Clinical, Quality and Safety Report. Public Board Meeting

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1 Title: Report to: Clinical, Quality and Safety Report Trust Board Date: 27 January 2014 Security Classification: Public Board Meeting Purpose of Report: The purpose of the Clinical, Quality and Safety report is to provide an indication of the Quality and Safety of our services. It will outline key quality developments which are occurring and areas which may require further work to address variation in standards of practice. The Trust has been subject to a number of regulatory visits during this period both from an Essential Standards of Mental Health Act Commissioner perspective. Significant improvements have been noted, as well as concerns in respect of mental capacity assessments, record keeping and use of seclusion rooms for non-seclusion purposes. Safeguarding activity continues to be a focus for all Trust staff and we have appointed a new Head of Safeguarding People to strengthen leadership. Complaints compliance remains a challenge for the Trust with some noted improvements in response times but we remain significantly below target for completion of new complaints within 25 days at 69% as at 31 December When reopened complaints are considered the Trust overall compliance is 81%. Additionally, training is being provided and a full review of our complaints processes, systems and behaviours will be undertaken once the new Head of Patient Experience has been appointed. Recommendations: The Trust Board is asked to consider the report and discuss any further actions or assurance they require in respect of clinical quality and safety. Sponsor: Mary Sexton, Executive Director of Nursing, Quality and Governance Report Author: Name: Mary Sexton Title: Executive Director of Nursing, Quality and Governance Tel Number: Name: Stephen Cook Title: Interim Deputy Director of Nursing and Clinical Governance Tel Number: Report History: Regular Report.

2 Budgetary, Financial / Resource Implications: Equality and Diversity Implications: Links to the Trust s Objectives, Board Assurance Framework and / or Corporate Risk Register List of Appendices: None None. None. Action taken will assist in delivering our core strategic aims of: 1. Excellent Services and Staff 2. Integrated and Holistic Services

3 Report 1. Introduction and Background 1.1 The Clinical, Quality and Safety Report supplements the integrated performance and quality dashboard by outlining the key clinical, quality and safety areas which the Executive Director of Nursing, Quality and Governance and the Medical Director would like to bring to the attention of the Board. 2. Care Quality Commission Inspections November to December 2.1 The Trust has received two regulatory visits to its in-patient facilities and a further two visits to its commissioned Recovery Houses. In addition, four Mental Health Act visits were carried out during November and December Fortis Green Recovery House The Recovery House received a regulatory inspection on 12 th November 2013, assessing compliance in respects to 6 regulatory outcomes, including outcome 2 (Consent to care and treatment) outcome 4 (Care and welfare of people who use the service), outcome 8 (Cleanliness and infection control), outcome 13 (Staffing), outcome 16 (Assessing and Monitoring the quality of provision), outcome 20 (Notification of other incidents) The CQC inspectors spoke with a number of service users, staff and examined relevant paperwork. They found service users to be generally happy with their care, that they had input and involvement in their care and that there was evidence of risk assessments and risk management plans signed by the individual service users The Environment was noted to be clean and hygienic, with regular audits taking place, and commented on the unit being adequately staffed. The unit was judged to be complaint across all 6 regulatory outcomes. 2.3 Magnolia Ward Enfield Community Services The CQC carried an unannounced essential standards inspection on Magnolia Ward on 19 th November They assessed compliance in respects to 6 regulatory outcomes, which included outcome 4 (Care and welfare of people who use the service), outcome 6 (Cooperating with other providers), outcome 11 (Safe, availability and suitability of equipment), outcome 13 (Staffing) and outcome 16 (Assessing and monitoring the quality of service provision) Inspectors interviewed a number of staff, examined relevant documentation and had the opportunity to talk to 10 services users and a number of relatives/carers. It is noted that both service users and carers spoke highly of the care provided Inspectors commented upon service user involvement in their own care, that care was patient centred, taking into consideration their cultural and communication needs. They found areas of good practice in respects to discharge planning and the units involvement and liaison with other agencies The inspection noted that staffing was appropriate, and that staff fully understood how to raise issues of concern and report incidents, and were able to articulate how the unit learnt lessons from such incidents. 2.4 Haringey Ward and Section 136 Suite Crisis and Emergency Service Line St Ann s received an inspection from the Care Quality Commission (CQC) on 22 nd November. Haringey Ward and the 136 Suite were the focus of the inspection particularly

