West Suffolk Hospital NHS Trust

1. West Suffolk Hospital NHS Trust Report To: Trust Board Date: February 2012 Title: Quality Report Report of: Nichole Day, Executive Chief Nurse

2. Introduction This Quality Report provides the narrative for performance in three key areas: Quality priorities, CQUIN performance and local issues requiring escalation. It should be read in conjunction with the Ward and Trust dashboards. The layout of this report identifies performance data followed by themes identified during the analysis process and actions being taken. The ward quality report summary has been used to highlight wards that have a number of red scores and these are discussed within the report.

3. 1. To further reduce hospital acquired infections Aim: To reduce hospital acquired MRSA bacteraemia to no more than 2 cases and C. difficile infection to no more than 29 cases between April 2011 and April 2012 There were no cases of MRSA bacteraemia during January and 1 case of MSSA bacteraemia.There were 3 cases of clinically significant hospital acquired C. difficile during January (giving a total of 20 year to date).In respect of compliance with the High Impact Interventions (HII), all interventions scored 100% except central venous catheter ongoing care (96%) and urinary catheter ongoing care (99%). The central venous catheter ongoing care was related to one documentation error on one patient on F10.Theurinary catheter ongoing care (99%) score was related to one patient who did not have their catheter care documented out of the 78 patients audited. The side room audit during January demonstrated that of the 32 side rooms available: 23 were used for Infection control purposes; 1 side room was empty and available for isolation. No high risk patients were not isolated at that time.

4. 1. To further reduce hospital acquired infections Aim: To improve the management of antibiotics by achieving 100% compliance with antibiotic policy The compliance with antibiotic prescribing policy was 100% in January. This gives a rolling three month compliance of 94%. It was reported last month that a revised rolling programme of audits will be initiated this year. Therefore a rolling quarterly compliance graph will be displayed from March 2011 when the new programme has taken effect. Until this time, the rolling quarterly compliance will not be as meaningful, as the wards audited within a quarter will not be consistent.

5. 2a) To achieve the highest levels of patient safetyAimsi) To assess at least 98% of admissions for risk of VTE ii) Provide prophylaxis to 100% patients at risk Compliance with risk assessment was 99.7% for January. Prophylaxis data is reported quarterly and is due in April’s report.

6. The CQUIN ceiling is 126 falls in Quarter 4 and the payment associated with Quarter 4 is £41,250. The total number of falls in January was 44 which is just above the trajectory. The ward with significantly increased fall rates against their normal performance was G5. Fall rates fluctuate to some extent, month on month, and examination of the falls identified patient related issues and falls occurring despite all preventative actions being taken. In addition, the ward’s nurse establishment/skill mix is agreed for a rehabilitation environment which requires a lower skill mix than general medical wards. However the ward is currently admitting general medicine patients. A recent establishment review suggests that the change in patient group has had a impact on staffing requirements. Themes from RCAs carried out in the first part of last year identified an issue in respect of documentation. This was subsequently addressed by new falls documentation. No more RCAs with this theme have been identified since the new documentation has been in place. Current themes appear to be falls at night when staffing levels are lower, and issues around toileting. However, it must be recognised that these patients are often confused, with fluctuating support requirements and admitted with a history of falls, therefore prevention is not straightforward. Benchmarking Information from National Sources To understand WSHFT falls data more comprehensively, a benchmarking exercise against national incidence data and evidenced falls reduction programmes has been completed. Benchmarking incidence data: • An average 800-bed acute hospital trust will have about 24 falls/week (NICE). Our incidence at average performance would therefore be 18 falls/week (447 beds). In January we had 10 falls/week (44 falls/31 days). • National variation of falls = 3-12 falls/1000 bed days (NICE). In January we achieved 3.59 falls/1000 bed days (12,230 total bed days in January with no exclusions applied). Benchmarking falls reduction programmes: The NHS Institute has designed a multi-faceted fall interventions checklist, covering both operational and strategic elements, to prevent falls which we have benchmarked our processes against.Areas that we could develop are: • Co-ordinate with physiotherapists to integrate programmes for muscle strengthening and balance. • Provide non-skid slippers/socks. We currently provide patients with slippers if they do not have them but non-slip TED stockings have only recently become available and are being considered. • Weekly medication review processes and adjustment protocols if patients are on “offending” medication. The Stepwise approach from the NHS Institute will be discussed at the next Falls Group with a view to incorporating the approach. 2b) To achieve the highest levels of patient safety Aim: To reduce the number of patients who fall in hospital by 35% in the last quarter of 2011/12

