BOARD OF DIRECTORS MEETING
To be held on
Tuesday 24 June 2014 at 10:00am
In the Boardroom
Trust Head Office, Goodmayes Hospital, Ilford, Essex, IG3 8XJ
BOARD OF DIRECTORS AGENDA
Tuesday 24 June 2014
1.
Apologies for absence
2.
Declarations of interest
3.
Minutes of the meeting held on 27 May 2014
4.
Matters arising from the minutes
5.
Chair’s report
Peter Wignall
5 mins
Chief Executive’s Report
John Brouder
5 mins
Brid Johnson
20 mins
Stephanie Dawe
10 mins
Stephanie Dawe
10 mins
Stephanie Dawe
10 mins
Caroline O’Donnell
5 mins
Brid Johnson
5 mins
Sue Boon
5 mins
Helen Essex
5 mins
John Brouder
5 mins
6.
Verbal report
Attached to receive for information
7.
Patient Journey (Thurrock)
8.
Integrated Quality & Performance report
• Safer Staffing report
Presentation
5 mins
Acting Chair
Chief Executive
Integrated Care Director, Essex Health Economy
Chief Nurse & ED of Integrated Care (Essex)
Attached for approval
9.
Infection Control Annual Report
Attached for approval
10. Patient Experience Surveys
Attached to receive for information
11. BHR Health Economy Report
Attached to receive for information
12. Essex Health Economy Report
Attached to receive for information
13. WELC Health Economy Report
Attached to receive for information
14. Use of the corporate seal
Attached to receive for information
15. BHR Integrated Coalition Strategic Plan
Attached to receive for information
Chief Nurse & ED of Integrated Care (Essex)
Chief Nurse & ED of Integrated Care (Essex)
Integrated Care Director, BHR Health Economy
Integrated Care Director, Essex Health Economy
Integrated Care Director, WELC Health Economy
Trust Secretary
Chief Executive
16. AOB
17. Questions from the public
Date of next meeting: Tuesday 22 July 2014 at 10:00am in the Boardroom, Trust Head
Office, Goodmayes Hospital, Barley Lane, Ilford, Essex, IG3 8XJ
5 mins
10 mins
NORTH EAST LONDON NHS FOUNDATION TRUST
BOARD OF DIRECTORS
Tuesday 22 April 2014
Attendees:
Peter Wignall
John Brouder
David Bedford
Joe Fielder
Marjorie Woodward
Brian Hagger
Martin Munro
Jacqui Van Rossum
Ian Cable
Acting Chair (PW)
Chief Executive (JB)
Non Executive Director (DB)
Non Executive Director (JF)
Non Executive Director (MW)
Non Executive Director (BH)
Executive Director of HR & OD (MM)
Executive Director of Integrated Care (London) (JVR)
Interim Executive Director of Finance (IC)
In attendance: Helen Essex
Brid Johnson
Bob Edwards
Chris Bright
Vaughan Williams
Alison Garrett
Sandra Courtney
Siobhan Quaine
Jo Byrne
Steph Bridger
Mog Heraghty
Sally Brempton
Trust Secretary (HE)
Integrated Care Director, Essex Health Economy (BJ)
Integrated Care Director, Redbridge (BE)
AD, Psychological Services, WF (CB)
Deputy Medical Director (VW)
AD, Quality & Patient Safety (AG)
Patient Experience (SC)
Communications (SQ)
By invitation:
Mr GS
Jenny Townsend
Patient Journey (GS)
Senior Manager, KPMG LLP (JT)
Public:
Nicholas Hurst
Adrian McLeod
Nikki Sharp
Fin Robinson
Lead Governor (NH)
Public Governor, WF (AM)
RUNUP (NS)
Public (FR)
Director of Nursing, WELC Health Economy (SB)
Patient Experience Manager (MH)
2014/114 Apologies
Apologies were received from Jane Atkinson, Stephanie
Dawe, Steve Feast, Ratan Engineer, Sue Boon and Caroline
O’Donnell.
2014/115 Declarations of interest
There were no declarations of interest.
2014/116 Minutes of the last meeting
The minutes of the meeting held on 22 April were agreed as
an accurate record following a minor amendment to item
2014/097.
2014/117 Matters arising from the minutes
2014/067 – action for audit committee to discuss where risk
should sit carried over.
2014/095 – BJ confirmed that the final Telehealth evaluation
would be published in April 2015.
2014/100 – JVR advised that she had addressed the issue of
communications around sexual health services with the CCG
Communications team. It was noted that NELFT does not
provide sexual health services but would signpost people to
available services.
All other actions were completed.
2014/118 Chair’s Report
PW provided the board with an update as to Jane Atkinson’s
progress. Jane was hoping to be back in the summer but this
is now likely to be early next year. Treatment is on schedule
but the recovery period is longer than anticipated.
Governor elections are in progress and results will be
announced on 30 June.
The trust has been involved in a review by the Royal College
of Paediatricians looking at efficiency measures and access.
PW and a number of other NEDs are meeting with East
London NHS FT in order to discuss the NEL Health Economy
and the London Health Commission.
2014/119 Chief Executive’s Report
JB provided some feedback from the BME strategy
conference which was extremely successful and attracted
two national speakers. The RCN also wish to use NELFT in
order to develop a pilot on national BME strategy.
There has been some positive press regarding the Community
Treatment Team/Intensive Rehabilitation Service which has
been receiving scores of 9.5/9.6/10 on the Friends and Family
Test. GPs are also extremely happy with the service and JB
commended teams on their continued hard work.
2014/120 Patient Journey (Waltham Forest)
GS told the board his story of how he had experienced work
related stress and his GP referral to the MH Access Team. The
referral took 18 months after which time he had an interview
RE
28.10.14
with the team and a MH nurse. Once he had been accepted
by psychology services there was no further involvement
from access. However, he heard nothing from psychology
services for an extended period of time and was forced to
track down and chase the referral after which he was told
that he was not suitable for the relevant treatment.
The referral was cancelled so GS had to reapply but by this
time he was unable to cope and his daughter took up the
cause and wrote to the local MP. GS received a visit from CB
who attended his home and was able to assist his access into
treatment.
GS explained that this delay had compounded his condition
and delayed the recovery process. Although he had a number
of CBT sessions this did not help with his mood and he still
needed support. He was signposted to the Recovery College
which helped him in dealing with a variety of problems. Once
this had finished he lost some of the momentum he had
gained and although had applied to IAPT in April is still
awaiting a response.
VW explained some of the difficulties with the case and how
the case had initially been deemed too complex for IAPT
whilst not meeting the criteria for access. CB added that
there had been a lack of clarity at the point of referral and
stressed the need to ensure patients are involved in their
plans. Recent changes have greatly increased capacity for
Access and for IAPT. There is also a focus on people being
able to manage their lives without services and coming to the
end of their treatment. GS said that it is difficult for a patient
to determine the best course of action and that patients need
to rely on professionals to use their expertise to assist. The
basic expectations of any patient are to be treated with
dignity and respect and for treatment to be delivered in a
timely manner.
The board thanked GS for sharing his story and agreed that
the trust needed to establish whether or not the problem
was systemic and if it could happen again. A review will need
to be conducted.
It seems clear that periods of change and transition are
where people get let down and that having a joined up
service is key to providing quality patient care. JVR also noted
that the executive team had agreed to fund the Recovery
College for another year as a pilot in an effort to get
commissioner funding.
CB
24.06.14
2014/121 Annual Report, Annual Accounts and Quality Account
Annual Accounts
BH advised the board that the accounts had been reviewed in
detail at the Audit Committee and that the committee
recommended adoption of the accounts to the board.
MW asked about the amortisation of ICT equipment which is
currently 5 years. The mobile working strategy will affect this
and a more realistic figure (e.g. 3 years) needs to be built into
plans. IC replied that the position fits with current guidance
but would be reviewed in light of the strategy.
JT presented the ISA260 which had also been considered at
the Audit Committee. This document provides the auditor’s
opinion on economic and effective use of resources. HE to
circulate the amended version to board members.
JT advised that there were two management representations
relating to exit packages (which is a new requirement) and
instructions provided to valuers. There were some slight
adjustments in staff exit costs with four cases moving to the
12/13 year. The recommendation is that HR and Finance keep
lists/audit trails and circulate to the Remuneration
Committee on a regular basis.
There were two recommendations relating to CRS
(Commissioner Requested Services) and non-CRS and assets
related to both.
JT advised that KPMG would be offering a clean and
unqualified opinion on the accounts and that there were a
few presentation issues and one significant adjustment but
nothing material.
Quality Accounts
JT advised that work on the Quality Account focused on the
content and three indicators, two of which are mandated and
one that is locally determined. JT commented on some of the
issues found such as data input, activity being badged
incorrectly and required reframing of questions but no major
issues were identified. Some content omissions in the first
draft are now included and the document is consistent with
other information sources.
The limited opinion given by KPMG refers to the limited
scope of the audit rather than the outcome.
The board felt that there had been some real improvements
made but that more measurable targets should be included.
The trust is on a positive trajectory although there is more
work to do. There also needs to be some work done on
ensuring some of the indicators are given simple
interpretations so that it is easier for people to see where the
trust benchmarks. This will form part of the shorter published
document.
JT also suggested production of a M9 quality account so that
a preliminary audit can be done and this will be considered.
JVR
23.09.14
SD
Nov 14
The board approved the Annual Report 2013/14, Quality
Account 2013/14 and Annual Accounts 2013/14 along with
relevant statements and agreed chair’s action to approve any
final non-material amendments or additions prior to
submission
2014/122 Corporate Objectives
JB presented an exception report from the 13/14 objectives
set last year. The following areas will form the basis for
developmental objectives in 14/15:
•
Progressing plans to create the environment for a
more agile workforce
•
Ensuring that all services face scrutiny and provide
evidence that they are efficient and cost effective
•
To establish plans investment bids to become a
provider ready to operate and compete in the
primary care market
•
To develop and implement integrated service models
agreed with commissioners in at least two areas of
specialty
•
To secure additional investment from commissioners
in new models of care and to expand our portfolio
and geographical coverage.
•
To invest in and develop an initiative specifically
designed to add value to our business which
incorporates a collaborative approach and actively
contributes to the regeneration of the local
community
MW asked to see a list of objectives that have been met and
also how the trust can show an improvement on quality
targets.
JB
24.06.14
2014/123 Integrated Quality & Performance Report
Mandatory and contractual indicators will be included by the
end of May. It was noted that there is still a lot of manual
collection of quality data so a greater level of checking and
assurance is needed.
PW asked that the cover page contain a summary of the
issues discussed at the Quality & Safety committee and for
‘go green’ dates on indicators to be captured.
SD
24.06.14
It was noted that the ‘well-led’ domain contained lots of red
indicators (appraisal, vacancy, DBS checks, etc.). MM did
advise that the recent changes to the DBS procedure mean
that the trust no longer receives a copy and the individual
staff member has to bring in their original which causes some
lagging. Executive team to review this domain.
JB
24.06.14
Ward staffing
There is a new requirement to publish staffing data for
inpatients. There will be some timing issues in the initial
period but data will come through QSC then through to board
from July onwards. Information is required ward by ward.
The trust needs to be able to support staff if they are unable
to cover shifts and report as incidents so data can be collated.
A task group has been established.
It was noted that there are risks to having this information in
the public domain as raw data does not provide the full
picture. There is also no mandated staffing establishment for
MH/CH. NICE guidance should be available next year.
The board received and noted the report.
2014/124 BHR Health Economy Report
BE highlighted the following points:
Joint assessment/discharge services – will be launched on 1
June and focuses on discharge from acute inpatient settings.
LBBD is the lead and the aim is to streamline and standardise
services.
CQC visit to Redbridge LAC. Generally positive but principal
recommendation to ensure more robust case recording for
families for quality assurance purposes.
CTT in BHR – seen as a positive alternative to hospital, getting
direct referrals from London Ambulance Services. 49 in the
first month of 14/15.
Cabinet Office visit – very positive, using recruitment of HV
staff to inform national recruitment strategies. NELFT chosen
to host national HV project.
2014/125 Essex Health Economy Report
BJ highlighted the following points:
CQUINs achieved for last year
Working closely with MH and community teams on care coordination and making good progress. GPs have chosen this
area for a specific piece of work.
Attended an Essex 5-year plan event relating to primary care
capacity and capability and another event in Thurrock.
Engaged in acute reconfiguration work streams and MH
developments in areas such as dementia.
Work in children’s services to empower parents to help
children with technology.
Community Stroke service shortlisted for a National Patient
Safety Care Award.
2014/126 WELC Health Economy Report
CB highlighted the following points:
MH bed reconfiguration – looking to improve clinical quality.
Declining bed base in older adults services. Looking at models
of care and will undertake public/staff consultation where
required.
Coping through football – grant received to cover all London
boroughs and CAMHS for three years along with an award
from UEFA. Will be launched 18 June.
Equine therapy on Moore Ward for PD/LD clients. Involves
horse care, taking on different tasks and responsibilities.
2014/127 AOB
None.
2014/128 Questions from the public
PW advised that the board had received an emailed question
from Jon Abrams of Redbridge Concern for Mental Health
voicing concerns about the proposed move of the Memory
Clinic from Grovelands to Sunflowers Court. BE answered the
questions as follows:
Is the Board aware that the decision to move the Memory
clinic from a community setting to a hospital setting is
contrary to Nice Guidance and good practice?
Goodmayes is no longer used as a hospital and is used as a
base for a number of community services. There have been
no issues with attendance at any of these services due to
patients feeling stigmatized. Although it will be possible for
patients to be seen at a satellite site if they wish, the trust
strongly believes that it should stand against stigma wherever
possible.
Does the failure to consult with people with dementia,
relatives and cares about the decision to relocate the
Memory clinic raise any strategic organisational/cultural
issues within the Foundation Trust?
This is a service relocation rather than a service change and
there is no requirement for a full public consultation. The
trust has undertaken a wide-ranging communications
exercise and engaged fully with people using the service as
well as scheduling open evenings and drop-in sessions.
How is the Board ensuring the senior management team
‘change ways of working’ and engage with patients, carers
and relatives in light of the Francis Report
recommendations?
A great deal of work has been done post-Francis with staff
and users. The outputs of this work have been considered at
public board meetings. The trust has also adopted the Friends
and Family test.
Can the Board please explain how ‘due regard’ under the
Public Sector Equality Duty was tackled in relation to the
decision to transfer the clinic especially as the move impact
on some of the most vulnerable members of our
community?
The trust does not accept that there has been any
discrimination. There will be an increase in the quality of
access and will allow NELFT to develop the service further.
Any changes will be made as and when needed. A full
equality impact assessment has been completed.
FR said that he had written a letter of complaint about the
trust breaking the law in relation to him but had not received
an acknowledgement which should be received in three
working days. PW advised that the matter is going through an
official complaints process and that the trust would check
that an acknowledgement had been sent.
JVR
24.06.14
NS raised the issue of the reduction of Woodbury beds (15 by
June). CB said that the longer term strategy is for one
integrated unit with a plan as to how to best operate beds.
This is just one option and there are others to be looked at.
There would be a public consultation on this issue before any
decisions are made.
NH congratulated the board on the encouraging £11.7m
surplus and the quality account although there is still room
for improvement. He also asked that the corporate objectives
and MH bed reconfiguration go to the governor information
forum in May.
2014/129 Date of next meeting – Tuesday 24 June 2014
HE
27.05.14
AGENDA ITEM 03a
BOARD OF DIRECTORS 24 JUNE 2014
Patient/Public query tracker
Meeting date
Query raised by
Lead
Query
Feedback given
Outcome
27.05.14
Jon Abrams
(RCMH)
BE
Emailed question (see minutes
of the meeting)
27.05.14
Emailed questions answered at the meeting and
email response sent.
27.05.14
Fin Robinson
PW
FR said that he had written a
letter of complaint about the
trust breaking the law in
relation to him but had not
received an acknowledgement
which should be received in
three working days.
24.06.14
27.05.14
Nicola Sharp
CB
NS raised the issue of the
reduction of Woodbury beds
(15 by June).
27.05.14
Completed. CB said that the longer term strategy is
for one integrated unit with a plan as to how to best
operate beds. This is just one option and there are
others to be looked at. There would be a public
consultation on this issue before any decisions are
made.
27.05.14
Nicholas Hurst
HE
NH asked that the corporate
objectives and MH bed
reconfiguration go to the
governor information forum in
May.
28.05.14
Completed.
