Item 19c
Quality & Safety Committee
Hambleton Richmondshire and Whitby CCG Boardroom Wednesday 24 January 2018
09:30-12:00 CONFIRMED MINUTES
Present: Dr Jon James (JJ) Secondary Care Doctor (HRW CCG) (Chair) Dr Jacquie Moon (JM) GP (Quakers Lane)
Katie Needham (KN) Consultant in Public Health (NYCC) (part)
Angela Edmunds (AE) Quality & Safety Manager & Deputy Chief Nurse (HRW CCG)
Steven Crutchley (SC) Contracting Procurement and Quality Manager (NYCC)
Linda Lloyd (LL) Lay Member for Patient and Public Involvement (part)
Elaine Wyllie (EW) Designated Nurse Safeguarding Children (HRW CCG) (part)
Gill Collinson (GC) Chief Nurse (HRW CCG) (part)
Abi Barron (AB) Head of Strategy/Community Care (HRW CCG) (part)
Richard Kirby (RK) Service Improvement Officer (HRW CCG) (Minutes)
Apologies: Lisa Kitson (LK) Nurse Practitioner (Leyburn Medical Practice) Christine Pearson (CP) Designated Nurse Safeguarding Adults
Olwen Fisher (OF) Designated Nurse Safeguarding Adults Nigel Ayre (NA) Healthwatch
Item Number
Agenda Item Action
1 Introductions and apologies
JJ welcomed everyone to the meeting. Apologies were received from those listed above
2 Conflicts of Interest No changes were advised
3 Minutes and action log from previous meeting
The minutes from 22 November 2017 were accepted as a true and accurate record.
Action Log
168a: AE noted the original action related to understanding what the “miscellaneous” category comprised of on the spreadsheet from STHFT, as this indicated many operations were cancelled without understanding the reasons why. The latest report shows the breakdown and therefore action could be closed. However anomalies in reported % figure of cancelled ops for the CCG and confusion about what it is actually measuring. RK has been working with business intelligence team to better understand the meaning of the statistics. The indicator is not a simple measure of
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cancelled operations, but operations cancelled “on the day for non-clinical reasons with patients not being treated within the subsequent 28 days”. RK will try to identify reasons why patients are not being treated within this timeframe as this is the fundamental basis of the “cancelled ops” indicator, what the actual figure is that should be reported through performance and how it compares to peer CCG’s (action 218)
197: Carried over. RK to pull together details of all Programme Boards
200: LL advised percentage of GP newsletters opened had risen to 36%. Closed.
202: AE advised that the service manager is not responding to e-mails or telephone messages. A formal response has now been requested through Tees, Esk and Wear Valleys NHS Trust (TEWV). AE will obtain update. Carried over.
203: Quakers Lane is the only surgery to have used the Soft Intelligence tool in past two months. System needs to understand value of this tool and how loop is closed when something is put on. Discussions will continue in the CCG. Still appears to be some confusion about when to upload an issue as soft intelligence, incident or SI despite circulation of information and advice on CCG’s website.
JM noted there is a lot of extra admin work involved when no updates/answers are received from the Trust after reporting soft intelligence/incidents through directly to STHFT. AE reiterated all incidents should be reported via NRLS for NHSE to review and address learning across the system and/or intervene where required.
It was discussed whether it would be beneficial if a representative from South Tees Hospitals NHS Trust (STHFT) was invited to the meetings. AE advised that STHFT are only a part of the picture for QSC and that there have been a number of changes to the Quality Team, but would have a conversation with STHFT Head of Quality. Any representation from STHFT however would need to be appropriate and add value and it may be more productive if they were just invited to attend specific meetings where topical issues are to be discussed (action 219a)
AE also to have similar conversation with NHS England as it is their responsibility to investigate reported incidents and pick up themes across primary care – however it is acknowledged that events are not always being reported correctly and therefore they are not always aware.. (action 219b). Local concerns re STHFT will be taken through Quality Assurance Committee (QAC) and AE is the conduit for this meeting and will update QSC. The original action can be removed.
RK
AE
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205: SC confirmed the number of suspended homes is known, as is the total number of beds in those homes, but not the number of empty beds. NYCC can’t make placements to homes in suspension and so the number of empty beds is essentially irrelevant. AE/SC will discuss further but the action can be closed. 207: Closed
212: AE confirmed that the new Vaccinations and Immunisations lead Samantha Dyson had been invited to the meeting, but was unable to attend. She will, however, be attending the March meeting and giving an update. Closed.
