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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 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: “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. Action Minutes Page 2 of 6 Action 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 Action Minutes Page 3 of 6 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: • • • • 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: • • 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 • • • • • • • • 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: • • 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%). Page 4 of 20 Meeting of Bristol CCG Governing Body 28th March 2017 • 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: • • • • • • • • 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: • • • • • • 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: • • • • • 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: • 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 • • • • • 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: • 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 Urgent care adverse movement £0.3m Other Non-PbR beneficial movement £0.1m 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 Urgent care adverse movement £0.4m Critical care adverse movement £0.1m 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: 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 25 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services 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, 26 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services 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. 27 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services • 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 28 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services 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 29 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services 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 30 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services • • • • • 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 • • • • 31 University Hospitals Bristol Main Site Quality Report 02/03/2017 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 Urgentandemergencyservices Urgent and emergency services 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. 32 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services • 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 ––– 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%. 33 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services 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 34 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services • • • • • • • 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 35 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services • • • • • • • 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, 36 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services • • • • • 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 • • • • 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 37 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services 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. 38 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services 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. 39 University Hospitals Bristol Main Site Quality Report 02/03/2017 Urgentandemergencyservices Urgent and emergency services 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 Medicalcare 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 Medicalcare 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 Medicalcare Medical care (including older people’s care) • 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 Medicalcare Medical care (including older people’s care) • 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 Medicalcare Medical care (including older people’s care) • 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 Medicalcare Medical care (including older people’s care) • 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. ––– 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 Medicalcare 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 Medicalcare 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 59 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • • • • • 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 61 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • • • • • 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. 62 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare 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. 63 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • 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 ––– 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 64 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • • • • • • 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. 65 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • 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 ––– 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. 66 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • 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. 67 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • 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 68 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • • • • 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 69 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • • • • 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 70 University Hospitals Bristol Main Site Quality Report 02/03/2017 Medicalcare Medical care (including older people’s care) • • • • • • 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 • • • • • • • 71 University Hospitals Bristol Main Site Quality Report 02/03/2017 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. Surgery Surgery • 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. 81 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 • • • • • • 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 Surgery Surgery 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 83 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 84 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 85 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 86 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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. 87 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery • 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. 88 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery • 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 89 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery • 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. 90 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery • 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 91 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 92 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery • • • • 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 93 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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. 94 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery • 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 95 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 96 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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. 97 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 98 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery • 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 99 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 100 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. University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery • 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 101 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery Surgery 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 102 University Hospitals Bristol Main Site Quality Report 02/03/2017 Surgery 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. 105 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. University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 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. University Hospitals Bristol Main Site Quality Report 02/03/2017 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 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. University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging • 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. 112 University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging • 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 113 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging 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 114 University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging 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 115 • • • • • 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. University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging • 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 116 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging 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 118 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging 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 • 119 University Hospitals Bristol Main Site Quality Report 02/03/2017 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 Outpatientsanddiagnosticimaging 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. 120 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging 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 121 • • University Hospitals Bristol Main Site Quality Report 02/03/2017 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 Outpatientsanddiagnosticimaging 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 122 • • • University Hospitals Bristol Main Site Quality Report 02/03/2017 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% Outpatientsanddiagnosticimaging 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 123 • • • • • University Hospitals Bristol Main Site Quality Report 02/03/2017 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. Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging • 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. 124 • 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, University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging • • • • 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 125 • University Hospitals Bristol Main Site Quality Report 02/03/2017 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. Outpatientsanddiagnosticimaging 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 126 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 University Hospitals Bristol Main Site Quality Report 02/03/2017 Outpatientsanddiagnosticimaging Outpatients and diagnostic imaging • • • • • • 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. 10 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. 11 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. 12 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. 13 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, 14 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 15 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. 16 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. 17 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 18 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. 19 Bristol Community Health C.I.C. Quality Report 16/02/2017 • 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. 20 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. 21 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. 22 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 23 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. 24 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. 25 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 27 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 28 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. 30 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