GLOSSARY OF ACRONYMS
Acronym
A&E
AC
AFC
AHM
AHP
AOD
AOT
ALOS
AMD
ARU
ASD
AQP
AWOL
BAF
BCH
BHRUT
BAME
BMI
BTA
BTUH
CAF
CAMHS
CARS
CASH
CBT
CCG
CCIO
CCP
CDAT
CHD
CHS/CS
CIDS
CIP
CMHT
CNST
COO
COPD
CPA
CPN
CPR
CQC
CQUIN
CRB
CRG
CRT
CRS
CDAS
CSO
CSU
CTO
CTT
DAT
DIPC
Details
Accident & Emergency
Audit Committee
Alastair Farqharson Centre
Associate Hospital Manager
Allied Health Professional
Assistant Ops Director
Assertive Outreach Team
Average Length of Stay
Associate Medical Director
Assisted Reproduction Unit
Autistic Spectrum Disorders
Any Qualified Provider
Absent without leave
Board Assurance Framework
Brentwood Community Hospital
Barking, Havering and Redbridge University Trust
Black, Asian and Minority Ethnic
Body Mass Index
Business Transfer Agreement
Basildon & Thurrock University Hospitals Trust
Common Assessment Framework
Child and Adolescent MH Services
Clinical Activity Reporting System
Contraception and Sexual Health
Cognitive Behavioural Therapy
Clinical Commissioning Group
Chief Clinical Information Officer
Competition and Co-operation Panel
Community Drug and Alcohol Team
Coronary Heart Disease
Community Health Services/ Community Services
Community Information Data Set
Cost Improvement Programme
Community Mental Health Team
Clinical Negligence Scheme for Trusts
Chief Operating Officer
Chronic Obstructive Pulmonary Disorder
Care Programme Approach
Community Psychiatric Nurse
Cardio Pulmonary Resuscitation
Care Quality Commission
Commissioning for Quality Innovation
Criminal Records Bureau
Control Risk Group
Community Recovery Team
Care Records Scheme
Community Drug and Alcohol Service
Chlamydia Screening Office
Commissioning Support Unit
Community Treatment Order
Community Treatment Team
Drug & Alcohol Team
Director of Infection Prevention and Control
GLOSSARY OF ACRONYMS
DNA
DoH/DH
DoLS
DQAG
DQIP
DTOC
D&V
E&D
EBITDA
EIP
ELFT
EMT
EOLC
ERS
ESR
EU
EVO
EWTD
FD
FRP
FRR
FTE
FTN
GUM
H4NEL
HCAI
HCA
HCAS
HCLA
HDU
HIV
HTT/OAHTT
HONOS
HONOSca
HoP
HPV
HR
HV
IA
IAF
IAPT
ICIP
ICM
I&E
IHP
IPAD
ISA
IT
ITT
JNCC
KPI
KSF
LA
LAC
Did not attend
Department of Health
Deprivation of Liberty Safeguards
Data Quality Action Group
Data Quality Improvement Plan
Delayed Transfers of care
Diarrhoea and vomiting
Equality & Diversity
Earnings Before Income Tax Depreciation and Amortisation
Early Intervention in Psychosis
East London & City Foundation Trust
Executive Management Team
End of life care
Electronic Record system
Electronic Staff Record
European Union
Employment and Vocational Opportunities
European Working Time Directive
Finance Director
Financial Reporting Procedures
Financial Risk Rating
Full Time Equivalent
Foundation Trust Network
Genito-urinary medicine
Healthcare for North East London
Healthcare Acquired Infection
Healthcare Assistant
High Cost Area Supplement
High Cost Living Allowance
High Dependency Unit
Human Immunodeficiency Virus
Home Treatment Team/Older Adults Home Treatment Team
Health of the Nation Outcome Scores
Health of the Nation Outcome Scores for child and adolescent mental health services
Head of Procurement
Human Papilloma Virus
Human Resources
Health Visitor
Internal Audit
Information Assurance Framework
Improving Access to Psychological Therapies
Intermediate Care Inpatients
Intensive Case Management
Income & Expenditure
Integrated Health Projects
Inpatient and Acute Directorate
Individual Service Agreements
Information technology
Invitation to tender
Joint Negotiating and Consultative Committee
Key Performance Indicators
Knowledge and Skills Framework
Local Authority
Looked After Children
GLOSSARY OF ACRONYMS
LAT
LBBD
LBH
LBR
LBWF
LCFS
LD
LETB
LIFT
LINKS
LOS
LSCB
LSP
LSB
LTC
LTFM
LTPS
MASH
MAU
MBT
MCA
MCATS
MDECS
MDT
MECC
MEND
MEP
MHA
MHLT
MHMDS
MHS
MIU
MOU
MP
MSAE
MSK
NCB
NELCS
NHS
NHSL
NHSLA
NMC
NPSA
NTA
NTAC
OBC
OD
OIGG
ONEL
OSC
OT
PALS
PbR
PCAT
Local Area Team
London Borough of Barking & Dagenham
London Borough of Havering
London Borough of Redbridge
London Borough of Waltham Forest
Local Counter Fraud Service
Learning Disability
Local Education Training Board
Local Improvement Finance Trust
Local Improvement Networks
Length of Stay
Local Safeguarding Children’s Boards
Local Strategic Partnership
Local Service Board
Long Term Conditions
Long Term Financial Model
Liability to Third Parties Scheme
Multi Agency Safety Hub
Medical Assessment Unit
Mentalization Based Treatment
Mental Capacity Act
Musculo-skeletal Clinical Assessment Treatment Service
Medical and Dental Education Commissioning
Multidisciplinary Team
Making Every Contact Count
Mind Exercise Nutrition Do It
Medical Education Provider
Mental Health Act
Mental Health Leadership Team
Mental Health Minimum Data Set
Mental Health Services
Minor Injuries Unit
Memorandum of Understanding
Member of Parliament
Medical Supplies & Equipment
Muscular Skeletal
National Commissioning Board
North East London Community Services
National Health Service
NHS London
NHS Litigation Authority
Nursing & Midwifery Council
National Patient Safety Agency
National Treatment Agency
NHS Technology Adoption Centre
Outline Business Case
Operations Director/Organisational Development
Operational Integrated Governance Group
Outer North East London
Overview & Scrutiny Committee
Occupational Therapy
Patient Advice and Liaison Service
Payment by results
Primary Care Assessment Tool
GLOSSARY OF ACRONYMS
PCT
PDC
PDP
PDU
PEAT
PHP
PFI
PICU
PID
PLG
PMO
PMVA
POPE
PPE
PQQ
PREMs
PSPP
PST
PTSD
QIPP
QOF
QSC
R&D
RAID
RCA
RDAS
RIDDOR
RTT
SALT
SAS
SCB
SCG
SGH
SIC
SHA
SLA
SLM
SLR
SOC
SI
SPA
SURG
SWECS
TCS
UCC
UCL
UCLP
UNISON
UQAT
VFM
VTE
WIC
Primary Care Trust
Public Dividend Capital
Personal Development Plan
Patient Discharge Unit
Patient Environment Action Team
Personal Health Plan
Private Finance Initiative
Psychiatric Intensive Care Unit
Project Initiation Document
Professional Leadership Group
Project Management Office
Prevention Management of Violence and Aggression
Patient Outcome Patient Experience
Patient and Public Engagement
Pre-qualifying questionnaire
Patient Reported Outcome Measures
Public Sector Payment Policy
Prescribing Support Team
Post Traumatic Stress Disorder
Quality, Innovation, Productivity and Prevention
Quality and Outcome Framework
Quality & Safety Committee
Research & Development
Rapid Assessment Interface and Discharge
Root Cause Analysis
Redbridge Drug and Alcohol Service
Reporting of Injuries, Diseases and Dangerous Occurences
Referral to treatment
Speech and Language Therapy
Staff and Associate Specialist (doctors)
Safeguarding Children Board
Specialist Commissioning Group
St Georges Hospital
Statement on Internal Control
Strategic Health Authority
Service Level Agreement
Service Line Management
Service Line Reporting
Strategic Outline Case
Serious Incident
Single Point of Access
Service User Reference Group
South West Essex Community Services
Transforming Community Services
Urgent Care Centre
University College London
University College London Partnership
Union for staff in public services
User Quality Action Team
Value for money
Venous Thromboembolism
Walk-In Centre
AGENDA ITEM 06 – CHIEF EXECUTIVE’S REPORT
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
By:
Chief Executive
Subject:
Chief Executive Report
___________________________________________________________________
This report covers the period May 2014 – June 2014
Highlights in this period
• Friends and family test
• Estates strategy update
Performance
Performance is good with no significant variations to report in this period.
Financial
This month’s financial position shows an improvement on the previous month’s position.
The slight deficit reported has been recovered and we are on plan.
Monitor Targets
Q4 report from Monitor states that we have maintained governance and financial risk
ratings in accordance with our plans.
Contracts 14/15
NHS England contracts still in the process of being finalised.
Strategy
Estates
The full Estates Strategy update will come to the board in November. However, it is
important that the board, governors and public are aware of some of the key schemes
taking place across the localities. A brief update paper is attached at Appendix 1.
Quality
Friends and family test
The annual staff survey friends and family question is supplemented by a requirement for
local employee surveys on this specific question in the other three quarters of the year. The
Quarter 1 results are as follows:
Recommend quality of care to a friend or relative (extremely likely or likely): = 62%
(November 3013 National staff survey Q12d = 56%)
Recommend as a place to work (extremely likely or likely): = 53%
1 of 2
(November 2013 National staff survey Q12c = 51%)
The full results will now be analysed by staff group, directorate, ethnicity etc. and will be
reported in a further update, together with an analysis of low response staff groups/areas
indicating where supplementary written postcards/questionnaires should be distributed for
the next quarter.
John Brouder
June 2014
2 of 2
AGENDA ITEM 08 – INTEGRATED QUALITY & PERFORMANCE REPORT
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
Report by:
Chief Nurse and Executive Director of Integrated Care (Essex)
Subject:
Integrated Performance, Quality and Safety Report
Purpose of the report
This report provides the trust board with high level assurance around quality and performance.
Executive summary
The report is a summary of the more detailed information, discussion and actions that took place at the Quality &
Safety Committee (QSC), Performance Committee and at the corresponding integrated care directorate groups.
Information in the report has been drawn from existing dashboard sources. To further strengthen quality and
patient safety, the trust has reviewed contractual, mandatory and statutory quality and performance reporting
requirements. A list of indicators is being drawn up which will then form the basis of future quality and safety
dashboards and reports.
Financial implications
Failure to provide services that are safe and clinically effective will lead to financial and regulatory sanctions.
Risk implications
Failure to identify risk and ensure effective controls are in place will lead to safety incidents and quality noncompliance.
Legal implications
Failure to provide services that are safe may lead to litigation.
Action required
The board is asked to approve the report.
Page 1 of 13
Exceptions reported at the Quality and safety Committee June 2014
1.
Risks rated 15 and above plus any other risks to be shared with the Board
There were no new risks rated 15 and above or other risks identified by the integrated care directors.
The Quality and Safety Committee (QSC) received the following papers as per the cycle of business reporting:
2.
Exception papers
Hard Truths – Publishing of Staffing data
The paper and presentation provided assurance to the committee that the actions required and associated
risk are being lead and managed with clear roles and accountabilities. The staff data will be displayed on
NHS choices and the trust’s own website. To support the public understanding of the context of the data, a
staffing page has been developed on the NELFT web site that explains potential
variance http://www.nelft.nhs.uk/about_us/performance/safe_staffing
The trust board is asked to note that national monthly reporting requirements are outside the trust’s cycle of
reporting and therefore ratification of the data will be made by the executive management team was
approved by the QSC. The QSC will receive monthly reports by exception.
3.
Intensive trust board workshop reviews 2013/14
•
•
•
•
Medicines management
Integrated children and adults safeguarding (including mental capacity and deprivation of liberties
safeguards)
CQC process
Mandatory training
The committee viewed robust action plans that demonstrated improved quality performance in the areas of
medicines management, safeguarding and CQC process.
Exceptions
Safeguarding
• The impact of a Supreme Court ruling of the Chester West case has impacted on the implementation of
the trust’s policy and procedures relating to the deprivation of liberties safeguards. The trust has made
additions to the safeguarding action plan which aim to increasing referral rates through greater
awareness.
• To further support safeguarding training additional face to face sessions have been arranged.
Mandatory training
• The trust wide mandatory training compliance report (June 2014 data) demonstrates improvement and
sustained compliance across all 12 training domains. Mandatory training data accuracy continues to
improve through the functionality of AT learning technology and local scrutiny by the integrated care
directors.
Quality data and information is shared with patients, service users, staff and other key stakeholders such as
the Health Watch, CQC and commissioners. The integrated care directors and trust executives are actively
engaged in discussions in how the trust can provide locality based quality contractual data.
The committee requested further information should be provided at the July committee on the broader work
force quality targets and potential risks of non-compliance.
Page 2 of 13
4.
Quarterly reports
•
•
•
•
Learning the lessons from serious incidents, complaints and claims.
Learning about serious incidents and other events (LASER)
Patient experience Surveys
Serious Incidents report October 2013 – march 2014
The information contained within the above reports was written clearly and most recent available. Specific
risks to quality were identified by the authors providing assurance of leadership and accountability. Quality
assurance recommendations within the reports made were approved by QSC.
Exceptions
Patient Experience
• Local services are required to develop action plans for improvement when patient satisfaction is low.
Serious Incident
• Serious incident management performance in the London localities has continued to show steady
improvement in terms of the overdue investigations. Close monitoring of the progress of all reports and the
full participation of all involved in reporting, investigation and approval of reports with robust learning for
practice improvement action plans is required to maintain this quality performance indicator.
5.
Six monthly updates
•
NRLS (national reporting learning system)
Exceptions
The trust has completed all actions required by the NRLS following an invitation to attend a learning event
organised by the NRLS. Data quality and NRLS profile of NELFT as an organisation requires further review. A
member of the NRLS has been invited to present to the trust board annual risk management awareness
event held on 17th June 2014.
6.
Annual quality report
Complaints Annual report 2013/14
The report provided clear information on the trusts performance in complaints and concerns handling.
Exceptions:
•
•
•
•
•
•
•
•
The Trust has incorporated recommendations from national inquiries into the complaints policy and
process.
A total of 215 reportable complaints were received which is a 22% increase on last year. The trust
welcomes and encourages complaints and concerns as a means of feedback and learning. Further
analysis is required to understand and manage the increase in complaints.
Of the total of 215, 71 (33%) complaints were partially upheld and 60 (28%) upheld.
There is an improvement in the number of complaints acknowledged within 3 working days to 94%.
53% of complaints were responded to within timeframe.
35% of complaints were open over 90 days.
The highest number of complaints related to all aspects of clinical treatment (45%), followed by attitude
of staff (17%) and Communication (16%).
8 complaints (4%) were referred to the Parliamentary & Health Service Ombudsman which is the same
percentage as 2012-13.
Page 3 of 13
•
•
The Trust is scheduled to implement a web-based complaints management system from 1 July 2014.
The Trust is responding to the CQC key lines of enquiry.
In October 2013, the executive management team agreed that the trust should participate in the corporate
benchmarking project that was being coordinated by NHS Benchmarking Network. The results were released
Friday 4th April, and in total, 93 organisations submitted data. In relation to complaints, both the costs and
the whole time equivalent staff employed in complaints function per 100m turnover was significantly below
the average, however it should be noted that the number of complaints investigated was also below average
and that complaints are investigated by operational staff.
The quality and safety committee requested further analysis into the number and categories of complaints
and that this information is to be included in the next report due in December 2014.
7.
Integrated Care Director Exception Reports
The quality and safety committee (QSC) reviewed the integrated care director exception reports for Barking,
Havering and Redbridge, Basildon/Brentwood, Thurrock and Waltham Forest health economies and were
sufficiently assured that the current and potential risks to quality are being identified, assessed and that
appropriate controls and actions are in place. The committee was made aware of specific gaps in assurance
which fell outside NELFT’s control and how communications with partner agencies and commissioners
regarding the risks were being progressed where possible. There were no new risks identified this month
which scored 15 and above on the trust’s risk matrix.
8.
Minutes from quality and safety group monthly meetings
The minutes from the integrated care quality and safety group monthly meetings provided the committee
with assurance that there are well understood processes for escalating and resolving issues and managing
quality performance. It was noted that the KPMG Quality Governance Framework (QGF) audit (May 2014)
identified 10 recommendations aimed at refining the quality governance processes, KPMG did not deem any
of the recommendations to be high risk, as they found the trust’s processes are generally functioning
effectively in relation to quality assurance. The committee requested an interim update of progress to be
provided by the Chief Nurse, with a full report in October as per the QSC cycle of reporting.
9.
The QSC Self-assessment
The results provided assurance to the committee, that the membership, terms of reference and content of
the quality and safety committee meeting are fit for purpose.
Full papers are available from the trust secretary on request.
Page 4 of 13
1. Safety
Are people protected from physical, psychological or emotional harm?
