time as all members of the team including the
ward staff were ready on time. Theatre staff told us how
this had improved operation start times and started the
theatre day smoothly and efficiently.
Meeting people’s individual needs
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• We found some reasonable adjustments were made to
take into account the needs of different people on the
grounds of religion, disability, gender, or preference.
• Most people were satisfied with the quality of the food
provided. Of the six patients we discussed this with one
said the food could be improved. One patient said “the
food was hit and miss and I put it down to the fact I
didn’t always receive his menu to choose my food”. On
the wards all of the patients we spoke with about food
were consistently positive about the variety and the
quantity of food available. One patient said “they were
always offered more food when they finished their
meal”. We spoke with one patient who was
complimentary about the service because they were
able to provide them with Halal food. Staff we spoke
with said regardless of logistical challenges which may
come with respecting religious needs they would always
ensure these needs were met. Some staff we spoke with
gave us examples of the types of adjustments they
would make for different religions or beliefs showing
understanding of the different patient needs. Services
were planned in such a way which ensured patients in
the discharge lounge received ample food and drink
during their stay in this area. One patient we spoke with
said they had been in the lounge all day waiting for
transport and was regularly offered food and drink.
• There were mixed levels of satisfaction from patients
with regards to access to facilities. One patient we spoke
with said they were given access to the internet, a
television, a radio and were offered newspapers on a
daily basis. One patient said “what impressed me the
most was the fact that every staff member at every level
made his stay as comfortable as it can be”. However, one
patient said they brought puzzles in with them for their
stay but was never offered them by the staff.
• We found reasonable adjustments were made so
disabled people could access and use services on an
equal basis to others. Staff we spoke with discussed
how they would change the way they communicated
with patients depending on their disability. For patients
living with a hearing impairment they were able to use
to white boards to allow them to communicate better
and could access information in brail for patients with a
visual impairment. We spoke with one patient who was
living with a speech and language impairment who was
satisfied with the care and the adjustments made to
allow him to communicate with staff.
• There were suitable arrangements in place for people
who needed translation services. Nurses we spoke with
described how they would use a telephone service if
they needed a translator. This phone service was
available 24 hours a day seven days a week. Staff
described why they would not use a member of a
patient’s family to translate for them as there was a risk
of mistranslation or misrepresentation of the
information. We were given an example of where an
interpreter attended an appointment between due to
the sensitive nature of a conversation. Staff described
how it was not appropriate to have such a delicate
conversation using the phone line. However, we found
there were a limited selection of leaflets in foreign
languages available on the wards. In some areas, such
as the discharge lounge we found no leaflets at all in any
language other than English.
• We found there were some suitable arrangements in
place for people with a learning disability. Discussions
between the doctors, nurses and outside providers
(such as GP) were held prior to elective admission and
information about learning disabilities was transferred
well between areas of the hospital. Hospital passports
were used as part of the admission process to rate the
level of impairment and the support required. This
document went with them throughout their visit to
hospital. Additional support was available through the
Learning Disabilities Liaison Nursing Team. However,
this team was small and was only available during
weekdays.
• We found the service was designed in a way to care for
people with complex needs when they got to hospital.
For example, all areas of the wards and theatres were
accessible by wheelchairs with ample space for disabled
visitors to be at a patient’s bedside. There was also clear
signage and an information point to help patients get to
where they needed to go. However, there was limited
parking for disabled patients which made access
difficult. The trust’s website encouraged people to use
public transport to get to the hospital which may not be
ideal for patients with complex needs although drop off
points was available with access to wheelchairs at the
entrances to the hospitals.
• Training in managing people living with dementia was
embedded into the adults safeguarding training. Staff
we spoke with on the wards had a clear understanding
of the adjustments they needed to make to manage
patients living with dementia. All patients diagnosed
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with dementia or had cognitive impairment had a ‘this is
me’ document produced when they were admitted. This
allowed staff to understand what the patient’s likes and
dislikes were. Patients living with dementia had a
forget-me-not flower above their bed and on the ward’s
white board so people coming into the ward knew of
their impairment without looking in the notes.
• The Commissioning for Quality and Innovation (CQUIN)
framework contained a national goal for improving
dementia care promoting the identification of patients
living with dementia and other cognitive impairment, to
prompt referral and then follow up after they leave
hospital. The hospital audited against this and
performed better than the target for all questions on
identification, assessment, and referral and follow up
between April 2016 and August 2016.
• The Bright Ideas Project was a multidisciplinary project
to improve the experiences of patients in hospital living
with cognitive impairment. This group developed a
questionnaire and reported on the experiences of 46
patients and their relatives. From this group an action
plan was developed to introduce therapeutic activates
for patients on wards. We found some adjustments had
been made for people living with dementia. We saw on
some of the wards we visited there was an activities
cupboard with a range of puzzles, books, and games.
Staff told us they would often sit with patients and do
these activities with them and found it had a positive
effect on the patients’ wellbeing.
• Psychiatric support was available for all patients on
wards between the ages of 18 and 64 and was
accessible through a referral process. The service
offered included medication advice, helping people
cope with the psychological effects of their physical
health problems, medically unexplained symptoms,
support and advice regarding anxiety or mood
disorders, anxiety management and relaxation
techniques and was available seven days a week.
Learning from complaints and concerns
• People we spoke with knew how to make a complaint.
Of the patients we spoke with many said they would be
happy to raise concerns with staff and could make a
complaint of they wanted to. One patient we spoke with
said they felt enabled and “confident to speak up” if
something happened that they didn’t like. Many
patients went on to say they had nothing they would
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wish to raise a complaint or concern about due to the
good quality of care. There were information leaflets
available for complaints in different languages, although
these were only available on request.
We found posters were on the wards to invite people to
raise concerns or issues with members of staff or
through the trusts complaints team which were
available via email, telephone, or by post. The service
also offered a ‘drop in’ session for patients and visitors
to raise concerns directly with the team five days a
week.
The NHS constitution gives people the right to have
complaints dealt with effectively, be investigated, and to
know the outcome of an investigation. We looked at a
selection of complaints and found they were managed
in a compassionate and caring way. The outcome was
explained and a sincere apology was given.
There were a total of 75 complaints between February
2016 and August 2016. The hospital took an average of
32 days to investigate and close these complaints.
Timescale for resolution of complaints were agreed as
part of individual resolution plan based on the
complexity of the complaint rather than by a set date.
Timescales for these individual resolution plans were
met 95% of the time within the division and 90% of the
time when the trust executive team was involved (for
the most complex of complaints).
Lessons of complaints were shared with staff at safety
briefings and through newsletters. Staff could give us
examples of where they had changed practice as a
result of learning from complaints not only on their
ward or theatre but in the wider trust.
•
•
•
•
Are surgery services well-led?
Outstanding
–
We rated well-led as outstanding because:
• The strategy and supporting objectives were stretching,
challenging and innovative whilst remaining achievable.
The strategy for the surgical division was detailed and
set out clear objectives for each of the service lines.
• Governance and performance management
arrangements were proactively reviewed and reflect
best practice.
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• Leaders have an inspiring shared purpose, strive to
deliver and motivate staff to succeed. Comprehensive
and successful leadership strategies were in place to
ensure delivery and to develop the desired culture.
• There were high levels of staff satisfaction across all
equality groups. Staff were proud of the organisation as
a place to work and spoke highly of the culture. There
are consistently high levels of constructive engagement
with staff. Where there had been a poor culture
identified innovate and effective actions were put into
place to resolve them.
• Innovation was actively encouraged throughout the
surgical division from staff led forums to improve the
efficiency of work streams to research in pioneering
research techniques. All changes were monitored
effectively to evidence the improvements to patient care
the changes had.
• There had been clear improvement since the last
inspection in September 2014. All requirement notices
which were issued that time had been managed
appropriately.
Vision and strategy for this service
• There was a clear mission statement, vision, and a set of
values with quality and safety the top priority which
were developed in partnership with staff working in all
of the hospitals in the trust. Staff were clear as to what
the vision was and worked in line with the values.
• There was a realistic strategy for achieving priorities and
delivering good quality care. A divisional operating plan
for 2016/17 and 2017/18 highlighted the trusts strategic
objectives broken down into ten divisional objectives,
actions required to complete the objectives, and how
they were going to complete them. Examples of this
included the trust objective to “continually deliver high
quality individual care, delivered with compassion” was
broken down into five divisional objectives which
included “improve the care for patients presenting with
fractured neck of femurs” and highlighted the need of a
comprehensive review of the service with wider health
partners. Similarly to this was a set of transformation
priorities which were to be integrated into divisional
business plans, health and safety priorities and quality
priorities with each element having actions and
timescales to complete them.
• Senior staff were clear in their understanding of the
strategy, their role in achieving it, and were enthusiastic
about delivering it. All managers we spoke with were
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aware of the strategy for the service, their involvement
in transformation, and the importance on delivering
quality to patients. Staff had progress on the divisional
objectives shared within the ‘Cutting Edge’ newsletter
which was released quarterly.
• The positive attitude and commitment to the trusts
vision and values was evident with all of the staff we
spoke with across the surgical directorate. Staff in
theatres were positive, enthusiastic and forward
thinking, and told us they were committed to delivering
the best care. It was clear the department embraced
change, which was apparent with the new technology
being trialled at the time of our inspection.
Governance, risk management and quality
measurement
• There was an effective governance framework which
supported the delivery of the strategy and good quality
care. The Surgery Head & Neck division was managed by
a clinical chair, divisional director, a head of nursing, a
deputy divisional director and a deputy clinical chair.
The division was split into eight service lines
(anaesthetics, dental, Ear Nose and Throat & Thoracic,
Eye, Gastrointestinal, Intensive care, Theatres, and
Trauma and Orthopaedics) which were managed by a
clinical director, a matron, and a service line manager.
All management staff we spoke with were clear about
their roles and understood what they were accountable
for.
• The governance frameworks and management systems
were regularly reviewed and improved. A rolling
programme called the ‘governance assurance review’
looked at the effectiveness of governance processes in
place within each of the eight service lines every four
months. The divisional management and the patient
safety teams used this to seek assurance that areas of
improvement are being identified and addressed. This
was then rated and recommendations made.
• The trust held the divisional managers to account on a
monthly basis. Senior managers within the division said
they were challenged fiercely around quality and risk
management, but were also well supported and given
resources when necessary to perform improve.
Divisional meetings were held on a weekly basis where
the divisional managers would hold the service line
managers to account for the quality and safety of the
care being delivered. Information would then be
disseminated down to local teams. Team leaders we
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spoke with were positive about the divisional
governance meetings and one member of staff said they
were impressed by the divisions “willingness to try and
improve”.
• Locally team meetings were held on a monthly basis
where messages were disseminated. Staff discussed
these as a forum to raise issues as well as listen and
took a lot from them. At the end of each shift handover
the teams had a ‘safety brief’ to ensure that lessons
from incidents were shared. This included local learning,
learning between wards, and learning for the whole
trust known as ‘trust messages’ which included ward
messages (such as learning around discharge planning),
divisional messages (such as three point identification
checks), and trust messages (such as disposal of
confidential information). Staff in theatres were positive
about how these meetings were conducted and felt they
always learnt something from them. However, we found
in the surgical trauma assessment unit this felt rushed
and not all staff were listening to what was being said.
• There were comprehensive assurance systems and
service performance measures which were reported and
monitored on a regular basis. Action was taken to
improve performance. The division held a dashboard to
gain oversight of performance measures for quality,
flow, and workforce which fed into divisional
governance meetings. Where standards were slipping
action plans were immediately put in place to resolve
them. Information around actions were disseminated to
staff through staff meetings, safety briefings, and written
leaflets and posters. Risk registers were held in each of
the service lines and anything rated under a twelve was
managed locally. Action plans were created for these
risks with accountable individuals, and timelines for
resolution. We were told the divisional managers
provided high challenge and support to encourage local
teams to improve quality.
• There were 11 risks rated 12 or above on the divisional
risk register. The highest risk scored a 15 and was
around meeting cancer standards. This risk was
reviewed weekly at a divisional level and weekly at a
trust level to ensure oversight of the ongoing actions to
resolve the issues. The remaining ten risks were rated 12
with themes around referral to treatment standards,
staffing, financial cost, and quality of care. Each had
rigorous controls in place and were regularly monitored.
• Leaders had the skills, knowledge, experience and
integrity they needed to lead the service effectively. All
leaders we spoke with, at both ward and divisional level
understood and carried out their responsibilities well
and had a clear understanding of their own work and
the work of others around them.
• Leaders were visible, approachable, and encouraged
appreciative and supportive relationships amongst staff.
All team leaders we spoke with commented on the
positive relationship they had with divisional leaders
despite them being new into position. We were told they
listen to concerns and worries and had a “good style of
managing”. Others said they were supportive, focused
on staff and one member of staff said they were a
“breath of fresh air”. Team leaders appreciated the
opportunity to meet with them on a weekly basis and by
having monthly one to one sessions to discuss personal
development and concerns. Staff told us the trust team
were approachable and were always “caring towards
their staff”. One member of staff gave an example of
when they were called up by the chief nurse at seven in
the evening on a Friday to discuss a traumatic situation
which occurred that day.
• At a ward and theatre level staff were equally as
complimentary about the sisters and managers.
Everyone we spoke with said they were well supported
by their managers and could go to them with any
concerns. We were given examples of where managers
had listened to staff and acted upon concerns swiftly
and effectively. Staff described the matrons as “brilliant
and supportive” and were available whenever needed.
• Doctors we spoke with were complimentary about their
leaders. We were told they were proactive and felt
appreciated by them.
• We saw evidence of recognition schemes for staff
excellence. All staff were encouraged to nominate
individuals. The divisional managers gave awards in
recognition and appreciation of the teamwork and
commitment to patient services they display.
• Staff we spoke with could identify their divisional
leaders Photographs of the senior management team
for the directorate were clearly displayed in ward areas
and staff nurses and health care support workers we
approached knew who their senior management team
were.
Leadership of service
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Surgery
• We saw how proactive and forward thinking senior
leadership in the theatre departments had become.
New technology was being trialled at the time of our
inspection with the overarching aim of streamlining
services across the trust.
Culture within the service
• The attitude across all the departments in the surgical
directorate was overwhelmingly positive. We saw how
engaged senior members of the team from the clinicians
to matrons were with the department staff to ensure
they felt respected and valued. Senior staff clearly cared
what their teams were feeling and actively encouraged
collaborative working to improve the service; this was
evidenced by the trial in Hey Groves theatres of the
Happy App. We were shown an example of how well this
worked when a team member had added an idea and
was encouraged to develop it; this resulted in a new
stock checklist for the theatre department and the
sterile services unit.
• Staff reported how a positive culture change in main
theatres gave them the confidence to speak out without
concerns. Staff reported they were ‘being listened to’.
• Staff were open to challenge and actively challenged
others on the quality of their work. One example was
when a nurse challenged the quality of patient notes
when transferring a patient from one ward to another.
• There was engagement from all levels of staff within the
operating suites to the World Health Organisations
(WHO) surgical safety checklist.
Public and staff engagement
• Outside of ward areas there were posters which
displayed “you said, we did”. These were comments left
from patients which resulted in a change in the ward.
For example, one patient commented about the
temperature of the ward, this was resolved by
introducing air conditioning. Another example was
when a patient raised there was no clear
communication from the staff, so changes were made to
the multidisciplinary team process to improve
communication.
• Friends and family results were displayed across the
departments of the hospital and we observed during
the pre-admission process all patients received a
comments card.
• There was a strong emphasis on promoting the safety
and wellbeing of staff. The trust held a theatre quality
103
and culture week to support staff to deliver high quality
care. During this time 37 different theatre liaison officers
(staff with management experience but from outside of
the directorate) spent four days supporting 32 theatres.
A fifth day was spent giving immediate feedback and
discussion points for teams and managers. The
feedback and data were collated and themes shared
with the teams at the end of the week event. These were
then taken to the Transformation project steering group
meeting to enable the theatre management team to
agree and plan actions going forward. Key themes
included the operating theatre profile rising in a positive
light, with a greater understanding of theatre process
and challenge from everyone and a greater sense of
connection between management team and theatre
staff team.
• The trust had introduced a programme of work called
‘Happy App’ into various areas of the surgical division.
This was a tablet based programme, which engaged
staff in regular real time feedback. This allowed staff to
express whether they were feeling positive or negative
about their work and the reasons behind them
anonymously. This enabled the trust to respond to
these issues in real time and avert potential problems as
well as sharing positive emotions and comments. On
two surgical wards on 9 August 2016 there was a total of
75 comments placed onto the ‘’ with 31 of these being
positive, 20 being neutral, and 24 being negative. A
report was created on the same day which
acknowledged the good comments (some of these
being “brilliant team work within staff, good atmosphere
and good vibes” and “the team have all worked
together”) and recognised and acted upon negative
comments. For example one comment was “not enough
staff to manage the number of confused and venerable
patients” which was responded with “please make sure
all have their enhanced observation risk assessments
completed so we can request additional staff if required.
Should dependency outweigh skill mix please talk to me
or on call matron to see if anyone can help us”. This
ensured a quick response to the issue and supported
staff to act upon these concerns. The trust engaged with
staff to get their views on the programme and some of
the comments included “already seeing changes from
the comments made each week” and “I feel that being
able to report, our issues are being listened to which is
positive in itself”. Managers explained to inspectors
there had been a correlation between an increase in
University Hospitals Bristol Main Site Quality Report 02/03/2017
Surgery
Surgery
incident reporting and the use of the ‘Happy App’. A
report stated “rapid changes in mood in a department
highlighted on the app may act as a smoke detector for
problems arising indicating that this may then provide
an impetus for early intervention”.
• Senior staff had identified how important peer support
was for developing a strong team and a new forum for
band seven staff across all the theatre departments was
being set up during the time of our inspection. Terms of
reference were being finalised and meetings were
scheduled to commence early 2017.
Innovation, improvement and sustainability
• There was clear indication of improvement since the
last CQC inspection in September 2014. During the last
inspection there were several breaches in regulation
including for discharge planning, medicines
management, meeting nutritional needs, privacy and
dignity, and sufficient staffing. We found that
throughout the service there were improvements in all
of these areas. The trust was no longer in breach of the
regulations within the surgery service.
• Where any changes to services were made they were
always effectively reviewed, assessed and monitored to
identify the impact on quality and patient care on an
ongoing basis. These were managed within the division.
For example, we saw evidence which showed that due
to innovation and improvement in thoracic surgery
104
there were improvements in the patients’ length of stay.
Another example was within the pain team where the
development of a new pathway had improved
outcomes for patients suffering with a fractured rib.
• Leaders and staff strove for continuous learning,
improvement and innovation. Suggestions to improve
the service were actively encouraged and all
suggestions were taken seriously. This had resulted in
many changes on the wards and in theatres, for
example, changes to the organisation of the ward, the
introduction of protected nursing meal times, changes
to paperwork to improve efficiency. These ideas were
encouraged through staff meetings and forums. Staff we
spoke with said they felt no idea was too small or too
big and they were always listened to.
• Staff were focused on continually improving the quality
of care within the surgical head and neck division and
collaborated well with outside organisations and
universities to integrate innovation and research within
clinical care. This was apparent in cardiac surgery where
90% of patients were given the opportunity to take part
in research. The trust worked with The National Institute
for Health Research and as a result of grants have two
biomedical research units (for cardiovascular disease
and nutrition) within the trust, hold programme grants
for cardiovascular surgery, eye surgery, and maxillofacial
surgery and a plethora of single project grants
throughout the division. The trust had been awarded
NIHR biomedical research status from April 2017 with
the University of Bristol.
University Hospitals Bristol Main Site Quality Report 02/03/2017
Outpatientsanddiagnosticimaging
Outpatients and diagnostic imaging
Safe
Good
–––
Not sufficient evidence to rate
–––
Caring
Good
–––
Responsive
Good
–––
Well-led
Good
–––
Overall
Good
–––
Effective
Information about the service
University Hospitals Bristol NHS Foundation Trust
outpatient services are provided on the University
Hospitals Main Site at the Bristol Royal Infirmary, Bristol Eye
Hospital and University of Bristol School of Oral & Dental
Sciences. Outpatient services are split into different service
lines relating to specialties.
We spoke with 60 patients, 12 relatives and 75 members of
staff .We observed care and treatment and looked at 11
records of care. We reviewed information relating to
performance about the hospital prior to and following our
inspection. We also received feedback via comment cards
from patients.
The trust provides a full range of diagnostic imaging,
including general radiography, computed tomography (CT),
ultrasound, magnetic resonance imaging (MRI), nuclear
medicine, cardiac imaging, interventional radiology and
radiotherapy services at the Bristol Royal Infirmary.
Radiography services are also provided at University of
Bristol School of Oral & Dental Sciences.
Between July 2015 and June 2016 there were 188,914
patient attendances across the specialties that make up
the outpatients department. The specialties where the
largest number of patients attended were dermatology,
cardiology, physiotherapy and trauma and orthopaedics.
We had previously inspected the outpatients department
in November 2014 where the service was found to require
improvement in the safe, responsive and well led domains.
We carried out the announced part of the inspection
between 22 and 24 November 2016 and an unannounced
visit on 1 December 2016.
During our inspection we visited the cardiology,
dermatology, trauma and orthopaedics, oncology,
gastroenterology, respiratory, endocrinology, dental,
ophthalmology, neurology and radiology departments.
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University Hospitals Bristol Main Site Quality Report 02/03/2017
Outpatientsanddiagnosticimaging
Outpatients and diagnostic imaging
Summary of findings
We rated the outpatients and diagnostic imaging service
to be good because:
• There was a good incident reporting culture and
openness and transparency were encouraged. All
staff we spoke with understood and fulfilled their
responsibilities to raise concerns. Lessons learnt
were shared in both outpatients and diagnostic
imaging to make sure action was taken to improve
not just the affected service.
• There were clearly defined systems and processes to
keep people safe and safeguarded from abuse. All
staff we spoke with had a good awareness of
safeguarding legislation and what to do if they had
any concerns.
• People’s care and treatment in both outpatients and
diagnostic imaging was planned and delivered in line
with current evidence based guidance, standards,
best practice and legislation. We saw evidence of
audit to ensure that practice was monitored ensuring
consistency
• Feedback from patients and relatives had been
consistently positive. They praised the way the staff
really understood their needs and involved their
family in their care. Patients were treated as
individuals.