4 around the use of seclusion and 136 suites to address capacity issues. The three inspectors spoke with two nurses, two doctors, three nursing assistants and seven (out of the 12) inpatients on Haringey ward. Six patients risk assessments, care plans and daily records were reviewed during this inspection. The CQC was in receipt of information regarding the number of times the seclusion facilities on Haringey Ward were used to sleep patients who did not present a clinical risk as to require seclusion The 136 Suite was inspected and the staff spoken with stated it was at times used to sleep patients. Additional information provided to the CQC confirmed the seclusion facilities and S136 suite on Haringey were used to sleep patients in In response to the findings of the inspection, the Trust has received an enforcement notice from the CQC received on the 13 th December. The notice has been served on St Ann s for outcome 4, Care and welfare. The notice requires the Trust to be compliant with outcome 4 by 31 st March An action plan is in place and seclusion rooms have not been used as bedrooms since 10 th December Suffolk House Recovery House Suffolk House received an essential standards regulatory inspection on 31 st December The CQC assessed their compliance against two regulatory outcomes outcome 4 (Care and welfare of people who use services) and outcome 9 (Management of medicines). The purpose of the visit was to review as to whether there had been improvements made since their last visit in June 2013, when evidence was found that service users were not receiving detailed physical health assessments and that the planning of care in respects of service user medicines did not always ensure their safety. In addition they had previously found that medicines in the unit were not being accurately recorded, or stored During the visit on 31 st December inspectors found significant improvements, and noted that service users physical health needs were being assessed and met, and that there was evidence of care plans with identified health conditions. They noted that medicines were not only stored safely, but that regular checks were being made to ensure they could not be accessed by others. The unit was judged to be compliant across both regulatory outcomes. 2.6 Dorset Ward Crisis and Emergency Service Line Dorset Ward received an unannounced visit on 25 th October The MHA Commissioner identified some inconsistencies in the way the ward evidences discussions of rights with detained patients, and found a small number of examples of insufficient evidence around assessment of patient capacity in relation to medication. A standardised method of evidencing discussions of rights has now been implemented, and the Trust has undertaken to revise its strategy for improving compliance with the recording of assessments of patient capacity in relation to care and treatment. 2.7 Trent Ward Crisis and Emergency Service Line Trent Ward received an unannounced visit on 5 th November The MHA Commissioner raised a number of issues around risk assessment, care planning, the provision of activities to patients, and the assessment of patient capacity in relation to care and treatment. The Ward and Service Managers were proactive in addressing the specific issues reported on the day, and in implementing systems to provide assurance on continued compliance in these areas. 2.8 Thames Ward Crisis and Emergency Service Line Thames Ward received an unannounced visit on 6 th November The MHA Commissioner raised issues around care planning, risk assessment, the recording of

5 patient leave, and the regular discussion of rights with detained patients. The Ward and Service Managers were proactive in implementing systems to provide on-going assurance in these areas, and the MHA team have implemented a new system to aid improved compliance around the discussion of rights with detained patients. 2.9 Sage Ward Forensic Service Line Sage Ward received an unannounced CQC visit on 26 th November The MHA Commissioner was very positive about the high standard of MHA compliance found on the ward, but raised issues around ward environment, care planning and adherence to the trust s observation policy. The team have responded and addressed the concerns raised CQC Actions Plans The Nursing Directorate has, following CQC visits over recent months been monitoring Service Line action plans to ensure that robust management is in place to support the ongoing improvements in these areas. Whilst Service Lines have made improvements, further work will be undertaken over the coming weeks to ensure that action plans are robust, are evidenced and are sustainable Deloittes Internal Audit Regulatory Compliance During September Deloittes carried out an Internal Audit of the controls in place to provide evidence and assurance of our Care Quality Commission (CQC) Compliance. This was undertaken in accordance with the 2013/14 Internal Audit Plan. The audit covered a range of areas pertaining to CQC regulatory compliance, including the Governance structure, Key responsibilities of staff within the Trust in respects to CQC compliance, Staff Training, Monitoring compliance and Action Planning in respects to areas of risk / variation and noncompliance The Trust received a draft report in December 2013 which demonstrated substantial assurance, with three recommendations, one priority 3 recommendation, and two further priority 2 recommendations. The recommendations were: The need for the existing Patient Experience a Clinical Governance Strategy to be reviewed The review of the current Terms of Reference of the Trust Deep Dive Meeting To develop an electronic sign off at a service line level in respects to the Peer Service Review action plans to ensure completion These actions will be addressed and taken forward over the coming weeks. 3. Serious Incidents 3.1 In the period (1 st November to 31 st December) there has been a slight increase in overall incidents, with 26 serious incidents being reported to North and East London Commissioning Support Unit (NELCSU). 7 incidents were taken forward via the Trust s governance processes for moderate incidents. All incidents are subject to investigation and lessons learnt are shared across teams and service lines. 3.2 Independent Inquiries VERITA / Board Level Inquiry Report into the care and Treatment of HAA (Homicide) An independent inquiry is currently being carried out by VERITA, regarding the Trust s Board Level Panel Inquiry Report relating to HAA.