1.1. Indicators
Indicator
Freq
Target
Patients who received at least one new
harm while in care of NELFT (Safety
Thermometer Adults)
M
no target
Serious Incidents (reported on STEIS)
M
no target
Prev Current
Period Period
1.00%
36
-
-
Total No
in Past
12
Months
-
264
Risk of
Failing Risk to Future
Quality/
Target
in the Performance
future
Trend
4%
3%
2%
1%
0%
J
F M A M J
J
A S O N D J
F M A M
J
F M A M J
J
A S O N D J
F M A M
J
F M A M J
J
A S O N D
J
F M A M
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
40
30
20
10
0
Gov'nce
no
target
QSC
no
target
QSC
no
target
QSC
no
target
QSC
12
Unexpected deaths
M
no target
1
-
8
48
4
0
Patient Falls (CHS-intermediate care
beds & MHS-older peoples;cook, stage
and woodbury)
M
Avoidable Grade 3 and above pressure
ulcers acquired whilst in care of NELFT
M
Medication errors causing serious
harm
Number of avoidable Clostridium
Difficile cases
Number of avoidable MRSA
bacteraemia cases attributed to NELFT
M
M
M
Number of new safeguarding
allegations against staff (Adults &
Children)
M
Number of RIDDOR incidents related to
staff
M
no target
0
no target
0
0
no target
4
11
0
0
0
2
-
-
-
-
-
-
68
113
6
8
0
5
10
8
6
4
2
0
20
16
12
8
4
0
QSC
5
4
3
2
1
0
no
target
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
5
4
3
2
1
0
QSC
5
4
3
2
1
0
QSC
5
4
3
2
1
0
J
no target
0
-
12
AWOLs resulting in serious incident
(Mental Health)
Number of new claims where NELFT is
the responsible organisation
M
no target
-
-
780
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
F M A M J
J
A S O N D
J
0%
1%
-
-
100
80
60
40
20
0
J
F M A M J
J
A S O N D J
F M A M
J
F
J
A
F
20%
0%
M
no target
1
-
13
M
A
M
J
S
O
N
D
J
M
A
F M A M J
J
A S O N D
J
no
target
QSC
no
target
QSC
no
target
QSC
no
target
QSC
-
QSC
M
5
4
3
2
1
0
J
QSC
F M A M
40%
M
no
target
M
4
3
2
1
0
J
Incidents of violence & aggression
(under review)
QSC
F M A M
15%
Locations with Major or Moderate
Concerns against CQC standards
(internal assessment) (under review)
10%
M
-
1.0%
-
-
5%
0%
J
Safer Staffing-% average staff fill rate
(actual staffing levels against planned
staffing levels)
M
TBC
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
-
Page 5 of 13
1.2. SAFETY Indicator Exceptions
Acquired Pressure Ulcers Grade 3 and 4
Update from January 2014 to date
Actions
The trust strives to achieve zero tolerance to the development of pressure ulcers.
This month (April data 2014) there has been a slight increase in the number of people affected by grade 3 and
4 pressure ulcers. The strategic pressure ulcer group chaired by the director of nursing for patient safety has
been established. Clear leadership and accountabilities in relation to pressure ulcer governance is
demonstrated within the term of reference, membership and improvement action plan and associated work
streams. Clear links have been made to the trust’s risk register.
Number of serious incidents reported on STEIS
There has been an increase in the number of reported serious incidents, reaching an upper warning limit
within the control chart. This is due to the number of reported pressure ulcers, which from April 2014, now
includes both avoidable and unavoidable (previously only avoidable pressure ulcers were included in the total
number of reported serious incidents).
New safer staffing indicator
This new indicator, “% average staff fill rate”, determined by actual staffing levels against planned staffing
levels, will be reported in July’s report relating to May’s data. This indicator has been included in line with
requirements set out in the National Quality Board; how to ensure the right people with the right skills are in
the right place at the right time.
Page 6 of 13
2. CARING
Are people treated with compassion, respect and dignity and is care is tailored to their needs?
2.1. Indicators
Indicator
Complaints Received
Freq
M
Prev Current
Target
Period Period
no
target
27
-
Total No
in Past
12
Months
275
Trend
30
20
10
0
J
Compliments Received
Friends & Family Test (data not
available)
M
M
no
target
no
target
149
-
-
-
679
104
Risk of
Failing Risk to Future
Quality/
Target
in the Performance
Future
F M A M J
J
A S O N D J
100
50
0
-5 0
-1 00
F M A M J
J
A S O N D J
J
F M AData
M availble
J J A from
S ONov
N 13
D J
no
target
QSC
no
target
QSC
no
target
QSC
F M A M
150
120
90
60
30
0
J
Gov'nce
F M A M
Mark please insert graph here
F M A M
2.2. Indicator Exceptions
Complaints received
The “risk to future quality performance” has been reviewed and changed from amber to red rating in view of
the Care Quality Commission’s new inspection methodology.
Compliments received
There is a sharp increase in the number of compliments received this month, indicative of an improved
performance trend (rule 3 how to read control charts). This may be explained by a change in the process for
collecting and reporting numbers received.
New Duty of Candour Indicator
The being open policy has been reviewed to include duty of candour and is being presented to the trust’s
senior leadership team for ratification on 17 June 2014. The policy will then be launched across the trust to
advice staff. A new quality indicator will be included in this report to capture duty of candour reporting
requirements.
Page 7 of 13
3. Responsiveness
Do people get treatment and care at the right time, without excessive delay, and are they are listened to in a
way that responds to their needs and concerns?
3.1. Indicators
Indicator
Certification against compliance with
requirements regarding Access to
healthcare for people with a learning
disability
Freq
Target
Prev Period
Current
Period
Total No
in Past
12
Months
Risk of
Failing
Target
Trend
Risk to Future
Quality/
Performance
Gov'nce
100%
75%
M
100%
100%
100%
-
PC
50%
25%
0%
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
600
Days Lost due to Delayed Transfers of
Care
400
M
N/A
278
394
-
-
200
PC
0
Average transfer time from acute to
community (NELCS Only)
M
3 Days
1.54
1.7
-
5
4
3
2
1
0
PC
J
% Bed Occupancy (Essex CHS)
% Bed Occupancy (London CHS)
% Bed Occupancy (London MHS)
M
M
M
85%
95% (WF
only)
Varies
depending
on ward
76.1%
88.1%
83.2%
85.0%
91.2%
83.0%
-
-
-
M
21
19.1
20.4
-
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
PC
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
100%
90%
80%
70%
60%
50%
PC
100%
90%
80%
70%
60%
50%
PC
J
ALOS (NELCS)
F
100%
90%
80%
70%
60%
50%
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
35
30
25
20
15
10
PC
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
30
ALOS (SWECS)
M
21
19.0
19.0
-
PC
20
10
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
30
25
ALOS (MHS Adults)
M
25
23.3
24.8
-
PC
20
15
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
Page 8 of 13
ALOS (MHS Older Adults)
M
45
41.0
40.6
-
60
50
40
30
20
10
0
PC
J
Referral to treatment waiting times:
18 week Consultant-Led Incomplete
Pathways
Referral to treatment waiting times:
18 week Consultant-Led Completed
Pathways
Improved Access to Psychological
Therapies (MHS Only)
M
M
Quarterly
Reporting
from April
2014
92%
95%
NELFT Total:
96.7%
London:
95.9%
Essex:
98.6%
NELFT Total:
97.1%
London:
89.2%
Essex:
100%
Reported
a month
Retrospe
ctively
Reported
a month
Retrospe
ctively
-
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
100%
98%
96%
94%
92%
90%
88%
PC
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
100%
98%
-
96%
PC
94%
92%
60%
55%
N/A
53%
-
-
-
50%
45%
PC
40%
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
100%
Walk In Centre 95% - 4 hour waiting
time
M
95%
100%
100%
-
PC
95%
90%
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
3.2. Indicator Exceptions
Although data is not provided for 18 week referral to treatment time for consultant lead services above (it
will be included next month), there is concern regarding the community Paediatric services achievement
against target. The overall NELFT position is ‘green’ (target achieved) however the Redbridge community
Paediatric service is breaching the 18 week target and this is being questioned by CCG commissioners. The
position is currently being reviewed by Redbridge Integrated Care Director and remedial actions will be put
in place and advised.
3.3. Responsive Related Significant Risks
Referral to Treatment (RTT) achievement is not reportable to Monitor and is not set as a KPI for London
boroughs, however it would be considered best practice for a provider to comply with national RTT
guidance. Failure to do so is likely to result in a Contract Query Notice from the commissioner.
Page 9 of 13
4. Effectiveness
Are people’s needs met, is their care in line with national guidelines and NICE quality standards, are
techniques used which give them the best chance of getting better or living independently?
4.1. Indicators
Indicator
CPA Reviews (formal review within 12
months)
Freq
M
Target
95%
Total No
Prev Current in Past
Period Period
12
Months
96.1%
95.4%
-
Risk of
Failing Risk to Future
Quality/
Target
in the Performance
Future
Trend
100%
98%
96%
94%
92%
90%
Gov'nce
PC
J
F M A M J
J
A S O N D J
F M A M
100%
Admissions to inpatients services had
access to Crisis/Home Treatment
Teams
98%
M
95%
98.7%
100.0%
-
96%
PC
94%
92%
J
New Psychosis cases by early
intervention teams
M
95%
129%
107%
-
F M A M J
J
A S O N D J
F M A M
140%
130%
120%
110%
100%
90%
80%
PC
J
F M A M J
J
A S O N D J
F M A M
60%
The proportion of people who complete
treatment who are moving to recovery
Q
50% (5%
Tolerance)
56%
-
-
40%
data not yet available
20%
-
PC
-
PC
0%
J
Regular reviews of antipsychotic
prescriptions are conducted for people
with dementia and communicated to
GPs and patients/families
% of patients readmitted to a
community bed within 30 days of
discharge from a community bed
(excluding patients within acute adm in
the interim period) - Excl Stroke (Essex
CHS only)
% of patients reporting improved
overall quality of life (at discharge)
following AHP intervention - using
agreed MYMOP assessment tool (Essex
CHS only)
F M A M J
J
A S O N D J
F M A M
100%
Q
90%
97%
-
-
95%
90%
85%
J
M
<=5%
0.0%
5.0%
-
>=50%
73%
-
-
J
A S O N D J
F M A M
10%
8%
6%
4%
2%
0%
PC
J
Q
F M A M J
F M A M J
J
A S O N D J
F M A M
100%
80%
60%
40%
20%
0%
J
F M A M J
J
A S O N D J
PC
F M A M
4.2. Indicator Exceptions
National Institute for Health and Social care excellence (NICE) – reporting indicator construct under
development as per NICE standards and trust policy and process’ reports will commence to capture May 2014
data.
Page 10 of 13
5. Well Led
Is there effective leadership, governance (clinical and corporate) and clinical involvement at all levels of the
organisation, and is there an open, fair, transparent culture that listens and learns from people’s views and
experiences to make improvements? Does the board make decisions about quality care using sound evidence
and information and are concerns discussed in a frank and open way?
5.1. Indicators
Indicator
Category A & B audits completed on
time with recommendations
(excluding NICE)
Freq
Target
Prev
Period
Total No
Current in Past
Period
12
Months
Trend
80%
60%
M
80%
0%
-
-
QSC
40%
20%
0%
J
Documentation not returned to NICE
leads within 3 months of initial
review
Risk of
Failing Risk to Future
Gov'nce
Quality/
Target
in the Performance
Future
M
-
-
-
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
A new NICE Trustwide process is commencing Feb
2014. Data will be reported from May 14
QSC
40%
Manager's actions for medication
error incidents not completed within
14 days
M
no
target
30%
12%
-
-
no
target
20%
10%
J
Number of open SI action plans
where deadline has passed
(excluding actions from SCR cases
being taken through the criminal
justice system)
QSC
0%
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
60%
M
10%
42%
-
-
40%
awaiting data
20%
QSC
0%
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
100%
Appraisal (within previous 12
months)
75%
M
85%
47%
50%
-
PC
50%
25%
0%
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
13%
12%
% Rolling 12 month Turnover
M
10%
11.9%
11.7%
-
11%
PC
10%
9%
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
6%
% Sickness (reported a month
retrospectively)
5%
M
3.7%
4.36%
4.08%
-
PC
4%
3%
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
15%
% Vacancies
M
10%
15.4%
16.0%
-
13%
PC
11%
9%
J
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
Page 11 of 13
% of eligible staff whom have an up
to date DBS (i.e. DBS which is <3
years old)
M
95%
84%
-
-
100%
80%
60%
40%
20%
0%
-
100%
80%
60%
40%
20%
0%
QSC
J
% eligible staff with Adult
Safeguarding training completed
M
95%
77%
81%
% of completed 'must do' H&S risk
assessments
M
M
-
100%
84%
-
-
-
-
Q
-
-
-
A
M
J
J
A
S
O
N
D
J
F
M
A
M
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
Need to determine which aggregated training
PC
100%
80%
60%
40%
20%
0%
QSC
J
Monitor Quality Governance
Assessment
M
QSC
J
Training (Aggregate Compliance)
F
F
M
A
M
J
J
A
S
O
N
D
J
F
M
A
M
Construct is in development to be agreed by May 2014
QSC
5.2. Indicator Exceptions
Manager's actions for medication error incidents not completed within 14 days
This is the third consecutive month reporting a positive trend in performance; manager’s actions are being
completed within 14 days. A suspected trend/permanent shift in performance may be indicative if the trend
continues for five/six consecutive months.
Appraisal, Vacancy Rate, Sickness
The trust has a developed robust plan of actions to address recruitment and staff and retention in key clinical
areas such as nursing and health visitors both of which are monitored in the board assurance framework.
•
•
•
•
•
•
Vacancy figures are substantially exceeding target across the Trust.
Turnover is high in all areas other than Basildon, Brentwood & Thurrock.
Sickness is reporting 5% or above in Havering, Redbridge and Thurrock.
Appraisal rates have declined again across Barking, Havering and Redbridge and Waltham Forest. The
position has been robustly reviewed by the Integrated Care Directors and remedial actions and controls
have been put in place.
Basildon and Brentwood achieved 88.9% and Thurrock 84.8% appraisal compliance by the end of last
financial year.
Corporate appraisal figures have also fallen this month
Yearly appraisal is one line of enquiry as to whether the trust is well led, other indicators include monthly 121
clinical supervision meetings between managers and supervisors and training opportunities.
6. Strategy and investment needs
This section will be developed in future reports in line with the Trust Strategy
7. Looking forward
This section will be developed in future reports.
Page 12 of 13
Appendix A – Control Charts
KEY to Charts
Average Performance (based on 12 months historical data)
Target Performance (if one has been set)
Upper & lower control limits (+/- 2 std dev from the average performance), Upper & lower warning
limits (+/- 2 std dev from the average performance)
1. What is a control chart?
Even the most well controlled processes will produce a natural variation in performance (caused by factors internal to that
process such as staff capability, staff numbers, equipment, policies etc).
Control charts use probability (expressed as control limits) to help determine whether an observed performance measure
would be expected to occur or not expected to occur, given normal process variation.
If a particular measurement falls within plus or minus three standard deviations (the control limits) of the process average,
it is considered “expected” behaviour for the process.
However, if a measurement falls outside of the control limits, something special has happened to the process. In other
words, something out of the ordinary has caused the process to go out of control. This situation is known as special cause
variation, meaning that, based on the behaviour of the process up to that point, the probability of that situation occurring
by chance is less than 0.3%. A measurement with such a low probability suggests that special circumstances affected the
process.
Of course, although a process may be well controlled (i.e. with little variability around its average performance) it may still
not be meeting the desired target performance.
2. Reading a Control Chart
Control charts can help:
- Control a process by knowing when and when not to take action
- Understand and predict process capability based on trends and other performance insights
- Determine whether changes made to the process are having the desired result
- Provide an on-going, continual view of the performance of the process
Rule One (Warning Limits)
If a measurement falls outside two standard deviations of the average (the warning limits), then the process may be subject
to special cause variation. Action: Further checks should be made
Rule Two (Control Limits)
If a measurement falls outside three standard deviations of the average then it is subject to a special cause variation.
Action: immediate action is required.
As well as identifying variability in the process, a control chart can also confirm whether suspected trends and permanent
shifts in performance are real (i.e. unlikely to be caused by random variation alone)
Rule Three (A Performance Trend)
Indicated when five/six consecutive measurements each exceed (or are each less than) the previous measurement
Rule Four (A Substantive Performance Shift)
Indicated when seven consecutive measurements are on the same side of the historical average
Page 13 of 13
AGENDA ITEM 08a
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
Report by:
Chief Nurse and Executive Director of Integrated Care (Essex)
Subject:
Hard Truths – Publishing of Staffing Data
Purpose of the report
To inform the Board of the progress against national requirements for staffing data reporting.