213a and b: Closed
214: Update provided as part of agenda item 8
215: RK noted that there had been changes made to the CCG website and the enquiries contact was now the first on the list. Closed.
216: Carried over.
217. AE confirmed that although STHFT had not considered an action plan as yet, the subject was discussed at a recent meeting with HRW and South Tees CCGs. Collaborative working will continue, more meetings have been planned, and KN asked to be kept in the loop. Action can be closed.
4 Strategic Items for Discussion
4a Non-Elective position – verbal update given by Abi Barron High rate of non-elective admissions continues to create a significant financial challenge for the CCG – the current position is >6% off anticipated improvement plan
Patient flow = 75% STHFT, 11% County Durham & Darlington Trust, 10% York Trust, 4% Others.
Data shows 45% of all patients are aged 70 and over and are responsible for 60% of the total cost. Main causes of admission are septicaemia, pneumonia, fractured neck of femur (highest actual cost), COPD and UTI (urinary tract infections). 91% of admissions are from home, the remaining 9% from nursing or residential homes. Overnight admissions have been identified as an outlier, and availability of services is being reviewed.
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treatment/care costs £5 million. GP practices have been provided with a list of patients with multiple admissions and have responded positively to CCG visits/meeting and support.
The feedback suggests the “frequent flyers” are younger (50s-60s) but more complex patients. This would indicate the older frailty patients are being identified and care plans created.
Other issues:
Step-Up Step-Down (SUSD) beds have periods of unoccupancy and during turnaround days (waits for equipment transfer) CCG is still paying for care hours. Looking to see if care can be redirected – e.g. welfare visits to frequent flyers.
NHS 111 triage- Call handler not always selecting the most appropriate course of action, which can result in ambulance calls that may have been avoidable. YAS call rates to the clinical assessor are below the national average. How can this service be improved? 70% of calls to Immedicare (a service which the CCG is continuing to fund) are completed with no onward referral. Up-front clinical intervention reduces onward referral but it can be difficult to instigate change as part of a consortium of CCGs.
The Primary Care Nursing Workforce project has involved a small number of GP practices, and has looked at how to provide better support to the frail population in the community – service spec is being developed. The Electronic Frailty Index (EFI) only provides a warning of frailty; a clinical verification will then be undertaken, which will help determine what interventions can be put in place to help prevent hospital admission..
KN mentioned patients who were further down the frailty pathway and queried the possibility of prevention strategies being implemented at an earlier stage before patients become severely frail. AB noted that according to EFI scores the cohort of moderately frail patients is huge – significantly above the national average – but the smaller cohort of moderately frail patients with anxiety or depression is recognised as being more likely to deteriorate and may benefit more from early intervention. The first priority is the severely frail.
AB noted the positive results of proactive discharge planning work. Focussing on delayed transfers of care (DToC), three new decision to assess (DTA) pathways have been introduced and discharge assessments being carried out in an acute setting has fallen from 48% to 0% with proactive rehabilitation prior to assessment resulting in much better outcomes for patients.
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An extra bed had been added to the 2 available at Orchid House in Thirsk in response to public concern regarding end of life provision after the loss of the Lambert Hospital. A new end of life pathway has seen more people being cared for in their own home – their preferred place of care – which has reduced the need for beds and as a consequence, the extra bed at Orchid House has now been removed with both remaining beds available for rehabilitation or end of life patients. An extra bed has now been introduced at The orchards in Brompton (Northallerton) due to high demand.
4c Friarage Hospital (FHN) - verbal update given by GC
Background: STHFT contacted the CCG approx. 10 months ago to advise that there were problems with some services at FHN. The integrated Front of House pilot had started (and is still ongoing), but the CCG was alerted to issues in the A&E department relating to anaesthetic rota (on site at night, and the consultant rota). If there is no anaesthetist on site overnight, there would be implications for critical care, surgery and emergency admissions. James Cook University Hospital (JCUH) could not cope with the work generated if FHN was unable to continue. FHN is not closing but will need to evolve in a different way to be sustainable. The CCG will have to consult on what FHN will look like going forward and QIAs (Quality Impact Assessments) for various options would need to be reviewed by the committee from the perspectives of patient safety, experience and clinical effectiveness. GC asked if members would be willing to possibly review papers outside QSC meetings. This was agreed by all present.