• We found although people were waiting too long for
appointments, there were innovative approaches to
the appointment booking systems and the
management of the capacity and demand of
outpatient’s and diagnostic imaging clinics. This was
under constant review and scrutiny from senior
managers.
• In response to the last inspection and feedback from
patients, each outpatient department had
introduced waiting time boards which displayed the
waiting times for each clinic for that day.
• Services were planned and delivered in a way that
met the needs of the local population and took into
account patient choice.
• There was a clear statement of vision and values,
driven by quality and safety. It was translated into a
credible strategy for outpatients with defined
objectives that were regularly reviewed and relevant.
106
• Staff and patients were engaged in how care was
delivered. Staff felt as if they were active contributors
to how the service was developed.
However:
• Some medical records were not being stored
securely in outpatient departments.
• There was a backlog of appointments and high levels
of referrals meaning people were not able to access
the services for assessment, diagnosis or treatment
when they needed.
• We found doors to the MRI scanners were unlocked
and were accessible to patients in the main waiting
area.
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Outpatients and diagnostic imaging
Are outpatient and diagnostic imaging
services safe?
Good
–––
We rated safe as good because:
• There was a good incident reporting culture and
openness and transparency were encouraged. All staff
we spoke with understood and fulfilled their
responsibilities to raise concerns. Lessons learnt were
shared in both outpatients and diagnostic imaging to
make sure action was taken to improve not just the
affected service but also throughout the hospital.
• There were clearly defined systems and processes to
keep people safe and safeguarded from abuse. All staff
we spoke with had a good awareness of safeguarding
legislation and what to do if they had any concerns.
• Staff we spoke with from all levels of the organisation
had an understanding of duty of candour, when they
would use it and the actions they would take.
• Techniques used ensured cleanliness and infection
control measures were in line with National Institute for
Health and Care Excellence (NICE) quality standards.
• The environment and equipment kept patients safe.
• Systems for the safe storage and administration of
medicines were appropriate and there were audit trails
to monitor the use of controlled drugs.
• In both outpatients and diagnostic imaging
arrangements for managing medicines and contrast
media kept people safe. Contrast and controlled
medications were stored in locked cupboards and
fridges and fridge temperatures were checked daily to
ensure they were in the required range.
• Risks to people who used the service were assessed and
their safety was monitored and maintained.
However:
• We found records were not always stored securely. In
cardiology and dermatology we found record storage
units were not always locked.
• The diagnostic imaging department was spread out
over two floors, and had several sub waiting areas which
were not always monitored by staff meaning patients
were not always observed.
107
• The imaging service had not ensured non-ionising
radiation premises in particular two Magnetic
Resonance Imaging (MRI) scanners had arrangements in
place to control area and restrict access.
• Mandatory training was below the trust target of 90%
completion for medical and dental staff, in particular
information governance training which was at 42% and
manual handling 64%.
• Diagnostic reference levels, which are used to check the
correct amount of radiation is being used to image a
particular part of the body were not always calculated
and displayed in diagnostic imaging rooms
Incidents
• There was a good incident reporting culture, and
openness and transparency were encouraged. Incidents
were graded in accordance with the trust risk
management policy and risk assessment matrix guide.
The guide used the National Patient Safety Agency
(NPSA) risk assessment 5 x 5 matrix and was based upon
guidance ‘A risk matrix for risk managers’. Internal and
external reporting requirements were appendices within
the trust serious incident policy and policy for the
management of incidents. Between September 2015 to
August 2016 there were 959 incidents within the
outpatient departments, of which two resulted in major
harm, 26 moderate harm and 93 minor harm the rest
were classified as having negligible or no harm.
• Between April 2016 and October 2016 there were a total
of 34 incidents in the diagnostic imaging department,
including one incident which was classified as serious.
The serious incident was in relation to a missed finding
on a scan which had been outsourced to a radiology
reporting company. The investigation showed the
finding was not related to the reason the patient had the
scan, and the scans were double reported, in line with
best practice guidelines issued by the Royal College of
Radiologists (RCR). Staff understood their
responsibilities to report incidents externally. The
serious incident relating to a missed diagnosis of a
nodule on a CT scan was reported to the Strategic
Executive Information System (STEIS).
• A trust policy set out the procedures for reporting,
investigating and managing incidents. The policy
included incidents relating to patient safety, health and
safety, information governance, safeguarding, major
outbreaks of communicable diseases, serious IT
systems failures, as well as operational and reputational
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Outpatientsanddiagnosticimaging
Outpatients and diagnostic imaging
incidents. The policy described the root cause analysis
investigation process and the roles and responsibilities
of staff involved in the process. All staff were responsible
for making themselves aware of the contents of the
policy and undertaking the parts of the process for
which they were involved as and when required. Staff
could access the policy via the trust intranet.
• Staff were confident to report incidents using the
electronic reporting system and could give examples of
when they had used it. All staff we spoke with
understood their responsibilities to raise concerns,
record safety incidents and near misses and said they
felt confident to do so because management listened to
them.
• When things went wrong in the outpatients and
diagnostic imaging department, investigations were
carried out. Most relevant staff and people who used
services were involved in the investigations. Staff told us
of an incident where an examination had been repeated
due to patient movement, but a doctor insisted the
radiographer repeat the examination again. An
investigation showed not all radiographers were
comfortable to challenge senior staff or doctors, so the
radiology management team arranged additional
training for the radiographer in how to handle similar
situations. All staff, including the doctor involved were
written to and informed of the outcome of the
investigation.
• Lessons were being shared in both outpatients and
diagnostic imaging to make sure action was taken to
improve not just the affected service but also other
services. We saw evidence of feedback and learning
from service and trust level being shared at team and
staff meetings. Information was also shared in weekly
newsletters and during morning safety huddles which
took place in individual outpatient departments.
Duty of Candour
• Regulation 20 of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014 is a regulation
which was introduced in November 2014. This
Regulation requires the trust to be open and
transparent with a patient when things go wrong in
relation to their care and the patient suffers harm or
could suffer harm which falls into defined thresholds.
• Staff we spoke with from all levels of the organisation
had an understanding of duty of candour, when they
108
would use it and the actions they would take. They
explained there was an open and honest culture with
patients even if the incident did not reach the threshold
for duty of candour.
• The trust 72 hour report template contained a prompt
and section for initial duty of candour. The root cause
analysis template contained a section on full duty of
candour. These were reviewed by divisional and trust
patient safety managers to ensure compliance with
quarterly audits for all serious incidents.
• All new staff (excluding doctors), were introduced to the
principle of being open and duty of candour during the
quality and governance session on induction. A further
patient safety session on induction outlined the
requirements and expectations for staff when complying
with duty of candour. Doctors had a separate induction
programme with a patient safety session which
contained the same content for duty of candour as for
clinical staff. A reminder of duty of candour
requirements and areas for improvement from audits
were included in three yearly patient safety update
sessions for all clinical staff including doctors. Duty of
candour was also included as part of the in-house root
cause analysis training. There were also resources on
the duty of candour intranet pages.
Cleanliness, infection control and hygiene
• High standards of cleanliness were maintained in all
areas of the outpatients and diagnostic imaging
departments. Areas appeared visibly clean, tidy and
clutter and dust free. Equipment was regularly cleaned
and staff were aware of this by the use of ‘I am clean’
stickers and daily cleaning checklists on the doors of
clinical rooms. The daily checklists we observed were all
completed, dated and signed.
• Disposable curtains were used in all outpatient and
diagnostic imaging departments to help prevent the
spread of infection. These were dated and changed in
line with trust policy.
• In all outpatient and diagnostic imaging areas we saw
staff to be observing the bare below the elbow policy.
Staff used aprons and gloves correctly to prevent the
spread of infections. We saw all staff were washing their
hands or using sanitiser gel immediately before and
after patient contact which was in line with the National
Institute of Clinical Excellence (NICE) Quality Statement
61 (Statement 3). Hand gel facilities were available and
clearly signposted in all departments we visited. Staff
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Outpatientsanddiagnosticimaging
Outpatients and diagnostic imaging
•
•
•
•
•
•
explained how standards of cleanliness and hygiene
were maintained. For example, staff could explain the
importance of handwashing and limitations associated
with using alcohol gel. Hand gel was also available for
patients and visitors and these were clearly signposted.
Cleanliness audits were conducted on a monthly basis
to ensure there was continual monitoring of compliance
in regards to cleanliness. We saw evidence of these
cleaning audits in outpatient and diagnostic imaging
departments. Any action was undertaken and
reassessed at the next monthly audit.
Hand hygiene audits were completed on a monthly
basis and we saw records of these. Departments were
regularly 100% compliant. We saw these results clearly
displayed in the Eye Hospital, oncology,
gastroenterology, physiotherapy and dermatology
departments however, we did not see them displayed in
the cardiology or trauma and orthopaedic department.
Reliable systems were in place to prevent and protect
people from a healthcare-associated infection. Staff told
us patients with suspected or confirmed infections were
put at the end of lists to allow cleaning of the rooms and
equipment. These systems were regularly monitored
and improved when required. For example, the
portering system now allowed staff to book patients into
timed slots, which staff said had improved the flow and
flexibility when trying to arrange imaging lists.
Precautions were taken in the diagnostic imaging
department when seeing people with suspected
communicable diseases, and staff showed us where to
find and how to use aprons, gloves and other personal
protective equipment.
Waiting area furniture was clean and in good condition,
able to be wiped clean and fully compliant with the
Health Building Note (HBN) 00-09: Infection control in
the built environment.
Disposable items of equipment were discarded, either in
clinical waste bins or sharp instrument containers.
Nursing staff said these were emptied regularly and
none of the bins or containers we saw were
unacceptably full. All bins we saw were stored securely.
Environment and equipment
• The design, maintenance and use of facilities and
premises kept people safe within the outpatients
departments, but not always in the diagnostic imaging
departments.
109
• The diagnostic imaging department was spread out
over two floors, and had several sub waiting areas which
were not always monitored by staff meaning patients
were not always observed. However, the department
had recently undergone a remodel in some areas such
as trauma and orthopaedic x-ray and the main
reception area and inpatient recovery areas. In these
areas we saw CCTV was used to monitor the waiting
areas and patients. In the newly refurbished areas, there
was plenty of wipe clean seating and the areas were
brightly lit.
• We saw several large delivery cages containing supplies,
bedding and stationary lining the walls of one corridor
which patients needed to navigate to gain access to
some parts of diagnostic imaging. Staff reported this
happened regularly.
• Equipment in outpatient departments had regular
services carried out. All equipment we looked at clearly
displayed the date it last underwent a service and date
the next service would be required. Within the
diagnostic imaging department we saw they had an
asset register which monitored the age of equipment as
well as service history and helped plan when equipment
needed to be replaced. However, two dose metres,
which are used to measure radiation doses were waiting
servicing to ensure they were accurately measuring
doses of radiation.
• Staff used equipment safely and we saw a detailed
competency checklist for each member of staff working
in the different radiological areas. Staff told us they
updated these every three months and highlighted any
examinations or procedures they did not feel confident
carrying out.
• Waiting rooms within the outpatients department were
arranged in a way so patients were always visible to
reception and nursing staff so patients could be
observed and any deteriorating patient detected. We
were informed those patient deemed at higher risk of
deterioration were sat directly opposite and as close as
possible to reception.
• Waiting rooms within the outpatients departments
contained a variety of toys for children as well as
televisions and magazines for adults. Coffee and tea
machines as well as water coolers were also available
for patients.
• A hoist and trolley were available and maintained for
emergency evacuation from the hydrotherapy pool in
the physiotherapy department.
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Outpatientsanddiagnosticimaging
Outpatients and diagnostic imaging
• Consulting rooms contained facilities appropriate to the
specialty of the consultant practitioner, for example
ophthalmic equipment.
• We found utility rooms were unlocked. This meant
cleaning products were not stored securely and could
be accessed by patients, relatives and members of the
public. Within the dermatology department we
observed a cabinet containing chorine based cleaning
products within the unlocked utility room was also
unlocked. This was raised with the trust during
feedback.
• Annual business cases were submitted to the trust for
refurbishment in most areas. There were plans to
revamp the ground floor of the Eye Hospital to provide
more consulting rooms which included a temporary
move to another area.
• In the physiotherapy department the hand unit had
been refurbished; however, there were still a number of
snagging issues to be resolved. There were requests to
change the therapy cubicles to treatment rooms and to
improve the hydrotherapy waiting facilities. There was
an issue with the drains in the changing areas within the
physiotherapy department which prevented patients
using the facilities. This had been ongoing for some time
and had been escalated to the senior management
team. There were also problems with the uneven
pavement at the entrance to the department and
lighting covers at the entrance doors had been removed
as they presented a trip hazard.
• Some clinic rooms were hot and this had been placed
on the risk register following staff raising concerns.
Business cases had been made for the installation of air
conditioning units.
• Staff told us their offices were small with no windows or
air conditioning and could become very overcrowded
and uncomfortable.
• The imaging service carried out prompt and thorough
risk assessments for all new or modified uses of
radiation. These risk assessments addressed
occupational safety as well as consideration of risks to
people who use services and the public. New or
modified uses of radiation were discussed at the twice
yearly radiation protection advisors (RPA) meeting
where all risk assessments associated with the change
in use were discussed. We saw evidence of RPA audit
records where risks and non-compliance were raised
and actions plans but in place.
110
• The diagnostic imaging department had two MRI
scanners which were accessible directly from a corridor
which patients could access from the main reception
area. Doors from the corridor led directly into the
scanners and these were not locked meaning a patient
or member of staff could enter and be exposed to the
magnetic field.
• In ultrasound, sonographers reported on their images in
the area directly outside the examination rooms, which
meant patients had to walk past the reporting stations
to get into and out of the examination rooms. Staff told
us when they were bringing a patient through the area,
they came out of the room first to give the sonographer
a chance to close down the report they were working
on.
• The imaging service used diagnostic reference levels
(DRLs) as way to check the correct amount of radiation
was being used to image a particular part of the body as
required under Regulation 4(3) (c) of IR(ME)R 2000 and
IM(ME) amendment regulations 2006 and 2011. Some
staff were able to locate and explain how they used
these as a tool. However, these were not available or
displayed in all rooms.
Medicines
• Staff had access to the trust medicines management
policy which defined the policies and procedures to be
followed for the management of medicines and
included obtaining, recording, handling, using, safe
keeping, dispensing, safe administration and disposal of
medicines. Staff were knowledgeable about the policy
and told us how medicines were ordered, recorded and
stored.
• We looked at the medicines storage audits, incidents
and complaints, storage security, medicines records,
and supply and waste-disposal processes. Medicines,
including those requiring cool storage, were stored
safely and kept within recommended temperature
range. During our inspection we found all medicines
stored securely, and were only accessible to authorised
staff. All cupboards were locked and the stocks well
organised.
• There were reliable systems for storage, recording and
the administering of contrast media. Computed
tomography (CT) scanners kept contrast containers in
warming cabinets which is in line with manufacturers
guidance. The department had an electronic automated
injection pump, fed by an internal container for the
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Outpatientsanddiagnosticimaging
Outpatients and diagnostic imaging
contrast. The pump was programmed by staff to
administer an amount of contrast over a set period of
time. Batch numbers of contrast containers used were
recorded on the computer records for each patient.
• The imaging service took account of The Medicines
(Administration of Radioactive Substances) Regulations
1978 [MARS]. Each radiologist had in date
Administration of Radioactive Substance certificates
clearly stating the different licences they held and which
radiopharmaceuticals they could administer and for
what purpose.
Records
• Patients' individual care records were written and
managed in a way that kept people safe. In the
outpatients department we looked at 11 sets of paper
records. Ten out of the 11 were clearly written and
legible. All were accurate, up to date and had any known
drug allergies noted.
• Paper records were in use within the outpatients and
diagnostic imaging departments with the introduction
of a new computer based record system due to be
introduced in February 2017.
• Standard Operating Procedures (SOPs) outlined the
processes that were followed for the management of
health records. Processes for the creation, storage,
tracking, access, disclosure and destruction of health
records were in line with the requirements of the policy
• The policy applied to all types of health records
regardless of the media on which they were held. These
included patient health records, X-ray and imaging
reports, output and images, photographs, slides, and
other images, microform (i.e. microfiche/microfilm),
audio and video tapes, cassettes, CD-ROM and DVD,
computerised records and scanned records.
• Notes within the outpatients department were not
always stored and locked away securely. We found in
the cardiology department that record storage bins had
been introduced. However, they were not all locked and
were not always visible to staff meaning patients and
unauthorised staff had access to them. Within the
dermatology department records of allergy testing
which also contained patients personal information
were found in folders stored in unlocked cupboards
within an unlocked treatment room. In oncology notes
were stored in plastic boxes which were under constant
supervision of member of staff. However, confidentiality
could not always be assured.
111
• There were some delays in obtaining patient notes for
clinics, particularly for two week wait appointments.
These had been raised as incidents on the electronic
reporting system and also as a risk on the risk register
and were being investigated by the head of clinical
preparation. The records prepping team had devised an
action plan to look at areas of improvement. Staff had
reported that access to records had improved since the
last inspection and this was audited at 6 monthly audits.
The most recent audit for the outpatients department
showed 11,747 out of 11,798 patient case notes were
available equating to 99.6% being available.
• We witnessed computers being locked when not in use
and these were password protected to prevent
unauthorised access to them.
Safeguarding
• There were systems, processes and practices in place to
keep both adults and children safe from abuse. Staff
had good knowledge of the trust safeguarding policy
which was easily accessible on the trust intranet pages.
Staff were able to show us the contact information for
the safeguarding leads within the trust and local
safeguarding services.
• Safeguarding has three levels of training; level one for
non-clinical staff, level two for all clinical staff and level
three for staff working directly with children and young
people. Training records provided by the trust showed
as of November 2016 100% of nursing staff had received
level two adult safeguarding training against a target of
90% whilst only 88% had completed level two
safeguarding children against a target of 90%. This was
lower in medical and dental staffing where 76% had
completed level two adult safeguarding training whilst
only 66% had completed level two safeguarding
children training.
• Staff we spoke to were able to demonstrate a good
understanding of their responsibilities and the process
involved in raising a safeguarding concern. We heard of
one example where a safeguarding concern was raised
in regards to a patient and their child. The staff worked
with both the local safeguarding teams and
departments within the hospital to ensure any
safeguarding concerns were addressed and the support
was given to the patient and child pre- and
post-treatment.
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• Staff had attended training regarding female genital
mutilation (FGM). This provided instruction for staff on
when they were legally required to report any identified
or suspected risk from FGM to women and children and
how to make these reports.
• Staff were also provided with domestic abuse training to
ensure they were able to recognise warning signs in
order to safeguard patients. We did not see any
information for patients displayed in regards to
domestic abuse.
• Information was also contained in the policy on the
government’s Prevent strategy. Prevent was part of the
government’s counter-terrorism strategy and aimed to
stop people becoming terrorists or supporting
terrorism. Prevent focused on all forms of terrorism in a
pre-criminal space, and provided support and
re-direction to vulnerable individuals at risk of being
groomed into terrorist activity before any crimes were
committed.
• The trust’s safeguarding arrangements were monitored
by the trust safeguarding steering group, chaired by the
chief nurse and included senior divisional
representation. The group reported to the clinical
quality group which in turn reported to the quality and
outcomes committee and subsequently to the trust
board.
• The imaging service ensured the World Health
Organisation (WHO) surgical safety checklist was used
as a checklist when carrying out non-surgical
interventional radiology. An audit carried out in October
2015 showed 34% compliance with all standards
measured, which included signing the patient in and
out, and dating and signing the checklists. The
department had set a target for compliance of 100%,
and was planning to re-audit progress in April 2017.
During our inspection we observed the WHO surgical
safety checklist was carried out for all procedures we
observed.
• There were processes in place to ensure the right person
received the right radiological scan at the right time.
Staff told us they used stop and check procedures as
recommended by the Society of Radiographers as well
as ID bands.
•
•
•
•
staff had received training against a trust target of 90%.
This figure was lower for medical and dental staff, in
particular information governance where only 42% of
medical and dental staff had completed training against
the 90% trust target.
Managers and individuals were informed through an
email flagging system of those staff members whose
training was due to expire. This email also contained
dates of the next available training sessions for these
staff to attend. As well as this staff training analysis
reports were available to enable attendance to be
reviewed, thereby enabling staff and managers to check
their compliance with mandatory training. Managers
were aware of the current status for staff and details
were displayed on white boards in some areas to alert
the team.
The trust provided a programme of mandatory training
for staff which included conflict resolution, equality and
diversity, fire safety, food safety, harassment and
bullying, health and safety, infection prevention and
control, information governance, manual handling,
safeguarding adults, clinical record keeping and conflict
resolution awareness.
Mandatory training was delivered via classroom based
learning and electronic learning. Most staff within the
outpatients department reported they were given the
time to attend training sessions and it was engaging and
responsive to their needs. However, one member of staff
told us staffing shortages often meant it was difficult to
keep up with mandatory training. One member of staff
had stayed on after their shift to complete some on-line
training. We were told within the diagnostic imaging
department it was becoming harder for staff to be
released for face to face training sessions due to the
staffing shortages, which staff said had worsened over
the last six months.
A corporate induction and local induction policy created
a framework in which all staff, whether temporary or
permanent, were effectively introduced to the trust
culture, environment and ways of working. New
members of permanent or temporary staff attended a
corporate induction programme on their first day of
employment.
Mandatory training
Assessing and responding to patient risk
• Almost all staff received training in the systems and
processes which helped keep people safe. Data
provided by the trust showed 89% of outpatient nursing
• Risks to people who used the service were assessed and
their safety was monitored and maintained.
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• Staff we spoke with were able to describe the processes
involved when managing a deteriorating patient. There
were clear pathways and processes for the assessment
and management of deteriorating patients within
outpatients who were clinically unwell and required
hospital admission. In most clinics nurses had acute
experience and were able to recognise and manage
patients who became unwell and transferred them.
• Due to an increase in the number of unwell patients an
emergency blue box had been devised in a number of
clinics within the hospital. A413 and A410 and A407 to
streamline care. The box contained specific equipment
to be able to take blood tests or administer intravenous
medication swiftly. This enabled nurses to spend more
time with the patient and focus on their treatment and
care rather than gathering the equipment. Traditional
sphygmomanometers (an instrument for measuring
blood pressure) as well as automated observation
machines had also been placed in each observation
room. This enabled nurses to measure blood pressure
readings and pulse rate manually particularly for
patients with abnormal blood pressure and to act on
the reading as necessary.