BACKGROUND
On 31st March 2014 Jane Cummings (Chief Nursing Officer, NHS England) and Sir Mike Richards
(Chief Inspector of Hospitals, Care Quality Commission) circulated ‘Hard Truths Commitments
Regarding the Publishing of Staffing Data’ to the Chief Executives of all Trusts. This outlined the
actions necessary to support the implementation of the requirements set out in the National
Quality Board (NQB) and the Chief Nursing Officer’s report ‘How to ensure the right people with
the right skills, are in the right place at the right time: A guide to nursing, midwifery and care
staffing capacity and capability’.
An initial report went to the Quality and Safety Committee on 13th May 2014 and to the Board of
Directors on 27 May 2014.
SUBMISSION OF MAY DATA
NHS England requires Trusts to submit monthly staffing data which will be displayed on NHS
Choices and on the Trust website.
The staffing information required to be displayed is the total monthly planned staff hours versus
actual staff hours (percentage fill). This information is split by day shift/ night shift and by
registered nurses/ unregistered care staff. NHS England have not yet released the parameters
against which staffing levels will be RAG rated.
The national data must be uploaded by midday on 10th June 2014 and will be displayed on NHS
Choices and on the Trust website on 24th June 2014.
The Board will receive monthly updates on staffing information in line with this reporting.
The data for the period 1st – 31st May is presented as Appendix 1
EXCEPTIONS AND ACTIONS
There are times when it will be legitimate for wards to have staffing levels which fall below 100%
or are significantly above 100%. For example our community hospitals operate within a matrix
which determines staffing levels against bed occupancy. Many of our wards will also have
increased staffing levels if patients require intensive 1:1 nursing support. A staffing page has been
developed on the NELFT web site that explains this potential variance
http://www.nelft.nhs.uk/about_us/performance/safe_staffing
When staffing falls below the planned level required to meet the care needs for the number of
patients on a ward a risk assessment is carried out, a datix incident report is completed and the on
call manager is informed of the situation.
This month, out of 546 shifts, eight were reported on datix under the category ‘adverse events
that affect staffing levels’. This equates to 1.5% of shifts. Actions were taken to provide emergency
cover. Where this was not possible a risk assessment was undertaken. Seven of these incidents
were rated as ‘no harm’, as there were no adverse incidents and patient safety was maintained.
The severity of one was rated ‘minor: disruption to services’, as one ward was temporarily left
short of staff as emergency assistance was needed on the other ward on the site.
Although only one datix staffing incident was reported for Brookside (Child and Adolescent Mental
Health), the data is showing an average day shift fill rate for unregistered care staff of 79%. The
interim Modern Matron is reviewing this, as Brookside had a number of risk incidents reported
over the same period.
Ogura and Picasso wards (Adult Mental Health) are showing particularly high average staffing fills
over all shifts. This is in direct correlation to the number of shifts where 1:1 nursing care was
required. IPAD are in the process of recruiting a number of ‘floating’ staff to increase continuity of
care and reduce the agency spend when additional staff are required.
Hepworth and Turner wards (Adult Mental Health) have three ‘swing beds’. This means that at
times of higher demand for male beds Turner can increase its occupancy to 23 beds, whilst
Hepworth reduces to 17 beds. For the month of May Turner had additional beds 55% of the time,
necessitating additional staffing.
Financial Implications
The publishing of the NICE guidance will necessitate the review of staffing across all inpatient
areas. If this review highlights the need to make significant changes to staffing establishments
there are potential cost pressures.
Risk Implication
There are National concerns about the potential reputational risk to Trusts if publically published
staffing reports highlight nursing shortages
Legal Implications
As noted above
Actions Required
The Board is asked to note the content of this report
Stephanie Dawe
June 2014
Appendix 1
Day
Ward name
Registered
midwives/nurses
Night
Care Staff
Registered
midwives/nurses
Care Staff
Total monthly
Total monthly
Total monthly
Total monthly
Total monthly
Total monthly
Total monthly
Total monthly
planned staff hours actual staff hours planned staff hours actual staff hours planned staff hours actual staff hours planned staff hours actual staff hours
Ainslie Rehabilitation Unit - Ground Floor
930
1000.5
1395
1340.5
510
620
255
310
Ainslie Rehabilitation Unit - Top Floor
930
824.5
1395
1328
505
620
252.5
300
Alistair Farquharson Centre
1860
1955.25
2325
2459.5
620
610
930
930
Brookside
1425
1563
2490
1978
620
660
1240
1232
Foxglove Ward
1395
1342.5
1627.5
1605
620
600
620
620
Galleon
930
858.5
1395
1275
620
628
310
314
Heronwood
930
853.5
1395
1427.5
620
608
310
314
Grays Court Ward 1
930
889
1860
1627.5
620
620
620
620
Grays Court Ward 3
930
1029.5
1395
1558
620
620
310
310
Mayflower Community Hospital
1395
1244.25
1627.5
1521.75
620
620
620
600
Thorndon Ward
1395
1288.04
1860
1701.26
620
620
620
620
Woodbury Unit 1
930
887
465
926
620
610
310
320
Woodbury Unit 2
930
942
465
1063.84
310
310
620
710
Cook Ward
1057.5
1082.25
1297.5
1156.25
620
610
620
609.25
Hepworth Ward
1327.5
1004.75
930
973.5
620
380
310
290
Kahlo Ward
1035
938
1035
990
620
650
310
320
Monet
1095
1072.5
930
1109
620
660
620
769.5
Moore Ward
795
724
1065
1557
620
531.5
310
463
Morris Ward
1395
1494.25
930
895
620
650
620
609.5
Ogura Ward
1057.5
1281.75
1087.5
1346.5
620
650
310
712.5
Picasso Ward
930
1014.99
930
765.5
620
630
310
330.5
Stage Ward
930
937
930
900.75
620
620
310
320
Titian Ward
1260
1268
1065
1457
620
680
620
800
Turner Ward
1095
1038
930
1139.5
620
530
310
490
Hawkwell Court
465
474
930
852.25
310
390
310
310
Day
Average fill rate registered
nurses/midwives
107.60%
88.70%
105.10%
109.70%
96.20%
92.30%
91.80%
95.60%
110.70%
89.20%
92.30%
95.40%
101.30%
102.30%
75.70%
90.60%
97.90%
91.10%
107.10%
121.20%
109.10%
100.80%
100.60%
94.80%
101.90%
Average fill rate care staff (%)
96.10%
95.20%
105.80%
79.40%
98.60%
91.40%
102.30%
87.50%
111.70%
93.50%
91.50%
199.10%
228.80%
89.10%
104.70%
95.70%
119.20%
146.20%
96.20%
123.80%
82.30%
96.90%
136.80%
122.50%
91.60%
Night
Average fill rate registered
nurses/midwives (%)
121.60%
122.80%
98.40%
106.50%
96.80%
101.30%
98.10%
100.00%
100.00%
100.00%
100.00%
98.40%
100.00%
98.40%
61.30%
104.80%
106.50%
85.70%
104.80%
104.80%
101.60%
100.00%
109.70%
85.50%
125.80%
Average fill rate care staff (%)
121.60%
118.80%
100.00%
99.40%
100.00%
101.30%
101.30%
100.00%
100.00%
96.80%
100.00%
103.20%
114.50%
98.30%
93.50%
103.20%
124.10%
149.40%
98.30%
229.80%
106.60%
103.20%
129.00%
158.10%
100.00%
AGENDA ITEM 09 – INFECTION PREVENTION AND CONTROL ANNUAL REPORT
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
Report by:
Chief Nurse and Executive Director of Integrated Care (Essex)
Subject:
Infection Prevention and Control Annual Report 2013/14
PURPOSE OF THE REPORT
This report is intended to meet the DIPCs obligation to produce an annual report detailing the
arrangements for infection prevention and control (IPC) within the organisation and the activities
undertaken to ensure services provided for our patients are conducted in a safe clean environment
by suitably trained staff.
EXECUTIVE SUMMARY
•
•
•
•
•
•
•
•
•
•
•
NELFT remains registered without restrictions against CQC Outcome 8.
There were zero cases of MRSA, MSSA and E.Coli bacteraemia NELFT wide in 2013/14
11 Cases of C.difficile were found and have been fully investigated; none of these were
attributed to NELFT and all were unavoidable. A CDI reduction strategy has been developed
to work towards the zero target in 2014/15.
There was one outbreak of Norovirus lasting 10 days that lead to a ward closure
Surveillance systems have been transformed to positively improve outcomes and the quality
of care patients with infection receive, as well as detecting high risk patients and ensuring
where possible they don’t go on to develop infections whilst in our care.
87% of staff are in date with mandatory training in IPC
IPC Link Practitioners has been transformed with over 112 members, quarterly conferences,
and a defined role.
Quarterly audits are completed by operations based services against Essential Steps criteria
using an in-house automated software system, with instant feedback for the auditor
IPC have a comprehensive intranet page for staff access, and a duty nurse system to provide
real time support for issues that arise
All district nurses have staff issued hand hygiene kits to use in the community
Arrangements for decontamination of medical devices has been strengthened
FINANCIAL IMPLICATIONS
Infection Prevention & Control activity is a key part of minimising risks and potential litigation
associated with care and treatment.
1
RISK IMPLICATIONS
Report provides details of compliance with Health and Social Care Act, CQC outcome 8 and details
current risks around IPC within NELFT
ACTION REQUIRED
Board is asked to consider the report as a 12 month summary of progress and it is intended to
provide assurance of the IPC measures in place within NELFT. Members are asked to note the
contents and provide feedback on anything that could further improve and enhance the standards
and delivery of IPC NELFT wide.
Stephanie Dawe
June 2014
2
NELFT
Infection Prevention and Control Annual Report
1.4.13 – 31.3.14
Clostridium difficile
Kris Khambhaita Nurse Consultant Infection Prevention and Control
June 2014
Page 2 of 48
Forward
Welcome to the 2013/14 Infection Prevention and Control Annual Report for North East London
Foundation Trust (NELFT). This report looks back at 2013/14 and records achievements and
challenges, providing a comparison to 2012/13 where possible so as to enable the reader to see the
progress made with IPC activities. It also looks forward to some of the arrangements and plans for
2014/15 so that we can continue to meet the challenge of infection prevention and control, in
particular the prevention of Healthcare Acquired Infections (HCAIs).
The team has progressed all of the positive developments that had been started and carried on
developing our approach to the proactive and reactive elements of the infection control programme so
that we continue to adapt to meet the changing environment in which we work.
We continue to learn from the experiences of others and have taken action to implement changes to
practice as a result of root cause analysis, investigations into winterbourne view, and Francis report
post Mid Staffordshire Hospitals inquiry so that we can ensure similar situations should not develop
locally.
The Infection Control Service is working closely with NELFT operational services and services we
commission to ensure that we have robust processes in place to monitor and manage HCAIs with
tough improvement targets to stimulate significant reductions in Health Care Acquired Infections
(HCAI) locally.
As we all know, Infection Control and Prevention is everyone’s responsibility. Staff across the
organisation have embraced their responsibilities in infection prevention and control and worked as a
team to prevent the spread of infection. This commitment will continue and we must ensure that all
good practice is embedded consistently at all times so harm free care is delivered.
I would like to thank everyone for their contribution in achieving these results and look forward to
another year of building upon and strengthening processes in place.
Page 3 of 48
Contents
Page
Executive summary
4
1. Introduction
5
2. Infection Control Service
2.1 Team structure
2.2 Staffing resource
2.3 Service delivery
2.4 Director of Infection Prevention and Control
2.5 Infection Control Doctor
2.6 Governance
2.7 Health & Social Care Act
2.8 Infection Control Committee
2.9 Reporting lines to trust board
5
5
6
6
8
8
8
9
9
10
3. Surveillance of Healthcare Associated Infection
3.1 Surveillance
3.2 MRSA colonisation rates
3.3 MRSA bacteraemia rates
3.4 Clostridium difficile rates
3.5 Alert organism surveillance
10
10
11
12
12
14
4. Outbreaks and incident management
4.1 Outbreaks
4.2 Incidents
14
14
14
5. Education and training
5.1 Mandatory training
5.2 Link practitioners
14
14
17
6. Audit programme
6.1 Audit cycle
6.2 PLACE
17
17
19
7. Decontamination and Cleaning
21
8. Appendices
22
Appendix 1 – Infection Prevention and Control Strategy
Appendix 2 – Service Objectives 2013/14
Appendix 3 - Health & Social Care Act self assessment NELFT wide
Appendix 4 – Terms of Reference IPC groups and Dates of 2012/13 meetings
22
34
35
42
Page 4 of 48
Executive Summary
The Infection Control Service (ICS) has been focusing on the investigation, prevention, surveillance and
control of infection during this reporting period enabling staff to provide care in a safe environment. This has
involved working closely with the quality and patient safety team and health & safety staff as well as
building strong co-operative links with nearby acute Trusts IPC teams in order to help meet national targets.
The Infection Control Service provides a reactive and proactive level of service to all operational services in
NELFT. The team has worked closely with the commissioning teams to ensure infection control is given
due consideration when commissioning services and also at performance management reviews.
ICS continue to ensure NELFT complies with The Code of Practice for the Prevention and Control of
Health Care Associated Infections (The Health & Social Care Act 2009). Self- assessments are
undertaken and reviewed internally, and for this reporting period NELFT has remained registered
without restrictions with the Care Quality Commission (CQC).
There has been a significant amount of work undertaken on the development and transformation of
individual historical clinical audit cycles into standardised tools, implementation of the education strategy,
achieving 87% compliance NELFT wide for IPC mandatory training and the commencement of policies
review, standardisation in the preventative measures undertaken and in everyday responses to reactive
elements coming in. Furthermore, the service has been developing the surveillance systems for monitoring
HCAI’s during this reporting period and progressed with recruitment to posts, achieving compliance with the
zero target for bacteremia's and a reduced rate of Clostridium difficile infection (CDI).
These systems assist in the identification of outbreaks/ and infection trends at an early stage so that
immediate action can be taken to identify and control the source, identify problem areas, set priorities for
infection control activity and meet national standards with an aim to further reducing rates of HCAI’s in the
trust. It also enables us to report thoroughly and accurately on the state of healthcare associated infections.
The latest figures show that there was zero MRSA bacteraemia within this reporting period. There was 1
outbreak to report both in the inpatient areas and within the community, and a total of 11 CDI cases all
when investigated were not attributable to NELFT and deemed unavoidable.
Provision of infection control education and training are considered a priority. A variety of educational
initiatives have been utilised, a broad outline of the approaches taken are detailed in the report. In general
the frequency, timing, location and delivery methods utilised have been reviewed and evaluation forms
have shown effective session delivery uptake which has significantly improved and provides good
assurance at the current level of "herd knowledge" in existence.
NELFT participated in the annual PLACE inspections and in this reporting period standards have been
maintained comparative to previous years. There were also more areas than before inspected given the
extra registered locations.
This report intends to outline the progress made with meeting the infection control strategy and
highlight the areas for further work in 2014/15. This report is intended to serve the DIPC responsibility
to make available an annual report in quarter 1 of the current year for the last 12 months activity.
Page 5 of 48
1. Introduction
1.1
This annual report aims to reflect the activities, substantial achievements and challenges faced by
the Infection Control Service (ICS) in the delivery of the infection control programme for the period
1stApril 2013 to 31stMarch 2014.
1.2
The Infection Control Service provides a reactive and proactive level of service to all operational
services in North East London Foundation Trust (NELFT). Additionally the team have worked
closely with the strategic lead for infection prevention and control, director of infection control and
the commissioning teams to ensure infection control is given due consideration when
commissioning services and also at performance management reviews.
1.3
Since the publication of Department of Health (DH) Winning Ways: working together to reduce
healthcare associated infections (2003), infection control has moved to the foreground of the clinical
and political arena. The national priorities for infection control are set down in a number of DH
sponsored initiatives.
1.3.1
The prevention and control of healthcare-associated infection is currently a top priority for the
National Health Service (NHS). NELFT, and its Board, has obligations as a provider of healthcare
services to ensure that, as far as reasonably practicable, patients are protected from the risks of
healthcare-associated infection, as detailed in the Health & Social Care Act 2009; Code of Practice
for the Prevention and Control of Healthcare-Associated Infection.
1.4
The DH estimates that approximately 15% to 30% of Healthcare Associated Infections (HCAIs) are
preventable. The cost of HCAIs is estimated to be £1.1 billion per annum and contributes to more
than 15,000 deaths per year. Reduction in the incidence of HCAIs by 15 percent would free up
£150 million a year and most importantly, save lives.
1.5
The Infection Control Service is committed to improving health care services by promoting
excellence in the practice of infection prevention and control. The team strives to promote these
principles through the reactive and proactive elements of the annual infection control programme.
1.6
The key components of the Infection Control programme are:
o
o
o
o
o
o
o
Specialist timely advice
Strategic management
Policy development & implementation
Audit both environmental and clinical
Surveillance on a real time basis, and retrospectively for trend spotting
Education mandatory and non- mandatory
Outbreak prevention and control
Intranet page created last year with useful information for staff has been further developed while
maintaining the previous achievement. This has assisted in keeping the numbers of enquiries by
phone and email low; empowering staff to access information that is up to date at all times when
they need it.
