TAUNTON AND SOMERSET NHS FOUNDATION TRUST INTEGRATED PERFORMANCE REPORT

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Integrated Performance Report Various

Trust Board Part A – 28 05 15

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TAUNTON AND SOMERSET NHS FOUNDATION TRUST INTEGRATED PERFORMANCE REPORT

Report to: Trust Board on 27 May 2015 Purpose of the Report:

To provide an overview of high level performance reporting for April 2015 in the areas of Finance, Clinical Quality, Performance and Workforce.

Sponsor: All Executives

Authors:

Contact Details:

Stephen Thomson, Head of Integrated Governance

Kelvin Grabham, Associate Director of Performance and Information

Martine Price, Head of Patient Experience Helen Stapleton, Head of People & Systems Reporting

Adrian Mountford, Head of Financial Planning Kat Keogh, Head of Management Accounts Tina Garrity, Financial Accountant

Indicative Timings (Mins) Financial/Resource Implications: N/A

Risk Implications – Link to Assurance Framework or Corporate Risk Register:

a) 1.1, 1.2 and 3.2

b) Failure to deliver financial targets agreed with Monitor c) F1003 Operating Framework & Contract – 20 (15)

PC004 Orthopaedic RTT – 15 (15) CS009 Cancer Targets – 16 (16)

EU003 Delivery of Financial Plan – 16 (12) TB001 HOT Site – 15 (15)

IN001 Cerner Contract – 15 (0)

AM001 Poor Patient Experience – 15 (9)

Legal Implications: RTT 18 weeks is a legal right for patients from 1 April 2010 and part of the national contractual requirement.

Link to CQC Essential Standards

Outcome 16 - Assessing & monitoring the quality of service provision.

Freedom of Information Status:

Tick if one of the following apply:

 Data protection – staff or patient detail  Commercially sensitive

 Stakeholder management

 Early stage of discussion – Potentially prejudicial to staff morale or partnership working

Previous Considerations: Report presented at each Trust board

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Integrated Performance Report for the Trust Board

Performance Targets

C

an

ce

r

Topic Measure Latest

Month Threshold Monthly Performance Previous months

Cancer - max. 2 week wait from urgent GP referral

% Apr 15

90.5

92.9 93.0

Cancer - max. 2 weeks wait from GP ref symptomatic breast

% Apr 15

98.3

92.9 93.0

Cancer - max. 31 day wait for subsequent treatment - drug

% Apr 15

100

97.9 98.0

Cancer - max. 31 day wait for subsequent treatment - radiotherapy % Apr 15 98.0 93.9 94.0

Cancer - max. 31 day wait for subsequent treatment - surgery

% Apr 15

91.7

93.9 94.0

Cancer - max. 31 day wait from diagnosis to 1st treatment

% Apr 15

97.5

95.9 96.0

Cancer - max. 62 day

wait %

Apr 15 81.3

84.9 85.0

Cancer - max. 62 day wait referral from NHS screening service

% Apr 15

85.2

89.9 90.0

After the considerable improvement seen in March, the Trust’s cancer performance dipped in April, achieving four of the eight national targets. The 62-day under-performance was primarily due to a large carry-over of breach patients from March who still required dating; the two week wait under performance was due to two separate issues relating to a national shortage of barium (affecting colorectal patients) and the late cancellation of a locum’s weekend list (affecting dermatology patients). There were two breaches each against the screening and subsequent surgery targets where activity and thresholds are low and therefore performance is prone to more variability.

The 62-day and two week wait targets remain challenging through May, with a significant proportion of 62-day breach patients being shared cases with other Trusts (primarily Bristol and RD&E). High numbers of patient choice breaches and capacity challenges in diagnostics (particularly for CT & endoscopy) are also affecting two week wait performance as well as having a knock-on effect on 62-day waits.

R

TT

RTT admitted <18 weeks % Apr 15 73.1 89.9 90.0 RTT non- admitted <18 weeks % Apr 15 92.2 94.9 95.0 RTT incomplete pathways <18 weeks % Apr 15 92.3 91.9 92.0

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RTT backlog Number Apr15

1337

1101 1100

The Trust is continuing to work towards achieving all Referral to Treatment (RTT) targets by September 2015, now working to a slightly revised trajectory that has been shared with commissioners. April admitted stops performance was 73.1% against the 90% admitted target (compared to 69.9% in March). 521 breach patients were treated, the majority in ophthalmology (140), orthopaedics (127) and general surgery (106).

In April the Trust continued to underperform against the 95% non-admitted pathway target at an aggregate level with 92.2% of patients seen within 18 weeks (a slight improvement on the March performance of 91.6%) Each Directorate now has weekly PTL meetings or processes in place to review all over 22 week waits and to identify any process delays in booking appointments or reporting test outcomes.

The number of patients still waiting over 18 weeks for admitted treatment or non-admitted appointments (incomplete pathways) increased in April. The majority of the increase was in admitted pathways, where breaches grew to 910 in April from 817 in March. The majority of these breaches are in ophthalmology (250), orthopaedics (211) and general surgery (189). For non-admitted pathways, breaches reduced slightly (427 in March and 450 in April). Despite the overall increase in patients waiting over 18 weeks the Trust continued to achieve the national incomplete target with performance of 92.3% in April against the 92% target, the good non-admitted incomplete performance (96.5%) counteracting the under-performance for admitted pathways (82.5%).

Weekly monitoring is in place to track progress against the RTT improvement trajectory. Key risks in delivering the trajectory are the uptake of patients choosing to have treatment in independent sector providers and the impact of cancelled operations in late April and May due to Norovirus-related bed closures (26 cancellations in April, with 33 for the month-to-date in May).

A

&E

A&E 4hr performance % Apr 15 97.4 94.9 95.0 Ambulance turnaround - breach of 30 mins % Apr 15 3.8 3.5 3.6

The 95% A&E target was achieved in April with performance at 97.4%, consolidating on the previous improvements seen against this target. The proportion of 30 minute ambulance handover breaches remained at 3.8% with the majority of breaches occurring during the Easter holiday period.