• The cardiology department had devised a discrete
flagging system for those patients deemed high risk. We
observed a high risk patient attend the outpatient
department, their attendance was documented in a
book and a discrete sign placed on the patients notes.
Staff involved in the patient’s care were then informed.
These patients were also directed to sit directly in front
of the reception desk so they could be monitored.
• Risk assessments were carried out in line with national
guidance. We were informed in dermatology they had
adapted the World Health Organisation (WHO) safer
surgery checklist to ensure the minor procedures they
undertook were done so in a safe way. The radiology
department required woman to sign to confirm they
were not pregnant prior to undergoing any radiation
exposure.
• The radiation protection advisor was easily accessible
for providing radiation advice. There was a dedicated
team of physics experts based at the hospital who were
available for advice and support and carried out regular
checks and audits of equipment to ensure it was safe to
use.
• The imaging services had appointed radiation
protection supervisors (RPS) in each clinical area, and
they attended the twice yearly radiation protection
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advisor meetings at least once a year. The radiation
protection supervisors were responsible for feeding risk
assessments for new or modified uses of radiation into
the agendas for the meeting, and were subsequently
involved in discussions around them.
• The diagnostic imaging service ensured the ‘requesting’
of an X-ray, MRI, nuclear medicine or other radiation
diagnostic test, was only made by staff or approved
persons in accordance with Ionising Radiation (Medical
Exposure) Regulations (IR(ME)R). Staff told us they
regularly contacted GP surgeries to update the list of
doctors approved to request diagnostic imaging. Staff
also told us they kept an up to date list of non-medical
requesters (such as nurses). The department had been
involved in a project with two other large acute NHS
trusts nearby, to standardise the protocol for
non-medical requestors, which clearly set out what they
could and could not ask for. The policy also covered
IR(ME)R training which all non-medical requestors had
to undertake before they were signed off. The radiation
protection advisor team based at the trust were
supplying all training to non-medical requestors in the
geographical areas of the three trusts.
• There were signs and information displayed in the
radiation department waiting area informing people
about areas and rooms where radiation exposure took
place, however we saw a corridor leading off the waiting
area to an X-ray room where the access door was
propped open.
• There were local policies for the risk assessment and
prevention of contrast induced nephropathy, and staff
were aware of these policies which were in keeping with
the National Institute for health and Care Excellence
(NICE) guidelines and the Royal College of Radiologists
standards for the administration of intravascular
contrast agent administration. Staff told us estimated
glomerular filtration rates (eGFR) were always checked
for patients receiving iodinated contrast agents. Staff
said this was not always done when requests were
vetted, but was always done and documented on the
radiology computer system before any intravenous
contrast was given to a patient.
Nursing and allied health professional staffing
• Staffing levels within the outpatients department
compared well to the planned level and thus kept
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patients safe at all times. The outpatients department
reported in July 2016 they had an over establishment
resulting in a vacancy rate of minus 0.6% for nursing
staff.
• Staff reported they tried not to use bank and agency
staff and where possible when sickness or leave
occurred these shifts would be covered by staff within
the department. Between September 2015 and August
2016 the outpatients department reported a bank and
agency usage rate of 0.9%.
• Staff within the diagnostic imaging department did not
feel levels were sufficient to meet the needs of the
service. At the time of our inspection there was one
vacancy within the diagnostic imaging department.
Senior members of staff felt current staffing levels meant
the computed tomography (CT) scanners could not
always be run as efficiently as possible and staff were
often working alone.
Medical staffing
• Staffing levels and skill mix were planned and reviewed
so people received safe care and treatment at all times.
The diagnostic imaging department had constructed
and adapted a staffing model. The model had shown
the department needed 10 more radiologist posts to
meet all targets, and the department had been
increasing the number of radiologist post by two per
year for the two years prior to our inspection, alongside
training radiographers to report some examinations to
help meet internal and external targets for waiting times
and report turnaround times.
• Within the outpatients department, consultants held
regular clinics and were responsible for the care of their
patients. In July 2016 a vacancy rate of 3.4% was
reported for medical staff with a turnover rate of 10.4%.
• Sickness rates were reported as 0.4% in July 2016 with a
bank and locum usage rate of 0.3%
• All doctors who were employed at the trust in January
2013, who continued to practice had undergone
revalidation of their licence.
Major incident awareness and training
• There was a trust business continuity plan which
outlined the decisions and actions to be taken to
respond to and recover from a range of consequences
caused by a significant disruptive event ranging from a
technology failure to an influenza pandemic. The staff
we spoke to were aware of the plan and how to access
this on the trust intranet system.
• Systems were in place to manage computer system
failure. The diagnostic imaging department had a
continuity plan to manage a loss of their RIS and PACs
computer system and ensure patient safety.
Are outpatient and diagnostic imaging
services effective?
Not sufficient evidence to rate
–––
Although we inspected the effective domain in outpatient
and diagnostic imaging services we did not rate them due
to the lack of national data available to the CQC. We found
that:
• Patients' care and treatment in both outpatients and
diagnostic imaging was planned and delivered in line
with current evidence based guidance, standards, best
practice and legislation.
• Both the diagnostic imaging service and outpatient
services benchmarked against each other and actions
were put in place to improve outcomes.
• Staff had the right qualifications, skills, knowledge and
experience to do their jobs when they started their
employment, when they took on new responsibilities.
• All necessary staff, teams and services were involved in
assessing, planning and delivering patients care and
treatment.
• The systems that managed information about patients
supported staff to deliver effective care and treatment.
• Staff we spoke with understood the relevant consent
and decision making requirements of legislation and
guidance including that of the Mental Capacity Act 2005.
However:
• The diagnostic imaging service did not always ensure it
met best practice clinical guidance for report
turnaround time for medical staff requesting diagnostic
imaging to be carried out.
Evidence-based care and treatment
• Relevant and current evidence based guidance;
standards, best practice and legislation were identified
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and used to develop services in outpatients and
diagnostic imaging. Any alerts or information were
shared at either safety briefings or staff meetings. For
example, in dermatology they had introduced a minimal
eurythmic device which is a device to indicate the
strength of light that can be administered to patients,
this was line with the British Association of
Dermatologists guidelines and helped reduced the
number of appointments patients needed to receive
and reduce the level of UV exposure. The dermatology
department were also due to start photodynamic
therapy for superficial treatment of basal cell
carcinomas, this would reduce the number of patients
having to undergo surgery and thus also reduce surgery
wait times.
• Compliance with current evidence based guidelines was
monitored. Within the dermatology department an
audit had been undertaken to assess whether clinicians
were following 2012 clinical guidelines surrounding the
assessment of patients. It was determined some areas
of assessment were not always being completed,
learning and training from this audit was shared with
staff to assure full completion of assessments.
• National Institute for Health and Care Excellence (NICE)
guidance were followed in both the outpatients and
diagnostic imaging departments. The rheumatology
department followed NICE guidelines for the care
pathway for patients with rheumatoid arthritis. The
diagnostic imaging department ensured it followed
NICE guidelines for acting on radiologist reports, such as
NICE quality standard 17 for suspected lung cancer. Staff
described how they flagged urgent reports to GPs, and
followed this up to ensure the report and its
recommendations had been followed up on. We saw
the department had a standard operating procedure
(SOP) in place to deal with unexpected findings of which
staff were aware.
• The Commissioning for Quality and Innovation (CQUIN)
payment framework enabled commissioners to reward
excellence by linking a proportion of English healthcare
providers’ income to the achievement of local quality
improvement goals. A CQUIN was in place for the
development of a resource to illustrate the ‘3 Questions’
that patients should be asking with reference to their
treatment options. This resource was used at the
haematology and oncology centre and the heart
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•
•
•
•
•
institute for cardiology and oncology. As part of this
CQUIN, 8000 A5 postcards and 10 A3 posters were
designed and produced to educate patients about the
‘3 questions they should ask.
Patients were encouraged and supported to make
informed decisions about their treatment and
healthcare and were provided with information that
assisted them in asking questions about their treatment
they might otherwise find challenging. The objective
was to roll out a resource for patients in 2015/2016 that
would explain the ‘3 Questions’ to ask to support them
when making treatment decisions. The resource was
included in the patient information pack that was sent
out to all new patients with the appointment letter for
their first outpatient appointment.
Clinical teams were supported to engage with patients
and their carers and families to learn about what was
important to them, through structured conversations
about treatment decisions. This is also included the use
of ‘This is me’ documents which contained information
about patients history, likes and dislikes.
Physiotherapists participated in national benchmarking
and interest groups and network sharing with other
hospitals.
The Society and College of Radiographers produced
‘Pause and Check’ resources to reduce the number of
radiation incidents through misidentification occurring
within radiology departments. For all examinations we
observed, staff using the pause and check method and
‘pause and check’ posters were displayed in every room.
The diagnostic imaging service incorporated relevant
and current evidence-based best practice guidance and
standards, to develop how services, care and treatment
were delivered. For example, the National Institute for
Clinical Excellence (NICE) recommends computerised
tomography of the chest and abdomen in patients who
suffer an unprovoked deep vein thrombosis (blood clot),
which the department had integrated into its CT
protocols.
Pain relief, nutrition and hydration
• In each outpatient department there were tea, coffee
and water facilities available for patients. Snack boxes
were stored for those patients who required them as
well as vending machines and cafes throughout the
hospital with clear signposting to these displayed in
departments.
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• Staff said it was unusual to have to ask patients in
outpatient clinics to rate their pain although all staff
demonstrated a good understanding of simple comfort
scale methods available to them for the management of
patient’s pain.
Patient outcomes
• A governance framework was in place to ensure a range
of outcomes were reviewed and discussed.
• Patient outcomes such as “did not attend” and
cancellation rates were monitored in each outpatients
department as well as centrally by the appointment
booking centre. Clinics were then benchmarked against
each other and actions put in place to improve
outcomes. We were informed that the appointment
centre had conducted a short survey regarding the
effectiveness of text reminders by making changes to
the language used. In a separate work stream the trust
were introducing the option for patients to have their
appointment letters sent by email, in order to reduce
the number of patients that did not attend clinics. They
were also in the process of introducing email reminders.
• Patient outcomes were also assessed through audit and
annual review. Within the dermatology department
outcome data for each case of skin cancer excision was
collected and then benchmarked. The Trust informed us
the most recent data showed reduced re-operation
rates.
• The diagnostic imaging department was preparing to
submit documentation in preparation for an inspection
by the Imaging Services Accreditation Scheme (ISAS).
Previously the diagnostic Imaging service used ISO9001
as their set of quality standards for the diagnostic
imaging department. Staff preparing the
documentation for the inspection told us they had
found the process very useful as it had made them look
at and improve their internal processes and procedures.
The department had set a target to achieve
accreditation by September 2017. The Imaging Services
Accreditation Scheme is an assessment and
accreditation programme which covers a list of quality
standards covering quality, delivery, safety and patient
experience.
• In addition to the work surrounding ISAS accreditation,
the imaging department also participated in South West
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benchmarking. Managers attended the South West
regional radiology managers group where
benchmarking in regards to agency costs, staffing levels,
vacancies and scanner utilisation was looked at.
Competent staff
• Staff had the right qualifications, skills, knowledge and
experience to do their jobs when they started their
employment, or when they took on new responsibilities.
For example, a number of band 5 radiographers had
been allowed to undertake a formal qualification in CT
as part of their training, and the department had seven
reporting radiographers who had also undertaken
formal training in order to issue reports on certain types
of plain film X-rays. However, some staff were concerned
junior staff were being left alone in CT before they were
confident to run the scanner unassisted.
• Staff had their learning needs identified through an
appraisal. However, during the financial year 2015 to
2016 only 79% of staff within the outpatients
department had received an appraisal against a trust
target of 85%. The appraisal rate for medical and dental
staff was a lot lower with only 35% of staff receiving an
appraisal. Staff who had received an appraisal informed
us they felt they were a worthwhile process where their
developmental needs were addressed and acted on.
• Staff were supported in the revalidation process. Staff
we spoke to reported they were given the time to attend
continuing professional development training and time
was also given for them to complete the revalidation
process. There was a commitment to training and
education within outpatients. Staff felt well supported
to maintain and further develop their professional skills
and experience. They were encouraged to develop their
knowledge and skills and were supported in their
continuous professional development. There were
opportunities to attend external training and staff were
able to apply for full or partial funding depending on the
appropriateness for their job role.
• Most staff we spoke with were positive about the quality
and the frequency of clinical supervision they received.
• Attendance was monitored by managers with follow up
for non-attendance ensuring staff received training and
regular updates for maintaining a level of competence
appropriate to each individual’s employed role.
• All staff administering radiation were trained to do so.
Those staff who were not formally trained in radiation
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Outpatients and diagnostic imaging
administration, were always adequately supervised in
accordance with legislation set out under Ionising
Radiation (Medical Exposure) Regulations (IR(ME)R), and
we saw students working alongside qualified
radiographers, who provided supervision and guidance
for the students.
• An inability to recruit to some specialist roles had meant
the diagnostic imaging department had developed an
internal career pathway for some of the radiology
assistants to follow. For example, one member of
clerical staff had re-trained to provide Dual-energy X-ray
absorptiometry (DEXA) imaging.
• There were clear records showing which radiologists
were entitled to administer radioactive medicinal
products and we saw records detailing which staff had
the necessary certificate from ‘The Administration of
Radioactive Substances Advisory Committee’ (ARSAC).
Multidisciplinary working
• All necessary staff, teams and services were involved in
assessing, planning and delivering patients care and
treatment. We were told relationships between the
outpatient departments were good and learning was
shared. For example, the use of discrete labelling of
patient notes to highlight to staff patients who were
medically compromised or may require additional help
for example patients with pacemakers, at risk of falling
or visually impaired, was in use in both the cardiology
and gastroenterology departments.
• The outpatient departments worked well with the local
GPs in the area to help plan and deliver care. We were
informed due to the high level of patients not attending
appointments (DNAs) in the chest pain clinic, the
cardiology department had worked with local GPs and
determined a daily drop in chest pain clinic would be
more effective. This had improved DNA rates and
enabled GPs to give patients more options and flexibility
to attend appointments.
• Staff were aware of the need to work well with social
care services in the area. We were informed of
incidences where social care members of staff attended
multidisciplinary meetings to ensure patients received a
more comprehensive package of care.
• As part of the justification process to carry out exposure
to radiation, the imaging service always attempted to
make use of previous images of the same person
requiring the test, even if these have been taken
117
elsewhere. The trust had an image exchange portal
(IEP), which meant images could be transferred between
hospitals at any time of day or night. Senior managers
told us the system could be difficult to use for clinicians
who were not familiar with it, and some problems had
arisen when staff tried to search for patient images with
the trust’s unique reference number, rather than the
patient name or NHS number. Staff told us,
radiographers were often able to help with simple
queries, but for more complex questions, there was a
member of the picture archiving communications
(PACS) team on-call.
• The diagnostic imaging department had a number of
images which it had been agreed, did not need a formal
report. There was a policy outlining how these images
were selected, and covered follow up X-rays for
inpatients and any subsequent X-rays in the same
patient episode, unless the referring doctor asked for a
report.
• Managers told us it was the responsibility of the referring
doctor to record any findings from imaging in the
patients records. However when this had been audited,
the results showed this had not been happening in all
cases. Following a period of retraining, the diagnostic
imaging department re-audited a sample of notes in
August 2015 to see if this had improved. The results
showed this had improved and 80% of the records
looked at, image findings were being recorded. The
radiology team was engaging with different teams to
improve this result further.
Seven-day services
• Most outpatient services ran a traditional five day
service. However, if demand was particularly high then
some services had arranged weekend or out of clinics
on an ad hoc basis. When clinics were closed and
patients required advice or help they were directed to
their GP, 111 services or the accident and emergency
department. We were informed in the trauma and
orthopaedic department that patients could leave
messages if the clinic was not open; these messages
were then flagged to the department during their
opening times.
• Some diagnostic imaging services were available seven
days apart from interventional radiology (IR) and
nuclear medicine. Full access to CT, MRI and ultrasound
(including formal radiological reporting) had weekend
availability limited to emergencies only. However, the
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performance of non-emergency CT and MRI scanning
(with radiological report pending) was also undertaken
at weekends. There was no vascular service and
consequently an interventional radiology capability was
limited to normal hours, with an informal arrangement
with another NHS organisation for emergency provision.
Plans were proposed including formalisation of
interventional radiology arrangements with the other
NHS organisation and development of an in-house
non-vascular interventional radiology service and
formal dialogue was underway to progress this.
• Physiotherapy appointments were available on some
Saturdays to help with patient flow.
Access to information
• Most of the information required to deliver effective care
and treatment was found in patient case notes. The
availability of these is a requirement of NICE quality
statement 15 (statement 12) which states patients
should experience coordinated care with clear and
accurate information exchange between relevant health
and social care professionals. An audit into the
availability of these notes was carried out on a six
monthly basis with the last audit carried out in April
2016 showing 11,747 out of 11,798 patient case notes
which equated to 99.57% being available and 0.43%
unavailable.
• At the time of our inspection the outpatient
departments we visited were using paper records. We
were informed the introduction of a computer based
record system was due to go live in February 2017. It was
felt this would improve access to patient records and
the sharing of information between departments.
• The systems that managed information about patients
supported staff to deliver effective care and treatment.
For example, senior managers showed us they had
integrated the referrer programme into their electronic
requesting system, so guidance on which test to request
was always and immediately available to referrers not
just in the hospital, but in the GP surgeries and other
locations in the community. Ireferrer is an information
database created and maintained by the Royal College
of Radiologists which provides up to date best practice
guidance on requesting diagnostic imaging.
• The diagnostic imaging service provided electronic
access to diagnostic results for all referring staff in the
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hospital via its requesting system and also for all clinical
staff via its PACs system. The same electronic referring
system also allowed GPs and other community referrers
to access results electronically.
• When patients moved between teams and services or
hospitals the information needed for their ongoing care
was shared appropriately and in a timely way. Staff were
able to clearly tell us the different ways images were
shared securely depending on the receiving
organisations computer system.
Consent, Mental Capacity Act and Deprivation of
Liberty Safeguards
• Most staff were aware of consent and decision making
requirements of legislation and guidance, including the
Mental Capacity Act 2005 and the Deprivation of Liberty
Safeguards (DoLS). The Mental Capacity Act and
deprivation of liberty training was fully incorporated into
safeguarding training. Staff had attended mandatory
training and knew what their responsibilities were and
how to apply them within everyday practice. In both the
outpatient department and diagnostic imaging extra
time would be allowed for an appointment if staff were
made aware a patient had learning difficulties and may
require extra time.
• Staff had a good knowledge and understanding of the
processes involved in determining whether a patient
had capacity, how to gain adequate consent and their
responsibilities surrounding this. We heard of an
example where a nurse challenged a doctor’s decision
surrounding a patient’s capacity. It was deemed the
patient lacked capacity consent so an Independent
Mental Capacity Advocate was contacted to attend and
help ensure decisions were made in the patients best
interest.
• Staff said they obtained consent from patients prior to
commencing care or treatment. They said patients were
given choices when they accessed their service.
• Throughout the inspection we saw staff explaining the
assessment and consent process to patients and any
need to share information with other professionals such
as GPs, before obtaining written consent. We saw
consent forms were signed by patients.
• We heard staff discussing the treatment and care
options available to patients.
• Radiographers who were delivering radiotherapy
treatment or undertaking a clinical imaging examination
had a duty of care to ensure that patients were fully
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aware of the procedure and had consented. The
radiotherapy department had a consent procedure
which was part of its Quality Management System. An
audit had been conducted where documentation was
analysed for 50 eligible patients. Results showed 100%
of consent forms were present at the time of the audit
and had been signed by the clinician; 98% of patients
had signed their consent form before treatment
commenced and 87% had confirmation completed
before treatment commenced.
• Where it was deemed patients had capacity, staff still
recognised the need for relative’s involvement in
supporting patients to make a decision. We observed
carers and relatives being encouraged to attend clinic
appointments.
•
•
Are outpatient and diagnostic imaging
services caring?
Good
–––
•
We rated caring as good because:
• Feedback from patients and relatives had been
consistently positive.
• Patients said staff were caring and compassionate,
treated them with dignity and respect, and made them
feel safe.
• Staff were skilled to be able to communicate well with
patients to reduce their anxieties and keep them
informed of what was happening and involved in their
care.
• Relatives were encouraged to be involved in care as
much as they wanted to be, while patients were
encouraged to be as independent as possible.
• We observed staff treating patients with kindness and
warmth.
• Staff talked about patients compassionately with
knowledge of their circumstances and those of their
families.
•
•
Compassionate care
• We spoke with 60 patients and 12 relatives in the
outpatient departments and all were overwhelmingly
•
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positive about the care and treatment they had
received. Patients told us they had received
compassionate and sensitive treatment and care by
staff.
Throughout our inspection, we observed patients being
treated with compassion, dignity and respect. We saw
all staff going the extra mile to support patients’
personal and cultural needs. For example, staff made
great efforts to pass on specific needs about a patient to
the surgical team to ensure a smooth transition.
During our inspection we observed excellent
interactions between staff, patients and their relatives.
We saw these interactions were very caring, respectful
and compassionate. For example, when a patient
became concerned about the length of time their
relative had been waiting for them a member of staff
went to find the relative to let them know how much
longer they would be waiting. The member of staff
returned to reassure the patient.
Staff were skilled in talking to and caring for patients.
Patients were encouraged to be as independent as
possible and relatives were encouraged to provide as
much care as they felt able to. We observed all staff
taking time to talk to patients. They involved and
encouraged both patients and their relatives as partners
in their own care. We observed staff asking relatives,
with the patients consent, if they would like to attend
consultations
There were positive results from patient satisfaction
surveys with data from the diagnostic imaging
department showing between 95 and 100% of patients
would be either likely or extremely likely to recommend
the service to friends and family if they needed similar
treatment or care.
Patients we met spoke highly of the service they
received. All the feedback we received from the patients
was very positive about the care they received. The
comments we received during our discussions with
patients included, "the staff have been fantastic", "I’m
very happy with the care I’ve had … I can’t fault it.”
Patients in the diagnostic imaging department were
also unanimous in their praise and comments included,
“the staff are amazing, kind and lovely”, “I was really
scared about the scan but the staff explained everything
and helped me to stay calm”, “They really know their
stuff.”
