Board of Directors Meeting Report

Agenda Item:
Board of Directors
Lead Director:
Executive Summary
Monthly Quality & Safety Report
Thursday 19th December 2013
Susan Bowler / Amanda Callow
Susan Bowler – Executive Director of Nursing & Quality
This monthly report provides the Board with a summary of important quality and safety items
and our key quality priorities. In summary, the paper highlights the following key points:
Pressure ulcers – We continue to see a significant reduction in avoidable grade 2
and 3 pressure ulcers and have had zero grade 4’s for 11 months. This good
performance is also shown in our monthly safety thermometer audit figures.
Patient flow – Average length of stay continues to be around 6.2 days against a Trust
target of 6 days. There has been a reduction in 30 day re-admissions rates during
October and November. Focused work continues to reduce the number of patients
with four or more ward movements during their hospital stay.
Complaints – Of the 491 complaints received since 2013, 3 remain open past their
agreed timeframe. The numbers of complaints received has fallen to less than 50
during November. Clinical treatment and diagnosis remain the top themes for
complaints, followed by doctors attitude. The key recommendations from the
Clwyd/Hart review are summarised within the report and being factored into the redesign of the complaints service.
National Maternity Survey - The indicative results were received in November 2013.
Overall the Trust performed within the middle of the range. Out of 42 questions we
performed in the top 20% of Trusts for 14 and in the bottom 20% for 6 questions. The
results are being interrogated in further detail and an improvement plan is being
developed to target key areas.
CNST – maternity services have been successful in achieving level 2 during our
recent assessment.
Infection control – In terms of C Diff performance, as of 10th December there have
been 27 C Diff cases against a total year trajectory of 25. To date, there has been 3
Trust acquired MRSA cases during 2013/14. An external review undertaken by
Professor Duerden identified some specific recommendations which are being
implemented across the Trust.
Vitalpac – this project is now underway and has the support of a designated project
manager. Implementation of the system is currently planned for Spring 2014 and the
specific timescales and milestones are being discussed at the Vitalpac Programme
Summary of Discussions from Clinical Governance & Quality Committee
To note the content of the report and progress / position to date
Relevant Strategic Objectives (please mark in bold)
Achieve the best patient experience
Improve patient safety and provide high
quality care
Attract, develop and motivate effective teams
Links to the BAF and Corporate
Risk Register
Details of additional risks
associated with this paper (may
include CQC Essential Standards,
NHSLA, NHS Constitution)
Links to NHS Constitution
Achieve financial sustainability
Build successful relationships with external
organisations and regulators
BAF 1.3, 2.1, 2.2 2.3, 5.3, 5.5
Mortality, C Diff & Complaints on corporate risk register
Failure to meet the Monitor regulatory requirements for
governance - remain in significant breach.
Risk of being assessed as non-compliant against the
CQC essential standards of Quality and Safety
Failure to meet 2013/14 infection control trajectories –
impacts on governance risk rating
Principle 2, 3, 4 & 7
Financial Implications/Impact
Potential contractual penalties for C Difficile, Pressure
Ulcers, Never Event and MRSA
Legal Implications/Impact
Reputational implications of delivering sub-standard
safety and care
Partnership working & Public
This paper will be shared with the CCG Performance
Engagement Implications/Impact and Quality Group.
Committees/groups where this
item has been presented before
Monitoring and Review
Is a QIA required/been
completed? If yes provide brief
A number of specific items have been discussed at
Infection Prevention & Control Committee, Pressure
Ulcer Strategy Group, Nursing Care Forum, Clinical
Management Team and Clinical Governance & Quality
Monitoring via the quality contract, CCG Performance
and Quality Committee & internal processes, e.g.
Clinical management Team & relevant
1. Introduction
This monthly report highlights to the Board of Directors key areas in relation to quality and safety. It
complements the quarterly quality report, which gives a more comprehensive review of progress against all
of the Trust’s quality and safety priorities. The monthly report will include updates on 2 of the Trust’s top 3
quality priorities for 2013/14, which are:
Priority 2 – Delivering Harm Free Care by reducing hospital acquired pressure ulcers
Priority 3 - To reduce length of stay and readmissions by improving patient flows (i.e. reducing the
number of bed movements during the patients inpatient stay)
Priority 1 – Improving the effectiveness of care we deliver by achieving a reduction in mortality (HSMR,
SHMI and crude mortality) will be presented in a separate report.
2. Pressure Ulcer Reduction (Priority 2)
The organisation has clear targets for pressure ulcer reduction during 2013/14. We are currently making
good progress towards the goal of eliminating avoidable pressure ulcers by 2014. The table below
demonstrates actual numbers of avoidable pressure ulcers (by grade) in comparison to the contractual
• In October the target for Grade 3 Pressure Ulcers was achieved, but unfortunately there were 9
Grade 2 Pressure Ulcers.