4d Maternity/Paediatric ambulance decommissioning - verbal update given by GC
The ambulance will be decommissioned on 31 March 2018. Head of Urgent Care has met with the STHFT and the GP practice (where Yorkshire Ambulance Trust (YAS) paramedics are based) and an operational plan has been agreed.
5 Provider Updates
Verbal update given by AE
Some of the reorganisation at STHFT had been discussed in item 3 (203).
AE noted that Providers A and G were the two care homes not using Immedicare. A letter offering support has been written to both homes. AE will follow up and update at next meeting (action 220)
AE 6 Quality Dashboard
Dashboard presented by RK
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confirmed that the indicators are reviewed monthly (the QSC meetings are bi-monthly) and any issues routinely followed-up. AE advised she is awaiting further information in respect of the mixed sex accommodation breach as well as the Local Quality Requirements relating to complaint closure and electronic discharge
7 Safeguarding Children Report presented by EW
2.5 – the case is subject to judicial process. Were there any early indicators of radicalisation?
3.3 – the timescale for producing safeguarding arrangements is one year from the publication of the final guidance (expected in spring 2018)
3.4 – the Committee agreed with the proposed contract change wording included within the report
4.2 – assessments are required to be completed in 20 working days. Despite the number of requests increasing from 13 to 24 in December, compliance increased from 61% to 90%
8 Care Market and Care Home update Report presented by SC
SC advised that Provider A was under new ownership and had a new name. Formerly the nursing and residential sides of the business were registered separately with the CQC, but now the registration has been combined. SC noted that as one of the sites was subject to a phased lifting of suspension. This could have carried over to the whole site following re-registration; however the suspension will only remain in respect of the nursing element of the business. Any further suspension(s) would apply to the whole site.
SC also gave a detailed updated on Provider B.
AE highlighted staffing and other issues discovered during a visit to Provider G. A low-level concerns meeting was brought forward and with attendance from one of the home’s directors and a local GP, discussions were positive and the home was receptive to the offer of support.
AE is planning a care home engagement and education event which will be held at Leeming Bar Grange on 28 February. The agenda is currently being developed.
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Verbal update given by AE
STHFT are under trajectory for C.diff and MRSA. The Trust has also submitted three successful C.diff appeals, which means the cases in question would not be subject to a financial penalty.
The Gram Negative Bloodstream Infections (GNBIs) – E.coli – will not achieve the targeted 10% reduction during the financial year. An individual case review would help understand themes/issues but there is insufficient dedicated resource either in the community or CCG to undertake this work.
AE has been involved in developing a collaborative GNBSI action plan with STHFT, NTHFT and ST CCG. The plan has received positive feedback from other areas.
AE advised potential gap in continence service- reduced capacity for education and training to support work of GNBSI improvement plan,. Concerns that CCG is paying for a 5-day service, but only getting 3 days with training and education being compromised. This is being investigated
10 Patient Experience and Soft Intelligence
Patient Experience dashboards and Soft Intelligence received The lack of responsiveness in relation to soft intelligence had been discussed as part of item 3 (203), but the likely change to level 3 co-commissioning could lead to new procedures for incident reporting.
The number of PALS enquiries and complaints is on trend, but AE noted that two recent complaints have been particularly complex and resource intensive.
11 Risk Register
Summary of Quality risks received – no comments to note
12 Children and Young People’s Commissioning Team – Local Transformation Plan QIA
QIA and Plan received
JJ mentioned that on pp12-13 of the report, the happiness of children was considered to deteriorate with age. It is not easy to benchmark with other areas as not all Local Authorities provide this data. AE to speak to Jayne Hill (JH) to ask if there is any ongoing work in respect to this statement (action 221a). AE will also speak to JH with regard to the case study on p18 to see what ear tests were carried out on the person in question (action 221b)
AE AE
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Updated version received
AE highlighted a recent e-mail relating to payments made to what HMRC are deeming to be “office holders”. As far as the QSC is concerned, the matter can be resolved by changing the designation of the GP and Nurse Practitioner from “Members” to “Required Attendees” in the ToR. This change was approved by the Committee.
14 Any Other Business
LL raised an issue regarding the donation of a wheelchair to a care home. Her experience was the home would not accept the chair for health & safety reasons, and as chairs have to be person specific, it was actually possible that a brand new chair could be used once and then scrapped. AE will look at spec and discuss issues along with ongoing maintenance and liability with Abi Barron and Gemma Umpleby (action 222)
Items to be escalated to Governing Body Quality impact of non-elective admissions Collaborative working with NYCC (care homes) Step Up Step Down Beds
AE
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