A chaperone policy set out the policy and standard
operating procedures for promoting the privacy and
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Outpatients and diagnostic imaging
dignity of patients. We observed good attention from all
staff to patient’s privacy and dignity. We observed voices
being lowered to avoid confidential or private
information being overheard on arrival at reception
areas. All patients said their privacy and dignity was
maintained. However, we saw in the main waiting area
of radiology, there were double doors which led into a
patient recovery area. The central panels in the doors
were glass, which meant people in the main waiting
area could see clearly into the recovery area. Also within
the outpatient department we observed a door left
open and the conversation with the patient and their
relative could be overheard and did not guarantee
privacy and confidentiality.
• Care from the nursing, medical staff and support staff
was delivered with kindness and patience. We observed
staff giving patients the time to respond. The
atmosphere was calm and professional without losing
warmth and reassurance.
• In the main X-ray waiting area, patients were not always
able to speak to the receptionist without being
overheard, this could include confidential information.
Understanding and involvement of patients and those
close to them
• Patients were involved with their care and decisions
taken. We observed staff explaining things to patients in
a way they could understand. For example, during a
complex explanation, time was allowed for the patient
or their relative to ask whatever questions they wanted
to.
• Patients and relatives were encouraged to be involved
in their care as much as they felt able to. Patients we
spoke with all confirmed this was the case. One patient
said “I’ve felt very much included in the planning of my
treatment and I’m very happy with everything.”
• All healthcare professionals involved with the patient’s
care introduced themselves and explained their roles
and responsibilities.
• Staff recognised when patients needed additional
support to help them understand and be involved in
their care and treatment. They were knowledgeable,
compassionate and patient when dealing with
communication with families who were non-English
speakers, or for whom English was a second language as
well as patients with hearing or visual impairment, or
who had learning disabilities.
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Emotional support
• We observed staff providing emotional support to
patients and relatives during their visit to the
department. Patient’s individual concerns were
promptly identified and responded to in a positive and
reassuring way. One patient who regularly attended the
department said “nothing was too much trouble for the
staff … from the doctors and nurses to the
administration team.”
• Patients and their relatives were spoken with in an
unhurried manner and staff checked if information was
understood. We overheard staff encouraging them to
call back at any time if they continued to have concerns;
however, minor they perceived them to be.
• Opportunities for patients to ask questions or raise any
concerns was also observed during consultations Staff
responded in a reassuring and knowledgeable manner
and a patient told us they felt “so much more relaxed
about the whole thing … and I know can phone if I need
to go over what to do again.”
• Staff understood the impact the care, treatment or
condition might have on the patient’s wellbeing and on
those close to them both emotionally and socially. Staff
told us they felt they not only had a duty of care to the
patients but also to their families.
Are outpatient and diagnostic imaging
services responsive?
Good
–––
We rated responsive as requires good because:
• In response to the last inspection and feedback from
patients, each outpatient department had introduced
waiting time boards which displayed the waiting times
for each clinic for that day.
• Services were planned and delivered in a way that met
the needs of the local population and took into account
patient choice.
• Lessons were learnt from complaints and were
disseminated well to different teams with people
informed of the outcomes.
• The trust was performing better than the national
standard of 93% by seeing 94% of patients within two
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Outpatients and diagnostic imaging
weeks for urgent GP cancer referrals. It was also
achieving above the national operational standard,
96%, for people waiting less than 31 days from diagnosis
to first definitive treatment.
• The trust’s diagnostic and imaging departments were
achieving a trust total of 98.9% of the percentage of
patients seen within six weeks. This was above the
national average of 98%.
• A central appointment booking system had been
introduced to improve responsiveness to referrals and
members of the public.
• Tea and food was actively provided for all patients who
required transport or had a medical condition where
blood sugar levels had to be maintained.
•
However:
• In the outpatients departments the overall referral to
treatment standard on average was slightly worse than
the national average between September 2015 and
August 2016. In particular within the gastroenterology
48.6% and oral surgery department 64.3% of patients
were seen with 18 weeks.
• Of the patients classified as urgent 18% were not seen
within the two week target.
• Patients were not always able to locate the outpatients
and diagnostic imaging departments because they were
not clearly signposted.
• The parking facilities did not always meet the demand
leaving patients unable to find a space in a timely
manner.
• Each outpatient department had a wide selection of
information leaflets available to patients; however, they
were not available in other languages.
•
•
Service planning and delivery to meet the needs of
local people
• Appointments were arranged where possible around
the needs and requirements of the patient. The
diagnostics and therapies division had introduced a
patient survey with the most recent data showing 87%
of people were given a choice of appointment time if
they wanted one. Patients informed us staff where
flexible and listened to their needs.
• A central appointment booking system had been
introduced to increase response times to patient phone
calls and ensure all available clinic space was utilised.
An audit of the number of patient phone calls answered
within 60 seconds showed prior to the appointment
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booking system 40% of calls for the dental department
were being answered within the targeted time, this had
improved to 64% following the dental department
moving to the central appointment booking system. At
the time of the inspection not all outpatient
departments were using the central booking system;
however, there was a plan in place for this to occur in
the future.
In response to the last inspection (in September 2014)
and feedback from patients, each outpatient
department had introduced waiting time boards which
displayed the waiting times for each clinic for that day.
We found generally clinics ran on time and an audit of
waiting times showed 91% of patients were seen within
15 minutes. However, an audit of the waiting times in
the diagnostic imaging and the therapies department
showed that only 58% of patients were informed how
long a delay there would be (if over 15 minutes) and
only 53% informed as to the reason for the delay. At the
time of our inspection there was a system being
developed so reception staff could inform patients of a
more accurate waiting time when they checked in for
their appointment.
Changes had been made to the delivery of some
services in response to the needs of the patient. The
chest pain clinic within the cardiology department had
been experiencing a high level of patients who “did not
attend”. In response to this the service had decided to
run open chest pain clinics on a daily basis, giving
patients greater flexibility and access to the service.
Patients were not always able to locate the outpatients
and diagnostic imaging departments because it was not
clearly signposted. Staff told us the trust had recently
changed the system of signage to a combination of
letter and numbers (for example A217). Some patients
had mentioned it was difficult to identify which number
should correspond with the department they were
looking for.
Information was provided to patients in accessible
formats before diagnostic imaging appointments, which
included information about contact details, a hospital
map and directions, the consultant’s name and
information about the examination the patient was
coming for.
Patients raised concerns around travelling to and from
the hospital especially the difficulties in parking once
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Outpatients and diagnostic imaging
arriving at the trust. This was particularly difficult when
accessing the cardiology department where patients
with cardiac problems would often have to walk up a
steep hill.
• Whilst the vast majority of paediatric examinations took
place at a nearby specialist hospital, some children still
did need attend the department for specialist tests. The
facilities for children in waiting rooms were not always
adequate, and the small area designated for children
was dark and was not easily seen by staff.
• There were a number of satellite serves available at a
number of locations across the area. Oncology
outpatient clinics were held at a GP practice and a
community hospital and eye clinics were held at a GP
practice and a mobile ophthalmic clinic at a shopping
centre.
•
•
Access and flow
• Referral to Treatment (RTT) timeliness was monitored
on a weekly basis in the Surgical, Head & Neck division
which was reported to the trust board on a monthly
basis. Each sub-specialty within the directorate reported
to a RTT lead who held them to account for actions
against an action plan and discussed individual patients
who were waiting longer than 18 weeks with consultants
to ensure the patients at highest risk were seen first. In
outpatients referral to treatment standards (within 18
weeks) on average were worse than the national
average between November 2015 and October 2016. In
particular, gastroenterology which was only achieving
48.6% against a national average of 85.5%. Other areas
that were significantly below the England average for
referral to treatment times were, oral surgery, neurology,
cardiology and trauma and orthopaedics. Some
departments were above the national average for
referral to treatment times, this included rheumatology,
ophthalmology and ear nose and throat. Overall from
September 2015 to October 2016 the trust was achieving
90% of patients being seen within 18 weeks against an
operational standard of 92%. Where there had been a
slip in performance there were clear actions to address
these which had been proven to be effective. This was
recognised by the trust and, for example, in cardiology,
weekend clinics were provided and consultants were
held to account if the number of patients there were
seeing was below average.
• There was a high demand for therapy outpatient
appointments and the team had concerns about the
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backlog of appointments. A telephone triage system in
physiotherapy was in operation every day. Physio Direct
enabled patients to talk to a qualified physiotherapist
about their problem following an initial referral from
their GP or consultant. An exercise plan or an
appointment to attend a clinic assessment was
arranged if required. There were plans to extend the
service to include patients from more GP practices.
Urgent GP cancer referrals need to be seen within two
weeks to ensure timely diagnosis and treatment. The
trust was performing better than the national standard
of 93% by seeing 94% of patients within two weeks. It
was also achieving above the national operational
standard, 96%, for people waiting less than 31 days from
diagnosis to first definitive treatment.
The most recent ‘Do Not Attend’ (DNA) data provided by
the trust showed between April 2015 and March 2016
rates were better than the England average of 6%.
Reasons were monitored to look for themes and actions
taken to address any problems. The appointment
booking team had looked at whether the way in which
patients were reminded of appointments, by phone or
text, helped improve DNA rates.
The diagnostic and imaging department was achieving
a trust total of 98.9% of the percentage of patients seen
within six weeks. This was above the national average of
98%.
The diagnostic and imaging department managers met
monthly to go through the current reporting backlog
and prioritise those deemed to be high risk. However, at
the time of our inspection there were 187 patients who
had been categorised as urgent and needing to be seen
within 2 weeks. Of the 187 patients 34 had been waiting
over 2 weeks which equates to 18%. This meant patients
could be deteriorating and their condition worsening
whilst they were awaiting imaging. Risk assessments
were carried out for each of these patients during
weekly divisional level where action plans were put in
place and patients who required more urgent imaging
would be allocated an inpatient slot if necessary. A
patient tracking list was also used at departmental level
which looked at utilising any cancelled slots
Care and treatment was only cancelled or delayed when
absolutely necessary. Patients told us cancellations
were always explained to them, and they were
supported to access care and treatment again as soon
as possible. Investigations into the reason for an 11.8%
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Outpatients and diagnostic imaging
hospital cancellation rate within the outpatients and
diagnostic imaging department had been undertaken
by the outpatient steering group and work streams were
in place to try and address the causes.
• Patients were advised chaperones were available to
support them at any time during their appointment and
advised to ask a member of the nursing team. Posters
informing patients of this were displayed in each
department.
•
Meeting people’s individual needs
• Services were planned to meet the needs of individuals.
The cardiology and gastroenterology department had
devised a discrete flagging system to highlight patient’s
individual needs. This included patients that were living
with dementia, were visually impaired or diabetic. This
information was then shared with staff so support could
be given. Patients who were flagged as being diabetic
would then be offered a snack box containing food to
ensure they maintained a safe blood sugar level. Each
outpatient department had a dementia lead and staff
received training in dementia and learning disability
awareness as part of their training.
• Transport services were available for patients with
mobility problems. Staff reported sometimes patients
were dropped off early or had to wait to be picked up.
Staff ensured that if a patient arrived early they would
try and arrange to see the patient as soon as possible
and any patient waiting for transport was offered a drink
and a snack box.
• There was disabled access to all the outpatient and
diagnostic imaging departments, and the reception
desk had a lowered section for wheelchair users in most
clinics. The dental hospital had recently obtained a
bariatric chair as well as replacing the existing dental
chairs to ones that had a greater weight limit. However,
some departments were more difficult to access than
others. The dermatology department was situated in a
position which required patients to navigate numerous
corridors and areas outside which may prove difficult for
patients with mobility issues.
• The trust had a number of translation and interpreting
services which were accessible for patients.
Face-to-face, telephone and written interpreting
provided access to 35 different languages. All
interpreting services were available 24 hours a day, 365
days a year. The service was used for translating
documents such as internally produced patient
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information leaflets, patient letters and notes. For
patients with visual impairments, the trust used a local
company to provide translation of documents into
alternative formats including Braille. Interpreting
services for the deaf were available and included British
Sign Language. Staff could tell us how they would
access the services.
Religious needs of patients were also met and
respected. The department of spiritual and pastoral care
(chaplaincy) provided spiritual, religious and pastoral
care to patients, relatives and carers: people of all faiths
and those of none. The chaplaincy also provided a
confidential listening ear for staff and could help with
ethical questions, and de-briefing after difficult and
traumatic incidents. The cardiology department had
clear protocols and guidelines regarding blood
transfusions and the treatment of patients who did not
want to receive them. Staff informed us the views of the
patient were always respected and they were involved
in any decision made.
Support was sometimes available for bariatric patients.
For example new CT equipment commissioned by the
diagnostic imaging service had an increased table
weight limit and a larger area for patient to pass through
the scanner.
The diagnostic imaging service arranged appointments
so that new patients were allowed time to ask questions
and have follow-up tests at their first appointment. The
outpatient services arranged appointments so that new
patients were allowed time to ask questions.
Patients were telephoned a few days prior to their
appointments in thoracic and respiratory clinics to
inform them of their X-ray or CT scan appointments. This
enabled doctors to review patients’ results and to make
timely decisions for patients and make plans of care and
treatment.
For patients attending their first oncology outpatient
appointment a talk was available three times a week
outlining what to expect during treatment, the local
support services available and details about financial
assistance. One patient said this had been “extremely
helpful and reassuring for me and my family,”
The dermatology department was involved in a
tele-dermatology service encompassing Bristol and
North Somerset Clinical Commissioning Groups. This
enables GPS to gain secondary review with immediate
feedback meaning patients were not always required to
attend the hospital.
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• The rheumatology department had established a direct
access system for people with rheumatoid arthritis. This
involved a 24 hour helpline and short notice clinics. This
had resulted in a 30% saving in appointments and had
been recognised with a Guardian Public Access Award
with the system being adopted by departments
nationally and internationally.
• Each outpatient department had a wide selection of
information leaflets available to patients. These leaflets
contained advice and guidance regarding medical
conditions, hospital procedures and how to make a
complaint, however, they were not available in other
languages.
Learning from complaints and concerns
• Between February 2016 and August 2016 there were 22
complaints about outpatient services. The themes
included attitude and communication, appointments,
clinical care, information and support. The trust took an
average of 21 days to investigate and close these
complaints.
• Patients and visitors we spoke with did not all know how
to make a complaint or raise a concern. However, they
all reported they would feel confident in not only
enquiring how to do this but also in raising the
complaint. Information regarding how to make a
complaint was found on the trust’s web site, a patient
information leaflet, ‘Tell us about your care’ posters and
the patient support and complaints service and the
‘LIAISE’ service (the PALS service in the Children’s
Hospital). These were available in easy-read format and
had been translated into non-English languages,
• All new staff were provided with information during
corporate induction about how to deal with a complaint
informally if approached directly in their place of work.
Training was also provided by the patient support and
complaints team to give frontline staff the confidence to
deal with complaints informally and “on the spot”.
• Concerns were encouraged through feedback forms and
friends and family questionnaires. Each outpatients
department displayed a ‘you said we did’ board. This
contained patients concerns and the actions taken. We
were informed by a patient that they had raised a
concern with one of the outpatient departments, they
reported the department contacted them to discuss
their concern and action and change had occurred to
address it.
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• Where lessons had been learnt from concerns and
complaints this was shared with the complainant.
Radiation incidents were discussed at radiology clinical
governance meetings. Learning from complaints was
shared at governance and team meetings as well as
during morning safety huddles within the outpatient
departments. We saw evidence of this in safety huddle
meeting minutes. This ensured information was shared
throughout the Trust. We heard an example of how a
complaint had been dealt with in line with these
procedures.
Are outpatient and diagnostic imaging
services well-led?
Good
–––
We rated well-led as good because:
• There was a clear statement of vision and values, driven
by quality and safety.
• Staff and patients were engaged in how care was
delivered and staff felt as if they were active contributors
to how the service was developed.
• There was a clear governance framework that ensured
people’s responsibilities were clear and quality,
performance and risks were understood and managed.
• The culture centred on the needs and experiences of
people who used the services.
• Frontline staff and managers were passionate about
providing a high quality service for patients.
• There was a high level of staff satisfaction with staff
saying they were proud of the departments as a place to
work.
However:
• Staff expressed concerns at some leader’s inconsistent
approach to staff personal or sensitive issues.
Vision and strategy for this service
• There was a clear vision and values for the service which
put patient care and quality of care at the forefront of
the service. Staff had a good understanding of the core
trust values of: respecting everyone, embracing change,
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•
•
•
•
recognising success and working together; and were
committed to providing patient-centred care. The values
of the organisation were displayed on the walls of the
outpatient departments.
We saw a detailed strategy to achieve the vision for the
outpatient department where services worked together
to improve whilst maintaining effective working
relationships within their divisions. This strategy was
aligned with the trust strategy.
Outpatient managers informed us the progression of the
outpatients’ strategy was reviewed at an outpatients
steering group. We saw evidence of this in the meeting
minutes for this group where issues such as waiting
times, the appointment booking system were discussed.
The outcome of these meetings were shared with the
department managers with information being further
disseminated in team meetings.
The trust had a vision for the diagnostics service, which
included a programme of financial bids for equipment
and staff for the coming financial year, based on urgency
and need, and also a longer term operating plan, which
took the service forward into 2018/19. Staff were aware
of these bids and plans through a series of manager
engagement initiatives to include staff in the planning of
the future of their services.
There was a realistic strategy for achieving the priorities
set for the diagnostic imaging service. The senior
management were realistic in their request for staffing
and equipment, and backed their bids up with
operational evidence, such as using the reporting
backlog to justify training reporting radiographers in
chest and abdomen reporting.
•
•
•
Governance, risk management and quality
measurement
• There was a clear governance framework that ensured
staff responsibilities were clear and that quality,
performance and risks were understood and managed.
Information was disseminated down to staff through
staff meetings, safety huddles and newsletters. Staff
reported they were invited to attend governance
meetings but had not felt the need to attend as they felt
their thoughts and opinions were already valued and
listened to.
• Outpatient managers attended monthly outpatient
meetings where good practice and learning was shared.
Although, at the time of the inspection the outpatient
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manager’s post was vacant, staff reported the previous
manager had been very visible and there had been
more direction for the development and sharing of
information within outpatients.
There were effective arrangements in place to monitor
and mitigate risks in a timely way. Overview of the risk
register was managed at service level, and were
managed and reviewed at governance meetings and
were updated regularly. The acting outpatient managers
were aware of the risk register and staff felt it reflected
the concerns they had. The diagnostic imaging service
had a divisional risk register which was sortable and
contained assessments of risks including mitigating
actions and ongoing monitoring. This identified a
number of risks including concerns about the high
turnover of radiographers and the numbers of agreed
unreported images. The risks identified on the risk
registers were aligned to those that managers identified
as their main concerns, including radiologists, who said
the unreported images ‘did not sit well’ with them.
These images were discussed during the monthly
meetings and prioritised accordingly. There was a plan
in place to utilise reporting radiographers which would
also free up radiologists.
Regular auditing took place with evidence of
improvement or trends. Performance data and quality
management information was collated and examined to
look for trends, identify areas of good practice, or
question any poor results. This included the auditing of
clinic utilisation.
There was an effective governance framework to
support the delivery of the strategy and good quality
care which included a twice yearly Ionising Radiation
(Medical Exposure) Regulations (IR(ME)R) meeting which
all radiation protection supervisors fed risk assessments
into. We saw evidence of the minutes from these
meetings where protocols were considered and
changed in relation to risks.
Leaders of the diagnostic imaging service demonstrated
a good holistic understanding of performance, which
took into account safety, quality, activity and financial
information. Managers were realistic in the business
cases they made for equipment and staff, and
communicated this to the staff and managers told us
this hopefully ensured some of their bids were approved
with little adjustment.
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Outpatients and diagnostic imaging
• There was a systematic programme of clinical and
internal audit in the diagnostic imaging service, which
had recently been reviewed as part of the preparations
for ISAS accreditation submission.
• Clinical policies and guidelines were available for all
staff via the hospital intranet system. Staff were able to
show us how to access policies and guidelines and the
electronic incident reporting system and said the
systems worked well.
Leadership of service
• Leaders had the skills, knowledge, experience and
integrity to manage the outpatients and diagnostic
imaging services. During the last inspection in 2014
there was no overarching leadership of the outpatient
department reported at service level. On this inspection
we found there was good oversight through the role of
the outpatient manager and development of the
outpatient steering groups.
• Since our last inspection the appointment booking
system had been developed and a manager of this
service had been established. This service had been
used to utilise clinic spaces, improve response time to
patients and reduce the number of appointment
cancellations and rate of patients not attending their
appointment. The manager of this service worked well
with the interim outpatient manager and attended the
outpatient steering group meetings.
• Staff informed us leaders were visible and
approachable. At the time of our inspection there was
an outpatient’s manager vacancy. However, staff
reported the previous manager would attend and visit
clinics as well as attending team meetings and the
acting outpatients manager was approachable. Staff
said they were respected and valued by their managers
and they were always approachable and encouraged
them to develop ideas. However, staff expressed
concerns at some leaders' inconsistent approach to
personal or sensitive issues.
• Within the radiology department we saw staff and teams
worked collaboratively and senior staff took on the
responsibility to train and mentor junior staff. For
example, one member of staff oversaw the electronic
competency framework used to record staff experience
in modalities, and updated it every three months to
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reflect how much time each member of staff had spent
in the modality in the previous three months. In doing
this, it was hoped the framework would help identify
areas where staff needed extra training.
• Through the content of governance papers and talking
with staff, we saw the leadership reflected the
requirement to deliver safe, effective, caring and
responsive and well-led services.
• Managers were mindful of the ongoing cost
improvement programme and strove to deliver an
efficient service as possible without affecting patient
quality of care.
Culture within the service
• The culture centred on the needs and experiences of
people who used the services. All staff we spoke with
mentioned patient care was at the forefront of their and
their manager’s focus.
• Staff said they felt respected and valued and all staff
were supportive and approachable. There were regular
awards given to teams and individuals who had
excelled. The cardiology department had recently been
recognised as one of the happiest departments.
• All staff reported they felt listened to and their opinions
and views were listened to. They said they were
informed when the things they had requested could not
be obtained and leaders worked with them to develop a
new strategy to achieve their aim or goal and explained
the reasons why. One staff member said, ‘they never just
say no, they always try to find a solution’. However,
within the diagnostic imaging department staff told us
they did not always feel respected and valued, and
some staff felt they could be better used to help clear
the reporting backlog.