• In November we achieved our targets. There have been no avoidable grade 4 pressure ulcers for
11 months
Table1: 2013/14 SFH Avoidable Pressure Ulcer Reduction Trajectory
Target No
Grade 4
Actual No.
Target No.
Grade 3
Actual No.
Target No.
Grade 2
Actual No.
Sept Oct
Mar April
14 14
We discuss performance at the monthly quality review meetings with commissioners and no contractual
penalties have been applied during this financial year. They remain satisfied with our progress to date in
reducing avoidable pressure ulcers. There has been 101 avoidable pressures ulcer against a target of 115
The number of avoidable pressure ulcers against patient admissions for the last 12 months gives the
incidence rates demonstrated below.
The safety thermometer data, which is the point prevalence census undertaken once a month across all
inpatients areas correlates with the incidence data, showing an improved performance over recent months/
The Pressure Ulcer Strategic Group are currently reviewing the Pressure Ulcer Strategy, including the key
priorities and the action plan for Quarter 4 to put additional measures in place, given that during winter last
year the number of patients with pressure ulcers increased due to case mix and acuity. This was a national
picture. In Quarter 4 there will be continued emphasis upon competence based training in practice,
embedding mattress selection and availability and heel management. Focusing on these areas should
enable us to sustain the good performance through winter.
3. Improved Patient Flow (Priority 3)
The urgent care workstream have continued to progress actions to improve length of stay overall, the
length of time patients remain on the emergency assessment unit and ensure there is real focus on risk
assessing patient moves.
Length of stay in November was 6.27 days against a Trust target of 6 days. Given that November is the
technical start of winter it is encouraging that we have been able to bring back the likely impact of half term
performance in October. We are however flat lining at an average 6.5 days and not achieving the 6 days
target set this year. The Clinical Director has established a specific task and finish group to further support
this agenda, particularly focusing on processes around shorter stay patients which can be directly
4 hour target performance in November was 96.87% with Q3 to date at 96.43% and year to date 96.62%.
In November, the key issue impacting on performance was medical manpower, not patient flow and
remedial action has been taken to improve streaming at peak times within the department.
Readmissions information is not fully reliable until all coding has concluded. The November data is
therefore not fully accurate until January. This therefore shows that readmissions was sustained at below
10% since August and there is confidence that this is being sustained as winter pressures take hold and
innovative practices take place because of capacity.
We are also monitoring the length of stay and number of patients who remain on EAU longer than 48
hours. There is a cohort of short stay patients who we expect to remain on EAU longer than 48 hours
however our aim is for right patient, right ward, right specialty to ensure that all patients are receiving care
in the right place. The graphs below show the significant improvement made during the early part of the
financial year to ensure patients are treated in the right environment. This started to deteriorate again as
flow became more difficult in July and September. However further progress is being made in relation to
turnaround. The group will be concentrating on how we ensure we sustain the timely and safe movement of
patients during high demand.
The number of ward moves is continuing in the right direction following an increase late summer. Changes
made to the risk assessment and outlier process should continue to positively impact on patient experience
and ensure moves are minimised and only when clinically appropriate.
Patient Experience & Complaints
Complaints Performance - Current Position
The numbers of complaints received by the organisation are shown in the diagram below:
Please note the above table slightly differs to the report given in September (April 2013 onwards) as the
pending (without consent to act) complaints have now been included. This shows that the organisation has
seen a decrease in the numbers of complaints received in November 2013.
As of the 4th December 2013, the position is as follows:
There is no backlog of complaints
Of the 491 complaints received since 1 April 2013 there are only 3 that remain open past their
timeframe. This is due to the complexity of the complaints and the fact that other hospitals are
involved. All of the complainants are kept fully informed at every stage and are aware of the
Planned Care and Surgery:
• 47 complaints are open, 7 reopened complaints and 4 new complaints are awaiting consent to act.
• Of the 47 complaints – 2 have passed their deadline dates
Emergency Care and Medicine:
• 31 complaints are open, 8 reopened complaints and 6 new complaints are waiting consent to act.
• Of the 47 complaints - 1 has passed its deadline date.
Diagnostics and Rehabilitation:
• 11 complaints are open, 2 reopened complaints and 1 new complaint is waiting for consent to act.
• There are no complaints open beyond their deadline date.
Corporate / Central Services:
• 2 complaints are open.
• There are no complaints open beyond their deadline date.
Parliamentary Health Service Ombudsman
We currently have 3 active Ombudsman cases plus 1 case which was upheld by the Parliamentary Health
Service Ombudsman whereby all work required has now been concluded including an action plan. There
are a further 8 complainants that have contacted the Ombudsman however we are awaiting feedback as to
whether these will be put forward for investigation.