6 3.3 Independent Review Homicide NLFS The independent review report prepared by Winchcombe & Associates has been submitted to NHS England. We await NHS England decision regarding next steps and publication. 3.4 Key Learning Lessons Events (Board Level Panel Inquiry ) Haringey HTT On the 19th December 2013 a further key learning lessons event was held for staff within the Home Treatment Teams and community mental health teams regarding the learning lessons arising from the Trust s recent Board Level Panel Inquiry into an incident relating to a service user of Haringey Home Treatment Team. The event was chaired by the Director of the C&E / SCNP/DCI Service Line. 3.5 Serious Incident RCA Management Reports The Patient Safety Team (PST) continues to work to clear complete SI reports that have accumulated during the months of November / December There currently are 11 management reports that are overdue, and the team continue to circulate weekly updates advising senior managers of the status of reports, and is making every effort to assist service line investigators in ensuring the prompt completion of reports is adhered to. Current delays are attributed to complexity, particularly when other agencies and involved Themes arising from the investigation of incidents continue to be reported back to service line teams via team local governance meetings and Deep Dive Forums, with the main themes arising from SI investigations including communication / the quality and standard of documentation, risk assessment and risk management and the completion and implementation of care plans. 4. Complaints and Claims 4.1 Complaints status at 31 December Complaints compliance stands at 69% across the Trust. Please note that this figure does not include complaints which have been reopened. When reopened complaints are added in overall complaint compliance is 81% The Trust has seen an increase in this business year receiving the same number of complaints as in the whole of the business year by the end of quarter Claims Claims figures are presented to each SI Group and since October 2013 the Trust has received 9 new personal injury claims and 2 new medical negligence claims. As of 9 January 2014 the Trust is working with the NHSLA on a total of 54 claims Service lines have been reminded that in order to provide evidence to the NHSLA as to incidents all staff involved in or witnessing an incident should complete a full Datix entry which needs to be reviewed and authorised by the appropriate manager as soon as possible. 5. Infection Control 5.1 Infection control training Infection control mandatory training continues to run for all clinical staff across the Trust. During November and December 2013, 17 sessions were provided, and the infection control team continue to promote attendance and adherence to this mandatory training across all service lines. Whilst previously reported that training compliance had fallen over

7 recent months (October 2013 =73.3%), there has been a marked improvement over the past two months. Compliance rate shows a 10% improvement in training. Total number of staff Total number of staff trained Compliance (+3.5% for sickness absence) December November Outcome 8 inspections During November and December 2013 the infection control team carried out 11 inspections, under the CQC outcome 8 standard. It is worth noting that only minor issues were found in some areas, they were rectified immediately by ward teams. All areas inspected have performed well over the past 2 months. Outcome 8 Results November - December % 95% 90% 85% 80% 75% 70% 65% 60% Oct-Dec Results 5.3 Spot checks Spot checks continue to be carried out by the infection control team which is proving to be helpful in identifying issues early. The infection control team continue to provide a heightened profile across all service lines, identifying issues as early as possibly, and continue to liaise closely with ward teams and our estates and facilities teams to address issues as they arise or are identified. 5.4 Notifications There was one community acquired MRSA bacteraemia in Enfield Community Services. The case was notified to us on the 16 th of December by the CCG. A post infection review (PIR) was conducted and the case was apportioned to Enfield CCG. The Trust team involved in the patient s care was commended for their good practice.

8 5.4.2 The Trust continues to manage a TB case previously reported to the Board. Following patient screening on 6 th November 2013, a letter from the infection control lead was sent out for information to all GPs whose patients did not turn up for their appointments. The GPs were informed that Public Health England have written to these patients and that they have been offered a second opportunity to attend the chest clinic. Staff are being followed up with Occupational Health. 5.5 Outbreaks No outbreaks have been reported over the previous reporting period (November to December 2013). Over the Christmas period, 5 patients on Magnolia developed nausea, with some experiencing vomiting. All cases were symptomatic only once and resolved within 24 hours. All infection control measures were complied with. 5.6 Influenza vaccine uptake amongst healthcare workers To date 561 members of staff have been vaccinated. This represents an overall vaccination of 27.4%. Whilst this is an improvement compared to the 20.2% reported at the end of November 2013, it does remain some way away from the 75% target. Staff continue to be reminded and encouraged through staff meetings, communications and through existing governance structures, including Deep Dive meetings and other such committees. 6. Safeguarding Adults 6.1 Dementia and Cognitive Impairment Service Line The Oaks In December a Safeguarding Alert was raised by the Service Manager from the Oaks after a male patient had been admitted to the Oaks. Upon admission it became apparent that he had sustained the injuries from a family member. An initial strategy meeting was held and following a subsequent meeting it is planned that further action and an investigation will take place. 6.2 Crisis and Emergency Service Line/ Common Mental Health/Complex Care Barnet Home Treatment Team An alert was raised in November 2013 after a service user informed staff that she was being physically abused by a family member. Following discussion with the Team it was agreed to close the safeguarding case and a care plan around the support needs of the family has been agreed East Support and Recovery Team-Haringey An alert was raised in November 2013 after a female service user made allegations against her neighbour. She had contacted the police, and after screening from a safeguarding perspective it was felt that given her involvement with police and that she no longer lived near the alleged perpetrator. The case was subsequently closed.