2. Infection Control Service
2.1
Team structure
2.1.1
The established structure from the previous year has been maintained, a structure chart is available
on request. During 2014/15 it is anticipated that with automation of a number of processes the
structure can be reviewed to provide a better mix of nursing and administrative posts thus
supporting the locality structure of the organisation.
Page 6 of 48
2.2
Staffing Resource
2.2.1
The resource available during the reporting period is illustrated in the table below:
Post
Funded
Filled/Vacant
Band 8b
1.0 WTE
Filled
Band 8a
2.0 WTE
X1 8a left May 2013,
x1 8a left September 2013,
Post filled x1 October 2013, commenced February
2014
Band 7
3.0 WTE
Filled x 1 July 2013, commenced October 2013
X1 left December 2013,
x 1 left November 2013,
Band 6
2.0 WTE
X1 left January 2014
X 1 left February 2014
Filled post March 2013, commenced May 2014
Band 4
Total
1.0 WTE
Filled
9.0 WTE
Table 1: IPCT resource in Establishment
2.2.2
It is acknowledged that despite the resource available due to long term sickness, and staff leaving
with posts being recruited into there has been shortfall in the availability of a full establishment
which has equated in periods of reactive service delivery mechanisms and working at business
continuity mode. At the time of writing this report recruitment is progressing on 4 nursing vacancies
with bank admin staff being utilised to provide some capacity in the interim.
2.2.3
The skill mix review completed in 2013/14 will lead to one band 8a post being replaced by two
posts, one additional band 6 and a band 3 which will better support the locality model within
NELFT. The new structure will be led by a lead nurse and be supported by three whole time
equivalent band 6 (developmental posts) nurses, and three band 7 (clinical experts) nurses, whom
have administrative support at band 4 level. Each nurse will then cover a locality and a buddy
system will be implemented with a 7 and 6 becoming a pair supporting each other.
2.3
Service Delivery
2.3.1
The Infection Prevention and Control Strategy (appendix one) continues to be delivered to drive
improvements in all areas within NELFT. This is reviewed monthly to ensure we continue to meet
local and government targets set and reactive work that arises.
2.3.2
Additionally, transformation projects have been undertaken to ensure where practically possible
there is a consistent standardised approach on the key components of service delivery, these
include: the capturing, and undertaking of surveillance of healthcare acquired infections (HCAI)
transforming and embedding of a new holistic comprehensive system. This has been led and
undertaken by ICS rather than the ward staff, thus freeing up nursing time on the wards and
ensuring that where possible automated systems are used with data taken from credible sources.
Page 7 of 48
This has helped us minimise the incidence of HCAI and increase quality of patient experience and
safety by reducing avoidable harm. Section three of this report provides more information regards
this.
o
Education programme planning, implementation and delivery have been evaluated in order to
better use the nursing resource and overcome the challenges of traditional delivery methods. A new
strategy was formulated last year and this was implemented during 2013/14 concentrating on
mandatory training only. The view was that once the levels of mandatory training compliance are at
optimal levels then the other elements of the strategy could be implemented and staff released from
clinical duties to further build on the knowledge of IPC. This had a positive impact on the time
required by IPCT staff in delivery of education initiatives compared to previous years when
contrasted against the number of staff that are in date at any one time with mandatory training,
further detailed information is available in section five of this report.
o
During 2013/14 the clinical audit system efficacy was evaluated and was reported as an onerous
system to use due to the information technology requirements and systems in the trust. A new
programme of quarterly audits was developed with an in-house package to collate and analyse the
data; thus reducing the need for a software license to be purchased from an external company and
retaining control of the information and activity within the organisation. Further information on this is
available in section six of this report.
o
Access to patient’s records & results while working in a mobile way has been progressed with real
time results and advice being available, however this requires further significant attention to ensure
the data is used to add value to patient care.
o
A review of all the separate policies on IPC was commenced in 2012/13 with the intention to
complete in 2013/14. Drafts of three manuals listed below were prepared in early 2013/14 which
went out for comments and to the IPC groups. On reflection of the comments it was evident that
these manuals needed further significant input to make them user friendly. It is proposed that when
complete there will be three manuals that capture policies, protocols, leaflets, useful information and
guidelines all in one place targeted to the audience, this work will be taken forward in 2014/15:
Community Infection Prevention and Control Manual
Infection Prevention and Control in Hospitals.
Infection Prevention and Control in Mental Health Services (this will be further divided into
community and in-patients with two sections).
o
Draft leaflets have been developed for staff and patient information on five key subject areas. These
have been sent to the patient groups and public involvement for comments. During 2014/15 it is
intended to complete this work and ensure these are published.
o
A generic email account and duty nurse system developed in 2012/13 was successfully
implemented in 2013/14 to ensure all staff have timely access to IPC advice, support and
information as the need arises, with prompt responses. It has worked well and other specialist
teams in NELFT are now adopting this approach.
2.3.3
In order to continue to improve infection prevention and control across NELFT and the
services that ICS support, the service objectives for 2013/14 (available at appendix two),
agreed at a team away day, all have been implemented with exception of numbers 4, 9, 10,
and 16 which have not been possible due to reduced capacity. Service objectives for 2014/15
are to be agreed at the team away day planned for 11th June 2014 which will be made
available in the next report to Quality Safety Committee.
Page 8 of 48
2.4
Director of Infection Prevention & Control
2.4.1
In accordance with the CMO’s ‘Winning Ways’ (2003) document on the provision of actions
necessary to reduce HCAI’s, and as outlined in the CQC registration standards each organisation
must have a designated Director of Infection, Prevention and Control (DIPC). NELFT arrangements
are as follows:
Stephanie Dawe –Chief Nurse, and Executive Director of Integrated Care (Essex), DIPC.
2.4.2
The role of the DIPC is defined in Winning Ways: Working Together to Reduce Healthcare
Associated Infections, action area six:
•
•
•
•
Oversee local control of infection policies and their implementation
Be responsible for the Infection Control team within the health care organisation.
Report directly to the Chief Executive and the board and not through any other officer.
Produce an annual report on the state of health care associated infection in the
organisation for which he/she is responsible and release it publicly.
This report is intended to address this responsibility.
2.5
Infection Control Doctor (ICD)
2.5.1
Currently there is no infection control doctor in post. Service Level Agreement (SLA) has been
developed to reflect NELFT requirements and acute sector microbiology doctors have been invited
to express interest. In the interim the nurse consultant takes responsibility for prescribing care
pathways, treatment pathways and other infection prevention and control aspects of clinical care in
any given patient receiving care within NELFT where expert advice or specialist input is required in
liaison with local pathology labs, Health Protection Unit and medical consultants as required when
this falls outside of the normal pathways or presents as a highly complex case. Microbiology advice
is also sought as and when required. During 2014/15 a review will be completed into whether the
trust continues to seek to fill this or can this risk be mitigated with a different approach.
2.6
Governance
2.6.1
Infection Control Quality and Performance Standards
-
The Infection Control Service operates 0800-1800 Monday – Friday (excluding Bank
Holidays).
-
Routine telephone calls are answered immediately if coming into duty nurse, with messages
left within the following parameters:
Monday – Friday
Weekends
Bank Holidays
24 hrs
48 hrs
72-96 hours (depending on length of Bank Holiday)
-
Urgent calls are dealt with as soon as possible, and all nursing staff carry a mobile phone. Out
of hours, the Senior On-call rota handles urgent calls, and the individual may liaise with the
health protection agency as and when required.
-
Enquiries are logged for documentation and audit purposes demonstrating the advice given
and these are audited internally, by nurse consultant, quarterly, to check the standard of
advice provided is within operating standards and that it is within current best practice.
-
Managers are sent a written report/written communication summarising findings following site
visits and/or audits within 20 working days of the visit.
Page 9 of 48
-
Baseline audits feedback is in the form of verbal feedback at the time of the visit and followed
by an email/action plan with any other relevant information.
-
Incidents/accidents with infection control implications are investigated within 48 hours of
receipt of the information.
2.6.2
ICS has fully complied with all these standards during this reporting period despite the reduced
capacity in order to maintain quality standards and ensure staff are well supported around NELFT.
2.6.3
Quality of care and continued improvement in that quality, along with value for money has become
a focus of today’s healthcare agenda. ICS continues to work closely within the clinical governance
framework of the organisation and believe that the contribution made by our team continues to
contribute to quality improvements in all aspects of service provision.
2.6.4
An example of one quality improvement initiative, which will have a significant impact on the quality
of care, is the development of comprehensive surveillance systems for monitoring and reporting on
the state of healthcare associated infections. This will facilitate the Infection Prevention and Control
team to gain a wider perspective on the extent of HCAIs and target activities as required improving
compliance with good infection prevention and control practice.
2.7
Health and Social Care Act
2.7.1
The Care Quality Commission (CQC) publishes investigation findings into the hospitals it visits and
the shortfalls that are evident. The investigation findings are being utilised by ICS to bench mark
standards internally by working closely with the Quality and Patient Safety team and the trusts
compliance facilitators, thus identifying any areas that required attention; lessons that can be learnt.
During 2013/14 ICS attended and assisted with hosting the December Lessons Learnt event that
was held.
2.7.2
Attending network meetings has also provided the opportunity to remain informed with
developments and acquire shared learning opportunities from within the wider health arena so that
NELFT services continue to receive best practice, contemporary advice and information relating to
IPC. Both Essex and London based network programmes as well as the DIPC forum have been
attended regularly, positively contributing to the discussions in particular with the shared agenda
around root cause analysis and shared working.
2.7.3
The Code of Practice for the Prevention and Control of Health Care Associated Infections (The
Health Act 2006) was launched in October 2006. It is mandatory for every NHS organisation to
implement this Code from April 2007 onwards and trusts must be able to demonstrate that
they are doing so from then on.
2.7.4
A self- assessment is completed monthly against the criteria and fed back into governance
arrangements. NELFT has remained registered without restrictions for the duration of this
reporting period. There have been unannounced CQC visits to services which have resulted in
action plans being implemented to full effect so as to address any shortfalls in standards
observed and expectations; continuing to further improve. Appendix three provides a copy of
the self- assessment, and more details related to this are available on request from ICS.
2.8
Infection Control Committee
2.8.1
In accordance with the Controls Assurance Standards for Infection Control (NHS Executive, 2000),
there had been separate Infection Control Committee meetings for the respective areas of what
now is all NELFT (SWECS, ONEL, B&D, MHS) with representatives from across the organisation,
the local Health Protection Team and the acute trusts. The committees were changed to bi-monthly
IPC group meetings in 2012/13, and these continued to be held until December 2013.Terms of
Reference and membership can be found at appendix four.
Page 10 of 48
2.9
Reporting line to the Trust Board
2.9.1
The strategic lead for IPC meets with the DIPC regularly; the DIPC meets with the Chief Executive
to discuss progress and any issues pertaining to infection prevention and control. This is then fed
back to nurse consultant IPC. DIPC sits on trust board and takes forward any relevant
developments.
2.9.2
Bimonthly reports were provided to IPC group members, these papers and the meetings were
reporting into the Strategic IPC group which was held quarterly. Strategic IPC reported into the
quality and patient safety committee that then reported into trust board.
2.9.3
With the restructure of the organisation and a new management structure with locality based
working implemented into NELFT in December 2013, the IPC groups were disbanded, instead IPC
remains alive on agenda's with exception reports into Leadership Team meeting, Locality based
Quality Safety Group meetings - monthly, quarterly reports to senior leadership team, and bi-annual
reports into Quality Safety Committee, annual report to Trust Board. Copies of these reports are
available on request.
2.9.4
Quarterly reports are produced and provided to meet assurance requirements to each clinical
commissioning group. Copies of these reports are available from ICS on request.
2.9.5
Formal links have been developed between prescribing and infection control, Commissioning
Support Unit IPCT resource, and Public Health England leads for IPC as well as acute sector
IPCT’s. It is recognised that in response to the changes in the healthcare landscape stronger links
need to be developed between Clinical Commissioning Groups and ICS.
3.
Surveillance of Healthcare Associated Infections
3.1
Surveillance
3.1.1
Surveillance systems for monitoring of HCAI’s have been in place during this reporting period,
however it is recognised these were outdated against current best practices in the field and were
therefore significantly strengthened. There is now a weekly contact made (visit or telephone) to
each ward looking for patients susceptible to infection and ensuring that preventative measures are
in place, capturing information for the monthly MRSA admission screening audit. MRSA screening
is audited monthly, and positive results reported to ICS from the acute sector laboratories are
followed up with advice to the ward / community staff. Patients are followed up by ICS until they are
deemed to be infection free or no longer at risk of infection.
3.1.2
These systems assist in the prevention and identification of outbreaks/ and infection trends at an
early stage so that immediate action can be taken to identify and control the source, identify
problem areas, set priorities for infection control activity and meet national standards with an aim to
reducing rates of HCAI’s in NELFT. It also enables us to report thoroughly and accurately on the
state of healthcare associated infections in NELFT in-patient areas.
3.1.3
Methods of collating information from laboratory notifications and the follow up of these exist. A
system that did not exist in prior reporting periods has been implemented so that patients who
come back into the care of NELFT can be followed up with history available. It is intended that in
2014/15 this system can be further improved and made electronic once capacity improves.
3.1.4
A database to capture all the relevant surveillance data for reporting purposes and prevent a reoccurrence of loss of data is required and is one of the key priorities identified for the current year.
Access to the database will also be reviewed to facilitate data protection and still allow all the
members of the Infection Control Team to search and view data whenever required when working
in a mobile format away from base.
Page 11 of 48
3.1.5
Reduction of HCAI’s requires commitment from clinical teams, infection control teams, managers,
the patient, and their carers. It is everyone’s responsibility. Currently the infection control
surveillance system focuses on the following:
o
o
o
o
o
o
o
MRSA colonisation (in-patients)
MRSA bacteraemia (in-patients and community)
MRSA admission screening (in-patients)
Clostridium difficile (in-patients and community)
Alert organism surveillance (in-patients and community)
Ecolab bacteraemia (in-patients and community)
MSSA bacteraemia (in-patients and community)
3.1.6
Summary of surveillance data for this reporting period (to facilitate clear comparison the data split
has been left with the three business units rather than spilt into locality from December 2013.
During the next reporting period this will be presented with the locality format).
3.1.7
2013/14
Organism
MRSA bacteraemia
MSSA bacteraemia
Clostridium difficile
E. coli bacteraemia
Total
0
0
11
0
SWECS
0
0
4
0
NELCS
0
0
7
0
MHS
0
0
0
0
SWECS
1
0
3
1
NELCS
0
1
4
0
MHS
0
0
0
0
Table 2: Mandatory HCAI surveillance figures 2013/14 NELFT
2012/13
Organism
MRSA bacteraemia
MSSA bacteraemia
Clostridium difficile
E. coli bacteraemia
Total
1
1
7
1
Table 3: Mandatory HCAI surveillance figures 2012/13 NELFT
3.1.8
It is positive to note and credit to the IPC strategy implementation that rates reported in 2013/14
are much lower than 2012/13 with no bacteraemia cases. In recognition of the work required
around Clostridium difficile infection (CDI) incidence reduction a CDI strategy for NELFT has been
written for implementation in 2014/15.
3.2
MRSA colonisation rates
3.2.1
MRSA colonisation reflects the carriage of MRSA on the body, usually without clinical signs of
infection.MRSA admission screening targeted at detecting colonisationallows us to determine the
prevalence of MRSA colonization amongst patients admitted to our in-patient areas and whether
this varies by hospital, ward or by geographical area.These results allow appropriate management
strategies so the risk of cross infection is reduced.
3.2.2
NELFT in-patient services are required to undertake admission screening for MRSA as
outlined in the government policy on screening. The trust policy lists the areas that are
required to participate in this, and standards expected.
3.2.3
During the first quarter compliance was declared at 100% however during quarter two it was
around 95%. The review of the data capture process suggests work was required to
strengthen the data collection, capture, storing and reporting consistently NELFT wide, in
addition disparate systems had been in place thus far coupled with limited input and access to
pathology result systems which were contributing.
Page 12 of 48
3.2.4
During quarter two pathology accesses to all three laboratories used by NELFT had been set
up for each clinician in the service for the first time which facilitates real-time result reporting
and quicker treatment to patients that need it, this has been utilised successfully in
subsequent quarters and is assisting with real time access to results making a positive impact
on patient care around known and suspected infections. During quarter three a new system
was implemented with robust data to underpin audit results becoming available that shows the
trend working towards 100%.
3.2.5
During quarter four when looking at those admitted versus those who need to be screened
and are then actually reported with a screen was on average at 86%(it should be noted that
within mental health services a risk assessment is undertaken to determine if screening is
required). Work is underway with the wards to address this and feedback is provided monthly
of shortfalls in screening.