7. 2c) To achieve the highest levels of patient safety Aim: To reduce the number of avoidable Grade 3 and 4 pressure ulcers by 80% in the last quarter of 2011/12 No patients developed a Grade 3/4 hospital acquired pressure ulcer during January. 8 patients developed Grade 2 hospital acquired pressure ulcers this month: • A #NOF patient developed a Grade 2 sacral ulcer on F3. This was considered unavoidable as the patient was medically unfit for surgery and was on skin traction for 1 week. Pressure mattress was in place but he refused to be lifted to relieve the pressure on his sacrum. The ulcer had healed before discharge. • An end of life patient on F5 developed a Grade 2 sacral ulcer. All care was given and this was classified as unavoidable. • A patient on G5 developed a Grade 2 heel ulcer; he refused to use the heel protectors to prevent an ulcer developing. This was unavoidable. • A patient on F7 developed an avoidable pressure ulcer. A pressure relieving mattress was used on EAU but this was not transferred to the ward with the patient. The patient had a Grade 1 sacral ulcer on admission which deteriorated to a Grade 2 sacral ulcer. • A patient developed a Grade 2 sacral ulcer on F9. All care was in place and this was considered unavoidable. • Two patients on Critical Care developed pressure ulcers. These patients had all care in place but developed pressure ulcers due to their critical conditions and were therefore considered unavoidable. • One patient on G1 developed a Grade 2 sacral ulcer. This patient had all preventative care but was unable to tolerate being repositioned due to gross abdominal ascites and oedematous legs. This was considered unavoidable. RCAs: Issues arising from concise RCAs have been reported each month and actions incorporated into the Pressure Ulcer Action Plan over the last year. These include, training in the grading of ulcers and assessment of risk, availability of pressure relieving mattresses and the introduction of the red flag checklist to ensure high risk patients are identified and preventative actions implemented. No additional themes were identified from the full RCAs. The CQUIN target is to have no more than 2 hospital-acquired Grade 3/4 pressure ulcers in each of Quarters 1,2 and 3 and 1 hospital-acquired Grade 3/4 pressure ulcer in Quarter 4 with a quarterly payment of £41,250. We have met all these CQUIN quarterly targets so far and are confident in achieving Quarter 4. We now aim to eradicate avoidable Grade 2 pressure ulcers.

8. 3a/b) To continuously improve the experience of patients using our services Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction rating in our internal patient experience surveys Survey results Overall percentage scores for the surveys for December are provided in the table (left). Individual question scores were high for all questions in the Outpatients, A&E, and short stay surveys. However, information provided about waiting times in OPD was high in the Diabetes clinic but very low in Ophthalmology. This will be addressed through the actions identified in the OPD national patient survey report. The recommender question and overall satisfaction with the care provided have been removed from the graphs as these are reported in the table and are consistently high. In patient survey results are similar to last month, however, the numbers of responses have reduced on some wards and are being addressed with those areas concerned.

9. 3a/b) To continuously improve the experience of patients using our services Aims: At least 90% of patients would choose to use the hospital again. To achieve at least an 85% satisfaction rating in our internal patient experience surveys Survey results As reported last month, the scoring related to the question on call bell response times was changed in September to reflect the scoring within the national patient survey, hence the reduction in scores. The average call bell response times in January on the wards with the new call bell system are displayed in the pie chart on the right. In total, from the 1/1/2012 to the 31/1/2012, the wards F3, F4, F5, F6 and G3 as a collective, received 10597 calls for assistance. The overall average response time for an Aidcall (all call response times added together) was 124 seconds. 2204 of the responses failed to meet the 180 second target, giving a failure rate of 21%.

10. 3c) To continuously improve the experience of patients using our services Environment and Cleanliness The overall Trust score was 91% and all clinical areas scored equal/greater than 85% except G3 who scored 84%,

11. 4a) To achieve optimal clinical outcomes and effectiveness Aim: To consistently achieve a Hospital Standardised Mortality Ratio that is below the expected rate HSMR remains well below the expected level as can be seen by the overall mortality shown in the graph and the table giving a mortality rate for the five Dr Foster - How Safe is Your Hospital indicators. This table provides information on relative risk, with red, blue and green traffic lighting. Blue indicates that the score is within the standard deviation.