Themes and Learning
We are currently collating information to enable us to analyse what the most common issues identified by
complainants are and the areas highlighted. Discussions are underway with divisional teams in order to
create a suite of information that can be usefully reviewed at divisional governance forums, the Clinical
Management Team and Clinical Governance Committee. This is a key action within the complaints
sustainability work outlined below so that learning and changes can be enacted in response to these
The graph below illustrates complaints which were received for November 2013 by the subject that the
complaint related to. The most common themes for complaints received in November 2013 were clinical
treatment, for which a total of 11 complaints were received and clinical diagnosis for which 7 complaints
were received.
The following table gives an understanding of what complainants are complaining about in relation
Complaint Theme
Clinical Treatment
Specific Concerns as specified by complainant
Clinical – Diagnosis
3 attempts to find an artery during
angiogram, left patient with pain and
discomfort groin, left and right wrist.
Care and treatment whilst on the maternity
Inadequate pain relief given
Patient referred to another clinic without
being examined
Cannula blocked resulting in delay in
Delay in diagnosis
Misdiagnoses of fracture to foot
Misinformed diagnosis
Misinterpretation of consultants letter
resulting in delay in treatment
Patient diagnosed with fractured elbow then
x-ray revealed it was fractured collar bone
Complaints relating to Doctors Attitude
From August to November 2013 there have been 36 complaints received regarding doctors attitude. It is
difficult to distinguish in detail which doctors these refer to as very often there in no name attached to the
complaint. The divisional management teams are currently undertaking some detailed analysis to
investigate this further.
The complaints received relate to doctors attitude both within clinic and on the wards and are mainly about
the way in which the doctor spoke to the patient or their carers i.e. abrupt or dismissive. When a doctor
has been identified they have been spoken to about their attitude and this is relayed back to the
complainant within the response letter.
The graph below represents the number of doctor attitude complaints by month from August to November
Complaints received 2012/13
We are currently assessing how the number of complaints we receive benchmarks against other Trusts.
The table below details how many complaints have been received by other Trusts throughout the local area
for 2012/13. The figures represent how many actual complaints have been received as a whole, rather
than the different subjects of concern within each complaint.
Chesterfield Royal Hospital NHS Foundation Trust
Complaints Received
Derby Hospitals NHS Foundation Trust
Sherwood Forest Hospitals NHS Foundation Trust
Kettering General Hospital NHS Foundation Trust
Northampton General Hospital NHS Trust
United Lincolnshire Hospitals NHS Trust
University Hospitals Of Leicester NHS Trust
Nottingham University Hospitals NHS Trust
Lincolnshire Partnership NHS Foundation Trust
Leicestershire Partnership NHS Trust
Northamptonshire Healthcare NHS Foundation Trust
East Midlands Ambulance Service NHS Trust
Derbyshire Healthcare NHS Foundation Trust
Lincolnshire Community Health Services NHS Trust
Derbyshire Community Health Services NHS Trust
Nottinghamshire Healthcare NHS Trust
Sustainability of Complaints Performance
During September, a senior consultant was commissioned to undertake a review of current service
provision. The review has utilised the Guiding Principles of NHS Complaints Procedures in England 2012
as a basis upon which to identify a clear way forward. The new process will closely align the PAL’s and
complaints function, whilst also creating more local management through the divisions.
This process is now well underway. The workforce change application is going to the Workforce Change
Committee on 17 December and it is anticipated that there will be a 45 day consultation with staff. For
these reasons the specifics of the new process have not been included within this paper as the staff
affected need to be sighted of the change in the first instance.
It is envisaged that once the proposal is accepted the changes can be implemented swiftly to ensure
complaints performance is sustained and the service is improved for patients. The Divisions have
requested we stay with the current process whilst the change process is implemented to ensure quality and
performance is retained during
The Clwyd/Hart Review
This report outlines the Clywyd/Hart review that has taken place around the complaints process within
health as a result of the Francis report.
It is envisaged that the Department of Health (DOH) will focus on:
• Communications between complainants and Trusts
• Patient communication in the first place
• Getting things put right at front line level
• Possibly a position to oversee patient interaction at DOH level
Although it is felt that the current complaint procedure was adequate the document does contain many
references to CCG’s and their services which would need renewing and might lead to a new document or a
large number of amendments to the current one. The current NHS England process is not covered at all in
the current document and therefore it is more likely that a new document would be forthcoming, although
with much the same process for Trust’s just more emphasis on communications and training staff.
Communication feedback is that patients feel alienated by the process and there are some strong views by
some complainants as to the accuracy of their responses.
Healthwatch England
Healthwatch England welcomes the recognition of the problems individuals face when thinking about, or
trying to make a complaint. Their comments are:
Recognises the issues outlined in the report in relation to complaints advocacy services and PALS.