3.2.6
It was expected that with the implementation of an automated system to detail those admitted
versus those screened for MRSA and using the laboratory reports to evidence this, the
compliance level would fall compared to the manual return from wards whereby they would
self declare manually on a monthly basis 100% compliance based on admissions books kept
locally. During 2014/15 by sharing the audit results and working with the wards we are aiming
to truly reach 100% compliance that is evidence based.
3.2.7
Management of MRSA infection and/or colonisation in the community continues to be
assessed on an individual basis and in partnership with the client/patient and carer, taking into
account for example, planned surgical intervention or planned hospital admission. This
approach has been agreed with the Health Protection Agency (HPA), and complies with
current national evidence.
3.3
MRSA bacteraemia rates
3.3.1
MRSA bacteraemia reflects the burden of serious (bloodstream) infection associated with
MRSA and not MRSA colonisations or superficial infections. Acute Trusts in England have
been involved in the mandatory surveillance of MRSA bacteraemia since April 2001.
3.3.2
The figures in table 2show that there was no MRSA bacteraemia in NELFT during this
reporting period which is excellent given the size, geography and scale of the organisation and
the patients we care for.
3.4
Clostridium difficile Rates
3.4.1
When Clostridium difficile is transmitted to vulnerable patients, often older people who have
been treated with antibiotics, it produces symptoms of varying severity, from diarrhoea to
severe inflammation of the bowel. This may cause considerable morbidity and mortality among
older people and imposes a substantial financial burden on healthcare services, including
prolonged hospital stay, requirements for isolation, more intensive nursing, extra treatment,
laboratory and infection control costs.
3.4.2
The Chief Medical Officer and Chief Nursing Officers letter (December 2005) outlined actions
required of Directors of Infection Prevention and Control, in order to minimise the risk of
infection caused by Clostridium difficile.
3.4.3
NELFT had embedded into practice all the recommendations made by HPA on control and
management of Clostridium difficile infection nevertheless a key priority for 2013/14 was to
develop an individualised action plan for the management of Clostridium difficile, given the
number of cases in the previous year, the action plan was intended to outlined lead
responsibilities and actions to be taken to allow and drive further compliance and
improvements with these requirements and so that the risk of cross infection is minimized this
is in line with the zero tolerance targets set for current financial year. A CDI reduction strategy
was written and is available on request. Due to reduced capacity operationalising this has
Page 13 of 48
been delayed to 2014/15 and will be a key priority given in the KPI's there is a zero target for
2014/15 and that 11 cases were detected in 2013/14.
3.4.4
A breakdown of C.difficile cases 2013/14 is provided in table 4 below; all cases after
investigation have been unavoidable and not attributable to NELFT. It should be noted that
this covers both in-patient and community areas which previously (table 5) only focused on inpatient areas due to the surveillance systems in place at the time. When comparing 7
cases were detected in 2012/13 versus 11 in 2013/14. The increase is believed to be as a
result of better detection and surveillance systems with no fall in CDI incidence within the
wider health economy at the same time
London
Case 1; DF known history of bowel surgery and antibiotic usage
Case 2; RM previous infection prior to admission
Case 3; CB known carrier
Case 4; JG on medication that can trigger C.difficile, and history of antibiotics
Case 5; PM repeated use of antibiotics
Case 6; GG being investigated at time of writing this report
Case 7; JM antibiotic use and symptomatic prior to admission
Essex
Case 1; EM known carrier, history of antibiotic use
case 2; RE bowel surgery, on medication that can trigger infection and antibiotics for
wound
case 3; GT Previous CDI 2 months previous to admission
case 4; LS on medication that can trigger CDI, cancer of lung therefore susceptible to
infection
Table 4: CDI cases and predisposing factors identified on RCA
Month
April
May
June
July
August
September
October
November
December
January
February
March
Number of Clostridium difficile cases
and where
0
1 – Gray Court Ward 1
0
0
1 AFC
1 – Thorndon Ward
0
0
0
1 – AFC
1 – Grays Court Ward 2
1 – Foxglove Ward
1 – Grays Court Ward 1
0
Table 5: 2012/13 NELFT clostridium difficile positive stool samples reported within in-patient areas
3.4.5
Each positive notification was analysed and a full root cause analysis undertaken. Findings have
been shared within the organisation and at local level where there is benefit to enhance the patient
experience and quality of care, when there is shared care with other organisation.
3.4.6
Training on how to conduct RCA's and post infection reviews plus CDI in general and its
management has been provided on a six monthly basis to the ward staff to raise awareness and
knowledge levels. Both sessions were well attended and received.
Page 14 of 48
3.4.7
ICS has produced Clostridium difficile leaflets for both staff and patients/visitors. These leaflets
once ratified by the reading group will be widely available across the trust and in areas where
patients can access them readily.
3.5
Alert Organism Surveillance
3.5.1
ICS continues to complete alert organism surveillance in community and in-patient areas. This
involves continuous monitoring of the incidence of healthcare associated infections so that
outbreaks are identified early and control measures are implemented promptly. There have
been no cases in 2013/14.
3.5.2
The Infection Control Team continue to support and advise healthcare professionals involved in the
care of patients/clients with communicable diseases and/or colonised/infected with resistant
organisms. There are plans for 2014/15 to provide staff with knowledge on how to deliver news on
positive results to patients and the impact this has on them.
4.
Outbreaks and Incident Management
4.1
Outbreaks
4.1.1
IPCT continues to react to outbreaks and incidents of infection to develop appropriate control
strategies in collaboration with clinical staff and management across the trust - not just in the
inpatient areas.
4.1.2
During 2013/14 there was one outbreak of infection in Essex in-patient ward lasting 10 days,
caused by Norovirus. There is a separate report written and available on request with full
details of this incident.
4.1.3
A total of 9 patients were symptomatic over this period of time and two had confirmed
Norovirus samples, of the staff reporting that they were affected none provided stool
samples. Wider surveillance activities show that Norovirus was prevailing in the community
at this time. Lessons to be learnt identified that the cleaning contract and resource
required be reviewed as the recently implemented schedules were insufficient for the ward’s
needs. As this is subcontracted out by NELFT, discussions are being held with all relevant
parties.
4.2
Incidents
4.2.1
Incidents related to or about infection control are reported on NELFT incident recording system;
Datix. There were a total 62 Datix reports filled in 2013/14. These are reviewed as they arise and
fully investigated. Reports of actions were provided to IPC group members on a bi-monthly basis,
and now in the quarterly reports. Of the 62 incidents 13 were due to needle stick injuries, and the
rest around building and environmental issues as well as CDI infections.
4.2.3
A list of all the incidents is available on request. There have been no major incidents due to
infection control in 2013/14.
5.
Education & Training
5.1
Mandatory Training
5.1.1
With the implementation of the Education Strategy the frequency of mandatory training was
set to once every three years for all staff across NELFT. During this reporting period the face
Page 15 of 48
to face delivery of training was phased out and the development of the formal module course
for AT Learning allowed the disbanding of the temporary E-Learning presentation and quiz
marking that were in place previously. The introduction of the AT Learning and the change in
frequency has allowed NELFT to reach an overall 87 % compliance at year end.
5.1.2
A copy of the education strategy is available on request, it is intended that in 2014/15 given
that the mandatory training compliance has reached an acceptable level time and resources
can be spent on the development of the non mandatory elements of the strategy which
includes key facts for staff, link practitioners programme, infection control in practice for
professionals and infection control in practice for healthcare workers sessions.
5.1.3
Compliance figures are as below. One session was cancelled due to very low numbers.
Total number of face to face sessions conducted between period April 1- December 31 Sessions arranged via E&T
Bespoke including Mandatory Training
Bespoke non Mandatory Training
Total
24
13
2
39
table 6: face to face class room sessions delivered
Numbers attending – All Sessions prior December 31, 2013 and split between Essex and
London
Sessions Via E&T (Total)
London
Essex
Bespoke including Mandatory Training (Total)
London
Essex
Bespoke non Mandatory Training (Total)
London
Essex
Total
301
243
58
161
98
63
40
40
0
502
table 7; total numbers split analysis
5.1.4
In comparison to 2012/13
Face to Face
Face to Face
Face to Face
Online
Total
Total Staff Trained 2012/2013
114 session delivered
SWECS
597
22 session delivered
NELCS
1236
28 sessions delivered
MHS
1260
All
702
3795
Table 8: summary of total number of staff trained 2012/13
It is not possible to provide the above figures in table 8 as percentages of staff trained per
business unit as the number of staff employed at any one time fluctuates throughout the year.
5.1.5
Table 9 below provides the breakdown per unit/locality and percentage compliance throughout
the year.
BOROUGH
MHS
NELCS
SWECS
MONTH
Apr-13
TARGET
AUDIENCE
1689
2057
1385
MEETS
REQUIREMENTS
1378
1426
1049
COMPLIANCE
%
81.59%
69.32%
75.74%
Page 16 of 48
CORPORATE
415
181
43.60%
1751
2041
1385
412
1422
1475
1182
204
81.21%
72.27%
85.34%
49.51%
1750
2027
1386
409
1441
1554
1211
234
82.34%
76.67%
87.37%
57.21%
1709
2015
1385
399
1440
1564
1225
250
84.26%
77.62%
88.45%
62.66%
1734
2025
1374
No results
1436
1573
1217
No results
82.80%
77.68%
88.60%
No results
1742
2046
1413
No results
1455
1565
1226
No results
83.52%
76.49%
88.60%
No results
1742
2047
1414
393
1481
1558
1232
258
85.02%
76.11%
87.13%
65.65%
755
532
497
1139
749
1312
61
667
472
423
938
586
1108
57
88.30%
88.70%
85.10%
82.40%
78.20%
84.50%
93.44%
786
538
490
1122
767
1346
542
702
481
421
964
616
1147
411
89.31%
89.41%
85.90%
85.92%
80.31%
85.22%
75.83%
794
534
483
1095
771
1339
552
721
493
418
975
621
1167
441
90.81%
92.32%
86.54%
89.04%
79.92%
87.15%
79.89%
Basildon & Brentwood
796
Thurrock
541
Barking & Dagenham
486
Mar-14
Havering
1107
Redbridge
646
Waltham Forest
1362
Corporate
597
Table 9; mandatory training compliance 2013/14
728
500
421
986
646
1184
478
91.46%
92.42%
86.63%
89.07%
83.25%
86.93%
81.06%
MHS
NELCS
SWECS
CORPORATE
MHS
NELCS
SWECS
CORPORATE
MHS
NELCS
SWECS
CORPORATE
MHS
NELCS
SWECS
CORPORATE
MHS
NELCS
SWECS
CORPORATE
MHS
NELCS
SWECS
CORPORATE
Basildon & Brentwood
Thurrock
Barking & Dagenham
Havering
Redbridge
Waltham Forest
Corporate
Basildon & Brentwood
Thurrock
Barking & Dagenham
Havering
Redbridge
Waltham Forest
Corporate
Basildon & Brentwood
Thurrock
Barking & Dagenham
Havering
Redbridge
Waltham Forest
Corporate
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Oct-13
Nov-13
Dec-13
Feb-14
Page 17 of 48
5.2
Link Practitioners
5.2.1
There have been three link programmes in existence from historical arrangements in place
that have been attended by staff. Table 10 below details historical attendance. During this
reporting period due to the low uptake and challenges of capacity within the team a decision
was made to stop the regular link meetings, review the programme.
Meeting 1
Meeting 2
Meeting 3
Meeting 4
Adults
8
6
3
Cancelled
Children & Dental
services
5
6
Cancelled
Cancelled
Total
13
12
3
N/A
Table 10: figures of attendance for Link meetings in SWECS 2012/13
No data is available for NELCS and MHS, although 1 meeting took place for MHS in July and
one in June for NELCS.
5.2.2
Link workers were changed to link practitioners, the role was defined and a role definition was
created. This is available on request. The Link Practitioners membership was revised and staff
details database created. It was decided to have quarterly whole day events that practitioners
or their nominated deputy would be invited to attend. The conference agenda would include
contemporaneous but current issues of note and that being held outside the workplace would
help focus the minds of staff attending. The event held in December 2013 was a success with
over 40 people attending and some very positive reviews.
5.2.3
In 2014/15 there will be a programme of notice board information created monthly and send
out to Link staff to display in prominent locations, and BOM - Bug of the month newsletter will
also be produced monthly and provided to aid learning and knowledge building within the
workforce.
5.2.4
A rewards scheme will also be set up to reward staff for the activities they undertake and this
will help drive continued compliance with key target areas using the gamification marketing
theory in a healthcare environment to incentivise the scheme making it an attractive add on to
the roles staff have and perform ordinarily. Collection of enough reward points will lead to
ambassador status being achieved and this will be recognised with an award.
6.
Audit Programme
6.1
Audit cycle
6.1.1
Audit aimed at assessing the work and clinical environment from an infection control
perspective forms part of the proactive infection control programme in each trust.
6.1.2
During 2012/13 standardised tools were developed for in-patient areas, community clinics,
mental health services; which allowed scoring and the introduction of traffic light system (see
below). It should be noted that this system complies with the audit tools for monitoring
Infection Control Standards (2005) circulated by the Department of Health & Infection
Prevention Society and enables IPCT to complete the audit cycle and hence effect change. In
the past the system of scoring where it existed led to perceptions that a high score indicated a
good level of compliance. In practice it is relatively easy to score high but still perform below
Page 18 of 48
standard. Therefore definitions have been made more robust and RAG has been introduced
also based on risk assessments within action plans.
6.1.3
Traffic light audit tool to be implemented in 2013/14
RED
If the overall standard achieved fails to reach 70%, the department will be reaudited within 3 -6 months.
AMBER
If the standard achieved is between 70%-85% the department will be re-audited
within 6 – 9 months of the original audit. If the standard achieved fails to reach
85% on re-audit the lead nurse IPC should be informed.
GREEN
If the standards achieved are above 85% a repeat audit will be undertaken as
part of the continuing annual audit programme.
6.1.4
The IPC lead nurse monitors red and amber audits in each area to ensure improvements
continue and progress until 85% is achieved. This allows NELFT to deliver high quality care in
a fit for purpose environment that is in line with current best practice.
6.1.5
Due to reduced capacity in the team only in-patient areas have been audited, scores and
action plans have been fed back to managers and individual reports are available on request.
The salient themes within action plans are the need to have more robust systems in place for
recording decontamination of equipment and surfaces, the products used to achieve this and
for standardisation of practices such as treatment of common infections. Results also
highlighted shortfalls in cleaning standards which have been fed back to the facilities manager.
There were also a number of maintenance issues noted which again have been fed back but
highlight the need to train staff in wards about looking at the environment and reporting
problems as they arise. Overall scores were around 80% or more in all ward areas.
6.1.6
The intention is that with improved capacity in 2014/15a new baseline for an audit cycle and
there on in an annual cycle of continuous improvements will be sought and measured against
current policies, tools will be adapted as required and in line with national changes so as to
ensure NELFT remains in line with best practice.
6.1.7
Audits required post incident or on a reactive basis have been conducted as have spot checks
and audits arising as part of incident investigation.
6.1.8
A new programme of clinical audits was launched in April 2013. NELFT wide there were three
standard workbooks available to facilitate clinical audits, feedback was provided instantly to
local areas through auto generated graphs and scoring.
6.1.9
Audits are quarterly in frequency and required 5 clinical observations to be undertaken during
the quarter. There had been an improved uptake within services with returns made in quarters
1 and 2, as operations based teams become familiar with auditing, and the data collection
books. In quarter three the return was limited; services were focused on organisational
change, and the time of year (end December/ beginning of January) also impacted return
rates.
6.1.10 Due to varying computer access and compatibility issues trust wide the workbooks were
causing much frustration when using the document and the feedback was that it was complex
for staff to use and enter into. Therefore in preparation for quarter four, audits were created on
SNAP – the trusts audit software used for all other auditing of this nature. SNAP being internet
based provided a clean fresh interface with the same audit questions and made access and
use easier. Details of the results are available to view on request.
6.1.11 The move to this new audit standard and method equates to a financial saving of 6k
recurrently due to the termination of using externally purchase software previously, it also
Page 19 of 48
ensures services are engaged with audit and have access to timely feedback at no cost,
empowering them to make changes required to enhance the patients experience and quality
of care provided.
6.2
Patient-led assessments of the care environment (PLACE)
6.2.1
Patient-led assessments of the care environment (PLACE) is the new system for assessing
the quality of the hospital environment, which replaced Patient Environment Action Team
(PEAT) inspections from April 2013. PLACE assessments apply to all hospitals delivering
NHS-funded care.
6.2.2
PLACE assessments put patient views at the centre of the assessment process, and use
information gleaned directly from patient assessors to report how well a hospital is performing
in the areas assessed – privacy and dignity, cleanliness, food and general
building maintenance. It focuses entirely on the care environment and does not cover clinical
care provision or staff behaviours. Importantly, patients and their representatives make up at
least 50 per cent of the assessment team. The assessments are undertaken annually, and
results are made public by the Department of Health during September of each year.