12. Local issues requiring escalation Patient surveys All ward areas had fewer than 4 red scores on their patient experience surveys. Nutrition scores on F10 F10 had decreased performance in nutritional assessment during January. This was related to 2 patients not screened or assessed and 4 patients not re-weighed. This will be discussed at the ward governance meeting and plans developed for performance improvement. Environmental Audit Ward G4 scored 69% on their Environmental Audit. Issues identified were a lack of storage capacity and boxes being stored on the floor inappropriately. The ward is currently undertaking the Productive Ward module: “Well Organised Ward”, which will help to address the issues, however storage is an issue on wards that have not undergone recent refurbishment. Short term issues related to availability of hand gel at the bedside and the cleanliness of a side room were addressed when identified in the audit. Complaints Two areas had a higher number of complaints in January than usual for the area: A&E had 3 complaints. Two of these related to patients who had been discharged from A&E and had to return for a second visit; the injury that required intervention had not been identified at the first visit. The third complaint was from the daughter of a patient who had been placed in the escalation area of A&E and complained about the environment of care, delays in pain relief, attitude of staff, and later had issues with the ward to which the patient was admitted. These are in the process of investigation. Ward F3 had four complaints. One related to a patient who was discharged to residential care with their house keys when the relative felt they should have been handed to the next of kin and another related to failure to update address details leading to letters being sent to the wrong address. The remaining two complaints covered a range of issues. All of the complaints are currently being investigated.

13. Local issues requiring escalation cont. Cancer The Trust failed the 62 days screening in January. This was 2 breaches in colorectal, when both patients were treated in January due to the Christmas holidays. The breaches are recorded in the month the patients are treated, hence January activity. A national bowel cancer screening campaign commenced at the end of January and already there is an increase in referrals to rapid access clinics. The Trust has planned extra capacity for clinics and additional operating sessions, however this is a specialty where there is little room on the margins to absorb additional capacity. Stroke The Trust failed to achieve the 90% admission to stroke unit in 4 hours and the % stage on a stroke unit in January. The numbers of strokes each month continues to increase and outbreaks of noro virus across the hospital has meant there has been significant pressure on medical beds. The stroke unit has increased it’s capacity to accommodate additional patients, however we have still not managed to hit the required standard. Performance compared to the East of England remains strong. The referrals to the TIA service are late referrals from GP’s. These are all escalate to the PCT and the CCG for investigation. A&E Overall A&E performance deteriorated in January. This included, overall time spent in the department, time to initial assessment, single longest wait, ambulance handover and the threshold for admissions. Bed flow in the Trust in January ( and continuing into February ) has been severely hampered with outbreaks of noro virus across mainly medical but a surgical ward at the very beginning of January. In January, ward F3 and G3 were affected by the outbreak. In February wards, G5, F9, G4 and F10 have all been affected. The Trust has additional 25 beds open, however this has not prevented an increase in waits in the A&E department. Admission levels have not risen overall, although the conversion level of admissions from the A&E department has increased slightly, above the 25% threshold. Length of Stay has increased on the wards where noro virus has prevailed.

14. Local issues requiring escalation cont. A&E – cont. The single longest wait time is again as a result of a delay with mental health assessment and identification of an appropriate bed for a patient. The introduction of a Mental Health SLA in April should help reduce some of these excessively long waits. Work continues on the discharge planning, with the introduction of discharge planning standards across the Trust. The new EAU opened at the end of January. It has been a challenge to ensure that additional beds are not placed in the assessment bays, however there is some evidence that keeping the space free has allowed for patients to sit in chairs for their assessment. The numbers of patients that are having alternative treatment options offered as a result of the consultants answering phone calls from GP’s is increasing. The standards for elective cancellations and 18 week waiting times have both been achieved, however there has been a deterioration in performance on both these standards.