Calls for consolidated advocacy services and agrees with the need to review PALS so it is clear
what the service offers to patients.
Wants to work with the Department of Health and others to design and promote standards for health
and social care complaints handling alongside a consolidated PALS and complaints advocacy offer.
Healthwatch England welcomes the recognition in the report that providers need to meet their existing
statutory obligations and that the existing regulations need revising to bring in additional duties.
Healthwatch England believe that the Regulations should be changed so that ‘worried bystanders’ can also
register concerns or complaints and be directed to local Healthwatch.
The report which gives recommendations on how to make improvements focuses on four key areas of
change including:
Making improvements in the quality of care in the NHS hospitals so fewer people have to complain;
Making improvements in the way complaints are handled;
Giving the complaints process independence; and
Avoiding the need for whistle-blowing in the future, and protection for those who speak out.
Key Recommendations
1. Chief Executives need to take responsibility for signing off complaints. The Trust board should also
scrutinise all complaints and evaluate what action has been taken. A board member with
responsibility for whistleblowing should also be accessible to staff on a regular basis.
2. Trusts must publish an annual complaints report in plain English which should state complaints
made and changes that have taken place.
3. Trusts should ensure that there is a range of basic information and support on the ward for patients,
such as a description of who is who on the ward and what time visiting and meals take place.
4. Patients and communities should be involved in designing and monitoring the complaints system in
5. Trusts should provide patients with a way of feeding back comments and concerns about their care
on a ward, including by putting a pen and paper by the bedside and making sure patients know who
they can speak to, to raise a concern.
6. The Patient Advice and Liaison Service should be rebranded and reviewed so its offer to patients is
clearer and it should be adequately resourced in every hospital. The Independent Advocacy
Services should also be rebranded and reorganised.
7. Staff need adequate support and training in listening to and acting on feedback, with appraisals
linked to their communication skills.
Our Response
The Chief Executive of Sherwood Forest Hospitals NHS Foundation Trust does currently sign off all
complaints unless he is unable to do so due to leave and then it is delegated to another Executive
i.e. Director of Nursing, however this is rare.
2. All complaints data is recorded and reported to the Trust Board on both a quarterly and monthly
basis. We are continually to enhance this data month by month and presented our first patient
experience report at the end of October. We are mindful we have further work to develop this
aspect of the recommendation. Further reports are also regularly undertaken including the net
promoter, ward reports and a weekly update. Staff within the complaints department are always
available for any member of staff or patient to contact from 8.30 - 5pm daily. The Interim
Complaints Manager is available 24/7 via mobile.
3. Previously annual reports have been undertaken, but due to the major difficulties in our complaints
service we did not publish an annual complaints report for 2012/13, but we will definitely publish a
report for 2013/14.
4. Patient information is available on all wards however this is being emphasized by the inception of
the new ‘Communication Boards’ located in all wards, which tells the patients and public; who is the
ward sister, nurse : patient ratios, improvement initiatives based upon feedback and grade of staff
on duty. All ward entrances now have the same published information which includes uniform
descriptors, visiting times, cleanliness standards, infection control expectations and ‘making
mealtime matters’ information
5. At present patients are not directly involved in the complaints process however patients are invited
to the Trust Board to tell their story and every complainant is asked whether they would like a
meeting to discuss their complaint and are invited to join the membership scheme at the Trust. The
Trust is exploring the opportunity to create a Trust Wide Patient Experience and Engagement
Group, following the ‘In Our Shoes’ co creation events.
6. The current interim complaints manager has discussed with two of the Divisional Matrons the
possibly of starting ‘complaints focus groups’ with both staff and pass complainants to allow for
reflective learning. This will enable all involved with complaints to talk through what went wrong and
how assurance can be given that it won’t happen again.
7. The Trust currently uses comment cards and these are available throughout the hospital. All
comments are reported and acted on appropriately including being sent through to the complaints
department if there are issues that cannot be resolved within PALS. We are reviewing the pen and
paper proposal
8. PALS will be rebranded within the new structure. The complaints Advocacy service (ICAS) has now
been taken over by POhWER. (People of Hartford want equal rights)
9. The interim complaints manager has undertaken some training within the Trust around complaints
however once the new structures have been implemented further training will be rolled out. At
present only doctors have complaints against them brought up at their revalidations/appraisals but
with nursing revalidation being progressed the opportunity to expand this to nursing will be explored
in 2014/15.
Family and Friends
October and November 2013 Family and Friends Test Results are as below:
Response Rate
Net Promoter Score
During October, of the 23 acute inpatient wards taking part in the survey, 11 scored below the Trust wide
average of 73. The three lowest scoring wards were wards 52, 35 and 31.
During November, of the 23 inpatient wards taking part in the survey, 7 scored below the Trust wide
average of 74. The three lowest scoring wards were wards 34, 35 and Sconce Ward.