6.2.3
NELFT has completed all of the PLACE assessments required to be undertaken and the
results are now within the public domain. The Health & Social Care Information Centre have
published the findings of the 2013 PLACE visits, the key findings being:
Nationally a total of 1,358 assessments were undertaken
The National average score for Cleanliness was 95.74%
The National average score for Food and Hydration was 84.98%
The National average score for Privacy, Dignity and Wellbeing was 88.78%
The National average score for Condition Appearance and maintenance was 88.75%
6.2.4
Action plans have been developed following the PLCAE assessments to deal with any matters
that are of concern to the assessing team. Some of these actions will require expenditure of
revenue and in some instances capital funding. A programme of remedial/improvement works
will developed as indicated on the action plans, and where possible incorporated into the
revenue and capital programmes at the earliest opportunity.
6.2.5
The aim of PLACE assessments is to provide a snapshot of how an organisation is performing
against a range of non-clinical activities which impact on the patient experience of care –
cleanliness; the condition, appearance and maintenance of healthcare premises; the extent to
which the environment supports the delivery of care with privacy and dignity; and the quality
and availability of food and drink.
6.2.6
The assessment of cleanliness covers all items commonly found in healthcare premises
including patient equipment; baths and showers; furniture; floors and other fixtures and fittings.
6.2.7
The assessment of condition, appearance and maintenance includes the above items as well
as a ranges of other aspects of the general environment including décor, tidiness, signage,
lighting (including access to natural light), linen, access to car parking (excluding the cost of
car parking), waste management and the external appearance of buildings and the tidiness
and maintenance of the grounds.
6.2.8
The assessment of privacy, dignity and wellbeing includes infrastructure/organisational
aspects such as provision of outdoor/recreation areas, changing and waiting facilities, access
to television, radio, computers and telephones; and practical aspects such as appropriate
separation of sleeping and bathroom/toilet facilities for single sex use, bedside curtains being
sufficient in size to create a private space around beds and ensuring patients are
appropriately dressed to protect their dignity.
Page 20 of 48
6.2.9
The assessment of food and hydration includes a range of questions relating to the
organisational aspects of the catering service (e.g. choice, 24 hour availability, meal times,
access to menus) as well as an assessment of the food service at ward level and the taste
and temperature of food.
6.2.10 The criteria included in PLACE assessment are not standards, but they do represent both
those aspects of care which patients and the public have identified as important, and good
practice as identified by professional organisations whose members are responsible for the
delivery of these services, including but not limited to the Healthcare Estates Facilities
Managers Association, the association of Healthcare Cleaning Professionals and the Hospital
Caterers Association.
6.2.11 The assessments undertaken in 2013 were the first under this programme. It is the intention
that they will be undertaken annually.
6.2.12 NELFT Results, table 11 below provides detailed information
Site Name
ALASTAIR
FARQUHARSON
CENTRE
WOODBURY UNIT
CHAPTERS HOUSE
AKA GOODMAYES
HOSPITAL
BROOKSIDE
BRENTWOOD
COMMUNITY
HOSPITAL
GOODMAYES
HOSPITAL ADULT
SUNFLOWERS
GALLEON AND
HERONWOOD
MAYFLOWER
COMMUNITY
HOSPITAL
GRAY'S COURT
COMMUNITY
HOSPITAL
Site Type
Cleanliness
Food &
Hydration
Privacy,
Dignity and
Wellbeing
Condition
Appearance &
Maintenance
Community
99.36%
91.24%
90.00%
86.26%
Mental Health
96.27%
94.21%
76.67%
81.65%
Mental Health
95.71%
94.87%
84.27%
79.79%
Mental Health
95.52%
97.49%
86.82%
75.66%
Community
100.00%
92.62%
100.00%
95.63%
Mental Health
99.61%
94.97%
97.23%
89.72%
Community
99.67%
94.50%
97.89%
87.14%
Community
97.25%
93.59%
90.70%
78.72%
Community
99.68%
95.01%
81.69%
87.18%
Table 11: NELFT PLACE scores 2013/14
6.2.13 NELFT overall score in comparison with National Average detailed in table 12
Criteria
Highest
Lowest
National
Average
NELFT Overall
score
100%
24.46%
95.74%
98.16%
100%
26.67%
84.98%
94.44%
100%
52.26%
88.87%
89.88%
100%
36.25%
88.75%
85.07%
Cleanliness
Food & Hydration
Privacy, Dignity and Wellbeing
Condition Appearance &
Maintenance
Table 12: national averages in comparison
Acknowledgement to Estates and Facilities for the information and data provided to enable section 6.2 of this report
to be written.
Page 21 of 48
7.
Decontamination
7.1
Decontamination of medical devices
7.1.1
NELFT have a medical devices group that meet monthly that monitors the application of
decontamination practices in the trust, reviews the incidents arising from decontamination
issues and ensures the decontamination of medical devices is in line with the policy and that
items procured for can be adequately cleaned after purchase. ICS ensure that a member of
staff sits on this group.
7.1.2
Decontamination Lead has been delegated via the DIPC and Strategic lead for IPC to Nurse
Consultant Infection Prevention and Control (NCIPC).
7.1.3
The NCIPC has contributed to the medical devices policy writing and this is available on the
internet. Audits conducted quarterly highlight that services are imbedding the policy into
practice, with incident forms on Datix providing insight into the incidents related to
decontamination, these are investigated; corrective actions implemented.
7.1.4
Most services in NELFT utilise single use or single patient use equipment and a search of
sundries purchased over the 12 months provided evidence to support this. There is a need to
standardise the equipment and care aids used around the trust, and a standardisation group
has been set up to oversee this. During 2013/14 gloves were standardised to one supplier for
non sterile examination gloves, one supplier for sterile examination and sterile procedure
gloves all in a range of sizes. This will assist with building consistency but also will aid with a
54K recurrent saving based on if NELFT continued to use all the deferring suppliers and
makes prior to standardisation. The supplies and procurement team have been instrumental in
achieving this in collaboration with ICS.
7.1.5
Services such as dentistry that continue to use reusable equipment perform quarterly audits,
have been provided with bespoke training, and ensure they are working within the regulations.
they also perform daily, weekly, monthly, quarterly and annual checks by a combination of
internal and externally commissioned services.
7.1.6
All services are encouraged and inspected to ensure they have decontamination of medical
equipment logs. That indicator tape is used to mark items clean for use after decontamination.
In 2014/15 this work needs to be progressed so that logs are meaningful and can be produced
at time of audit, that the asset register is linked into and used to ensure all equipment is
included.
Appendix 1
Infection Prevention and Control Strategy
Introduction
The purpose of this strategy is to ensure there is a shared vision for infection prevention and control,
and outline what the Trust will achieve over the next three years in order to achieve our ambition to
prevent all avoidable infections within NELFT..
Patient Safety
NELFT places the utmost importance on ensuring patients’ safety. Minimising the risks from infection
is paramount to that aim.
Infections acquired in healthcare can cause serious problems; they can complicate illnesses, cause
distress to patients and their family, and can in some cases lead to patient death. There are also
economic consequences such as the effect on bed availability and the ability to meet some
Government targets.
There is a significant amount of national guidance now available to ensure organisations have
sufficiently effective systems and processes in place to assure patients and staff alike that the care
provided is of a quality that safeguards patients in primary, secondary and community care. The most
notable documents being;
•
•
•
•
•
•
•
•
•
•
The Health and Social Care Act (2008) – code of practice for health and social care on the
prevention and control of infection and related guidance
Care Quality Commission (2009)
Essential Steps to safe, clean care (2007)
Saving Lives (revised edition 2007)
National Specification for Cleanliness in the NHS (2007)
Revised guidance on contracting for cleaning (2009)
Towards Cleaner hospitals and lower rates of infection (2004)
Winning Ways – Working together to reduce HCAI in England (2003)
Matron’s charter: an action plan for cleaner hospitals (2004)
NICE Guidance 2011
The guidance from all national documents and Government directives needs to be embraced by
NELFT and embedded within its infection prevention and control systems and processes.
The code of practice for health and social care on the prevention and control of infection and related
guidance (Health and Social Care Act 2008) reinforces the need to continuously monitor and improve
the quality of the infection prevention & control services.
Failure to observe the code of practice may result in enforcement action by the Care Quality
Commission as it may be used as evidence of a breach of the registration requirement.
NELFT needs to be able to demonstrate its over-arching commitment to ensuring its patients, staff
and visitors are cared for in an environment where best practice in the prevention and control of
infection is second nature to its entire staff whether they are doctors, clinicians, healthcare assistants
or support workers. All staff, and particularly all health and social care workers, have a vital part to
play in helping minimise the risk of cross-infection.
Our Vision
‘Staff will be empowered to embed infection, prevention and control practices to maintain zero
tolerance in avoidable infections ensuring the service user is and feels safe in our care.’
Page 23 of 48
Our aims
1. Clear governance assurance framework
To ensure the organisation has the appropriate governance systems to identify, monitor and manage
risk, ensure the appropriate reports, audits and surveillance of infection prevention and controls are in
place.
2. Surveillance
To ensure we proactively review, monitor, analyse reports and information concerning healthcare
acquired infections, identifying areas with higher risks of infection, and implement appropriate control
measures.
3. Education and training
To ensure our staff have the appropriate knowledge and skills and champion infection prevention and
control.
4. Policy development and implementation
To ensure application of evidence-based protocols and practices for both staff and users of services.
5. Design and maintenance of the environment and medical devices
To ensure the environment and the devices used are clean, safe and appropriate.
6. Stakeholder involvement
To ensure we listen, inform, involve and work together with our patients, public and partners.
To deliver these aims, we will require strong leadership from ‘board to service user,’ good
management, communication and engagement.
NELFT Infection Prevention & Control Strategy
ACTION PLAN 2012 - 2014
Red = started but requires significant progress to meet target date of completion
Amber = in progress and likely to meet target date of completion
Green = completed and measures in place
Updated 3.3.14
Heading
1.
Clear
governance
assurance
framework
Aim
Objective to be
reached
To ensure the organisation
has the appropriate
governance systems to
monitor and manage risk,
ensure the appropriate
reports, audits and
surveillance of infection
prevention and controls are
in place
To continue to
meet CQC
essential standards
Outcome
CQC outcomes
achieved and
maintained
Target Date
31.3.13
RAG
Rate
Progress Record
Governance systems have been reviewed to
align into NELFT.
Gap analysis of Health and Social Care Act,
essential steps, NICE guidelines completed by
IPC managers
To continue to
adhere to the
Health & Social
Care Act 2008 to
ensure we meet
national standards
National
standards met
and maintained
First
milestone
31.3.13
Gap analysis shows areas that require input and
support from IPCT
IPCT to work with service to bridge gaps
identified
Page 25 of 48
Heading
Aim
Objective to be
reached
Outcome
To ensure a clear
governance
framework is in
place to review,
implement and
monitor infection,
prevention and
control
Structure and
governance
framework in
place
Target Date
31.12.12
RAG
Rate
Progress Record
Reports:
Quarterly reports – QSG
Annual Report - QSC
Meetings:
IPC groups feed into SIPCG
SICG feeds into QSC; This allows information to
be sent to trust board
TOR, agendas and meeting format for all three
BU IPC groups to be revised
To embed new
infection control
structure to
proactively manage
and monitor
infection prevention
and control
Standardisation of
reporting, auditing
and monitoring to
improve quality and
safety
Infection control
structure recruited
to and effectively
managing the
IP&C agenda.
Successful
delivery of the
Health and Social
care Act and
CQC standards.
31.12.12
Full establishment – vacancies are being
recruited to.
DIPC
DoN – strategic lead for IPC
nurse consultant
2 nurse managers
3 IPC nurse specialists
2 IPC nurses
administrator
30.9.13
Audit cycles being reviewed
Software in place as support systems to audit
programme currently vary across the BU’s
New plan of clinical audit is require NELFT wide
New plan of environmental audit is required
NELFT wide
Page 26 of 48
Heading
Aim
Objective to be
reached
Outcome
Target Date
RAG
Rate
Progress Record
Agree infection,
prevention and
control SLA,
achieve KPI’s and
share agreed data
SLA’s for each
business unit
agreed and
signed off. KPI’s
achieved
(30.8.13)
30.10.13
KPI’s agreed with commissioners-SWE
NEL-Poor engagement
SLA for microbiology:
Whipps Cross – found; to be reviewed
King Georges – nothing in place, to be reviewed.
BTUH – last signed SLA in 2009. To be reviewed.
DS discussed KPI with commissioners and
separate SLA is not required.
To review
contracts/SLAs
relating to infection,
prevention and
control
All associated
contracts and
SLA’s meet
NELFT needs to
deliver the
agenda.
(30.7.13)
30.10.13
Meeting with Procurement completed to outline
when setting up SLA with IPC related matters to
involve IPCT
Standardisation groups set up to address this and
progress work
Meeting slot obtained for NELFT estates and
facilities meetings so that facilities contracts can
be reviewed
DS discussed KPI with commissioners and as
contracts arise IPC will be involved with review.
To review
governance
processes,
strengthen further
where indicated
Audit shows
strong
governance
systems in place.
31.3.14
Work commenced on looking at PCA’s and how
IPCT can cross check service self-assessments
at time of PCA submission in line with IPCT audit
cycle
PCA’s no longer relevant. KK met with QPS to
review monitoring and map out issues.
DS to pick up with AG early 2014.
Page 27 of 48
Heading
Aim
Objective to be
reached
Outcome
2. Surveillance
To ensure we proactively
review, monitor, analyse
reports and information
concerning healthcare
associated infections,
identifying areas with
higher risks of infection and
implement appropriate
control measures
To receive and
proactively manage
information
cohesively across
the organisation
All surveillance
information is
reviewed and
actions taken
accordingly to
ensure NELFT
responses
appropriately and
in a timely
manner to
prevent and
control infection.
Target Date
(30.8.13)
31.3.14
RAG
Rate
Progress Record
Reliant on IT and patient information systems as
well as pathology lab results systems across 3
providers to deliver on this
Contact made with each pathology lab, limited
collaboration as formal SLA not in place regards
IPC microbiology cover/provision
Contact made with pathology to ask if they can
send results electronically and staff now have
access to the pathology systems to enable real
time surveillance
Systems in place. IPC now receiving pathology
results however Bart's and London have IT
issues.
KK met with Bart's Health 31.1.12 re remote
access to Cyberlab
Improve quality and
safety by
undertaking root
cause analysis and
sharing lessons
learned
Lessons are
learned and
subsequent
reductions in
incidents are
seen.
30.9.13
RCA’s completed at present on MRSA and C.diff
bacteraemia
To standardise the
processes, data
collection and
monitoring to
improve quality and
safety
Robust data
collection and
monitoring
process in place
(30.7.13)
30.12.13
SWECS use system 1 and NELCS & MHS use
RiO.
IPCT have gained access to both systems as
stage 1, team to look at using the records to
document both remotely and also when at work
base
Then to look at how data arrives, is logged and
actioned. Transformation group set up and to
meet monthly to progress this within the team.
Actions in place awaiting NELFT IT strategy to be
implemented re: Systmone.
Page 28 of 48
Heading
Aim
Objective to be
reached
To standardise the
use of microbiology
to ensure 24 hour
access is available
from a nominated
infection control
doctor (ICD) across
the trust
Outcome
Microbiology
service is fit for
purpose and
provides
appropriate
microbiology
support.
Target Date
(30.7.13)
(30.1.14)
31.3.14
RAG
Rate
Progress Record
SLA’s found
SLA’s for current year written and agreed
Cover to be arranged
Looking at microbiology costing
Unable to secure IPC Dr. and further work
progressing to identify suitable Dr.
DS to escalate to SD to identify whether IPC Dr is
required across Trust.
3.
Education &
Training
(delivery &
accessibility of
training)
To ensure staff have the
appropriate knowledge and
skills and champion
infection prevention and
control
To review
surveillance
systems and
lessons learned
Robust
surveillance
systems in place
for monitoring and
sharing lessons
learned.
31.3.14
To be looked at once new service operating
model is agreed
To standardise
mandatory training
across the Trust
Standardised
Mandatory
training in place
31.3.13
Mandatory training is available online and face to
face the same content is used.
Education Strategy in place
To standardise the
education reporting
processes and
monitoring across
the trust
Standardised
education
reporting and
monitoring
process in place
(30.8.13)
30.3.14
Meeting with business team and E&T completed
to outline the various methods at present
IPCT are reliant on trust reporting systems to
capture the staff who have completed training
Online training to be included in AT learning
programme, package developed and ready to
use.