• There was a culture of candour, openness and honesty
within the service. Staff we spoke with reported they
were encouraged to raise any issues or questions. We
heard of incidences where staff challenged more senior
peers on decision making and staff felt empowered and
supported to do this.
Public and Staff engagement
• Staff and patients’ views and experiences were gathered
and used to shape and improve the services and
culture. There were friends and family questionnaires
and feedback forms in every clinic we visited. We were
given examples from staff when things had changed as a
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•
•
•
result of patient feedback. This included the alteration
of the way in which waiting times were displayed within
the cardiology department following feedback from
patients that they found the electronic board confusing.
Staff reported they felt actively engaged so their views
were reflected in the planning and delivery of the
service and this helped shaped the service culture. Staff
we spoke to felt as an outpatient service they felt more
recognised and appreciated both at a departmental and
trust wide level. One staff member said, “we are no
longer seen as the departments that attract the waifs
and strays”.
All staff we met said they felt valued and part of the
team. They said the outpatient division was an
“enjoyable place to work” with a “diverse and interesting
range of job opportunities.” Staff felt supported by the
senior management team, heads of division and their
colleagues. One member of staff said “people make the
place … people go beyond to step in to help
colleagues.”
Thank you cards were on display throughout the
division to remind staff of their successes.
There was a parking scheme for staff and a cycle to work
scheme was promoted.
Access to counselling was available for all staff through
an employee assistance programme. This was a
programme based around cognitive behavioural
therapy and provided staff with an independent
counselling service and a 24-hour advice line.
An interactive web-based method had been designed,
piloted and implemented to collect, act and report on
real-time staff feedback. The “Happy-App” had been
introduced in some areas to encourage staff to actively
engage with managers to improve their working
environment and standards of patient care. The
Happy-App encouraged staff to express how they were
feeling whilst they were at work. All staff could use the
app, as many times as they liked during a shift, via a
computer or iPad in their department. On the user
home screen staff rated their current mood by selecting
either a happy, neutral, or sad face. They then chose the
category that most closely fitted the reason for their
mood (e.g. equipment, team etc.) and wrote a comment
explaining why they had picked that particular emotion.
Local managers could log in to an administrator’s screen
to see the mood of their staff in real-time and could
respond to the comments. This allowed managers to
understand the reasons why staff were feeling a
127
•
•
•
•
particular way and meant they could address and
resolve issues raised by staff. The trust had recently won
a National award for the introduction and use of ‘The
Happy App’.
The outpatients steering group had undertaken a
project to improve the content and quality of patient
letters. Patient’s views and opinions were used to shape
the new letters and the most recent audit showed 98%
of patients found the new letters easier to understand.
The diagnostic imaging service actively engaged with
patients, relatives and staff to involve them in decision
making about the planning and delivery of the service.
For example, a series of staff engagement meetings had
taken place to help managers better understand their
staff. As a result, five work streams had been developed
which covered health, wellbeing, culture,
communications, and leader development. Different
managers within diagnostic imaging were leading on
each work stream. Initial feedback from staff had been
positive as staff had previously felt they had been left
out of planning and decision making.
Patients were regularly asked to complete satisfaction
surveys on the quality of care and service provided. The
results of the survey were used by departments to
improve the service.
Members of the public were also engaged with through
the use of patient advisory groups. Patients who
accessed the rheumatology service were engaged in a
patient advisory group where discussion took place to
ensure patients were involved in teaching, research and
clinical care. The group met on a monthly basis.
The surveys covered the patient’s overall satisfaction of
experience and how likely they were to recommend the
hospital to friends and family if they needed similar care
and treatment. Comment cards and email feedback
from patients had resulted in the alteration of the
presentation in oncology clinics.
Innovation, improvement and sustainability
• Staff were clear their focus was on improving the quality
of care for patients. They felt there was scope and a
willingness amongst the team to develop services.
• Staff in the outpatients and diagnostic imaging services
were able to give multiple examples of where
developments had an impact on the quality of the
service. In dermatology we were informed of the
introduction of photodynamic therapy for superficial
treatment of basal cell carcinomas, this would reduce
University Hospitals Bristol Main Site Quality Report 02/03/2017
Outpatientsanddiagnosticimaging
Outpatients and diagnostic imaging
the number of patients having to undergo surgery and
thus also reduce surgery wait times. The outpatient
steering group was in the process of developing a live
tracker to improve clinic utilisation and accurate waiting
times.
• The use of digital dictation within the outpatient
departments had been introduced. We observed these
within the restorative department of University of Bristol
School of Oral & Dental Sciences. This had improved the
speed in which letters were sent to general dental
practitioners.
• The diagnostic imaging service had moved all of its
equipment maintenance to their in-house, onsite
engineering team. When new equipment was
purchased, the department’s own engineers went on a
128
training course alongside the equipment companies’
own engineers, to learn how to service and maintain the
equipment. This helped to reduce equipment down
time and expenses.
• “Bright Ideas” was a regular competition to promote
innovations which had the potential to improve patient
care, and to identify and reward innovative individuals
and teams within the trust. The competition
encouraged innovation, stimulated safety and quality
improvement ideas and provided help to get the best
ideas off the ground. The competition invited staff to put
forward innovative solutions to day-to-day challenges.
Innovative ideas were invited from any area of the trust
activity and were required to be original, feasible and
have the potential to be re-applied in other areas of the
trust.
University Hospitals Bristol Main Site Quality Report 02/03/2017
Outstandingpracticeandareasforimprovement
Outstanding practice and areas for improvement
Outstanding practice
• In times of crowding the emergency department was
able to call upon pre-identified nursing staff from the
wards to work in the department. This enabled nurses
to be released to safely manage patients queueing in
the corridor.
• The audit programme in the emergency department
was comprehensive, all-inclusive and had a clear
patient safety and quality focus.
• New starters in the emergency department received a
comprehensive, structured induction and orientation
programme, overseen by a clinical nurse educator and
practice development nurse. This provided new staff
with an exceptionally good understanding of their role
in the department and ensured they were able to
perform their role safely and effectively.
• In the emergency department the commitment from
all staff to cleaning equipment was commendable.
• The comprehensive register of equipment in the
emergency department and associated competencies
were exceptional.
• Staff in the teenagers and young adult cancer service
continually developed the service, and sought funding
and support from charities and organisations, in order
to make demonstrable improvements to the quality of
the service and to the lives of patients diagnosed with
cancer. They had worked collaboratively on a number
of initiatives. One such project spanned a five year
period ending May 2015 for which some of the
initiatives were ongoing. The project involved input
•
•
•
•
•
•
•
from patients, their families and social networks, and
healthcare professionals involved in their care. It
focused on key areas which included: psychological
support, physical wellbeing, work/employment, and
the needs of those in a patients’ network.
The use of technology and engagement techniques to
have a positive influence on the culture of an area
within the hospital. There were clear defined
improvements in the last 12 months in Hey Groves
Theatres.
The governance processes within the division to
ensure risks and performance were managed.
The challenging objectives in the strategy and how
they are used to proactively develop the quality and
the safety of the service.
The use of innovation and research to improve patient
outcomes and reduce length of stay. The use of a
discrete flagging system to highlight those patients
who had additional needs. In particular those patients
who were diabetic or required transport to ensure they
were offered food and drink.
The introduction of IMAS modelling in radiology to
assess and meet future demand and capacity.
The use of in-house staff to maintain and repair
radiology equipment to reduce equipment down time
and expenses.
The introduction of a drop in chest pain clinic to
improve patient attendance.
Areas for improvement
Action the hospital MUST take to improve
• Ensure all medicines are stored correctly in medical
wards, particularly those which were observed in dirty
utility rooms.
• Ensure records in the medical wards and in outpatient
departments are stored securely to prevent
unauthorised access and to protect patient
confidentiality.
• Ensure all staff are up to date with mandatory training.
129
• Ensure non-ionising radiation premises in particular
Magnetic Resonance Imaging (MRI) scanners restrict
access.
Action the hospital SHOULD take to improve
• Ensure chemicals are stored securely at all times in the
emergency department and on medical wards.
• Ensure checks of the equipment in the emergency
department’s resuscitation area are recorded
consistently.
University Hospitals Bristol Main Site Quality Report 02/03/2017
Outstandingpracticeandareasforimprovement
Outstanding practice and areas for improvement
• Ensure patients in the emergency department have
access to call bells at all times.
• Ensure reception staff are able to recognise patients
who attend the emergency department with serious
conditions need urgent referral to the triage nurse and
provide a formalised process for summoning help.
• Continue working towards providing 16-hours on-site
consultant cover in the emergency department, and
increase consultant cover at the weekend.
• Ensure the emergency department is accessible to
wheelchair users and the layout of the reception desk
allows staff to interact with wheelchair users whilst sat
at the desk.
• Ensure the emergency department develops and
formalises its vision and strategy.
• Ensure staff in the emergency department are
up-to-date with their mandatory training, including
safeguarding adults and children.
• Work with commissioners and the local mental health
service provider to ensure mental health patients
arriving at the emergency department receive the care
they require in a timely manner.
• Ensure all staff working in the emergency department
and medical staff receive an annual appraisal.
• Ensure clear signage and equipment is in place for
staff, patients and visitors to wash their hands when
entering a medical ward area.
• Ensure the environment in the oncology department
and ward keeps patients safe and comfortable,
especially for patients who may be confused or cannot
maintain their own safety.
• Ensure access to the staff room on the medical
assessment does not allow access to unauthorised
people.
• Take remedial maintenance action to ensure the
heating system on ward D703 maintains a suitable and
safe temperature for staff and patients.
• Ensure staff have a greater understanding and
awareness of the intercom system on the Hepatology
ward, to ensure safe and prompt access to the ward
and confidentiality of patient information.
• Ensure medical doctors’ inductions are undertaken in
scheduled blocks and planned so doctors do not start
work on the wards without an induction.
• Ensure clear signage and equipment is in place on
medical wards to advise staff, patients and visitors to
wash their hands when entering a ward area.
130
• Ensure delays in take home medicines does not delay
patients.
• Ensure medical records are legibly and fully
completed. This includes patient risk assessments.
• Audit records in the cardiac catheter laboratory to
ensure they are fully complaint with the World Health
Organisation surgical safety checklist for all surgical
procedures.
• Address the risk in the acute oncology service where
patients may be placed at risk by reduced staffing
levels at night due to admissions of emergency
oncology patients. There should be suitably skilled
staff in place at night to ensure safe triage advice is
given to patients accessing the emergency oncology
service. Whilst the trust recognised these risks,
sufficient action should be taken to minimise the risk
to patients in both the service provision and staffing
provision.
• Ensure pain audits are established to monitor if pain
was managed effectively for patients with an ability to
express their pain.
• Continue to monitor staff’s use of the Abbey Pain Scale
to ensure patients with cognitive impairment in the
specialised services division have an effective tool to
assess their pain needs.
• Continue to ensure all efforts be made to maintain
flow through the hospital and patients be nursed on
the correct wards to meet their needs.
• Reduce the risk on the hepatology ward in relation to
lone working practices, when accompanying patients
off the ward at night to smoke.
• Improve the level of safeguarding training for staff
working overnight in the surgical trauma assessment
unit.
• Improve compliance for mandatory training in surgical
areas.
• Improve patient outcomes to bring them in line with
the national average for the hip fracture audit and
improve the National Emergency Laparotomy Audit.
• Ensure patients within all of the diagnostic imaging
waiting rooms can be monitored by staff.
• Monitor the World Health Organisation (WHO) Surgical
Safety Checklist is always used in the appropriate area
as a checklist when carrying out non-surgical
interventional radiology.
• Provide leaflets within outpatient departments are
available in different languages
University Hospitals Bristol Main Site Quality Report 02/03/2017
Outstandingpracticeandareasforimprovement
Outstanding practice and areas for improvement
• Check local and national diagnostic reference levels
(DRLs) are on display as stated in Regulation 4(3)(c) of
IR(ME)R 2000 and IM(ME) amendment regulations 2006
and 2011.
131
• Make improvements on the follow up backlog waiting
list to meet people’s needs and minimise risk and
harm caused to patients through excessive waits on
follow up of outpatient appointments and the
reporting of images.
University Hospitals Bristol Main Site Quality Report 02/03/2017
This section is primarily information for the provider
Requirementnotices
Requirement notices
Action we have told the provider to take
The table below shows the fundamental standards that were not being met. The provider must send CQC a report that
says what action they are going to take to meet these fundamental standards.
Regulated activity
Treatment of disease, disorder or injury
Regulation
Regulation 17 HSCA (RA) Regulations 2014 Good
governance
The provider must maintain securely at all times records
in respect of each service user. These should only be
accessed and amended by authorised people.
Records within cardiology, dermatology and outpatient
departments were not always kept in locked containers.
Regulated activity
Diagnostic and screening procedures
Regulation
Regulation 12 HSCA (RA) Regulations 2014 Safe care and
treatment
2 (d)The provider must ensure premises used by the
service provider are safe to use.
Patients within the radiology department could access
unlocked Magnetic Resonance Imaging (MRI) rooms
Regulated activity
Diagnostic and screening procedures
Treatment of disease, disorder or injury
Regulation
Regulation 12 HSCA (RA) Regulations 2014 Safe care and
treatment
12(2)(g) the proper and safe management of medicines.
• There was not always proper and safe management of
medicines with sluices being used to store some
creams and treatments. The sluice rooms were not an
appropriate area for storage.
132
University Hospitals Bristol Main Site Quality Report 02/03/2017
This section is primarily information for the provider
Requirementnotices
Requirement notices
Regulated activity
Diagnostic and screening procedures
Treatment of disease, disorder or injury
Regulation
Regulation 23 HSCA 2008 (Regulated Activities) Regulations
2010 Supporting staff
The provider had failed to have suitable arrangements in
place to ensure all medical staff were supported to
receive fire training, resuscitation training and
safeguarding training to enable them to be prepared
should an event occur.
133
University Hospitals Bristol Main Site Quality Report 02/03/2017
Meeting of Bristol Clinical Commissioning Group Governing Body
To be held on Tuesday 28 March 2017
commencing at 13.30pm at the Greenway Centre, Southmead, Bristol
Title: CQC Quality Report on the Bristol Community Health
Community Interest Company
Agenda Item: 15a
1
Purpose
The attached Care Quality Commission (CQC) report was published on 16th
February 2017 and describes the findings from the announced inspection of the
Bristol Community Health (BCH) Community Interest Company services (CIC).
The attached report describes the CQC’s judgement of the quality of care at
BCH and is based on a combination of what the CQC found when they
inspected, information from their ‘Intelligent Monitoring’ system and information
given to them from people who use services, the public and other organisations.
The following link provides access to the full main report
http://www.cqc.org.uk/sites/default/files/new_reports/AAAG0260.pdf
2.
Background
The CQC inspected the BCH services between 16th and 18th, 27th & 28th, 30th
November and 1st December 2016 as part of their comprehensive inspection
programme for community organisations.
This was the first inspection for BCH since it was established as a CIC in 2011.
The focus of this inspection was on the following services:
 Community health services for adults
 Community health services for children, young people and families
 Community mental health services for people with learning disabilities or
autism
 Urgent care services
The CQC did not visit the BCH prison services as these are inspected by a
specialist CQC team alongside Her Majesty’s Inspectorate of Prisons.
During the inspection, the CQC visited a range of community teams, locations,
patient’s homes, schools and clinics and spoke with clinical and non-clinical staff,
patients and relatives. Prior to the inspection, the CQC reviewed the information
they held on the organisation, feedback people provided via the CQC website
and overviews of the organisations performance from the local Clinical
Commissioning Groups.
3.
Key Finding
The CQC rated BCH as ‘Good’ overall. The rating for each domain is as follows:
If you need this document in a different format telephone the CCG on 0117 900 2632
Page 1 of 4
Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP
Are services safe?
Are services effective?
Are services caring?
Are services responsive?
Are services well-led?
Good
Good
Good
Good
Good
•
•
•
•
•
As well as awarding an overall ‘Good’ rating for Bristol Community Health, the
CQC gave individual ratings for each service. Adults’ services, urgent care and
Learning Disabilities services were rated ‘Good’ or ‘Outstanding’ across all of the
key domains, and none of the services was deemed to be ‘Inadequate’. Areas of
outstanding practice were noted, including putting patients and families at the
heart of decision-making and multi-disciplinary working between teams and other
local organisations.
The table below shows the breakdown of the ratings for the service groups.
However, the CQC noted areas where improvements are required. The
Children’s Services were rated ‘requires improvement’ in all domains except
‘caring’. It was acknowledged this service is part of the Community Children’s
Health Partnership on an interim basis since April 2016. Areas that were
highlighted linked with: infection control processes; mandatory training and staff
appraisals; compliance with safeguarding training requirements; the transfer of
children to adult services and auditing of service quality and performance.
The CQC noted seven ‘must do’ actions relating to the above areas. The CQC
also identified six ‘should do’ actions for the organisation to address.
Page 2 of 4
Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP
4
Next Steps and Assurance processes
A Quality Summit was held on 13th March where the CQC presented their
inspection findings. The Quality Summit was attended by BCH staff, the CQC
and a range of stakeholders including Bristol CCG and NHS England.
As a response to the CQC report, BCH have drafted an action plan to address
the ‘must and should do’ actions and this will be put onto their public facing
website. The action plan will be submitted to the CQC by 31st March 2017 and
will be monitored at the monthly Quality Sub Group of the Integrated Contract
Quality & Performance Meetings.
5
How have service users, carers and local people been involved?
Service users and stakeholders were involved in the CQC inspection with their
views and comments taken into account to inform the CQC judgements.
6
Implications on equalities and health inequalities.
There are no specific health inequalities issues raised in the paper.
Please indicate below the age group/s covered by the service/affected
by the issue discussed
Children/Young
People
7
X
Adults
X
Financial Implications
There are no financial implications for the CCG.
8
Legal implications
There are no legal issues raised in this paper.
9
Risk implications, assessment and mitigation
The risks in this paper relate to the specific findings in the CQC report about
patient safety and delivery of the services.
10
Recommendation(s)
The Governing Body is asked to note the CQC findings in the inspection report
published on 16th February 2017 and agree that compliance monitoring of the
action plan will be through the Quality Sub Group.
Bridget James
Head of Quality
14th March 2017
Page 3 of 4
Meeting of Bristol CCG – 29 March 2016 - CQC report on the AWP
Alison Moon
Director of Transformation and Quality
14th March 2017
Glossary of terms and abbreviations
CQC
Care Quality Commission
The CQC are an independent regulator of health
and adult social care in England.
They make sure health and social care services
provide people with safe, effective,
compassionate, high-quality care and they
encourage care services to improve.
Page 4 of 4
Brist
Bristol
ol Community He
Health
alth
C.I.C.
Quality Report
South Plaza, Marlborough Street
Bristol BS1 3NX
Tel: 0117 900 2600
Website: www.briscomhealth.org.uk
Date of inspection visit: 16-18 November 2016, 27 &
28 November 2016, 30 November 2016 and 1
December 2016
Date of publication: 16/02/2017
Core services inspected
CQC registered location
CQC location ID
Community health services for
adults
Bristol Community Health
Headquarters
1-304870639
Community health services for
children, young people and families
Bristol Community Health
Headquarters
1-304870639
Community mental health services
for people with learning disabilities
or autism
Bristol Community Health
Headquarters
1-304870639
Urgent care services
Urgent Care Centre
1-401031903
This report describes our judgement of the quality of care at this provider. It is based on a combination of what we
found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from
people who use services, the public and other organisations.
1 Bristol Community Health C.I.C. Quality Report 16/02/2017
Summary of findings
Ratings
We are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings will
always be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring data
and local information from the provider and other organisations. We will award them on a four-point scale: outstanding;
good; requires improvement; or inadequate.
Overall rating for community health
services at this provider
Good
–––
Are services safe?
Good
–––
Are services effective?
Good
–––
Are services caring?
Good
–––
Are services responsive?
Good
–––
Are services well-led?
Good
–––
2 Bristol Community Health C.I.C. Quality Report 16/02/2017
Summary of findings
Contents
Summary of this inspection
Page
Overall summary
4
The five questions we ask about the services and what we found
7
Our inspection team
14
Why we carried out this inspection
14
How we carried out this inspection
14
Information about the provider
14
Outstanding practice
15
Areas for improvement
16
Detailed findings from this inspection
Findings by our five questions
17
Action we have told the provider to take
49
3 Bristol Community Health C.I.C. Quality Report 16/02/2017
Summary of findings
Overall summary
When aggregating ratings, our inspection teams follow a
set of principles to ensure consistent decisions. The
principles will normally apply but will be balanced by
inspection teams using their discretion and professional
judgement in the light of all of the available evidence.
Letter from the Chief Inspector of Hospitals
Bristol Community Health C.I.C. was inspected with
planned and announced visits over 16-18 November
2016. We visited many community teams, locations,
patients’ homes, schools, and clinics during this time. We
went back to a number of locations and teams for
unannounced visits on Sunday 27 November (the urgent
care centre), 28 and 30 November and 1 December 2016.
This inspection was a comprehensive look at all services
provided by Bristol Community Health C.I.C., with the
exception of its prison healthcare service, which is
inspected by a specialist CQC team alongside Her
Majesty’s Inspectorate of Prisons. The core services we
inspected were:
• Community health services for adults
• Community health services for children, young people
and families
• Community mental health services for people with
learning disabilities or autism
• Urgent care services
Among the sites we visited where services are provided
were: New Friends Hall in Stapleton, Bristol and The
Withywood Centre in Withywood Bristol. This was to meet
people and staff in the community learning disabilities
service. We visited the urgent care centre in Whitchurch,
Bristol. We visited health centres in Bristol, Eastgate
Centre Clinic, Osprey Court, local schools, and children’s
centres to inspect services for children, young people and
families. To inspect the community adults’ services, we
went to a range of health centres, went out with
community nursing teams to patients’ homes, visited
Knowle Clinic, an intermediate care centre, and
Southmead Hhospital. We met with the palliative home
care team and went on visits with them to meet their
patients and families they were supporting. In addition,
we went on visits with the ‘fast track’ team, who arrange
care and support for patients being discharged home
from hospital at the end of their life.
4 Bristol Community Health C.I.C. Quality Report 16/02/2017
All staff throughout Bristol Community Health were
cooperative, helpful and supportive to us at all stages of
the inspection.