Further Sources
Comments and reviews posted by Patient Opinion and NHS Choices were largely positive but there are
some negative comments. Our current rating on NHS Choices is 3.5 stars out of a possible 5 stars (172
Of the last 24 comments on Patient Opinion (posted over 4 weeks):
There are a large number of comments which spoke of the professionalism of doctors and nurses.
A&E, Maternity, Day Case (mentioned on a number of occasions), Orthotic Service and Ward 52
are mentioned positively
SAU/ Ward 21 were mentioned both positively and negatively – SAU staff were outstanding, Ward
21 ‘rude, failure to discuss with relatives.
Discharge processes, waiting for tests and staff attitude were negative comments. This included
rudeness, lack of respect and failure to keep relatives informed
‘Presently surprised at some of the improvements made’ – mentioned care and comfort rounding
Exceptional second visit – diagnosis of breast lump
National Maternity Survey
The 2013 National Maternity survey has been undertaken by Quality Health for our Trust. The maternity
survey was last undertaken in 2010 and seeks opinions on various aspects of maternity care, including,
antenatal care, check-ups, baby’s birth, the staff, post-natal hospital care and care at home after birth. The
full Management Report was received on 22nd November, which outlines the Trust’s score across a range
of questions. There are 42 questions, 50% of which are new/amended to the survey this year so no
comparison with previous score can be made. Of the remaining questions, there were 14 where we scored
higher this year than previous and 4 where we received lower scores.
Areas where we improved included:
Given a choice of where antenatal appointments will take place
Was able to move around and change position during labour
Treated with kindness and understanding
Areas where we showed some deterioration since the last survey include:
Saw midwife as much as they wanted to
Given advice about contraception
The results also show how the Trust performed against the national average. Sherwood Forest Hospitals is
in the top 20% of the country in 13 criteria and bottom 20% in 6 criteria. For the remaining 23 questions we
performed in the amber category, which is the remaining 60% of Trusts.
The top 20% include areas such as:
Midwives listened to women’s thoughts and personal circumstances
Involvement in decision making during ante natal care
Cleanliness of bathrooms for their labour care
Had trust and confidence in the midwives they saw after going home
Given information explaining how to recover and emotional impact after the birth
In addition, we scored in the highest percentage for length of stay and cleanliness of rooms during the post
natal stay.
We are in the lowest 20% for:
Taking concerns seriously in labour (the threshold was 77% and we scored 76%)
Response times to patient call buttons
Had telephone number of midwife to call when they were home
There are a number of new questions this year around breast feeding which we appear to have achieved in
the upper amber range compared to the national picture.
The National Document is due to be released on the 12th December 2013, which will offer a fuller picture to
enable us to undertake our ongoing improvement work. The senior midwives and obstetricians are currently
interrogating these results in more detail and developing an action plan to address the key areas where
progress is needed. The action plan will be presented at the Maternity specialty meeting and CMT in
February 2014.
Maternity services at the trust were successful at achieving CNST level 2 at our recent assessment. We
were one of the last trusts to be assessed using the current standards and method. As yet we are unsure
of what will replace this assessment, but it is thought that it will become more outcome focussed and
services will have to demonstrate learning.
We achieved a score of 48/50 obtaining 10/10 in four of the five criterions and 8/10 in the other criterion.
During the verbal feedback we were commended for our organisational structure and governance/risk
arrangements and training programmes. In the criterion we scored 8/10 for clinical care, we were praised
for some aspects of good practice, in particular our follow up of screening investigations. However we have
identified we are required to improve on our use of maternity early warning charts and ensuring we fully
complete all documentation including dating and timing entries especially in regard to entering test results.
We await with interest the changes to Maternity CNST assessment but in order to maintain the momentum
we have set ourselves some projects to address the above. We are expecting a full report within the next
14 days.
Never Events
As stated in the government’s response to the Francis inquiry, NHS England will begin publishing data on
never events in greater detail, including number and type of never event by reporting organisation. This will
initially cover data reported between April and September 2013, as well as less detailed data for the whole
of 2012/13. This will continue to published quarterly, and then on a monthly basis from April 2014.
As reported to our Clinical Governance and Quality Committee (August 2013) and the Trust Board, we
have experienced 1 never event during 2013. This was our first never event within a 3 year reporting
period and has been stated as 1 under the category (Other NE Types 4-25).
9.0 Healthcare Associated Infection
Sherwood Forest Trust is working very hard to tackle Healthcare associated infections (HCAI), but Hospitalacquired infections (HAI) still present us with a great challenge.
C.difficile Infection
As of 10th December 2013, the Trust has identified 27 cases of Trust acquired C. difficile infection against
a total year trajectory of 25.