O th e r Topic Measure Latest Mont h

Threshold Monthly Performance Previous months

% Stroke Patients direct admission to stroke ward in 4 hours

% Mar 15

69.6

59.9 60 70

TIA patients assessed

and treated within 24 %

Apr 15 92.3

59.9 60

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hours ₃₅ Diagnostic outpatient 6wk breaches Number Apr 15 334 39 40

The Trust continues to perform consistently well against the TIA assessment target and performance has improved against the direct admission to stroke ward in 4 hours target following a dip in performance in January.

The number of over 6-week diagnostic waits increased from 291 in March to 334 in April. This falls short of the original improvement trajectory of 268, partly due to an increase in imaging breaches caused by all barium enema investigations needing to convert to CTs because of a national shortage of barium. The Trust is working to a trajectory for achieving the national target (99% of all patients seen within 6 weeks) by September 2015. However, risk remains around securing sufficient audiology capacity to reduce breaches, whilst there is also pressure on waiting times for cardiac CT/MRI scans due to a 33% increase in demand and difficulties recruiting radiographers. Actions have been identified to resolve these issues and progress against the improvement trajectory is being reviewed on a weekly basis.

Contractual Penalties

The national acute contract contains a number of performance targets where penalties are applied for underachievement. For April 2015 total penalties would equate to an estimated £268,000 with the majority relating to RTT (£190,000) and diagnostic breaches (£56,000). A further £22,000 is linked to ambulance handover delays.

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Clinical Quality

C LIN IC A L E FF EC TIV EN ES S

Topic Measure Recent

data Threshold Monthly Performance Previous

3-month rolling hospital standardised mortality rate (HSMR) per 100 Feb 15 109.6 85 100 3-month rolling summary hospital level mortality indicator (SHMI) per 100 Jan 15 102.1 90 100

Average length of stay

Average number of days Apr 15 3.7 3.6 3.8 30 day unplanned

readmission rate Percentage

Feb 15 3.7%

4.0% 4.5%

Both HSMR and SHMI are currently above 100, although both remain within the expected range. As discussed previously at Board, the Trust has carried out a significant piece of work to review mortality, with the findings to be discussed in detail at the Trust’s Governance Committee.

PA TIE N T S A FE TY

Grade 2+ hospital acquired pressure ulcers per 1,000 bed days Per 1,000 bed days Mar 15 1.07 0.8 1

Rolling 3-month rate of high consequence falls per 1,000 bed days

Per 1,000 bed days Mar 15 0.08 0 0.05 Number of hospital

attributable MRSA BSI Number

Apr 15 0 0 Number of avoidable hospital attributable C. Difficile cases Number Mar 15 0 0 1 Number of never events Number Apr 15 0 0 Percentage of patients experiencing harm free care Percentage Apr 15 94.2% 95% 93% Number of ward-based

cardiac arrests Number

Apr 15 1

3 6

Percentage of patients risked assessed for VTE on admission

Percentage Apr 15 94.6%

99% 95%

Pressure ulcers and falls continue to be areas of concern, with significant focus being given to on-going improvement work, linked to Sign Up to Safety. VTE performance continues to fluctuate.

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PA TIE N T E X PE R IE N C E

Friends & Family Test – Inpatients Net promoter score Apr 15 97.3% 97% 95%

Friends & Family Test – Emergency Department Net promoter score Apr 15 93.7% 91% 88%

Friends & Family Test – Maternity Overall Net promoter score Apr 15 98.1% 95% 93% Percentage of patients rating their care as excellent Percentage Apr 15 67.7% 75% 65% Percentage of patients who felt always treated with respect & dignity Percentage Apr 15 97.0% 95% 90% Percentage of patients receiving help at mealtimes (of those who need it)

Percentage Apr 15 76.1%

95% 85%

Patient receiving help at mealtimes continues to be an area of concern, but is improving slowly.

SA FE S T A FF IN G

Average fill rate (Day,

Registered) Percentage

Apr 15 96.6%

97% 95%

Average fill rate (Day,

Unregistered) Percentage

Apr 15 106.0%

97% 95%

Average fill rate (Night,

Registered) Percentage

Apr 15 101.7%

97% 95%

Average fill rate (Night,

Unregistered) Percentage

Apr 15 114.1%

97% 95%

Areas of underperformance on fill rate of registered staff relate to the following: Periods of reduced patient activity or unfilled shifts covered by additional staff redeployed from other wards.

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Finance

Full Year A c tu a l V a ri a n c e -(A d v e rs e )/ F a v o u ra b le A n n u a l B u d g e t £000 £000 £000 Income 21,976 455 264,113 Pay Cost 13,718 (919) 155,231 Non-Pay Costs 9,348 164 113,782 Surplus / (Deficit) (1,090) (300) (4,900) Current Period

Income & Expenditure

£’m

VIP Underachievement (0.5) Underachievement of VIP is due to the level of

unidentified plans at the beginning of the year. Further work is underway to identify further schemes.

Premium Rate of Agency (0.5) The level of agency costs in April was higher than budget due to the opening of additional beds as a result of Norovirus, the continued high number of nursing vacancies and specialling costs which are currently exceeding those encountered in 2014/15. RTT / Growth Slippage 0.5 The underspend on RTT / Growth activity is due to

delays in identifying patients to go to external

providers. It is expected that this expenditure will still be incurred in due course.

Contingency 0.2 The contingency is phased in equal twelfths across the year. There is currently no expenditure allocated against this reserve.

Variance to budget (0.3)

I&E deficit in the month of April is £1.09m which is £0.30m behind plan (Plan: £0.790m deficit). This is impacted by underachievement of unidentified VIP (allocated across the

year in twelfths) and higher than planned temporary staffing costs, which has been offset by an underspend on external outsourcing relating to the RTT plan.

COS Rating

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VIP performance (chart)

VIP achieved in the month is £0.350m against a target of £0.825m, a shortfall of £0.475m.

£0.099m relates to identified schemes with the remainder a result of the unidentified element of the programme.

Cash position

Cash deposits amounted to £16.6m at the end of April, which is £0.6m higher than

planned. This is mainly the result of delayed capital expenditure as well as trade creditors,

accruals and deferred income being higher than plan and Non-NHS Receivables being lower than plan.

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Capital expenditure

Capital Expenditure amounts to £0.9m for the year to date compared to a plan of £1.1m.