Our key findings were as follows:
• We rated services for their safety as good overall,
although some improvements were needed to
children and young people’s services, which were
working under a temporary contract managed in
conjunction with three other health providers. The
contract had now been awarded to the three
organisations from April 2017 for the next five years,
and work to integrate children and young people’s
services was commencing. However, this had not
affected the quality of care provided by the children
and young people’s services. Patients were protected
from abuse and harm.
• We rated services for their effectiveness as good
overall, although there were some areas in the
children and young people’s services that needed
improvement. This included issues arising from
problems with the computer systems, the availability
of patients’ records, and the lack of an effective audit
programme. However, patients were receiving good
outcomes from their care and treatment. Quality of life
was promoted, and care and treatment based upon
the best available evidence.
• We rated services for caring as good overall, with
outstanding care in the urgent care centre. Patients,
their carers, parents and anyone who encountered
Bristol Community Health staff were treated with
compassion, kindness, dignity and respect.
• We rated all services for their responsiveness as good.
Services were planned, organised and delivered to
meet people’s needs. The organisation supported
people in vulnerable circumstances. It listened to
people’s concerns and improved when it recognised
something had gone wrong or could be done better.
However, there was a variable performance when
endeavouring to provide care to people at the right
time. Some services were doing well, but others were
struggling with the impact of rising demand and
shortages of staff.
• We rated services for the leadership and governance
as good overall, although work was needed to
Summary of findings
integrate and improve the systems and use of
information in the children and young people’s
services. Bristol Community Health was an
organisation with a strong culture. Staff were open,
honest, and wanting to deliver high-quality personcentred care. The organisation supported learning,
innovation and improvement.
•
We saw several areas of outstanding practice
including:
• There was an outstanding, dedicated and committed
approach to engaging with people who were patients
of Bristol Community Health, their families, their
carers, volunteers, and the wider community. The
Patient and Public Empowerment programme,
underpinned by the patient charter, put patients at the
centre of decisions, valued their feedback and input,
and made changes and improvements from listening
to and engaging with people.
• The chief executive and her leadership team had an
outstanding commitment to staff. The organisation
had been established as an employee-owned social
enterprise. It recognised staff for effort and
achievement through a number of different schemes,
including award ceremonies and personalised contact.
• The organisation’s approach to shared decisionmaking and inclusion of the patient was well
embedded within their culture. We observed this in
practice and in records.
• Specialist services were provided by Bristol
Community Health to meet the needs of people. These
services were flexible and innovative to make
improvements. They enabled services to deliver care
and treatment, which was accessible to the local
population, with no discrimination. For example,
through the migrant health services and the Macmillan
rehabilitation support service.
• The Haven service recognised the additional support
required for staff who were often dealing with difficult,
challenging and upsetting situations. Weekly access to
a psychologist was made available for staff.
• In children's services, staff respected and recognised
each child as an individual. We observed outstanding
caring from staff who were singing a song to each
individual child and addressing them using their name
5 Bristol Community Health C.I.C. Quality Report 16/02/2017
•
•
•
•
•
•
•
•
when they entered the room for their therapy session.
These children had profound needs, and we
recognised how their faces lit up when they came into
the session and had their special song.
Families and carers of children and young people
provided consistent positive feedback about the
service. One parent told us “staff are so supportive and
helpful,” “staff are always there when you need them,”
while another told us “staff are really friendly, helpful
and always welcoming.” Another mother told us '”the
service is brilliant, couldn't have asked for a better
one.”
In adult services, we observed outstanding
multidisciplinary team working both across the
organisation and with other healthcare providers. In
particular, staff worked hard to make sure all involved
in a patient’s end of life care were up to date with the
situation, and their visits were all coordinated.
There was an outstanding response to people who
were coming to the end of their life. The palliative
home care team made sure their service worked to
meet the needs of the patient and those they were
close to.
The visibility of, and support provided by the
safeguarding team had increased the quantity and
quality of safeguarding referrals across the whole
organisation.
The multidisciplinary working undertaken by the rapid
response team was helping to speed up patient
discharges and prevent hospital re-admissions.
The organisation had effective processes to review
staff teams and identify areas of risk to provide active
support. These were known as ‘hot teams’. This
allowed issues and risks to be identified early, and
plans to be made to help support these teams.
In the urgent care service, we heard of numerous
examples where staff had gone the extra mile to
support patients and those close to them.
The urgent care staff had developed a comprehensive
support network and a range of referral pathways for
adults and children in primary, secondary and
community health care settings.
The urgent care service had engaged the support of
the lead emergency consultant at the local children’s
hospital to facilitate joint working, and education.
Summary of findings
However, there were also areas of poor practice
where the provider needs to make
improvements.
Importantly, the provider MUST:
• Take action to ensure all staff in the children and
young people's service receive the appropriate level of
safeguarding training for their role.
• Ensure a complete set of records are transferred with
the child from the health visiting team to the school
nursing team in line with Royal College of Nursing
guidelines.
• Take action to ensure the health visiting team
maintains an individual set of records for each child,
which are filed under the individual child’s surname.
• Ensure staff in the children and young people's service
comply with safe systems to ensure that toys are
cleaned in line with the Cleaning and
6 Bristol Community Health C.I.C. Quality Report 16/02/2017
Decontamination of Toys’ policy and ensure there is a
system to monitor compliance around toy cleaning.
We also observed poor compliance with hand washing
and cleaning of equipment between use after each
child.
• Ensure compliance with staff mandatory training and
appraisal in the children and young people's service.
• Ensure there are standard operating procedures for
the transition of all children into adult services.
• Take action in the children and young people’s service
to ensure there is a systematic process of audit to
monitor service quality and performance, for example
records audits, and auditing the single point of access
system.
Professor Sir Mike Richards
Chief Inspector of Hospitals
Summary of findings
The five questions we ask about the services and what we found
We always ask the following five questions of services.
Are services safe?
Summary
This section relates to the safety of Bristol Community Health
as a managing organisation (provider) for its services
We rated safety at Bristol Community Health as the
provider as good because:
• There was recognition and application of the legal duty to
explain and apologise when something went wrong and
caused or could have resulted in significant harm (duty of
candour).
• There was a good culture among staff for reporting when things
went wrong or there was a near miss. These were investigated,
the board were informed, and staff were informed about
anything that needed to change. Lessons were learned from
incidents.
• There were systems, processes and practices to keep people
safe from abuse or avoidable harm. There were regular reports
to the board on these procedures, and how they were working.
Staff recognised when someone was at risk and needed
safeguarding, and knew how to take this forward. The
organisation was committed to supporting people and keeping
them safe.
• There were staff vacancies, but the organisation was using bank
staff and occasional agency staff to fill shifts when needed.
However:
• There were a number of vacancies in the community nursing
staff teams leading to some staff with high numbers of patients
on their caseloads. This was sometimes stressful for staff, and
meant patients did not always get as much time with staff as
they would have wanted.
This section relates to the safety of the four core services
We have rated safety of the four core services overall as
good because:
• Most staff understood the importance of reporting and acting
upon incidents.
• There was a culture of being open, honest and apologising
when things went wrong.
• Staff were clear about their responsibilities to report and act
upon safeguarding concerns.
• The administration of medicines was safe.
7 Bristol Community Health C.I.C. Quality Report 16/02/2017
Good
–––
Summary of findings
• Facilities and the environment were fit for purpose.
• The majority of patient records were good, although some were
incomplete in places. They were stored securely.
• There was good compliance with mandatory training in all
services, with the exception of the children’s team, which was
being provided at the time of the inspection on a short-term
contract. This was not helped by poor quality staff records
handed over by the acute trust transferring the service.
• There were good assessments to keep people safe and manage
anticipated risks.
However:
• There were teams that were short of staff and pressure on some
was high. There was too much variation in the caseloads staff
were expected to carry. The staffing tools for rotas and planning
were not being used effectively.
• Some staff in the children’s service needed to update their
safeguarding training.
• There was a variable performance in infection prevention and
control protocols.
• Mandatory training was not being updated as required in the
children’s team.
Are services effective?
Summary
This section relates to the effectiveness of Bristol Community
Health as a managing organisation (provider) for its services
We rated effectiveness at Bristol Community Health as
the provider as good because:
• The care and treatment delivered to patients delivered good
outcomes.
• The organisation focused upon promoting a good quality of life.
• The best available evidence was used to structure care
pathways and the standards used in treatment and procedures.
• There was a good multidisciplinary approach to delivering care
so it was coordinated, and benefitted from shared learning at
all levels in the organisation.
However:
• There was variable quality in the audits around consent. Those
we saw did not all provide assurance that consent was being
recorded and validly obtained at all times, and that actions
were being taken to improve compliance when there were
gaps.
8 Bristol Community Health C.I.C. Quality Report 16/02/2017
Good
–––
Summary of findings
This section relates to the effectiveness of the four core
services
We have rated effectiveness of the four core
services overall as good because:
• Care was delivered along national guidelines and recognised
pathways.
• Pain was well managed, as were nutrition and hydration needs.
• Patients had good outcomes from the care and treatment they
received.
• Most staff had been given an annual review (appraisal).
• There was professional development and courses available to
staff to give them new and updated skills.
• There was an excellent approach to multidisciplinary working
and coordination of care pathways.
• There were proactive services to help discharge patients from
hospital, and provide a rapid response to patients in need.
However:
• There was limited use of technology and telemedicine.
• Somewhat unreliable records showed appraisal compliance
had fallen behind in the children and young people’s services.
• The rapid response team had to go above and beyond the
service they were expected to provide, as the social care
packages were not always available when the rapid response
service should have ended.
• Some of the children and young people's services had no
standard operating procedures for handing over patients from
child to adult services.
• There was variable access to information due to issues with
mobile phone networking in some areas, and IT systems that
needed to be upgraded (of which the provider was well aware).
• Recording of consent decisions and mental capacity
assessment was poor. Not all consent decisions were following
legal principles where they involved children.
Are services caring?
Summary
This section relates to the caring of Bristol Community Health
as a managing organisation (provider) for its services
We rated caring at Bristol Community Health as the
provider as good because:
• A key principle of the organisation was to involve patients in
their care and decision-making and to work with and alongside
them and those close to them.
9 Bristol Community Health C.I.C. Quality Report 16/02/2017
Good
–––
Summary of findings
• The values of the organisation embedded how patients, their
carers and families were to be treated with respect and dignity.
Staff throughout the organisation, including at the senior level,
were kind and compassionate to people they supported and
treated them as individuals.
• The organisation encouraged staff to take time to interact with
people and be considerate and encouraging. It was recognised,
however, this was hard with the limited time and resources
available for the small things that sometimes meant a lot to
people. Staff interacted with people who supported the
patients, such as carers and families, and recognised when
patients needed extra support from those around them.
• Staff understood and had training to respect people’s cultural,
social and religious needs, and took account of these when
caring for and supporting people.
• Staff were encouraged to be sensitive with patients to help
them maintain or improve their health and their independence.
Staff understood the impact of conditions and treatment on
people’s lives and wellbeing.
This section relates to the caring of the four core services
We rated caring of the four core services overall as good
because:
• Patients and those close to them were treated with
compassion, kindness and respect.
• Privacy and dignity for patients was respected.
• People were involved in making decisions about what
happened to them.
• Families and carers were involved, enabled, and encouraged to
support patients.
• There was support for emotional wellbeing for patients and
those who cared for them.
Are services responsive to people's needs?
Summary
This section relates to the responsiveness of Bristol
Community Health as a managing organisation (provider) for
its services
We judged responsiveness at Bristol Community Health
as the provider as good because:
• Services were planned and delivered to meet the needs of the
local population and communities.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
Good
–––
Summary of findings
• The organisation worked effectively and cooperatively with
commissioners and other providers to deliver appropriate
services for people. This included services within acute
hospitals to enable patients to leave for more appropriate caresettings when they were able.
• There were professional working relationships with other
providers of health and social care in the local communities,
including the two major acute hospitals and the ambulance
service.
• There was outstanding engagement with local people and
communities to shape and provide services to meet their
needs.
• Services were planned to take account of people’s needs
associated with equality and diversity.
• The organisation understood the importance of providing
appropriate care for people in vulnerable circumstances. This
included people living with dementia, a learning disability, or
people who found it hard to access services.
• The board were informed and made aware of people’s
complaints, how they were listened to and responded to
appropriately.
However:
• The reporting of complaints to the board did not show if there
were proportionately more complaints in one service than
another. There was no record to show what actions were being
taken with the leading themes in complaints, and to inform the
board of the number of complaints upheld, partially or
otherwise. The board was therefore not assured that learning
from complaints has been embedded and how changes had
made a difference.
• Some parts of the organisation were working above and
beyond their commissioned work to support patients. This was
particularly in the community adults service, but also in the
urgent care centre. This was recognised by the organisation,
and showed a dedication to patients, but added to the pressure
on services already under pressure.
This section relates to the responsiveness of the four core
services
We rated responsiveness of the four core
services overall as good because:
• Services were planned to meet people’s needs. This included
services for vulnerable groups; to get people home from
hospital; avoid admissions; and avoid the need to involve the
emergency services.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
Summary of findings
• Equality and diversity was taken into account when services
were planned.
• The organisation supported people living in vulnerable
circumstances and made sure services met their needs.
• Complaints were taken seriously, responded to appropriately,
and lessons were learned where needed to improve services.
• Many services were able to provide care when it was needed.
There was an outstanding contribution from the palliative care
home service who responded rapidly to referrals for patients at
the end of their life.
However:
• Access to care in the children and young people’s services was
variable and sometimes not even close to targets.
Are services well-led?
Summary
This section relates to the leadership of Bristol Community
Health as a managing organisation (provider) for its services
We have rated well-led at Bristol Community Health as
the provider as good because:
• There was a clear vision and strategy for the core services. We
were confident a strategy would emerge for the services for
children, young people and families now the organisation had
been awarded a five-year contract.
• There were strategies for the organisation with the patient at
the centre and based upon delivering safe and quality care.
• There was an effective governance framework for the core
services, clear lines of accountability, a strong and committed
board of directors, regular review of systems, finances, and
resources. There was an oversight on services and teams, and
the board were assured that the services delivered safe care
that met people’s needs.
• There was a good culture within the organisation. There was
encouragement for all staff to be open, candid and honest,
alongside healthy challenge and collaboration. The views of
staff were encouraged and represented with the board of
directors.
• There was outstanding engagement with people who used the
services, and the communities in which they lived. People were
actively encouraged to be part of the future of services, and
involved in decision-making and feedback.
• Improvements, effort, achievements and success were
recognised, encouraged and celebrated throughout the
organisation.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
Good
–––
Summary of findings
However:
• The children and young people’s services (Child and
Community Health Partnership) did not, as yet, fit within the
governance processes of the core services of Bristol Community
Health. There had been, nonetheless, much effort to present
the service to the board. We were assured this would be
addressed now the contract to deliver these services had been
awarded permanently.
This section relates to the leadership of the four core services
We rated well-led of the four core services as good
because:
• There was committed and caring leadership in the local teams
and services.
• Most staff felt connected to the organisation, and worked hard
to do their very best for the patients, parents, carers, and other
people they supported.
• There was a clear vision and strategic direction for most
services. The new children’s service would now be enveloped
into the overall strategic direction for the organisation.
• There was a lot of structured governance work, and objectives
to deliver safe and quality care through knowing where the
risks, problems, and issues lay, but also what was working well.
• There was a strong and notable culture throughout the
organisation. This included engagement with patients, the
public and staff.
• There was innovation and improvement to services, and
encouragement for staff and patients to come up with new
ideas and ways of working.
However:
• The audit programme was not working in the children and
young people’s service. Although a lot of work was being
undertaken by staff and the teams, it did not have a clear
purpose, and changes because of shortcomings were therefore
not in evidence.
• The lone-working policy was not being followed, as it should
have been in some services.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
Summary of findings
Our inspection team
Our inspection team was led by:
Chair: Robert Aitken, invited independent chair
Team Leader: Alison Giles, Care Quality Commission
The team included CQC inspectors and a variety of
specialist professional advisors. We were joined by
community nurses, learning disability nurses, children’s
nurses, allied health professionals (including
physiotherapists and occupational therapists), clinicians
specialising in governance, and a nurse specialising in
end of life care. We were also supported by two experts
by experience who talked with patients who had
consented to talk with us by telephone about their views
and opinions.
Why we carried out this inspection
We inspected Bristol Community Health C.I.C. as part of
our comprehensive community health services
inspection programme.
How we carried out this inspection
To get to the heart of experiences of care for people who
use services, we always ask the following five questions of
every service and provider:
•
•
•
•
•
Is it safe?
Is it effective?
Is it caring?
Is it responsive to people’s needs?
Is it well-led?
Before visiting the services, we reviewed a range of
information we hold about the organisation, asked the
provider to send us a wide-range of evidence, and asked
other stakeholder organisations to share what they knew.
We carried out announced visits to many different
locations and community teams working for Bristol
Community Health on 16 to 18 November 2016. Prior to
this and during the visits we held focus groups with a
range of staff who worked within the services, such as
nurses, therapists, administrators, and managerial staff.
We interviewed staff working in the community teams,
many of the headquarters-based staff, the senior
executive team, and members of the board of directors.
We talked with people who use Bristol Community
Health’s services. Our experts by experience telephoned a
group of patients and their carers who were receiving, or
who had received care and support. During our visits, we
took time to observe how patients were being cared for,
and we talked with patients and their carers, and/or
family members. We reviewed treatment records and
other information about patients’ care.
We carried out unannounced visits on 27, 28, 30
November, and 1 December 2016.
Information about the provider
Bristol Community Health C.I.C. is a not-for-profit social
enterprise organisation serving community patients in
Bristol and the surrounding areas. The organisation was
established in 2011, and provides all care and treatment
under a contract with the NHS. The status as a
community interest company requires a company to
conduct a business for community benefit, and not for
private advantage.
Bristol Community Health provides a range of services to
the community including a learning disabilities team,
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Bristol Community Health C.I.C. Quality Report 16/02/2017
Summary of findings
community nursing team, a children and young person’s
service, diabetic eye screening, falls service, intermediate
care, community respiratory and health failure specialist
services, migrant health, palliative home care team,
physiotherapy, podiatry, rapid response teams,
healthcare for asylum seekers, and an urgent care centre.
The organisation also provides a prison healthcare
service at five prisons in the south west of England.
Bristol Community Health was awarded the new Offender
Health contract in April 2016 as the prime contractor and
is now managing a complex chain of healthcare
providers. These services are inspected by another team
within CQC in conjunction with Her Majesty’s Inspectorate
of Prisons, and were not part of this inspection.
In April 2016, Bristol Community Health took on the
contract to provide healthcare services for children
(Children’s Community Health Partnership) in South
Gloucestershire and Bristol alongside two other
experienced healthcare providers (another community
provider and an NHS mental health provider). This was
for a 12-month period. During our inspection, the
contract was awarded to this consortium for a fixed term
of five years from April 2017.
Excluding the prisons, this provider has two registered
locations. The majority of services are registered at the
Bristol Community Health Headquarters location, and
urgent care services are registered at the Urgent Care
Centre.
The provider has an income of £75 million to provide
services, and employs around 1,700 staff.
Bristol Community Health was last inspected in March
2014 and there were no actions raised at that inspection.
This is the first comprehensive inspection of the provider
under the new CQC methodology, and the first time the
provider has been rated for the safety, effectiveness,
caring, responsiveness and leadership of the services it
delivers.
Outstanding practice
• There was an outstanding, dedicated and committed
approach to engaging with people who were patients
of Bristol Community Health, their families, their
carers, volunteers, and the wider community. The
Patient and Public Empowerment programme,
underpinned by the patient charter, put patients at the
centre of decisions, valued their feedback and input,
and made changes and improvements from listening
to and engaging with people.
• The chief executive and her leadership team had an
outstanding commitment to staff. The organisation
had been established as an employee-owned social
enterprise. It recognised staff for effort and
achievement through a number of different schemes,
including award ceremonies and personalised contact.
• The organisation’s approach to shared decisionmaking and inclusion of the patient was well
embedded within their culture. We observed this in
practice and in records.
• Specialist services were provided by Bristol
Community Health to meet the needs of people. These
services were flexible and innovative to make
improvements. They enabled services to deliver care
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Bristol Community Health C.I.C. Quality Report 16/02/2017
and treatment, which was accessible to the local
population, with no discrimination. For example,
through the migrant health services and the Macmillan
rehabilitation support service.
• The Haven service recognised the additional support
required for staff who were often dealing with difficult,
challenging and upsetting situations. Weekly access to
a psychologist was made available for staff.
• In children's services, staff respected and recognised
each child as an individual. We observed outstanding
caring from staff who were singing a song to each
individual child and addressing them using their name
when they entered the room for their therapy session.
These children had profound needs, and we
recognised how their faces lit up when they came into
the session and had their special song.
• Families and carers of children and young people
provided consistent positive feedback about the
service. One parent told us “staff are so supportive and
helpful,” “staff are always there when you need them,”
while another told us “staff are really friendly, helpful
and always welcoming.” Another mother told us '”the
service is brilliant, couldn't have asked for a better
one.”
Summary of findings
• In adult services, we observed outstanding
multidisciplinary team working both across the
organisation and with other healthcare providers. In
particular, staff worked hard to make sure all involved
in a patient’s end of life care were up to date with the
situation, and their visits were all coordinated.
• There was an outstanding response to people who
were coming to the end of their life. The palliative
home care team made sure their service worked to
meet the needs of the patient and those they were
close to.
• The visibility of, and support provided by the
safeguarding team had increased the quantity and
quality of safeguarding referrals across the whole
organisation.
• The multidisciplinary working undertaken by the rapid
response team was helping to speed up patient
discharges and prevent hospital re-admissions.
• The organisation had effective processes to review
staff teams and identify areas of risk to provide active
support. These were known as ‘hot teams’. This
allowed issues and risks to be identified early, and
plans to be made to help support these teams.
• In the urgent care service, we heard of numerous
examples where staff had gone the extra mile to
support patients and those close to them.
• The urgent care staff had developed a comprehensive
support network and a range of referral pathways for
adults and children in primary, secondary and
community health care settings.
• The urgent care service had engaged the support of
the lead emergency consultant at the local children’s
hospital to facilitate joint working, and education.
Areas for improvement
Action the provider MUST take to improve
Note: This section relates to Bristol Community
Health and the core services overall
• Take action to ensure all staff in the children and
young people's service receive the appropriate level of
safeguarding training for their role.