9 6.2.3 Barnet Complex Needs Team A safeguarding alert was raised in November 2013 after a service user informed his Care Co-ordinator that he was being financially abused and being intimidated by his partner. Following a strategy meeting, the case was closed with a number of actions implemented in respect of on-going support. 6.3 Domestic Homicide review Following the death of a female in October 2013 at her home in Barnet, the Barnet Safeguarding Adult Board commissioned a Domestic Homicide Review. The female was known to the Trust. A panel meeting was held on 10 th December Each organisation has been requested to write a chronology which is to be submitted by 10 th February A further panel meeting has been arranged to take place on 28 th February 2014 at 11.00am. 6.4 Deloitte Internal Audit (update) - Safeguarding Adults Following the internal audit carried out by Deloitte there were two priority 2 and three priority 3 recommendations that were given. In order to address the recommendations from the audit a Memo was sent by the Assistant Director for Safeguarding Adults to all Team and Ward Managers on 28/11/13 for them to action. The Balanced Scorecard and the Policy update have been completed by the Assistant Director for Safeguarding Adults. 7. Enfield Community Services 7.1 Health Visiting The Trust has signed up to an NHS Employers project to build a work plan for the Retention of Health Visitors after March The work for this commenced in January and will last until May There is a risk to the new and increasing workforce of estates pressures. The service has approximately 20 more WTE to employ by March 2015 to meet the Government trajectory. 7.2 Young Parents Project The funding for this externally funded service will cease from the end of this financial year. The staff within this service will, as a result be at risk, with most of them that can be, being redeployed to the mainstream Health Visiting service. The vulnerable young people seen by this service will be referred to the new Family Nurse Partnership team and mainstream Health Visitor service. 7.3 Safeguarding Children The service currently have 1.80 wte working in the team to cover the Single Point of Entry (SPOE), provision of mandatory training in children s safeguarding, safeguarding supervision and audits and the general running of the team from an establishment of 3.6wte. Plans are in place to recruit though clearly there is pressure until new starters commence in post in February 2014.

10 7.4 Muscular Skeletal Physiotherapy Service There has been an increase of 255 in referrals to the Muscular Skeletal (MSK) Physiotherapy outpatients service during September and November2013, and as a result the waiting times are exceeding the services 13 week target. The service line is continuing to monitor and manage this situation, and is reporting the resultant effects on KPIs in their exception reports. 7.5 District Nursing The District Nursing service needs to recruit an extra 12 nurses to meet commissioner requirements for an enhanced service. Due to anticipated difficulties in recruiting at this scale the service is investing in some external support in order to target and improve the recruitment process. 8. Nursing and Governance 8.1 Future Clinical Quality and Safety Reports We would like to bring to the Board s attention that following a review of the format of the Clinical Quality and Safety Report, it is proposed that the structure and format will change in subsequent reports to better inform the board regarding clinical, quality and safety within the Trust, trends and focused attention on areas of concern. 8.2 Nursing and Governance Structure Following recent Executive Management Team approval, the Nursing and Governance Team consultation and implementation has now ended. The Way Forward document was circulated to staff affected on 8 th January 2014, and it is envisaged that the full implementation of the structure will have completed by April Safeguarding arrangement Following the resignation of the current Head of Safeguarding Adults, and in light of the Nursing and Governance re-structure, the Executive Director of Nursing, Quality and Governance has recently appointed two key roles: Assistant Director of Safeguarding People a temporary appointment, Christine Dyson, has been made to develop the safeguarding team and structure, and to implement changes to the safeguarding processes in the Trust Safeguarding of Vulnerable Adults (SOVA) Lead Joy Maguire has been appointed in December 2013, and will start in post on 3 February Ward Manager Development Programme 9.1 Following the success of the first Ward Managers Development programme, which was well attended and found to be very helpful in supporting managers with skills and knowledge to lead services, a second cohort will commence in February 2014.

11 Whilst the programme is targeted at in-patient Ward Managers currently, it is hoped that in autumn a similar programme will be rolled out for community managers. 10. Support worker/hca Conference 10.1 Planning is currently underway in preparation to have a conference in June 2014, specifically targeting support staff. This conference follows the success of the Nursing Conference last year, and it is envisaged will allow a range of support staff/hcas to attend and share their experiences, celebrate their valuable contribution to the care of service users and hear from unqualified nurses who have developed roles that have benefitted services users.

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