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People

ENGAGEMENT

Pulse Check Quarter 1 Quarter 2 Quarter 3 Quarter 4 Movement Best (highest) Worst (lowest) Advocacy:

to friends and family

as place to work 73% 67% 69% 77% Operational Mgt (100%) Specialist Surgery (53%)

to friends and family if they need care or treatment

90% 93% 92% 94%

Acute Surgery & Gastro; Diagnostics; Musculoskeletal; Operational Mgt (All 100%)

HOPE (90%)

Leadership Capability: overall leadership

capability index 59% 68% 64% 71% HOPE (84%) Specialist Surgery (62%)

Other Measures January February March April Movement Best (lowest) Worst (highest)

Sickness Absence % days lost, 12 month

rolling average 3.7% 3.7% 3.8% 3.8% Operational Mgt (1.5%) Critical Care (5.6%)

Long Term Sick

Number of people at end of month (% of total) 57 (1.4%) 54 (1.3%) 60 (1.4%) 64 (1.6%) Operational Mgt (0; 0.0%) HOPE (5;2.5%) Turnover % (12 month rolling) % leavers, 12 month

rolling average 11.0% 10.9% 11.2% 11.2% Diagnostics (8.2%) Operational Mgt (22.2%)

PERFORMANCE

Performance Review January February March April Movement Best (highest) Worst (lowest)

Appraisal Compliance % of people appraised

within last 12 months 85% 85% 84% 83% Operational Mgt (93%) Surgery (76%)

Mandatory Training January February March April Movement Best (highest) Worst (lowest)

Essential Learning % of people in date

with essential learning 86% 86% 86% 86% Operational Mgt (93%) Acute Medicine (79%)

Safeguarding

% of people in date with safeguarding training

87% 86% 85% 83% Operational Mgt (100%) Critical Care (75%)

Recruitment January February March April Movement

Internal Fill Rate % of job offers made

to internal candidates 58% 46% 44% 63% DEPLOYMENT Roster effectiveness Roster 19/01/15 to 15/02/15 Roster 16/02/15 to 15/03/15 Roster 16/03/15 to 12/03/15 Roster 13/04/15 to

10/05/15 Movement Best (highest) Worst (lowest)

Annual leave

% of rosters within annual leave tolerances

72% 59% 66% 66% Surgery (78%) Women & Children

(25%)

Total non-effective % of rosters within

headroom tolerances 41% 16% 6% 56% Women & Children (75%) Surgery (22%)

Additional hours

% of rosters within additional hours tolerances

53% 44% 34% 38% HOPE (100%) Critical Care (0%)

Temporary staff

% of rosters within bank/agency tolerances

31% 31% 31% 34% HOPE, Women & Children

(100%) Surgery (11%) People utilisation - WTE worked Nov14 - Jan15 Dec14 - Feb15 Jan15 - Mar15 Feb15-Apr15 Movement from Mar Nursing 1,561 1,575 1,577 1,602 24 Medical 460 462 465 465 0 Other Clinical 416 421 423 430 6 Non-Clinical 1,234 1,239 1,242 1,245 3

Staff in Post Analysis Budgeted In Post

Difference betw. Budgeted & In Post Mar 15 Difference Feb 15 Difference Jan 15 Difference Nursing - Registered 1,012 954 58 53 57 57 Nursing - Unregistered 522 482 40 38 36 39 Medical 452 442 9 12 27 22 Other Clinical 437 442 -5 2 6 11 Non-Clinical 1,304 1,184 119 87 88 78 % likely/extremely likely to recommend the Trust...

Average WTE worked (3 month rolling)

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1 ENGAGEMENT

1.1 Pulse Check

Pulse check results are as reported last month. The next Pulse Check survey will be carried out in June, with results reported to Board in July.

1.2 Engagement sub-measures

Annualised sickness and turnover levels have remained stable this month compared to last, with actions ongoing.

2 PERFORMANCE

2.1 Performance sub-measures

Performance management compliance has fallen slightly on last month. We expect a further deterioration next month before compliance improves again; this is following the earlier re-set of all review dates for colleagues at band 7 and above to the end of April, as managers are currently getting to grips with the new performance review process with their teams. However over 100 senior colleagues have now had a performance review with a rating applied using the new performance review process and confidence and capability in the process is improving continuously.

Mandatory training compliance is relatively stable with nothing unusual to report.

3 DEPLOYMENT

3.1 Roster effectiveness

Current roster KPIs refer to the 4 week roster period between mid-April and mid-May. There was a general improvement in roster effectiveness/availability in this period compared to the previous two periods, as we moved away from the difficult end of winter/Easter holiday periods. Use of additional hours above the basic roster template has improved slightly but is still relatively poor – this reflects the demands placed on the Trust due to the use of escalation beds and more acute patients. We anticipate that this situation will improve in the next roster period. Overall the use of temporary staff remains above plan due to vacancies and increased patient activity.

3.2 People utilisation

Average WTE worked for the last quarter was higher for nursing than in previous months (driven by reasons described above), other staff groups were consistent with last month.

Contracted people in post remained fairly stable; the only area of significance was a drop in non-clinical people in post driven by transfers of IT and finance (payroll) services.

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Our nurse recruitment campaign is starting to prove fruitful; 34 offers have so far been made to EU nurses following Skype interviewing and local interviews in Spain.

Appendix 1: Additional information on Quality

CLINICAL EFFECTIVENESS

Following discussions at the Trust Board and Governance Committee, work is underway to change the presentation of data within the clinical quality section of the integrated

performance report. Graphs will be presented as run charts and control limits will be used to set thresholds for exception reporting. The timescale for this work depends on the

procurement of a software package and delivery of training, but is expected to be in the next couple of months.

3-month rolling hospital standardised mortality rate (HSMR)

Source: Hospital Evaluation Data (HED)

Monthly position: Our monthly position is of concern and requires review (Amber). The 3

month rolling HSMR for the period ending February 2015 was 109.6 and the 95% confidence interval was 97.7 to 122.6.

Statistical Analysis: Although the HSMR is above the threshold set, the current value is still

within the expected range.

3-month rolling HSMR - Weekday vs. weekend non-elective admissions

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Monthly position: The rolling 3 month HSMR for February 2015 for non-elective patients

admitted on a weekend was 119.6 compared to 108.8 for those patients admitted on a weekday.

3-month rolling summary hospital-level mortality indicator (SHMI)

Source: Hospital Evaluation Data (HED)

Monthly position: Our monthly position is of concern and requires review (Amber). The 3

month rolling SHMI up to January 2015 was 102.08 with a 95% confidence interval of 93.0 to 111.8.