15. Local Priorities - Governance Dashboard 14

16. Local Priorities Care Quality Commission (CQC) Quality & Risk Profile Background The CQC publish a monthly Quality & Risk Profile (QRP) outlining the external sources of data which can be used to assess a Trust’s level of compliance using a statistical assessment to identify if a Trust’s performance is Much worse than expected; Worse than expected; Tending towards worse than expected; Similar to expected; Tending towards better than expected; Better than expected or Much better than expected. The expectation is that each Trust will study this QRP and use it to provide evidence of compliance and/or act upon those areas highlighted as below expected. In addition, this report contains Negative Comments or Positive Comments taken from local engagement, external inspectors’ reports and a range of other sources. There was no QRP published in January 2012. Indicators still outstanding / in progress in QRPs issued since January 2011 The Quality & Risk Committee review in detail, progress to address areas of concern. The Operational Steering Group allocate actions to individuals to address the areas highlighted as a concern and monitor the completion of these actions. Currently there are four actions still ongoing:

17. Local Priorities Patient Safety Incidents (PSIs) resulting in harm (including serious harm), Serious Incidents Requiring Investigation (SIRIs) and reporting PSIs to the National Reporting and Learning Service (NRLS) There were 223 patient safety incidents reported in January of which 81 resulted in harm. The number of serious incidents in January was 5 and there was 1 SIRI reported (a fractured neck of Femur). The five serious incidents in January were: 2 Norovirus outbreaks on two wards (reported as a joint SIRI with one other in February), 1 fractured neck of femur (reported as a SIRI in January), 1 Cardiac arrest (reviewed under CQUIN8) and 1 awaiting confirmation of grade. There is a downward trend in reporting of incidents overall from April onwards although it has risen again slightly in January The graph above shows how any harm incidents have been reported and how many SIRIs over the last 12 months. The bottom graph shows all incidents (including Near miss and No harm) reported to the NRLS against a benchmark of the median Trust for incidents per 100 admissions in the small acute Trust category (6.2 based on the Oct 10 – Mar 11 dataset). The second (red) line on the bottom graph shows what percentage of the incidents reported in total are categorised as serious (Red: actual major/catastrophic harm). This had been rising from July last year but has fallen again in the last couple of months. 16

18. Local PrioritiesComplaintsComplaint response within agreed timescale with the complainant: 82.4% of responses due in January were responded to within the agreed timescale (target 90). Of the 32 complaints received in January , the breakdown by Primary Directorate is as follows: Medical (16), Surgical (10), Clinical Support (2), Women & Child Health (4) and Facilities (0). Trust-wide the most common problem areas are as follows: - Attitude of staff 13 - Aspects of clinical care 12- Patient’s Privacy and Dignity 8 This breakdown reflects an expected distribution across the categories. (Please note that more than one category can be allocated to each complaint so the total number of problem areas does not correlate with the total number of complaints) . The data in the graph above demonstrates that there has been an increase in the number of complaints received in 2011/12 compared to 2010/11. Themes from Red complaints All actions identified from Red complaints are currently within deadline for completion. 17

19. Local PrioritiesPALS (Patient Advice & Liaison Service) The revised PALS database is now functional and, together with prompt recording of contacts and enquiry details, accurate and meaningful information is now readily available. As previously reported, categories are being collated to correspond with the categories for formal complaints but additional information is being recorded on primary and secondary concerns. A comparison of the number of enquiries dealt with from Feb11 to Jan12 is given in the chart and a synopsis of enquiries received for the same period is given below. Trust-wide the most common five reasons for contacts are as follows:   Communication, concerns about aspects of clinical treatment and general enquiries remain the most prominent reasons for contacting PALS. However, there are no trends identified for specific groups of staff, speciality or discipline. The PALS Manager continues to deal with requests for information which can vary from clarification of hospital procedure to specific details about treatment given; future care plans; outcome or length of time waiting for results of tests and discrepancies about diagnosis and/or discharge arrangements. A number of queries also relate to appointment dates and length of time waiting for these; the length of time waiting in clinics; and general enquiries about services not directly managed by West Suffolk Hospital. The PALS Manager frequently helps to improve communication between the Trust and patients’ family members both in this country and abroad. Any issues which are not able to be dealt with by PALS are directed, if appropriate, to the formal complaints process. The very nature of the PALS service requires responses to queries, concerns or complaints to be dealt with expediently. A Target of 80% for responding fully (completing the enquiry) within 48 hours has been set or within a timeframe agreed with the enquirer. This target is currently being monitored and evidence of compliance will be submitted in the new year, after three months data has been collected. 18