Root cause analysis has indicated that the majority of these cases are sporadic. Since April 2013, there
have been two periods of increased incidence, which were upgraded to outbreaks when the ribotyping
indicated the same strain of C. difficile, which is highly suggestive of cross infection. Outbreak meetings
were convened, action plans implemented, and to-date there has been no further cases in relation to the
outbreak (September Ward 24, 2 symptomatic patients, October Ward 51, 2 symptomatic patients).
Review of the Hospital Antibiotic Prudent Prescribing Indicators (HAPPI) audit has not highlighted any
concerning issues regarding the inappropriate antibiotic usage of antibiotics.
Actions instigated:
• Implementation of SIGHT poster in clinical areas across all divisions
• Infection Prevention and Control Team worked closely with staff especially Ward 24 and Ward 51
• Implementation of ‘RAG’ infection clean level regime (including posters, training)
• Aerosol hydrogen peroxide environment decontamination system is used at present by the Trust –
plan to review the appropriateness of moving to a hydrogen peroxide vapour environment
decontamination system
C. difficile infection cases against average reduction target April – November 2013
Number of C. difficile infection processed across East Midlands from April 2010 to October 2013
Incidence of C. difficile Trust apportioned cases per 100,000 bed days across the East Midlands
Hospitals Nottingham Hospitals
Foundation Foundation
NHS Trust
NHS Trust NHS Trust Midlands
2013 September
MRSA Bacteraemia
As of 10th December 2013, there has been three cases of Trust apportioned MRSA bacteraemia (May, July
and September 2013), and one case of Non-Trust apportioned MRSA bacteraemia (October 2013) since
April 2013. The post infection review for the three cases has already been completed. The third case that
was sent to Public Health England for arbitration was allocated to the Trust.
• Monthly audits continue to be undertaken by the Infection Prevention and Control Team on key
themes, reports and actions plans and represented at the HCAI Forum
• Review and update the Clinical Assessment packs for Naseptin-Bactroban-Chlorhexidine
• Reviewing the use of Chor-Prep® for skin preparation prior to venous cannulation continues
• Regular unannounced visits to various clinical areas by the Infection Prevention and Control
Monthly counts of MRSA bacteraemia ‘Trust’ and ‘Non- Trust’ apportioned processed by SFH Trust
laboratory since April 2010
Following the second Trust apportioned MRSA bacteraemia, Professor Brian Duerden, retired Microbiology
Inspector for DH, visited the Trust on the 15th October 2013, to carry a thorough external review the
infection prevention and control practices from ward to board.
Professor Brian Duerden External Visit
The review was commissioned by the Trust to provide an external view of the functioning and effectiveness
of the infection prevention and control arrangement within the Trust, with particular reference to the recent
occurrence of MRSA bacteraemia. Although Professor Duerden did not have any specific
recommendations to make about the leadership, management, governance and assurance arrangements,
he made some recommendations which are summarised below:
• Policies: although the content of these policies is entirely appropriate and reflect the needs of
current clinical practice, they were a good source document and as such provided good training
material and a good point of reference, Professor Duerden recommended that the policies
contained a short summary or abstract of the policy
o Actions: this recommendation is in the process of being implemented
• VIP audit: procedures for all IV access to be reinforced with added training on insertion and
monitoring, to redesigned the VIP chart to promote good practice, and VIP observation should be
done every 4 hours (we had already agreed this action prior to his visit)
o Action: the VIP chart has been redesigned taking into account 4 hourly observation, the
chart has been agreed by the document group, and is in the process of being printed.
• Isolation practices audit: should be reinforced, in particular the need to keep the door closed and
the correct use of personal protective equipment. Poster and signage.
o Action: the Infection Prevention and Control Team, conducts quarterly isolation audits, as
well as spot checks during their daily ward visits. Emphasise the important of door closure
and use of PPE at Trust mandatory training (clinical and medical staff). As part of the
isolation policy review the isolation posters were also redesigned to make them more
striking, less cluttered and providing clear instructions, Professor Durden strongly
supported this approach and commended the draft poster he was shown. Once the policy
and isolation resource package has been ‘signed off’ the posters will be printed and
implemented across the Trust
• Urinary catheter monitoring audit: procedures for monitoring urinary catheters should be reinforced
and the need for regular observations and decision on whether the catheter is still need
o Action: Vital Pak will be implemented across the Trust early 2014, indwelling devices is part
of this package, which will
• Hand hygiene audit: There is alcohol gel available in dispensers at the entrance to each ward and
at the bedside. Generally the dispensers were available and were being used; one entrance the
alcohol gel was empty. Recommend enhanced training and audit to raise compliance, which
should be maintained at over 90%.