Statistical Analysis: Although the SHMI is above the threshold set, the current value is still

within the expected range.

Breakdown of HSMR and SHMI by Diagnosis Group Source: Hospital Evaluation Data (HED)

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Data period

HSMR: March 2014 to February 2015 SHMI: February 2014 to January 2015

Key

Diagnosis group (Number of spells, Difference of observed and expected deaths) Red = Significantly higher than expected Green = Significantly lower than expected

The diagram above highlights the diagnostic groups (based on diagnosis at admission) for which the Trust is an outlier, either positively or negatively, for HSMR and SHMI over the last 12 months available data. The data include the number of spells and the difference between observed and expected deaths to help with context.

The small number of cases involved when the data are broken down to this level means that these may not be statistically significant, but the Trust’s Data Outlier Review Meeting reviews each of the “Red” items as they are identified.

Total number of in hospital deaths

Source: Information Services Department

Monthly position: In April 2015 there were 88 in-hospital deaths.

Average length of stay

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Emergency medical vs. emergency surgical admissions

Monthly position: The monthly position for the average (mean) length of stay is acceptable

(Blue). The average length of stay for all discharges (excluding day cases) in April 2015 was 3.7 days.

In April 2015 the average length of stay for elective admissions was 2.7 days compared to 3.8 days for emergency patients. For patients admitted as an emergency the average length of stay for patients in the Acute Medicine directorate was 5.3 days and 3.8 days for those within the surgical directorates (Head & Neck, Acute Surgery and Musculoskeletal).

30 day unplanned readmission rate

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Monthly position: The Trust achieved its stretch target (Green) for patients discharged in

February 2015. Data is not yet available for patients discharged in March.

CLINICAL EFFECTIVENESS EXCEPTIONS

Percentage of discharge summaries produced within 24 hours of discharge

In order to address low compliance with this is indicator the CCG have led work on a county-wide basis with the Trust represented by senior clinicians. The key focus of Trust actions was to roll out of the EPRO solution to improve quality and user acceptance of the electronic process. The solution has now been spread across the Trust and during April 2015 there were 3,464 discharge summaries completed on EPRO of which 3,132 (90.4%) were issued with 24 hours.

Further work is on-going to ensure all discharge summaries are being completed

electronically via the new EPRO system and the data now being produced has allowed the team to identify particular areas to target for improvement or to refine the criteria if discharge summaries are not clinically appropriate.

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PATIENT SAFETY

Rate of grade 2 and above hospital acquired pressure ulcers per 1,000 bed days

Source: Ulysses Incident Database

Monthly position: Our current position is of concern and requires review (Amber). In March

2015 there were 18 Grade 2 or above hospital acquired pressure ulcer incidents reported which equates to a rate of 1.07 per 1,000 bed days.

Causes: We believe that the increase is likely in part be related to an increase in patient

acuity, dependency and complexity alongside the high use of temporary staff.

Actions: As part of the corporate safe staffing risk assessment and action plan we have

instigated a range of interventions to mitigate this position; for example, buddy high risk wards with senior nursing staff, weekly safety huddles, 8 hourly safety briefings, increase HCA recruitment, redistribute staff from other areas in the hospital, increase leadership visibility. The overseas and local recruitment campaign continues.

Rolling 3-month rate of high consequence falls per 1,000 bed days

Source: Ulysses Incident Database

Monthly position: Our current position is of concern and requires review (Amber). During

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equates to a rate of 0.08 per 1,000 bed days. There was one fall that occurred in January 2014 and three in March 2015.

Following discussion at the Trust Board in February 2015, the run chart above is included in addition to the original charts.

Causes: Work is currently underway to review the wider measurement of falls to enable

identification of specific issues, as discussed at the Board in February 2015.

Actions: The Falls Group is co-ordinating a wide range of actions based on learning from

review of incidents, along with a focus on measurement strategies to enable clearer identification of the success of specific interventions.

Number of hospital attributable MRSA BSI

Source: Infection Prevention & Control

Monthly position: We have achieved our stretch target (Green). There were no hospital

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Number of avoidable hospital attributable C. Difficile cases

Monthly position: We have achieved our stretch target (Green). There was one hospital

attributable cases in March 2015 but this was not avoidable.

There were three hospital attributable case in April 2015 although the avoidability is yet to be determined.

Number of hospital attributable C. Difficile cases

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Number of bed days lost due to norovirus

Monthly position: The Trust lost 169 bed days due to norovirus or suspected norovirus in

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Number of Never Events

Source: SIRI Tracker

Monthly position: We have achieved our target for the month (Green). There were no

Never Events reported in April 2015.

Percentage of patients experiencing harm free care (All harms)

Source: Safety Thermometer

Monthly position: Our position is acceptable (Blue). In April 2015, 94.2% of patients

surveyed experienced harm free care.

The following are included as harms: old or new pressure ulcers, falls with harm, catheters with urinary tract infections (UTIs), and new cases of venous thromboembolism (VTEs).

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Percentage of patients experiencing harm free care (New harms)

Source: Safety Thermometer

In April 2015, 98.8% of patients surveyed experience care free from new harm.

New harms include new pressure ulcers, falls with harm, new catheters and UTI and new cases of venous thromboembolism (VTEs).

Number of ward-based cardiac arrests

Source: Resuscitation Team

Monthly position: We achieved our stretch target (Green). There was one ward based

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PATIENT SAFETY EXCEPTIONS

Percentage of patients risked assessed for VTE

Source: Weekly VTE Risk Assessment Audit

Monthly position: Our monthly position is of concern and requires review (Amber). In April

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PATIENT EXPERIENCE

Number of PALS

Source: Patient Advice & Liaison Service

NOTE: On-going improvement actions across all areas of patient experience are covered in the Q4 patient experience report below.

Monthly position: In April 2015 there were 105 PALS enquiries.

Number of complaints

Source: Patient Advice & Liaison Service

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Friends & Family Test Score

Source: Governance Support Unit

Monthly position: We achieved our stretch target for all measures (green).

In April 2015, 97.3% of 889 patients on our wards and day case areas said they would recommend the hospital. In March the result of 95% was within the top fifth of trusts in England.