• Ensure a complete set of records are transferred with
the child from the health visiting team to the school
nursing team in line with Royal College of Nursing
guidelines.
• Take action to ensure the health visiting team
maintains an individual set of records for each child,
which are filed under the individual child’s surname.
• Ensure staff in the children and young people's service
comply with safe systems to ensure that toys are
cleaned in line with the Cleaning and
Decontamination of Toys’ policy and ensure there is a
system to monitor compliance around toy cleaning.
We also observed poor compliance with hand washing
and cleaning of equipment between use after each
child.
• Ensure compliance with staff mandatory training and
appraisal in the children and young people's service.
• Ensure there are standard operating procedures for
the transition of all children into adult services.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
• Take action in the children and young people’s service
to ensure there is a systematic process of audit to
monitor service quality and performance, for example
records audits, and auditing the single point of access
system.
Action the provider SHOULD take to improve
Note: This section relates to the provider and
how it delivers executive oversight to the core
services. Other actions the provider should take
are referred to in the individual core service
reports.
• Review the reporting of complaints to the board so it
will be apparent if there were proportionately more
complaints in one service than another. Show what
actions were being taken with the leading themes in
complaints, and inform the board of the number of
complaints upheld, partially or otherwise. Ensure the
board know that learning from complaints has been
embedded and any changes have made a difference.
• Look at the variable quality and presentation of
documentation audits to ensure there is consistency
and valid actions taken when there are gaps.
• Ensure the newly appointed chair undertakes an
annual review for the chief executive officer and the
Good –––
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
non-executive directors as required by the
requirements of the Fit and Proper Persons’ Test. This
should be undertaken with limited delay due to the
oversight of this important review in recent years.
• Make sure the representation of patient’s views are put
into context as to what percentage of the patients
treated are being reported.
Good
• Work with commissioners to address the additional
work the organisation is carrying out over and above
it’s contract.
• Consider non-executive director oversight for the
palliative care service.
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
* People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory
abuse
Summary of findings
Summary
This section relates to the safety of the
provider and how it delivers executive
oversight to the core services
We rated safety at Bristol Community Health as
the provider as good because:
• There was recognition and application of the legal
duty to explain and apologise when something
went wrong and caused or could have resulted in
significant harm (duty of candour).
• There was a good culture among staff for reporting
when things went wrong or there was a near miss.
These were investigated, the board were informed,
and staff were informed about anything that
needed to change. Lessons were learned from
incidents.
• There were systems, processes and practices to
keep people safe from abuse or avoidable harm.
There were regular reports to the board on these
procedures, and how they were working. Staff
recognised when someone was at risk and needed
safeguarding, and knew how to take this forward.
The organisation was committed to supporting
people and keeping them safe.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
• There were staff vacancies, but the organisation
was using bank staff and occasional agency staff to
fill shifts when needed.
However:
• There were a number of vacancies in the
community nursing staff teams leading to some
staff with high numbers of patients on their
caseloads. This was sometimes stressful for staff,
and meant patients did not always get as much
time with staff as they would have wanted.
This section relates to the safety of the four
core services
We have rated safety of the core services overall
as good because:
• Most staff understood the importance of reporting
and acting upon incidents.
• There was a culture of being open, honest and
apologising when things went wrong.
• Staff were clear about their responsibilities to
report and act upon safeguarding concerns.
• The administration of medicines was safe.
• Facilities and the environment were fit for purpose.
Good –––
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
• The majority of patient records were good,
although some were incomplete in places. They
were stored securely.
• There was good compliance with mandatory
training in all services, with the exception of the
children’s team, which was being provided at the
time of the inspection on a short-term contract.
This was not helped by poor quality staff records
handed over by the acute trust transferring the
service.
• There were good assessments to keep people safe
and manage anticipated risks.
However:
• There were teams that were short of staff and
pressure on some was high. There was too much
variation in the caseloads staff were expected to
carry. The staffing tools for rotas and planning were
not being used effectively.
• Some staff in the children’s service needed to
update their safeguarding training.
• There was a variable performance in infection
prevention and control protocols.
• Mandatory training was not being updated as
required in the children’s team.
Our findings
This section relates to the safety of Bristol
Community Health as a managing organisation
(provider) for its services
Duty of Candour
• The organisation understood and met the
requirements for applying duty of candour. Regulation
20 of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014 was introduced in
November 2014. This Regulation requires an
organisation to be open and transparent with a patient
when things go wrong in relation to their care and the
patient suffers harm or could suffer harm, which falls
into defined thresholds. The organisation had a clear
policy and process for invoking this legal duty.
Corporate staff had been trained to recognise when
the duty of candour should be applied, and those we
met described this to us accurately.
• Duty of candour was acknowledged in incident
reporting. We reviewed six incident investigation
reports and each of these were for circumstances
where the duty of candour would apply. Each report
had an appendix covering how the duty had been
applied. Most of these had been completed or partially
completed, but the template did not provide sufficient
detail. The template recorded if a patient or family
member had been offered written confirmation of the
incident or a copy of the incident report. However, if
either of these things were accepted, the template did
not record if and when they had been provided. Two of
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Bristol Community Health C.I.C. Quality Report 16/02/2017
the six reports said there was no offer of a written
confirmation, or say why. One report had no report on
the duty of candour, although it did apply. Only two of
the six reports said the family had been asked if they
wanted to ask any specific questions about the
investigation, and a third was ambiguous. Our reading
of the incident reports suggested this part of the
template was not well understood by staff completing
it.
Safeguarding
• There were appropriate policies and procedures for
recognising and responding to adult and child
safeguarding. The policies were in date and
represented both local arrangements and national
guidelines. There were separate policies for
safeguarding vulnerable adults and safeguarding
children. The processes, as appropriate, were different,
to ensure procedures and communication were clear
for both adults and children.
• The board of directors were informed about
safeguarding matters. The monthly quality report to
the board updated the leadership on training, referrals
made, actions and recommendations. The report
included what level of reporting came from individual
teams in the services, and what categories were
reported. This enabled the organisation to look for any
recurring themes where action might be needed, and
review if there were any teams making an
unexpectedly high or low level of reporting.
Good –––
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
Incidents
• The organisation had a positive and open approach to
incident reporting. Senior managers explained the
importance of staff being open and honest about
incidents. They recognised how good organisations
are those prepared to listen, change and improve
when things went wrong, or could have been better.
Staff we met said they were encouraged to report
incidents, received feedback, which usually included
thanks for the report they had made, and what had
come from any investigation of the incident.
• Serious incidents had reduced over the last 18
months. In the year from April 2015 to March 2016,
there was an average of five serious incidents requiring
investigation each month. In this period, the number
of incidents in a month ranged from one to nine. In the
six months from April to September 2016, this had
reduced to four per month on average. In this period,
the number of incidents in a month ranged from two
to six. The services provided by Bristol Community
Health had also increased in this period with the
inclusion of services for children, young people and
families.
• All serious incidents were investigated in line with the
organisation’s policy and procedures, although there
was a variable quality to the investigation reports. We
reviewed six serious incident investigation reports. All
of these related to the organisation’s most frequent
serious incident – a patient’s development of a
category three or four pressure ulcer. These six most
recent incidents had occurred when the patient was
under the care of Bristol Community Health, but
circumstances showed these were unavoidable –
although this was not explained directly in the report.
Our review of the investigation reports found a lot of
good detail, background and care described well.
However, some reports skimmed over some key areas
(such as staffing levels, which were not then described
other than “challenging”) and the root-cause of the
incident focused on the lack of compliance by the
patient, when there were other clear factors
contributing. One particular report was also
contradictory, or became so due to some factors
reported not being clear as to their origin. We
discussed our findings in some depth with the
organisation and our concerns were understood and
acknowledged.
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• Incidents and investigations were peer reviewed
before they were approved at executive level. Before
they could be approved, serious incidents were
presented at regular complex case review meetings.
Each of the six reports we reviewed had been through
this process. We attended one of these meetings
during our inspection. The meeting included clinical
managers and staff relevant to those investigations
being considered. Also in attendance were the
safeguarding lead, the manager representing quality
and safety, clinical leads, operational, and governance
staff. Our view was the atmosphere of the meeting was
open and non-threatening. The organisation was not
looking to apportion blame, but to look for positive
actions and learning from incidents.
• The incidents reported were presented each month to
the board of directors for review and comment. The
monthly quality report started with a detailed review
of incidents that covered over around 10 pages. Each
section culminated in a review of incident trends in the
various categories. The report concluded with actions
and recommendations from any themes developing in
that reporting period. One area the report did not
cover was how the board were assured that actions
taken had produced the anticipated improvement.
Staffing
• The board of directors received an extensive and
informative report on staff – the Wellbeing report –
each month. The report updated the board on
sickness levels, vacancy rates, use of bank and agency
staff, staff turnover, and teams where risks had been
recognised. The report continued with training
compliance in some detail. The report contained
details on what the organisation called ‘hot teams’
which was where certain trigger points (absence rate
≥4%, vacancy rate ≥7.5%, and turnover rate ≥2.5%) had
been reached in these teams.
• There were levels of sickness that were slightly below,
so better than, those of public sector organisations
and other not-for-profit organisations. In the latest
board papers for November 2016, sickness absence
was reported at 3.7% (for August 2016), which was
slightly up on July at 3.6%. This was below the figure of
4.1% for the public sector and 4% in the not-for-profit
business sector.
• The organisation recognised it had an issue with
recruitment and retention of staff. Bristol Community
Good –––
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
Health competed for staff with two major NHS acute
hospitals, a large mental health NHS trust, the private
healthcare sector, GP practices who had or were
establishing nurse-led services, and other local
community service providers. In the services we
inspected (so excluding the offender health services)
the vacancy rate for September 2016 was 9.5%. When
this was reduced through the use of bank staff, the rate
fell to 7.6%. The organisation had been addressing this
problem, which was included within the strategic risk
register and consequently held and discussed by the
board each month. The risk was entered onto the
strategic risk register in July 2016. The organisation
had implemented a number of projects and actions to
mitigate the risk. These included, among others, a
review to provide assurance that there were no
underlying causes of staff turnover the organisation
was not aware of. There was the ‘Talkback Programme’
where senior executives met with staff in less formal
atmospheres, and their places of work to have open
discussions about pressures and successes. There had
been changes to employment terms and conditions,
workforce development programmes, and the
wellbeing programme, staff events, and career
progression.
The section relates to the safety of the four core
services
Incident reporting, learning and improvement
• There was a good culture among most community
teams and staff around incident reporting. Staff
recognised their responsibilities to report incidents
and why this was necessary to improve future care.
The only area of concern was around inconsistency
with the children’s service for what constituted an
incident. Not all staff were using the organisation’s
system as they should. This had been recognised to an
extent by senior staff within Bristol Community Health
and there were plans and work ongoing to raise
awareness of the importance of incident reporting.
• Incidents were investigated and lessons learned as a
result. We saw examples in each of the services we
inspected of good quality investigations and
recognition of where something should be changed.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
Actions to be followed were shared with teams. Staff
were given feedback when they reported an incident
saying what was being done to learn from incidents
and avoid them happening again.
Duty of candour
• Most staff in community teams were familiar with the
requirement to be open, honest and apologise to
patients if something was to go seriously wrong with
their treatment of care. Regulation 20 of the Health
and Social Care Act 2008 (Regulated Activities)
Regulations 2014 was introduced in November 2014.
This Regulation requires an organisation to be open
and transparent with a patient when things go wrong
in relation to their care and the patient suffers harm or
could suffer harm, which falls into defined thresholds.
There was some lack of knowledge in the community
adults’ team and not all staff had received training or
direction.
Safeguarding
• There were clear systems and processes for keeping
children and vulnerable adults safe from abuse. Staff
were confident about making safeguarding referrals
and had support from senior staff if they had any
concerns, questions or wanted guidance. They were
clear about who the Bristol Community Health senior
staff were with responsibilities for safeguarding and
how to get in touch with them. Feedback was given to
staff who made referrals so they could see that action
had been taken.
• There were high levels of training in safeguarding for
staff working with adults, although this dropped in
children’ services (CCHP). The board report for
November 2016 reported that at the end of September
2016 training in the adult teams was:
▪ Safeguarding adults’ training for all staff was 97%
▪ Safeguarding adults’ for relevant staff (level 2) was
92%
▪ Safeguarding children for all staff (level 1) was 99%
▪ Safeguarding children for relevant staff (level 2) was
95%
▪ Safeguarding children for relevant staff (level 3) was
86%
▪ Safeguarding children for relevant staff (level 4) was
100%
Good –––
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
The organisation’s target for completion was 90%, so just
one group of staff were not meeting this level of
compliance. The report was not clear, but we understood
these numbers did not include CCHP staff.
Further into the report, the CCHP staff training data was:
•
•
•
•
Safeguarding adults’ training for all staff was 82%
Safeguarding adults’ for relevant staff (level 2) was 46%
Safeguarding children for all staff (level 1) was 77%
Safeguarding children for relevant staff (level 3 – level 2
not required) was 81%
• Safeguarding children for relevant staff (level 4) was
100%
In this part of the organisation, only one group of staff
met the compliance levels for safeguarding training. This
had been recognised in the organisation, and there was
an action plan and report submitted to the board to focus
upon these areas as a priority.
Medicines
• Arrangements for the management, storage and
dispensing of medicines were safe. There were
appropriate storage facilities for medicines, including
controlled drugs. Any prescription pads were in locked
and secure storage and traceable. There were regular
stock checks to ensure medicines were not
mismanaged.
• The organisation had appropriate use of patient group
directions. These were a set of instructions for the use
and prescription of medicines in certain situations.
Those in use were up-to-date and had been
appropriately issued and approved.
• Actions were taken when incidents with medication
were reported. A recent trend of incidents with insulin
reporting in an area of the community adults’ service
had been identified. The problem, which was with the
records not being used correctly, was discovered,
rectified and a new system introduced. Staff had also
been reminded to administer medicines, including
insulin, with a calm approach and make sure they
were not distracted by the environment or other
people. The incidents had now decreased and the
continuation in this was being monitored at senior
level.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
Environment and equipment
• The facilities we visited were clean, and relatively well
maintained. The urgent care centre was spacious and
well laid out. It was easy to clean and maintain and a
relatively new premises designed for purpose. The
reception areas used by the learning disabilities team
were not as secure for staff as they could be, but there
were plans to improve this – although with no date for
the work to be completed. The community clinics for
adults and children were well maintained and
appropriate for their use, but some of the premises
were old and tired through regular use.
• Equipment was serviced and regularly checked if
required. Records we saw indicated maintenance had
been undertaken, and other equipment, such as
emergency trolleys, was checked on a regular basis as
required.
• Most equipment used by staff was in good condition.
Equipment used in the urgent care centre was in good
condition, and able to be maintained effectively.
Anything used by the community adults’ team when
working with patients was in good condition and fit for
its purpose. In the children and young people’s
services, there were some old and worn out changing
mats, which staff had asked to be replaced. Otherwise,
equipment was appropriate and available, and
specialist equipment would be provided when needed
to support children and adults.
• There were arrangements to ensure specialist
equipment was provided to patients when they
needed it. Bristol Community Health had around 1,500
staff qualified to recommend equipment, which was
then managed by the equipment coordination team.
The equipment coordination team ensured
appropriate equipment was ordered, and tracked any
special requests. A senior member of staff approved all
orders for equipment on the approved list. Equipment
not on the approved list, but seen as necessary for a
patient would be formally approved by a specialist
group within the organisation. There had been some
incidents recently due to confusion with the type of
pressure relieving mattresses being supplied. A pattern
of issues had been recognised and the system had
been amended to solve the problems.
Good –––
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
Quality of records
• There were legible, clear and well-maintained records,
although some were not as complete as they should
have been and some not fully available. Records about
people using the learning disabilities service were
good, and we reviewed 16 sets of these at random.
Records in the urgent care service were clear in
relation to the care and treatment provided. However,
for example, in the 10 sets of records we viewed at
random, the pain scores and consent had not been
documented consistently. In the community adults’
teams, the records we looked at were legible, accurate
and complete. The children’s records were completed
well, although not all services had full records for each
child. Some of the ‘red books’ used to record
significant events for a child were not always
complete. There was some duplication in records by
the therapy teams in the children’s service.
• Records were stored securely. Those records that were
hand written by community adults’ teams were
transferred to secure electronic records when the
member of staff came back to their base. Where
records were not electronic, these, such as with the
children’s service, and paper records used in the adult
services, were locked away in secure premises.
Cleanliness and infection control
• There was a variable performance in infection
prevention and control. There was good adherence to
policies and procedures in the urgent care service, the
community adults’ teams and the staff who supported
people with learning disabilities. However, the children
and young people’s services did not have reliable
systems to ensure they were preventing the spread of
infection. There was no evidence of preventable
infections originating from the service, but some of the
practices and equipment we saw did not meet the
Bristol Community Health policies or standard
operating procedures. The concerns included:
▪ Not all clinical waste bins were foot operated. We
observed some staff opening the bins by hand and
not cleaning their hands after disposing of waste.
▪ We observed poor infection control procedures at
some staff bases and clinics. Staff were not washing
their hands between seeing children and were not
cleaning some equipment between use.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
▪ There was no assurance that toys provided for play
or distraction were cleaned effectively. There were
some soft toys in use, which were not permitted by
the organisation’s policy due to difficulties with
keeping them clean.
• With the exception of what has been reported above,
we observed staff complying with recognised handhygiene standards. This included staff in clinical areas
being ‘bare below the elbow’ to make hand-washing
more effective. Staff had good techniques when
washing their hands, and knew when to use hand gel
or when it would not be effective.
• Most premises were clean and tidy, although some
were old and showing signs of wear and tear, and less
easy to keep hygienic. However, staff worked hard to
ensure cleaning was effective and there was no
evidence of the spread of infection. With the exception
of what has been reported above, we observed good
attention to cleaning of clinical equipment, which was
the responsibility of nursing or healthcare staff.
• The organisation had policies and procedures for staff
and patients when there were outbreaks of illness or
infection either on the premises (such as care homes
visited by the community adults team) or in the
community. Patients arriving at the urgent care centre,
for example, were asked to not enter the premises if
they had diarrhoea and/or vomiting, and to contact
the 111 service for advice. There were otherwise
procedures to isolate a patient who was exhibiting
signs of infection.
Mandatory training
• Most staff were up to date with their mandatory
training and, with the exception of the children and
young people’s services, most were exceeding the
organisation’s target of 90%. The children’s service was
showing compliance of 70%, although this figure had
been hard to obtain for the organisation. When the
service was transferred over to Bristol Community
Health from the NHS in April 2016, there had been a
failure to transfer the mandatory training records
satisfactorily. This left Bristol Community Health with
poor records they were unable to rely upon. An
improvement plan had been produced to deal with
the perceived lack of compliance and escalated to the
corporate risk register.
Good –––
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
Assessing and responding to patient risk
• There were good risk assessments for patients to help
keep them safe. This was the case in all the core
services we inspected. Risk assessments were relevant
to the patients being supported. Risks were acted
upon in a timely way. For example, in the service for
people with learning disabilities, the referrals to
speech and language therapists were a priority for
patients at a high risk of choking. Patients with a high
risk of diabetes were referred to a dedicated team for
advice and support.
• Bristol Community Health was committed to a culture
to reduce the risk and occurrence of pressure ulcers.
There was a dedicated wound-care service, led by a
tissue viability nurse specialist. Furthermore, there
were skin champions in each community nursing team
to support staff with training and advice. The objective
was to assess patients in every interaction for the risk
of developing a pressure ulcer. This had resulted in a
reduction in the incidence of pressure ulcers, and in
the year 2016/17 to the end of October 2017, there had
been no avoidable pressure ulcers recorded.
• The palliative home care team followed clear
procedures when people were at the end of their life.
This included when to escalate concerns to the
patient’s GP or the local hospice. The team had
handovers each day to make sure any new or
emerging risks were known by the staff coming on
duty.
• There was a standard triage system in use in the
urgent care service to manage patient risks. Staff had
annual training on signs and symptoms for the sick
child or adult. There was a fully-equipped
resuscitation room for patients recognised at serious
or significant risk.
• There was a wide-range of tools used in the
community learning disabilities’ teams when patients
were referred to them. There was appropriate use of
crisis plans or reacting to sudden changes or
deteriorations in a patient. An appropriate range of
healthcare professionals were involved in the patient’s
care to assure risks were managed by the right people.
Staffing levels and caseload
• As acknowledged by the organisation, there were
teams within the organisation that were short staffed
and under pressure. There were vacancies across the
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Bristol Community Health C.I.C. Quality Report 16/02/2017
services, with the exception of the urgent care service,
which had recently recruited staff to fill its vacancies.
However, the urgent care service was staffed to levels
of staff agreed within the contract with the
commissioners. This did not take account of the 26%
increase in demand for the service in the last 12
months. The organisation was working hard to fill
vacant posts, and used bank and agency staff to
supplement staffing levels. However, one of the key
areas of the staff survey was the high proportion of
staff who reported they were concerned about staffing
levels and time to do their jobs properly.
• There were significant variations in the caseloads staff
were working with. This was the case in all the
community teams (that is excluding urgent care).
Some staff had caseloads that were double the
average in the children and young people’s services,
and higher than recommended national guidelines. In
the community learning disability service, there were
some high caseloads, although the staff told us they
were safely managing these. However, the staffing
levels in this service had not been reviewed for some
time.
• The staffing tool used to plan and establish rotas by
the community nursing teams in both the adult and
children and young people’s services were not being
used effectively. This resulted in capacity measures
not being a true reflection of staffing levels, or the
work being undertaken. This resulted in the
organisation’s escalation procedures when staffing
levels were unsafe not being activated at times.
Managing anticipated risks
• In urgent care, the arrangements for providing care
and treatment in times of high demand were effective.
This meant patients who arrived at a time when the
service was at full capacity were redirected to other
services. This was only invoked for patients who did
not have a life-threatening condition, as they would be
urgently treated.
• There were policies and procedures to ensure risks to
patients or others were understood and managed.
When patients had conditions that were worsening, or
patients had been referred with significant concerns,
these patients would be seen as a priority.
• Bristol Community Health operated certain services to
provide an urgent response to risks. This included the
Good –––
Are services safe?
By safe, we mean that people are protected from abuse * and avoidable harm
urgent care centre, the rapid response teams, the
Bristol Intensive Response Team (for the learning
disabilities service), and safe-haven beds for people
who needed protection or urgent support.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
Are services effective?