o Action: The back plates for the alcohol dispensers have been installed, with the remaining
plates being installed week commencing the 2nd December 2013. Ward staff have been
requested to monitor and replaced any empty alcohol gel
o Glow and tell audit conducted by the Infection Prevention and Control Links during October
and November
o Development of a hand hygiene DVD for training, to incorporate staff from across the Trust
in music and dance activities
o To review the use of electronic version of the ‘Lewisham hand hygiene’ tool
• Antimicrobial stewardship: consider including junior medical staff in the audit and monitoring of
antimicrobial stewardship, to review the design of the prescription chart, with view to putting the
antimicrobial prescriptions into a separate section that incorporates the key indicators, ensure that
junior staff have easy access to a simple form of the antimicrobial prescribing guidelines, and to
establish links with primary care on antimicrobial prescribing so that common policies can be
o Action: Junior medical staff are conducting an audit into the usage of Tazocine. A summary
sheet is in the process of being developed by the DIT committee, for inclusion into the
antimicrobial policies.
• RCA: the findings of the RCA for the three MRSA cases to be combined into one action plan to
address the issues raised
o Action: the individual actions plans required for each of the Post Infection Reviews has been
brought into the generic bacteraemia reduction Trust action plan
Overall activity is beginning to show signs of seasonal increase in the number of norovirus and rotovirus
cases in the local population, although there have been no outbreaks of norovirus within the Trust since
May 2013. The norovirus posters have been placed across the Trust and the DH YouTube video suit is
available for the public to access on the Trust Facebook page, and a Norovirus awareness day was held on
the 15th November 2013.
The Trust has now committed to purchase the VitalPAC system by The Learning Clinic. This is a
revolutionary software system which allows nurses and doctors to capture clinical information, such as vital
signs, on portable electronic devices (iPods and iPads) at the patient’s bedside. Using this data the system
calculates the NEWS (National Early Warning Score) and then automatically alerts staff to signs of
deterioration. Evidence from hospitals already using VitalPAC shows that mortality rates are reduced,
cardiac arrest rates decline and fewer patients require admission to intensive care. There are other
potential benefits such, as reduced length of hospital stay, less infections and earlier detection of problems
such as sepsis, acute kidney injury, dementia, alcohol-related problems and poor nutrition.
A Project Board has been convened which is chaired by Dr Nabeel Ali/Dr Lisa Milligan. The Board
comprises of key individuals from clinical and IT backgrounds and representatives from The Learning
Clinic. The Project Board has met on two occasions now. A project manager has been appointed
The proposal is to complete “localisation” this quarter, then The Learning Clinic will build our software, and
it should be delivered for testing at the beginning of January 2014. Testing of the software will then take
place from January to March, with the start of ward roll-out and the “go-live” date proposed for the end of
March 2014. These are indicative timescales at this stage and will be agreed at the next Project Board
The Learning Clinic has suggested a 9 week roll-out across the wards of VitalPAC Core. Some of the other
modules we have purchased, such as VTE, Nutrition, Indwelling Devices, will be included in the software
that is rolled out at this time, but we can decide which of these to turn on nearer the time depending upon
how training with the core system is going. Other modules, such as Paediatrics and Maternity, require
additional customisation and will be rolled out later in 2014, along with Infection Prevention and Control
(IPC) Manager and the Fluid Balance module.
A Communications plan has been developed and the Communications Department have already begun to
promote the new system by all-user emails and there will be an item in the next edition of Best Magazine.
An article featuring the acquisition of VitalPAC by the Trust was in printed ‘The Chad’ on 23 October. A
VitalPAC website will be set upon the Trust intranet to act as an information resource and news update site
for all Trust staff.
Familiarisation sessions for Trust staff have begun, with a presentation given to Ward Leaders on 12
November. The training approach is to train a number of ‘Super-Users’ in the first instance, and then to use
them to disseminate training to all ward staff. Discussions are on-going regarding the details of training, and
training for other groups of staff, including nursing, medical staff, locum staff and other healthcare
practitioners who will use the system.
A group will be convened in the next few weeks to review the Risk Management issues relating to the
introduction of VitalPAC and a Business Continuity Plan (for use in the event of system failure) will be
developed and approved by the Trust’s Clinical Management Team prior to the roll-out and “go-live” date
on the wards.
A representative from the Finance Department is on the Project Board (Fran Steele/Michael Powell) to
ensure financial control of the project, and a meeting with an accountant from the Finance Department has
been arranged to discuss projected expenditure on VitalPAC for 2013/14.
The Project Board will report progress with the introduction of VitalPAC to the Trust Board on a regular
Summary of Discussions at Clinical Governance and Quality Committee
This report summarises the discussions and decisions made, and the assurances received at the Clinical
Governance and Quality Committee (CGQC) held on November 27th2013.