93.7% of 604 patients attending the Emergency Department in April said they would

recommend the department. March’s result of 98% was within the top quarter of all Trusts. Our combined Friends & Family Test result for our Maternity services in April is 98.1% which is based on 266 responses. Individually, over 95% of patients would recommend each service.

In April we also received 56 outpatient responses. 92.9% of these patients would be likely to recommend this hospital to their family and friends.

Percentage of patients rating their care as excellent

Source: Inpatient Experience Survey (rolling 3 months)

Monthly position: Our position for April 2015 is acceptable (Blue). 67.7% of 656 patients

surveyed in the last three months rated their care as excellent. 93.6% of patients rated their care as excellent or very good. It is important to note that despite a recent decline in the

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number of patients reporting their care as excellent; reporting of very good/excellent care has not changed.

Percentage of patients who felt they were always treated with respect and dignity

Monthly position: We achieved our stretch target (green). In the three months to April

2015, 97.0% of 660 patients surveyed felt they were always treated with respect and dignity.

PATIENT EXPERIENCE EXCEPTIONS

Percentage of patients receiving help at mealtimes (of those who need it)

Monthly position: The way we ask this question had been changed from January to make it

clearer for patients that we are asking specifically about help to eat.

Our position for April is of concern and requires review (Red). 76.1% of patients who reported they needed help with eating received it all of the time (n=155).

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Patient Experience Quarterly report – Quarter 4 (January – March 2015)

This report provides an overview of what our patients have told us about their care and treatment during the final quarter of the year, January to March 2015 and how that compares to previous months. This information is drawn from complaints, PALs concerns, patient’s feedback from real time surveys, the friends and family question and comments posted on sites such as NHS Choices.

The results of the national surveys for children and in-patients 2014 are included in this report.

The report includes learning from complaints and PALs concerns, with case study examples and learning.

Complaints and PALs numbers during Quarter 4

Total number of complaints

Source: PALS Department

There were 26 formal complaints in March 2015 and a total of 60 for the final quarter of 2014/15.

Total numbers of PALS

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There were 108 PALs enquiries in March 2015 and a total of 301 in the quarter.

To give perspective to complaints and concerns the following run chart has complaints and PALs measured as a rate per 10,000 trust patient activity. This is the total of all admissions, outpatients and A&E attendances including day cases, emergencies and elective. This represents the total number of contacts with patients each month.

In March 2015 the rate of PALS was 28.2 per 10,000 contacts and the rate of complaints was 6.8 per 10,000 contacts.

Analysis of Complaints and PALS

The following chart shows wards and departments across the hospital with 5 or more PALS and complaints in Quarter 4. It is important to note that a single complaint/PALs concern can cross a number of areas. This breakdown provides an overview to highlight those areas with the highest number of concerns raised.

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The Orthopaedic Department received the highest number of joint PALS and formal complaints and has seen a 59% increase from a total of 17 in Q3 to 27 in Q4. The majority of PALS concerns were about length of wait, primarily for appointments and secondly for treatment; 2 of the 4 formal complaints were regarding diagnosis problems, the others were: 1 x operation outcome and 1 x general medical treatment.

Although the Ophthalmology Department continue to receive a high number of PALS and formal complaints it has also seen a decrease from a total of 43 in Q2, 25 in Q3 to 20 in Q4. The majority of PALS concerns were about length of wait, mainly for appointments.

The X-ray Department as a whole received a substantial increase in PALS concerns from 4 in Q3 to 15 in Q4, together with 2 formal complaints (1 x Q3) ; a rise from a total of 5 in the last quarter. The majority of concerns related to waiting issues, mainly length of wait for treatment; others included concerns around conflicting information x 2 and attitude of staff x 1.

The number of PALS and complaints regarding the MAU department has again increased from a total of 6 in Q2, 11 in Q3 to 16 in Q4. Formal complaints reduced from 6 to 3 (These related to issues of nursing care, attitude of staff (nursing) and communication/Information to

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relatives). PALS concerns were a mixture but predominantly: attitude of staff (x3), discharge (x2), waiting related issues(x2).

Although in Q3 the Colorectal department experienced a large increase in PALS concerns from 4 in Q2 to 18, this quarter has seen a decrease down to 10 (formal complaints have also decreased from 3 to 2). The majority of concerns were about waiting, mainly length of wait for treatment followed by length of wait for appointment and another for results.

Overview analysis key themes from complaints and PALs concerns

Clinical treatment, attitude of staff and communication remain the top 3 complaint categories. Review of the category clinical treatment show these complaints to be across wards and departments, and they include a range of issues relating to treatment, mainly concerns relating to diagnosis, medical treatment and nursing care.

PALS & FORMAL COMPLAINT Q4 themes overall:

Categories : PALS F/COMPLAINTS

TOTALS:

(Q3 in brackets)

Waiting 107 (87) 0 (1) 107 (88)

Communication 58 (67) 12 (5) 70 (72)

Attitude of staff 29 (28) 3 (8) 32 (36)

Waiting continues to be the largest category for PALS concerns increasing from 87 in Q3 to

107 in this quarter. The majority of concerns regard length of wait for appointment x 41 (mainly Orthopaedics, Ophthalmology and Dermatology) followed by length of wait for treatment x 51 (mainly Orthopaedics and X-ray) and wait for results x 13 (mainly Gastroenterology).

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The category type of Communication has seen a reduction in PALS concerns from 67 in Q3 to 58 while formal complaints have increased from 5 to 12. PALS involved different departments and wards across the hospital. Of the 12 formal complaints, 2 each were Eliot Ward (1 x lack of communication with family, nursing and end of life care) and Sheppard Ward (1 x failure to inform family of patient’s death in a timely way). 23 PALS concerns were about questions about information that had been given e.g. 3 x general outpatients, 3 x Montacute.

There has been a small decrease in the category of Attitude of Staff: PALS concerns remain similar at 29 while the number of formal complaints has reduced from 8 to 3 cases (2 x Nursing and 1 x Admin staff). The majority of PALS concerns were 13 x nursing staff, 7 x medical staff and 6 x admin staff. Of the 29 concerns, 6 cases x A&E followed by 3 x MAU.