Good –––
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
Summary of findings
Summary
This section report relates to the effectiveness
of the provider and how it delivers executive
oversight to the core services
We rated effectiveness at Bristol Community
Health as the provider as good because:
• The care and treatment delivered to patients
delivered good outcomes.
• The organisation focused upon promoting a good
quality of life.
• The best available evidence was used to structure
care pathways and the standards used in treatment
and procedures.
• There was a good multidisciplinary approach to
delivering care so it was coordinated, and benefitted
from shared learning at all levels in the organisation.
However:
• There was variable quality in the audits around
consent. Those we saw did not all provide assurance
that consent was being recorded and validly
obtained at all times, and that actions were being
taken to improve compliance when there were gaps.
This section relates to the effectiveness of the
four core services
We have rated effectiveness overall as good
because:
• Care was delivered along national guidelines and
recognised pathways.
• Pain was well managed, as were nutrition and
hydration needs.
• Patients had good outcomes from the care and
treatment they received.
• Most staff had been given an annual review
(appraisal).
• There was professional development and courses
available to staff to give them new and updated
skills.
• There was an excellent approach to multidisciplinary
working and coordination of care pathways.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
• There were proactive services to help discharge
patients from hospital, and provide a rapid response
to patients in need.
However:
• There was limited use of technology and
telemedicine.
• Somewhat unreliable records showed appraisal
compliance had fallen behind in the children and
young people’s services.
• The rapid response team had to go above and
beyond the service they were expected to provide, as
the social care packages were not always available
when the rapid response service should have ended.
• Some of the children and young people's services
had no standard operating procedures for handing
over patients from child to adult services.
• There was variable access to information due to
issues with mobile phone networking in some areas,
and IT systems that needed to be upgraded (of which
the provider was well aware).
• Recording of consent decisions and mental capacity
assessment was poor. Not all consent decisions were
following legal principles where they involved
children.
Our findings
This section relates to the effectiveness of Bristol
Community Health as a managing organisation
(provider) for its services
Evidence based care and treatment
• Care and treatment provided to Bristol Community
Health’s patients was delivered along evidence-based
guidelines and through specialist staff. Staff had access
to a range of guidance for providing effective
assessment, diagnostics and treatment.
• The organisation was involved with research projects to
improve care and treatment and establish best practice.
For example, the urgent care service was involved with a
project to better understand why people attend
emergency and urgent care services.
• The clinical director – an experienced nurse – was
supported by staff leading in various areas where they
had training and experience. This included: infection
Are services effective?
Good –––
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
prevention and control; quality and patient safety;
medicines management; and clinical audit. The
operational team was led by an experienced director
with many years of NHS and community service
management. Staff with leading roles in this area
included: tissue viability (treatment for people with
pressure ulcers and wounds); allied health professionals
(physiotherapists, podiatrists, occupational health and
speech and language therapists); the lead nurse for
public health; and the lead nurses for urgent care,
community nurses, specialist services, learning
disabilities and continuing healthcare, musculoskeletal
care, and intermediate care. Those lead staff we met
described care and treatment supported by National
Institute for Health and Care Excellence (NICE) and other
relevant guidance. Examples included support for older
people suffering from a fall, where NICE guidance
underpinned the falls assessment service, and
prevention and pressure ulcer management.
• Policies, procedures and clinical guidance were
reviewed each month by the 'clinical cabinet', which
was part of the governance assurance framework. The
clinical cabinet reviewed NICE guidance, revisions to
care pathways, updates, revisions and new clinical
policies, and approved any research programmes.
•
•
•
Patient outcomes
• The board was provided with an annual report of clinical
audit. Clinical audit work was a contractual obligation of
the organisation, as required by the clinical
commissioning groups. The board also recognised
effective audit as a recommendation of the Francis
report, published in 2013 in response to the failings at
Mid Staffordshire NHS Foundation Trust. The work by
the audit team included local audit approved by the
organisation, and audits in response to guidelines from
NICE, and NHS England’s Commissioning for Quality and
Innovation (CQUIN) framework. The most recent report
(May 2016) covered the work for the previous financial
year – April 2015 to March 2016.
• Audit work provided oversight and assurance, and
produced change. It was underpinned by the work of
the quality assurance group and the harm-free care
group. The audit report described how learning had
emerged from clinical audit. In the May 2016 report, the
example came from work of the rapid emergency
assessment care team (REACT) who found there had
been little improvement in the process for falls referrals
26
Bristol Community Health C.I.C. Quality Report 16/02/2017
•
since the previous year. Work with the local NHS acute
trusts had resulted in a new falls' pathway document to
enable clinicians to refer patients to the most
appropriate service. The objective was to broaden the
range of falls’ clinics being referred to and reduce
waiting lists in over-used services. Early indications
showed this had a positive impact for patients.
Bristol Community Health had a strong focus upon
feedback from patients and their carers as a way of
determining outcomes of the care and treatment they
delivered. As reported in our section on public
engagement, there was a strong focus on patient
feedback, particularly in real time, rather than annual
questionnaires. This had increased feedback by more
than 100% since the system was implemented in 2015.
The organisation had a series of key performance
indicators to measure outcomes and specific indicators
reported to the board each month. This included harmfree care statistics (pressure ulcers, falls with harm,
venous thromboembolism, and urinary tract infections),
and health-care acquired infections. Harm-free care was
around 94% on average, although no target had been
provided to analyse how the organisation was doing.
There was cooperation and collaboration in the area of
clinical audit. The organisation was represented on the
Bristol Interface Audit Group and the South West Audit
Network. Audits for work that crossed organisational
boundaries (called interface audits) were discussed,
recommended and implemented by these networks. In
the 2015/16 year, Bristol Community Health contributed
to, for example, an audit on the use of syringe pumps.
There was also work with the local NHS acute hospital
trusts on improving pathways of care where they had
been seen to be failing in areas. This had included work
on improving the referral of patients who had suffered a
fall. The organisation had also been part of the
development of the South West Quality Improvement
Framework for the Prevention and Management of
Pressure Ulcers, commissioned by NHS England.
There was a low level of complaints to the organisation,
suggesting patients were happy with their care and the
outcomes of any treatment they received. There was a
high level of patient satisfaction with services, with the
most recent NHS Friends and Family Test (September
2016) reporting that 97% of people who responded
would recommend the service.
Are services effective?
Good –––
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
Multidisciplinary working
• Multidisciplinary working was encouraged and valued
by the organisation. This was both within teams,
between services, with staff in other teams, and with
external providers of care. At senior management level
there was professional involvement and engagement
with the local NHS acute hospital trusts, the local
mental health trust, and other stakeholders, such as the
local authority.
Access to information
• Bristol Community Health was about to upgrade IT
systems to enable staff working out in the community to
have access to patient records in the electronic system.
At the time of the inspection, staff would return to their
base office to input information to patient records to
keep them up to date.
• There was access for all staff to relevant information. All
staff had access to the Bristol Community Health
intranet, and this allowed them to view policies,
protocols, standard operating procedures, and other
information stored by the organisation.
• There were recognised issues with computer systems,
which were to be addressed by the appointment shortly
of a Chief Information Officer. The staff survey told us
low numbers of staff were satisfied with the IT systems
and felt they had good support when they had a
problem. The organisation freely admitted there were
problems with the infrastructure and there were too
make ‘workarounds’ and disparate systems. Some of
this was related to systems and services owned and
managed by other organisations, which Bristol
Community Health was unable to influence under their
contract with the lead clinical commissioning group. We
were told by the Chief Executive how “addressing these
issues is a key part of our business plan and business
cases are currently under consideration by our board to
make significant investment in solutions.”
• The introduction of the electronic patient record system
(known as EMIS) had enabled interfaces with primary
care (GPs) and was improving efficiencies for both staff
and patients.
Consent, Mental Capacity Act and Deprivation of
Liberty Safeguards
• There was good staff compliance with training in the
Mental Capacity Act 2005. The nature of care provided
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Bristol Community Health C.I.C. Quality Report 16/02/2017
by Bristol Community Health staff would rarely require a
patient to provide written consent, and most treatment
would be from gaining implied or verbal consent.
However, staff also met with patients who had a lacked
the mental capacity to provide valid consent. This would
require care to be provided in the best interests of that
patient, and this would need to be assessed and
recorded.
• There was a variable quality in audits where consent
was reviewed, and no overarching assurance it was
being consistently sought and recorded across the
services. Consent was reviewed within the audits of
documentation carried out in many of the services, but
the quality of the four of these we reviewed was
inconsistent. There was no evidence to suggest consent
was being inappropriately or incorrectly sought or
recorded. However, the four audits were all quite
different and did not appear to follow a set template.
This meant there was some inconsistency when looking
to consolidate and compare results. For example, not all
of the audits looked at the assessment of patients'
mental capacity. There were some gaps in actions
arising from concerns brought out of the audits.
Therefore, the audit reports would not provide the
organisation with a consolidated view of whether
consent decisions and recording of these was meeting
legal guidelines.
• Bristol Community Health specialised in community
care, and would therefore not be applying for or able to
grant themselves a temporary urgent authorisation to
deprive someone in their care of their liberty (a
Deprivation of Liberty Safeguard). Nevertheless, the
organisation would be caring for and treating people
who might be subject to this safeguard. This included
people living in a care home or supported setting for the
purpose of being given care or treatment. The
safeguards applies to people who had a mental illness
and lacked capacity to be able to consent to the
arrangements for their care or treatment. The majority
of these people will be those who had significant
learning disabilities, people living with dementia or a
similar disability, and people with certain other
neurological conditions. Community staff were trained
to understand how and why a Deprivation of Liberty
Safeguard was applied to a patient they might be
treating, for example, in a care home, and their role in
keeping that person and those around them safe and
well supported.
Are services effective?
Good –––
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
This section relates to the effectiveness of the four
core services
Evidence-based care and treatment
• Policies, guidelines and the pathways for patient care
had been developed across services in line with
national and evidence-based guidance. Staff had access
to a range of guidance for providing effective
assessment, diagnostics and treatment.
• Staff we met described care and treatment supported
by National Institute for Health and Care Excellence
(NICE) and other relevant guidance. Examples included
support for older people suffering from a fall, where
NICE guidance underpinned the falls assessment
service, and prevention and pressure ulcer
management.
• Policies, procedures and clinical guidance were
reviewed each month by the 'clinical cabinet', which
was part of the governance assurance framework. The
clinical cabinet reviewed NICE guidance, revisions to
care pathways, updates, revisions and new clinical
policies, and approved any research programmes.
• There were recognised pathways for patient care for
those at the end of their lives, although this was not as
well embedded among nursing staff as it should have
been. The pathway included Bristol Community Health
staff using the ‘five priorities for care’ for care of a dying
patient. When we asked community nurses about the
five priorities of care there was a variable response.
Some staff were not aware of it at all, others had limited
knowledge, although senior staff were well versed in the
pathway. The five priorities for care succeeded the
Liverpool Care Pathway (LCP) as the basis for caring for
someone at the end of their life. For example, one of the
five priorities is tailored to the individual and delivered
with compassion through an individual care plan.
• Bristol Community Health was involved with research
projects to improve care and treatment and establish
best practice. For example, the urgent care service was
involved with a project to better understand why people
attend emergency and urgent care services.
Pain relief
• Patients’ pain was being assessed and managed
effectively. This was one of the first questions asked of
patients who attended for urgent care. Staff ensured
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Bristol Community Health C.I.C. Quality Report 16/02/2017
patients who would have potentially long waits had any
pain managed while they were waiting. Asking patients
about their pain was a key part of visits to people in the
community.
• Pain and symptom control was a priority for staff caring
for patients at the end of their life. There were
anticipatory medicines prescribed for when they were
needed, and regular reviews of their effectiveness. There
was specialist palliative care advice available from the
local hospice 24 hours a day.
Nutrition and hydration
• There was an understanding in the different services
about the need for good hydration and nutrition. Health
visitors would provide support to parents, and
community nurses to patients and their carers. The
community nurses discussed eating and drinking with
patients where this was an issue, such as the patient
being under or over weight. Patients were encouraged
to eat and drink well. The importance of good hydration
was understood by the staff and explained clearly to
patients.
Use of technology and telemedicine
• There was limited use of technology and telemedicine
(which was a system to provide diagnostics from a
distance). Bristol Community Health had problems with
its IT system, which it was well aware of, and was a
priority for the near future. This was a particular issue in
the children and young people’s services, and would be
a key area to be resolved now the contract for this
service had been awarded to Bristol Community Health
for the next five years.
• There were issues with getting good connections for
mobile phones, which were not helping, in the use of
telemedicine. Bristol Community Health had trialled a
mobile clinical system (for reporting and accessing
diagnostic tools), but the telephone network had not
helped this become a success.
Patient outcomes
• From feedback and conversations with patients and
carers, we found patients had good outcomes from their
care and support. Patients we met who used services
told us they were happy with the outcome of their care
and treatment. Staff followed guidelines, quality and
innovation targets, and approved protocols to provide
Are services effective?
Good –––
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
•
•
•
•
29
good outcomes. Care was provided in accordance with
a different range of needs for patients and with them as
individuals. This meant the way care was delivered was
different, but designed to produce the same outcomes.
There was a range of clinical and other audit used to
evaluate practice. This was taking place regularly in all
services, with the exception of children and young
people’s services, where the organisation was yet to
embed this practice effectively, and in some elements of
end-of-life care. In relation to the children and young
people’s services and end-of-life care, this was
something the organisation was well aware of, and had
made plans to expand the audit work into both these
services in the near future. There was a range of good
information being collected in children and young
people’s services, but no systematic approach to using
this data in audit work or to measure outcomes.
Most audits were being completed, but some were
delayed due to staffing levels and higher priorities. For
example, there was a backlog with audit work in the
urgent care service due to staff shortages in the recent
past, and a vacancy for the operational lead. There was
recognised engagement in the audit process among the
learning disabilities’ teams.
Audit results were used to improve patient care. When
the service had a result that was showing some
improvements were needed, and action plan was
produced and followed through until completion. A reaudit of the results would then demonstrate if the
actions had resolved the problem, or whether there
were other factors at work. An audit of the ‘easy read’
documentation for people with learning disabilities had
identified how the care plans were not working for
everyone they supported. Work was being undertaken
to see how they could be improved to meet patients’
needs.
The annual audit report described how learning had
emerged from clinical audit. In the May 2016 report, the
example came from work of the rapid emergency
assessment care team (REACT) who found there had
been little improvement in the process for falls referrals
since the previous year. Work with the local NHS acute
trusts had resulted in a new falls' pathway document to
enable clinicians to refer patients to the most
appropriate service. The objective was to broaden the
range of falls’ clinics being referred to and reduce
waiting lists in over-used services. Early indications
showed this had a positive impact for patients.
Bristol Community Health C.I.C. Quality Report 16/02/2017
Competent staff
• Staff had the skills and knowledge to deliver effective
care. Staff training started with a local induction into the
service and continued with learning while observing
and then performing the role. For example, there were
preceptorships (a structured programme of transition
and mentoring) for newly qualified health visitors,
speech and language therapists, and school nurses.
• Staff were supported and encouraged to undertake
professional development. This included both new and
existing staff. The organisation had fast-track
programmes to develop and promote their own nursing
staff, and were part of the nationally recognised
healthcare assistant programme to develop these staff.
• There were training days and sessions, and evening
seminars for staff to increase their skills and knowledge
of the tools to do their jobs. This was, for example, a
popular programme with the urgent care centre staff.
There was continual professional development for
clinical staff, such as the physiotherapists and school
nurses.
• There was some varied compliance with staff appraisals,
although most services showing good results. These
annual reviews were fully completed for the staff in the
learning disability service. Almost all staff in the
community adults’ team had completed their review
and the target of 90% of staff was met. In the urgent care
service, 94% of staff had received their annual appraisal.
The area of concern was with children and young
people’s services where only 69% of staff had been
assessed for their competency and performance. Due to
the quality of data from the previous NHS provider of
children and young people’s services, the data Bristol
Community Health had to rely upon was not of a good
quality. The result of 69% could therefore have been
better, but was unreliable.
Multi-disciplinary working and coordination of
care pathways
• Bristol Community Health worked with a range of
healthcare providers and the local authorities to ensure
there was multidisciplinary working and coordination of
care. Most of the patients supported by Bristol
Community Health would have come into contact with
other organisations, such as social workers, GPs, the
Are services effective?
Good –––
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
local acute and mental health hospitals, and schools.
There were a wide-range of programmes with these
other organisations that Bristol Community Health took
part in. This included, for example:
▪ Work with the local authority to tackle childhood
obesity.
▪ The rapid response team working with the local
ambulance NHS trust.
▪ Care for patients at the end of the life with the local
hospice and Marie Curie.
▪ Liaison with X-ray teams (provided by a local acute
NHS trust) at the urgent care service.
▪ With the pastoral support teams at local schools.
We recognised the multidisciplinary working both
internally and with external healthcare providers as
outstanding practice.
• There was effective multidisciplinary work for people at
the end of their lives. Community nurses were involved
with those GP practices that held the Gold Standard
Framework – an accredited framework for providing the
best care at the end of a person’s life. Meetings were
held with the GPs to assess and plan care, including
effective pain relief. There was a close working
relationship with the local hospice and two-way support
to ensure patients received the most effective care.
• There was good multidisciplinary working within the
organisation. Teams supported one another with advice
and guidance. This included, for example, support to
the community nurses from the tissue vitality, and
bladder and bowel specialist nurses.
Referral, transfer, discharge and transition
• Bristol Community Health had a ‘single point of access’
team to coordinate referrals to the adult service to
ensure patients were provided with the right support.
This team took referrals from a number of sources,
including patients with a learning disability being able
to refer themselves, and from GPs and other healthcare
workers.
• There were services commissioned to support the
discharge of patients from hospital to home. Services,
called In-reach, were based in the local acute hospitals
to enable the discharge of patients to be planned at the
earliest stage, and any ongoing support needed once
the patients was discharged to be organised in advance
as much as was possible.
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Bristol Community Health C.I.C. Quality Report 16/02/2017
• The rapid response team had to go above and beyond
what they had been commissioned to provide in order
to keep people safe. This team were required to provide
a seven-day service to prevent patients being
readmitted to hospital. At the end of this period,
patients who needed further or ongoing support were to
be handed over to the local authority. However, there
were still some patients who were receiving support for
over 25 days, as the local authority package had not
been provided. This was reducing the number of
patients Bristol Community Health staff were able to
support.
• Staff were able to refer patients onwards to other
services within Bristol Community Health or provided by
other organisations. The exception to this was for
secondary care, where a patient needed to be referred
back to their GP. Otherwise, clinical staff were able to
refer patients, for example, to school nurses, for
physiotherapy or speech and language therapy, mental
health review teams, for X-rays, and sexual-health
clinics.
• There was no standard operating procedure to support
children transitioning to adult services. The children’s
teams were doing their best to make the transition work
for the child and the family. The physiotherapy team
were, for example, endeavouring to hold a joint clinic
with the child and adult teams to support the handover,
but this was only happening for 50% of children.
Mental Health Act (learning disability service)
• Staff in the learning disabilities’ service had a
reasonable understanding of the Mental Health Act and
its associated Code of Practice. There was information
about access to independent mental health advocates
in waiting areas and provided to all new patients. Any
support or guidance around the Mental Health Act was
available from contacting consultant psychiatrists
working with the patient.
Access to information
• Bristol Community Health was about to upgrade IT
systems to enable staff working out in the community to
have access to patient records in the electronic system.
At the time of the inspection, staff would return to their
base office to input information to patient records to
keep them up to date.
Are services effective?
Good –––
By effective, we mean that people’s care, treatment and support achieves good
outcomes, promotes a good quality of life and is based on the best available
evidence.
• There was access for all staff to relevant information. All
staff had access to the Bristol Community Health
intranet, and this allowed them to view policies,
protocols, standard operating procedures, and other
information stored by the organisation.
• There were issues with children and young people’s
services having access to full patient information.
Changes to caseloads had resulted in records not being
in the right place. School nurses did not have access to
some areas of a child’s medical history. However, the
speech and language team made sure they prepared
records in advance with the information they needed to
effectively assess and treat and patient.
• In the adult services, some staff had access to GP
records. However, this was dependent upon the county
in which the patient lived and the system used by the
GP, which might not be compatible with the systems
used by Bristol Community Health. Nursing staff
constructed their own records in circumstances where
they were not able to access other information, and
requested important information directly from patients
GPs.
• Consent from adult patients was gained in line with
legal principles. All adult patients who were mentally
capable were asked to give consent for any care and
treatment. All care and treatment provided by Bristol
Community Health staff would require either verbal or
implied consent, as the organisation did not carry out
treatment procedures likely to require written consent.
However, written consent was sought where any
photographs were needed to document progress (such
as would be needed for pressure ulcers), or any research
being carried out.
• We had some concerns about whether consent sought
for treatment given to children met the criteria to allow
children to give their own consent and what to do when
they refused consent. The immunisation programme
required parental signed consent for any immunisation,
which did not provide children, who were mature
enough to do so, with the right to give or refuse consent.
If a child refused to undergo screening (such as weight
or height measurements), there was no procedure to let
their parent know, should the child not be mature
enough to make this decision on their own.
Consent, Mental Capacity Act and Deprivation of
Liberty Safeguards
• There was poor recording of consent decisions or
mental capacity assessments in paperwork. The staff at
the urgent care centre were not noting in records that
consent was being given by patients, and an audit by
the safeguarding team showed assessment for mental
capacity were only being documented in 20% of
records. The audits of documentation carried out in
many of the services did not gather specific data on the
seeking and recording of consent and application of the
Mental Capacity Act 2005. There was no evidence to
suggest consent was being inappropriately or
incorrectly sought or recorded, but no evidence to say
the provider was assured application of the law or
guidance was understood and followed in all
circumstances.
• Training in the Mental Capacity Act 2005 was mandatory
for all staff in the learning disabilities’ teams. Almost all
staff were up-to-date with this area. Staff understood
how to provide care and treatment for a patient in their
best interests if they were not able to make their own
decisions. Across all services, where patients were not
able to give their own consent, staff followed the
principles of the Mental Capacity Act 2005. Staff
recognised they needed to act in the best interests of
the patient and seek input from others involved with the
patient’s care if the decisions were relatively major (such
as moving home or having an operation in hospital). The
safeguarding team provided support and guidance to
staff in relation to assessing a