Peter Marks
Susan Bowler
Gerry McSorley
Claire Ward
Non-Executive Director (Chair)
Executive Director of Nursing and Quality
Non-Executive Director
Non-Executive Director
In Attendance
Tim Reddish
Nigel Nice
Karen Fisher
Fran Steele
Jacqui Tufnell
Anne-Louise Schokker
Denise Berry
Jane Jones
Lynn Smart
Ann Gray
Stephanie Sheppard
Dr Kumar
Non-Executive Director
Public Governor
Director of Human Resources
Chief Finance Officer
Executive Director of Operations
Clinical Director
Clinical Governance Lead
Clinical Lead Diagnostics and Rehabilitation
Patient Services Manger
Tissue Viability Consultant Nurse
Consultant Microbiologist.
Serious Incident Log
The serious incident log was discussed. The Committee were informed that the Serious Falls group had
reviewed 4 of the 6 Serious Falls that were reported between the 15th October and the 12th November
2013. There was a delay in reporting 3 of the 6 incidents to the Commissioners via the STEIS data base
therefore it appeared that there had been an increased incidence of Serious Falls in a month’s period. This
was because serious harm had not been diagnosed until tests had been performed but all incidents were
reported on the Trust incident reporting system (Datix) timely. The format of the report was discussed by
the Committee and it was agreed that work was required to provide assurances about the themes and
lessons learnt. It was noted that Trends and Themes are being collated for the Quarterly Quality report.
Report on open incidents by the handler on Datix
A paper was presented to the Committee summarising the Trust position in relation to the investigation and
closure of incidents on Datix, within a 3 month period. Closure within 3 months is a Trust standard set by
the previous Risk Management Committee. On the 21st November 833 incidents were open and of these
111 were open beyond the standard: 16 in July and 95 in August. The Committee were informed that Trustwide actions have been agreed to improve compliance and this will be monitored through the Divisional
Governance Forums and by the Clinical Management Team. The Committee requested an update for the
January meeting.
The Mid Nottinghamshire Mortality review
The Committee was provided with a personal interpretation of the review findings and requested a copy of
the Executive Summary. It was acknowledged that this would be discussed at the next Trust Board
The Management of Hard Copy Patient Investigation Reports.
The Committee received a report on the backlog of loose documentation/reports not filed and available in
patients notes for admission and clinic appointments. This risk is on the Diagnostics and Rehabilitation
divisional risk register and has been escalated to the Committee by the Clinical Management Team. The
Committee considered the contents of the report and requested that this risk is monitored by the Clinical
Management Team. The plan to go live with the electronic reporting on ICE in December was also
Decontamination of Pressure Relieving Mattresses.
A paper was presented to the Committee summarising the concern raised at the Risk Committee that the
Trust was not compliant with alert MDA/2010/002. The alert relates to the Inspection of the exterior surface
of each mattress cover for signs of damage and removal of the cover to inspect the mattress core. This
alert related to static mattresses and the Trust has a rolling programme of inspection therefore deemed to
be compliant. The process for decontamination of Dynamic mattresses was not robust and the report
outlined the actions taken to address the mattress decontamination issues and provide assurances that
decontamination is being undertaken appropriately.
Update on Breakaway and Physical Intervention Skills Training.
An update was provided to the Committee on the delivery of training agreed as part of a HSE action plan.
As of the 8 October 2013, a total of 19 courses have now been delivered and 128 out of 408 identified staff
have been trained in breakaway and physical intervention skills training since the courses began in
February 2013. A further 7 courses are planned until the end of December 2013 with 79 staff currently
booked onto them which overall equates to 51% of the risk assessed staff group receiving training since
these courses started. The Committee supported the importance of this training and it was agreed that this
is to be included in the ward dashboard as a separate compliance metric for the 10 areas identified in this
paper in order to drive full compliance. An update will be provided in 3 months time.
Early Warning Dash Boards and Ward Assurance Matrix
The Committee were asked to note the contents of Trust wide Early Warning Dashboard which has
developed over the last 6 months to enable clinicians and managers to monitor Trust performance against
a number of key quality and safety metrics. It is collated monthly and will become a standard agenda item.
Alongside this will be the updated version of the ward assurance matrix. This matrix has been
supplemented with additional metrics, following a visit to Norwich and Norfolk NHS Trust and discussions at
the Nursing Care Forum. A number of additional metrics (including training compliance and ward based
audits) will be added over the next few weeks. The committee welcomed the progress on this work. The
incidence in falls had been noted by CMT and had requested an understanding of this concern and actions
required from the serious falls group (refer to section on serious incident log)
Infection Prevention and Control
Dr Kumar gave an update to the Committee on the Trust’s performance with Infection Prevention and
Control. Clostridium Difficile targets were discussed and Dr Kumar reported positive feedback following an
external review by Professor Dearden. Although this feedback was encouraging the Committee were
assured that a review of our action plans against other high performing Trusts would be initiated through
the CCG.
Susan Bowler
Executive Director of Nursing & Quality