Learning

Review of all the complaints highlights the need to focus attention on a more proactive approach to patients and relatives when they have questions or concerns they wish to raise at the time. To be able to resolve any questions/concerns at the time and to encourage patients and relatives to have the confidence to do this at the time is fundamental. A workshop is planned for early July with people directly involved in the handling and

response to complaints to explore how we can take forward a more responsive and timely approach. The workshop will be informed by examples of best practice both within the NHS and wider.

Effectiveness of Complaints and Concern handling and Outcomes

All complaints received are graded according to the severity of the complaint; the grading is in line with the Trust’s risk scoring matrix, red, amber and green. The following provides a breakdown of complaints received in quarter 3 by grade to denote the severity of the complaint and outcome where the complaint has been closed. The outcome relates to whether or not the complaint was upheld. This is an assessment made following the investigation and when the complaint is closed.

This is quarter 3 data to give a more complete picture of closed complaints.

Of the complaints received in of Q3 complaints by grade and outcome is as follows:

Green Amber Red No

grade

Not Upheld Second Letter 1

Initial 5 1

Partially Upheld Second Letter 1

Initial 32 6

Upheld Second Letter 1

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Open Second Letter 7 1

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All complainants are offered a meeting to resolve their complaint. During Quarter 4 there were 13 meetings held. This relates to formal complaints and does not include the work of the PALs Officers to achieve speedy and local resolution of concerns.

The number of second letters/complainants who come back dissatisfied with the initial response to a complaint is monitored. This is an important indicator of the quality of the response to the complaint. During January to March 11 second letters were received. Review of these cases shows the reasons to be, that the complainant was unhappy with the response/outcome of the investigation, that they felt not all the questions had been fully answered or that they are seeking compensation.

Also monitored are the numbers of PALS Concerns that are not resolved and go forward to formal complaint. In this quarter only 4 out of the 301 PALS concerns received converted to formal complaints. This low number of converted cases reflects well on the PALS process and patient satisfaction at that level.

Complaint response performance is monitored, that is the number of complaints where a

response which is a letter or a meeting is provided in the timeframe agreed with the complainant. In January 61 % of complaints, February 35 % and March 66 %. This

represents deterioration in complaints response time compared to previous months in 2014. Actions taken include agreement to recruit additional Band 3 post to the complaints /PALs team for 6 months pending further review of resources needed going forward. Revised performance metrics agreed with Director of Operations, new performance management arrangements commenced 8 May. Benchmarking exercise commenced to be

completed end of June with a workshop planned for end of June with key stakeholders to consider proposals to go forward.

Root cause analysis training is being provided in May 2015 for 24 investigators for incidents and complaints ; this will increase the available pool of trained investigators for complaints and incidents. This will help to improve the quality of investigations and reduce the current burden of investigation on the directorate/clinical service managers.

Ombudsman referrals

The Parliamentary and Health Service Ombudsman provides an independent complaints handling service for a range of public bodies. Should any of our complainants be dissatisfied with the handling and outcome of their complaint they have the right to request that the Ombudsman undertakes an independent review of their complaints. We ensure that every complainant is given information about the role of the Ombudsman.

During the year 2014/15 the Trust had 2 cases referred. At the time of writing this report one complaint was still being investigated. The other complaint was partly upheld. This was a complaint about bariatric care. The investigation by the Ombudsman found no failings in the clinical care, but did identify a failing in complaint handling, in that there was a delay in providing response and for not keeping the complainant updated between December 2013 and February 2014. They stated that there was no evidence that this was a systemic fault through any further instances of this failing.

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Listening and Learning

Every complaint is reviewed to identify the issues raised by the complainant this is to ensure that we can learn and continuously improve. The categorisation of issues identified for all complaints is recorded and reviewed to allow wider learning and identification of trends. This information is considered alongside other patient information such as incidents and feedback we gain from our patient surveys every month.

The following are examples of action and learning arising from complaints and PALs cases during the quarter.

PALS Concern: regarding Maternity:

A number of concerns were raised by a family regarding maternity care , these included the visibility of staff, and a feeling of not being listened to and having to keep asking for

assistance such as pain relief. Learning being taken forward:

Learning has been taken forward following the concerns raised, this has included further use of intentional rounding, improving accessibility of documentation and reviewing what is kept at the bedside and review of handover information.

Formal Complaint: the relative of a patient who was unable to communicate or care for himself due learning disability raised concerns about a meeting arranged to decide how best to assess the patient’s need for treatment. The meeting should have been held with the patient’s consultant but this did not happen and the registrar who attended did not know the patient and was not prepared.

Learning taken forward: Following review by the Lead Nurse for patients with learning

disabilities, there is now a more robust process for setting up best interest meetings to ensure that all who attend these important meetings are prepared with the aim of achieving the best outcome for the patient.

Compliments and Commendations

Patients and their families do not make complaints about their care and treatment lightly. Equally when a patient or relative takes the time share their experience and to write to thank us, their experience at Musgrove has often exceeded their expectations and they tell us how and what was important to them as a patient in our care. This is essential qualitative

information to help us to learn and improve on the care we provide

The Trust received many compliments and letters of thanks across the hospital, e.g.: “I am writing to offer a sincere thank you for the excellent care and attention which I received prior to and after my recent operation in Gynaecological Oncology. I am extremely

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grateful to the whole of the Musgrove team for the professional and compassionate care which I received in ITU, HDU and the Hestercombe Ward.”

And, following a procedure in the Day Surgery Unit, a patient wrote:

“The staff in this unit deserve recognition for the excellent work that they do and their dedication is second to none. I commend this unit to you and single them out for the praise that they so rightly deserve.”

Comments received on NHS CHOICES (Patient Opinion websites)

During this quarter 21 comments were posted on the sit and of those 17 were

commendations about hospital staff and the excellent care they received and 9 of those were thanks to the staff of A&E, for example:

“I attended A&E last Saturday following an accident, I was seen quickly (within 10 minutes)

by a nurse and within another 10 had been seen by 2 doctors & X-rayed, cannula sited, pain

relief given, and TLC & tissues given to stem my fears and concerns. I was admitted to

Portman ward promptly and also received wonderful care there. The staff in A&E are a credit

to the trust. They should be proud of themselves.”

In January another patient also wrote about their care on Portman Ward:

“I spent 2 nights on Portman ward following a fracture to my neck of femur last weekend,

prior to surgery. The staff without fail were considerate, kind, empathetic and professional.

Nothing was too much trouble for them and they ensured I was as comfortable as possible

during my time there. I cannot thank them enough.”

The PALS and Complaints Lead coordinates responses to all comments received either thanking people for taking the time to write commendations or offering the writer the opportunity to make contact with the PALS office direct to address any concerns raised.

Patient and Family Feedback - Inpatient Surveys

Across the hospital feedback from patients, relatives and carers is collected in many ways. This report provides a high level overview of feedback obtained during the period January – March.

Friends and Family Test

The Friends and Family Test score is a national indicator where all patients with an overnight stay are given the opportunity to answer the question; how likely they would be to

recommend their ward to their family and friends at the point of discharge; all maternity women are offered the opportunity to answer the question at four points in their journey and all people who attend A&E and Outpatients are offered the opportunity to give their level of recommendation.

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In addition to the score achieved, all people have the opportunity to give the reason(s) for the level of recommendation received. This feedback including the reasons and narrative comments received are reviewed and fed back to the areas.

In March 2015, 97.8% of 649 patients on our wards said they would recommend the hospital. In February the result of 97.8% was within the top quarter of trusts in England. 95.3% of 550 patients attending the Emergency Department in March said they would recommend the department. February’s result of 96.0% was within the top fifth of all Trusts. Our combined Friends & Family Test result for our Maternity services in March is 97.0% which is based on 176 responses. Individually, over 90% of patients would recommend each service and in birthing service 100% of patients would be extremely likely to recommend.

The following Pie chart shows the reasons given for the level of recommendation, the size of the pie chart represents the number of times a particular reason was selected, the more times selected the more significant i.e. the more important to patients when considering their experience, this is then broken down by whether it was positive, negative or a neutral

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Friends and Family question has been introduced in Outpatients and Day Surgery. During quarter 4 of 2014/15, there were 100 responses for the Outpatients Test, with 90.0% of patients likely to recommend. There were 293 responses for Day Surgery, with 94.5% of patients likely to recommend.

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Results of in-patient surveys undertaken during quarter 4

During Quarter 4 in addition to all patients being given the opportunity to take part in the friends and family question at the point of discharge, volunteers supported surveys for in-patients surveyed in-patients across all the adult wards.

3.5/3.6- Percentage of patients rating their care as excellent and excellent/very good

Source: Inpatient Experience Survey

Excellent thresholds: Green: 65% or over Blue: 60 % to 64% Amber: 50% to 69% Red: Under 50%

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In Quarter 4, 63.5% of the 701 patients surveyed reported the care they received as

excellent and 93.4% reported their care as either very good or excellent.

In the main this rating is not being sustained on the Medical and MAU wards. These wards

have experienced increased pressure, with factors such as nursing vacancies and use of temporary staffing. Results are reviewed by the ward sisters alongside other feedback including friends and family results and any concerns or complaints. The Associate Directors of Nursing met on the 15 January and have reviewed individual ward results alongside other factors such as vacancies, use of temporary staff and movement of patients across wards to ensure each ward has appropriate actions in place.

The in-patient survey has been amended to collect specific reasons from patients for the overall rating of care given. Review of all the comments received during the quarter shows that overall comments are extremely positive; the main themes for improvement relate to noise at night, this is very often noise from other patients, comments about the food, (all of these have been shared with the catering team) and comments about cleaning and staffing such as time taken to respond to call bell.

Each ward reviews their results and agrees what action they are taking to improve the experience of patients and relatives on their ward. Examples during the quarter include Triscombe, Wordsworth and Mendip focussing on reducing noise at night, proactively offering ear plugs and ensuring patient’s assistance at mealtimes. Montacute Ward is ordering televisions for the single rooms. Blake Ward is focussing on giving assistance at meal times and more active involvement of patients with discharge planning.

It is important to note that we are sustaining over 90% of patients rating their care as excellent/very good and that other patient experience indicators such as friends and family have not dipped.

3.9 - Percentage of patients who felt they were always treated with respect and dignity

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In the final quarter of 2014/15, 95.7% of patients reported that they were always treated with respect and dignity. (n=704)

3.10 - Percentage of patients who were happy with the level of involvement in their care

Thresholds: Green: 95% or above Blue: 85 to 94% Amber: 80 to 84% Red: Below 80%

93.4% of 684 patients reported they were happy with the level of involvement in their care.

3.11 - Percentage of patients who received help with eating (of those who needed it)

In the fourth quarter, 135 patients reported they needed help at mealtimes and 92.6% of those patients said they received it most or all of the time.

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Assistance to eat has continued focus; the question has a follow up question asking the reasons for the response. Comments from patients on the reasons highlight “sometimes there is a little wait before someone will help with cutting up” other comments specifically about assistance required were about preparation for meal times, helping to open jars such as jam, cutting up food and positioning

The results have been discussed with the ward sisters to raise awareness about support for patients at mealtimes and with the nutrition team. Wards have taken forward action in their areas with focus on mealtime support. Wards with high levels of nurse vacancies are reviewing the use of volunteers on the ward that have a specific role to support patients are mealtimes. This is being led by the Associate Director of Patient Experience.

For context, benchmarking these results against the national in-patient CQC survey undertaken annually for 2014.The Trust has received the early results of the national in-patient survey. In this survey in-patients are asked “Did you get enough help from staff to eat your meals?” our results when benchmarked show that we are significantly better compared to other Trusts on this question.

3.12 - Percentage of patients who always found staff to discuss their worries and fears

Thresholds: Green: 70% or above Blue: 65% to 69% Amber: 60% to 64% Red: Below 60%

79.8% of 420 patients reported that they could always find staff to discuss their worries and fears.

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3.13 - Percentage of patients who were given privacy when discussing their condition or treatment

In Q4, 85.1% of patients felt they were given privacy when discussing their condition or treatment. (n=698).

In the main this rating is not being sustained on the Medical and MAU wards. These wards have experienced increased pressure, with factors such as nursing vacancies and use of temporary staffing. During the quarter, further work has been undertaken to gain specific feedback from patients to understand the issues around privacy and dignity. Review of comments received from patients has identified the following:

 the need to be vigilant in ensuring curtains are fully closed or, if the patient is in a room, the door is closed when consultation or discussions are taking place.

 To consider if a conversation is confidential if possible this happens off the ward or the patient is asked whether they are happy for the conversation to take place.

The Associate Directors of Nursing met on the 15th January and have reviewed individual ward results alongside other factors such as vacancies, use of temporary staff and

movement of patients across wards to ensure each ward has appropriate actions in place, including raising awareness of the factors identified above.

CQC adult in-patients CQC survey 2014

The results of the national inpatient survey 2014 were published in May 2015. 451 patients participated in the survey with a response rate of 56%. Of the 60 questions the Trust was significantly better than average for eight of the questions, including patients overall reporting that they felt that they were treated with respect and dignity while they were in hospital and important aspects of care such as privacy, being able to find hospital staff to talk to about worries and fears, cleanliness and ensuring patients are given assistance to eat their meals. Looking at the groupings of questions relating to the nurses and care they give, the Trust came out as one of the best performing.

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The Trust was worse when compared to other hospitals in one question, when patients were asked if they ever shared a sleeping area with patients of the opposite sex. An Audit

of all the wards is being undertaken to better understand the reasons for this.

National Children’s and Young People’s inpatient and Day case survey 2014

The sample for this survey was patients discharged in July and August 2014, and included perspectives of children, young people and parents (aged 0-15 years). Response rates were: 0-7 years 36%, number 91, 8-11 years 40% 18 in number and 12-15 years 40.8% 29 responses. Headline results below.

The results including all free text comments are being reviewed by the Children’s department led by the Matron; an action plan is being developed and will be presented to the Patient Experience Improvement Group on the 9 June.

Martine Price

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SAFE STAFFING

In April 2015 we submitted our data to NHS England and NHS Choices. This reports our static or regular planned hours against our actual nursing hours, we reported 104.6% of our actual staffing against our planned staffing levels (101.3% by day, 107.9 % by night). Actual nursing hours above planned nursing hours is largely reflective of additional staff used for extra bed capacity or to special patients; this is often referred to as one to one nursing care.

When wards fall below our planned staffing level we are notified through our escalation

processes and we have a clear policy to support this. We analyse these areas immediately and very closely to understand why this has happened and to understand what actions can be taken. Often our staffing levels fall below planned staffing levels because we are less busy, this is common in our specialist departments such as maternity and paediatrics. This is important as it enables us work efficiently and to change staffing levels flexibly when our patient numbers increase or decrease.

We routinely look at our occupancy data (how busy we are) alongside our staffing levels and this forms part of the analysis in our board report. Looking at this information enables us to have confidence and evidence any reduction in staffing number.

In incidences where workload was not reduced, it is important to say that actions were taken to ensure that staffing levels remained safe, these include:

 Reallocating staff from another ward with less workload  Reduce beds available

 The ward Sister supported the ward  The Matron supported the ward  Staff on training supported the ward

 Practice development staff supported the ward  Therapy staff supported the ward.

CCU, Beacon Ward, Ward 9, the Surgical Admissions Unit, the Maternity Unit, the Children’s Unit and the Neonatal Unit all show a reduced fill rate for registered and/ or unregistered staff. We have looked at this and verified that it relates to periods of reduced activity and patient acuity in these areas.

Coleridge did not meet the expected fill rate for registered staff. We have looked at this closely and we can verify that additional staff were redeployed from other wards within the hospital to support the delivery of care to meet patient care needs. We monitor this closely and have an escalation process for identifying and resolving any potential deficits in staffing levels.

A number of our wards exceeded the planned hours for unregistered staff in April. This was a due to extra beds open within the hospital and planned increases to support the wards to special complex, dependent patients (this is often referred to as one to one nursing care).

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DAY NIGHT

Registered Unregistered Registered Unregistered

Ward/Dept Pl an n e d H rs A ctu a l H rs % F ill Pl an n e d H rs A ctu a l H rs % F ill Pl an n e d H rs A ctu a l H rs % F ill Pl an n e d H rs A ctu a l H rs % F ill Barrington Ward 1409 1399 99% 1415 1398 99% 1380 1346 98% 1029 1063 103% Beacon Ward 1288 1029 80% 671 592 88% 690 690 100% 345 345 100% Blake Ward 1067 1060 99% 887 828 93% 679 679 100% 253 406 161% CCU 1446 1308 90% 59 1035 1035 100% Childrens Unit 2290 2027 89% 189 316 168% 1648 1564 95% 343 343 100% Coleridge 1416 1269 90% 1096 1165 106% 1025 979 96% 633 674 107% Conservators 1382 1314 95% 1036 1220 118% 690 702 102% 690 932 135% Dunkery 1389 1351 97% 1225 1217 99% 1035 1023 99% 690 687 99% Eliot Ward 1656 1696 102% 1409 1822 129% 690 921 133% 1035 1633 158% Fielding Ward 1355 1307 96% 681 735 108% 690 679 98% 690 692 100% Gould Ward 1387 1380 100% 1052 1093 104% 690 690 100% 690 748 108% Hestercombe 1324 1528 115% 1329 1535 116% 1288 1465 114% 1252 1533 122% ITU 3119 3069 98% 3105 3213 103% Maternity Wards 4535 4444 98% 1718 1477 86% 3465 3468 100% 1723 1371 80% MAU 1836 1799 98% 1284 1444 112% 1380 1334 97% 690 1088 158% Mendip Medical 1219 1247 102% 1610 1553 96% 672 686 102% 685 743 108% Montacute Ward 1391 1389 100% 1393 1395 100% 1380 1375 100% 1334 1403 105% Portman 1378 1346 98% 1057 1057 100% 690 689 100% 690 764 111% SAU Ward 2 944 936 99% 690 654 95% 690 713 103% 690 564 82% SCBU 2414 1897 79% 435 300 69% 1200 1200 100% 300 300 100% Sedgemoor Ward 1433 1443 101% 1128 1642 146% 689 720 105% 1035 1195 115% Sheppard Gastro 1134 1145 101% 922 1051 114% 690 702 102% 690 904 131% Triscombe 1217 1161 95% 1435 1479 103% 690 724 105% 690 979 142% Ward 9 1289 1281 99% 345 275 80% 690 690 100% 345 345 100% Wordsworth 1029 1136 110% 1388 1543 111% 690 759 110% 690 920 133% TOTAL 40341 38956 97% 24392 25848 106% 27570 28044 102% 17211 19630 114%