Page 29 of 48
Heading
Aim
Objective to be
reached
Outcome
Target Date
RAG
Rate
Progress Record
To have an
appropriate IT
system to record
and monitor
training across the
Trust
Robust IT system
in place to
support recording
and monitoring of
training
2013/14
Work is underway with IT, and E&T to assist with
this.
Online training will be included in AT learning
programme.
At learning programme introduced 6.11.13 across
NELFT.
To embed the Link
Practitioner
Champions across
all services,
ensuring
appropriate
meetings are in
place
All services will
have Link
Practitioners (LP)
(30.9.13)
(1.12.13)
28.2.14
Different LP system in place at present across
NELFT are being reviewed
IPCT aims to have one LP system in place
Quarterly conference planned and to be held in
different locations, first conference being held
6/12/13 in Goodmayes area. Contact to be
maintained at other times via the use of webinars,
newsletters and small focus meetings, road
shows.
Link Practitioner’s list to be produced (after new
structure) detailing Practitioner and work base to
identify gaps across NELFT.
Link Practitioner conference 6.12.13 well
attended and successful. 3 monthly meetings
arranged. Gaps identified and need to push
Children’s and Dental.
To have a robust
competency
Framework in place
and audit
effectiveness
Competency
framework in
place and
embedded
(30.7.13)
30.3.14
Competency framework in place for SWECS
Competency framework being revised along
sides education programme review within IPCT
To link in with weekly news, link to Royal
Marsden manual.
Community Obs practice Audit tool in place &
used in visits. In patient areas to follow.
Page 30 of 48
Heading
4. Policy
development
and
implementati
on
Aim
To ensure application of
evidence-based protocols
and practices for both staff
and users of services
Objective to be
reached
Outcome
Target Date
RAG
Rate
Progress Record
To strengthen
Continued
Professional
Development
Appropriate CPD
commissioned
and provided to
meet the needs of
the organisation
31.3.13
Training strategy in place
CPD commissioned depending on need
Working with E&T department
Review training
delivery and
outcomes,
strengthen where
gaps are identified
Training
programme in
place.
30.8.13
Reviewed training – positive response
Online training to be included in AT learning
programme
To standardise and
implement
infection,
prevention and
control policies
All IP&C policies
in place
(30.8.13)
30.3.14
Reviewed policies and protocols
Draft ‘bundles’ in place and due to roll out,
comments captured and to be added to the
manuals, the content size to be minimised.
To streamline
policy and practice
All IP&C policies
in place
(30.8.13)
30.3.14
Reviewed policies and protocols
Draft ‘bundles’ in place and due to roll out
To develop care
bundles
(combination of
policy)
Care bundles in
place.
(30.8.13)
30.3.14
Reviewed policies and protocols
Draft ‘bundles’ in place and due to roll out
To continue to
influence, monitor
and review
systems, policy and
practices both
nationally and
locally
Robust review
and monitoring
system in place
(30.8.13)
30.3.14
Improve access to
policies i.e.
IT/manual
Easy access to
policy.
(30.8.13)
30.3.14
IPC page included on intranet
Implement effective
communication with
services, staff and
service users
Services users
and staff are
engaged with the
IP&C agenda.
(30.8.13)
30.3.14
Regular communication via team brief, weekly
news, team meetings etc
Further engagement with staff and service users
required
Page 31 of 48
Heading
5. Design and
maintenance
of
environment
and devices
Aim
To ensure the environment
and the devices used are
clean, safe and appropriate
Objective to be
reached
Outcome
Target Date
RAG
Rate
Progress Record
Audit and review
policy development
and implementation
Audit programme
in place
30.3.14
To identify
decontamination
lead
Lead for
decontamination
in place.
2012
Nurse Consultant undertaking duties on behalf of
DIPC
To streamline
governance of
medical devices
Medical device
governance
process in place
(30.12.13)
(30.1.14)
30.5.14
In progress. One MEMs contract and one asset
register.
IPC have slot at Medical Devices meeting
Contact in place and signed off.
Asset register being developed but not finalised.
Standardisation of gloves complete and
standardisation of aprons in progress.
To ensure all
Trust’s environment
are fit for purposes
including new
builds and
refurbishments
Health and Social
care Act
compliance
achieved.
(30.9.13)
31.3.14
Working with estates work plans in place
To monitor hotel
services effectively,
reviewing contracts
and streamlining
services
Hotel services
contracts are fit
for purpose and
monitored
(30.8.13)
30.12.13
IPC have slot at Hotel Services Meeting, to work
with clinic admin staff to embed monthly clinic
cleaning checks, link staff also to assist with this
once trained. Strengthening relations with hotel
service staff.
IPC engaged in appropriate meetings. Continue
to monitor site visits.
To ensure
appropriate
decontamination of
devices- dentistry
Monitoring
systems in place
to ensure
appropriate
decontamination
of devices
(Dentistry)
30.8.13
Quarterly audits now feed in to IPC Group.
Self assessments-no significant issues except
Grays Court.
Dentistry now use single use equipment.
Page 32 of 48
Heading
6. Stakeholder
involvement
Aim
To ensure we listen,
inform, involve and work
together with our patients,
public and partners
Objective to be
reached
Outcome
Target Date
RAG
Rate
Progress Record
Streamlining the
management and
maintenance of
medical devices
Governance
process in place
to monitor and
manage medical
devices.
30.12.13
Asset register being compiled. Tag and barcode
items. Procurement to monitor future purchase.
To ensure the
infection control
team is involved
with refurbishments
and new builds
Meet Health and
Social Care Act
standards
2012
All teams aware of the need to ensure IPC is
involved with new buildings and refurbishments
To strengthen
infection prevention
and control two
way communication
systems i.e.
leaflets,
publications, staff
and service user
feedback
Patients and staff
are engaged in
the IP&C agenda.
(30.9.13)
(31.3.14)
30.6.14
Leaflets for staff and patients
Service users drafted
Links made with practice improvement
Patient engagement group approached – happy
for IPCT to attend with information leaflets and
support dissemination of key messages.
Use of patient voice in new builds and
refurbishments planned is being trialled e.g. MCH
bedrooms; patient rep invited and attended to
influence the design and layout of the patient
accommodation.
Not able to join 5x5 but to trial contacting
identified client’s (who have DN input) and ask
Hand hygiene questions.
Revision to leaflets completed. Need to submit to
user group for ratification and then to Harjit for
translation.
Page 33 of 48
Heading
Last updated 4/3/14
Next update due 7/4/14
Aim
Objective to be
reached
Outcome
Target Date
To have
appropriate
systems in place to
receive, monitor
and implement
feedback i.e.
streamlining
questionnaires,
expanding patient
groups, audit
System in place
to receive,
monitor and
implement
feedback.
(30.12.13)
(31.3.14)
30.6.14
To have a robust
business
development plan,
to include
marketing and
advertising strategy
Business
development
programme in
place and
implemented.
(30.3.14)
30.6.14
To have an 24/7
on-call infection
control service
Infection control
service provides
24 hour support.
2012
To strengthen our
working
relationship with
partners i.e. CCG,
Acute Trust, social
care and third
sector
Stakeholders are
engaged with the
IP&C agenda.
(30.10.13)
30.3.14
Review progress
and further
strengthen
engagement
Stakeholder
engagement is
strong and
effective.
(30.3.14)
30.9.14
RAG
Rate
Progress Record
5x5 completed for January 2014
Via on call system
BHR/Queens go to CAUTI group. Regular
meetings with BHR/CCG.
Appendix 2
Service Objectives 2013-2014
1.
Work closely with the Strategic Lead for IPC & Director of Infection Prevention and Control so that
infection control is given due consideration at a senior level of the organisation.
2.
Undertake surveillance of MRSA admission screening, MRSA colonisation, MRSA, MSSA, E.coli
bacteraemia, and Clostridium difficile rates within in-patient and community areas and report on these
rates/trends as appropriate.
3.
Undertake alert organism surveillance in the community to monitor the incidence of infections to allow
early detection of outbreaks or infection, trends and early implementation of control procedures.
4.
Write and then implement all elements of the Clostridium difficile action plan so that the risk of cross
infection is minimised, and facilitates achieving zero tolerance target.
5.
Respond to changes in healthcare associated infection rates and develop appropriate management
action plans.
6.
React to outbreaks of infection and develop appropriate control strategies in collaboration with clinical
staff and managers.
7.
Ensure infection control aspects of Flu Pandemic Planning are given due consideration and addressed
in the wider health economy in collaboration with HPA, CCG’s, CSU IPCT.
8.
Work with estates and facilities departments on limiting infection risks associated with water and air
quality, cleaning and also clinical waste management.
9.
Develop and implement all elements of a hand hygiene strategy so that all staff, patients and carers are
aware of the importance of hand hygiene so that the risk of cross infection is minimised; this builds on
the current arrangements.
10.
Carry out an annual rotational audit programme within environments where care is delivered, and
oversee the annual audit programme of clinical audits undertaken by services supported by IPCT.
11.
Lead on decontamination and the decontamination elements registration standards as outlined in HTM
01-01 and HTM 01-05.
12.
Support clinical governance and audit activity within the organisations assurance objectives.
13.
Support the education of staff at all levels working for, and with NELFT.
14.
Promote and monitor e-learning Infection Control Programme for non-clinical and clinical staff.
15.
Continue to encourage and facilitate the development of wider ownership for infection control at all
levels within the organisation ensuring it is everyone’s business.
16.
Ensure that policies for infection prevention and control reflect contemporary practice and are available,
seek evidence and that these are widely available within the organisation.
17.
Support work of relevant committees and working groups within the organisation e.g. health and safety,
quality and patient safety.
18.
Provide specialist advice on healthcare new builds and renovation projects so that infection control is
given due consideration during planning and commissioning of these buildings.
19.
Continue to improve against the standards as set out in essential steps document.
20.
Promote and implement the Matron’s Charter in collaboration with cleaning teams so that we can work
together towards the goal of a clean and safe healthcare environment.
21.
Foster collaborative links both within the organisation and with external organisations as appropriate.
22.
Market the service so that we can improve commissioning prospect
Page 35 of 48
Appendix 3
The Health and Social Care Act 2009 Self Assessment
Criterion 1
Systems to manage and monitor the prevention and control of infection. These systems use risk assessments
and consider how susceptible service users are and any risks that their environment and other users may pose to
them.
A registered provider has an agreement within the organisation that outlines its collective
responsibility for keeping to a minimum the risks of infection and the general means by which it will
prevent and control such risks
An individual is designated as the lead for infection prevention and control and be accountable
directly to the registered provider;
The mechanisms are in place by which the registered provider intends to ensure that sufficient
resources are available to secure the effective prevention and control of infection. These should
include the implementation of an infection prevention and control programme, infection prevention
and control infrastructure and the ability to detect and report infections
Relevant staff, contractors and other persons, whose normal duties are directly or indirectly
concerned with providing care, receive suitable and sufficient information on, and training and
supervision in, the measures required to prevent and control the risks of infection
A programme of audit is in place to ensure that key policies and practices are being implemented
appropriately
A policy on information sharing when referring, admitting, transferring, discharging and moving
service users within and between health and adult social care facilities is available
A decontamination lead is designated, where appropriate.
Risk assessment-A registered provider should ensure that:
It has made a suitable and sufficient assessment of the risks to the person receiving care with
respect to prevention and control of infection
A registered provider should ensure that it has identified the steps that need to be taken to reduce or
control those risks
Recorded its findings in relation to the first two points
Implemented the steps identified
Put appropriate methods in place to monitor the risks of infection to determine whether further steps
are needed to reduce or control infection
Directors of Infection Prevention and Control (in NHS provider organisations)The role of the DIPC in NHS provider organisations is to:
Be accountable directly to the chief executive and to the board (but not necessarily a member of the
board);
Be responsible for the organisation’s infection prevention and control team (IPT) or infection control
team (ICT)
Oversee local prevention and control of infection policies and their implementation
Be a full member of the ICT and regularly attend its infection prevention and control meetings
Report directly to the NHS board and, in non-NHS care settings, the registered provider
Have the authority to challenge inappropriate practice and inappropriate antibiotic prescribing
decisions
Assess the impact of all existing and new policies on infections and make recommendations for
change
Be an integral member of the organisation’s clinical governance and patient safety teams and
structures
Produce an annual report and release it publicly as outlined in Winning ways: working together to
reduce healthcare associated infection in England.
Assurance framework:
Activities to demonstrate that infection prevention and control are an integral part of quality assurance should
Page 36 of 48
include:
Regular presentations from the DIPC and/or the ICT to the NHS board or registered provider. These
should include a trend analysis for infections and compliance with audit programmes;
Quarterly reporting to the NHS board or registered provider by clinical directors and matrons
(including nurses who do not hold the specific title of ‘matron’ but who operate at a similar level of
seniority and who have control over similar aspects of the patient or the patient’s environment). What
is reported on will vary according to the local arrangements. For example it may include:
• monthly cleanliness scores (unless this is done via the estates and facilities team);
• monthly Patient Environment Action Team scores (where this is agreed practice);
• contract performance measures where provision is outsourced, which will include cleanliness
measures and issues of noncompliance and subsequent rectification performance;
A review of statistics on incidence of alert organisms (for example, but not limited to, Methicillinresistant Staphylococcus aureus (MRSA) and Clostridium difficile) and conditions, outbreaks and
serious untoward incidents
Evidence of appropriate action taken to deal with occurrences of infection including, where
applicable, root cause analysis
An audit programme to ensure that policies have been implemented
In accordance with health and safety requirements, where suitable and sufficient assessment of risks
requires action to be taken, evidence must be available on compliance with the regulations or, where
appropriate, justification of a suitable better alternative. This applies to all healthcare and adult social
care.
The infection prevention and control programme should:
Set objectives that meet the needs of the organisation and ensure the safety of service users;
Identify priorities for action;
Provide evidence that relevant policies have been implemented to reduce infections;
If appropriate, report progress against the objectives of the programme in the DIPC’s annual report
or the IPC Lead’s annual statement.
Infection prevention and control infrastructure
An infection prevention and control infrastructure should encompass:
In acute healthcare settings, for example, an ICT consisting of an appropriate mix of both nursing
and consultant medical expertise (with specialist training in infection prevention and control) and
appropriate administrative and analytical support, including adequate information technology – the
DIPC is a key member of the ICT;
In other settings, there will be an infection control nurse (ICN) or another designated person who is
responsible for infection prevention and control matters and has access to specialist expertise as
necessary;
24-hour access to a nominated qualified infection control doctor (ICD) or consultant in health
protection/communicable disease control. The registered provider should know how to access this
advice.
Movement of service users:
There should be evidence of joint working between staff involved in the provision of advice relating to
the prevention and control of infection; those managing bed allocation; care staff and domestic staff
in planning service user referrals, admissions, transfers, discharges and movements between
departments; and within and between health and adult social care facilities. Where necessary,
ambulance providers, hospitals and primary care trusts (PCTs) may need to be involved in such
planning.
A registered provider must ensure that it provides suitable and sufficient information on a service
user’s infection status whenever it arranges for that person to be moved from the care of one
organisation to another, or from a service user’s home, so that any risks to the service user and
others from infection may be minimised. If appropriate, providers of a service user’s transport should
be informed of any infection
Criterion 2
Provide and maintain a clean and appropriate environment in managed premises that facilitates the prevention
Page 37 of 48
and control of infections. With a view to minimising the risk of infection, a registered provider should normally
ensure that:
It designates leads for environmental cleaning and decontamination of equipment used for diagnosis
and treatment (a single individual may be designated for both areas)
In healthcare, the designated lead for cleaning involves directors of nursing, matrons and the ICT or
persons of similar standing in all aspects of cleaning services, from contract negotiation and service
planning to delivery at ward and clinical level. In other settings, the designated lead for cleaning will
need to access appropriate advice on all aspects of cleaning services
In healthcare, matrons or persons of a similar standing have personal responsibility and
accountability for delivering a safe and clean care environment
The nurse or other person in charge of any patient or resident area has direct responsibility for
ensuring that cleanliness standards are maintained throughout that shift
All parts of the premises from which it provides care are suitable for the purpose, kept clean and
maintained in good physical repair and condition
The cleaning arrangements detail the standards of cleanliness required in each part of its premises
and that a schedule of cleaning frequency is available on request
There is adequate provision of suitable hand washing facilities and antimicrobial hand rubs where
appropriate
There are effective arrangements for the appropriate cleaning of equipment that is used at the point
of care, for example hoists, beds and commodes – these should be incorporated within appropriate
cleaning, disinfection and decontamination policies
The supply and provision of linen and laundry are appropriate for the level and type of care
‘The environment’ means the totality of a service user’s surroundings when in care premises or
transported in a vehicle. This includes the fabric of the building, related fixtures and fittings, and
services such as air and water supplies. Where care is delivered in the service user’s home, the
suitability of the environment for that level of care should be considered
Policies on the environment:
Premises and facilities should be provided in accordance with best practice guidance. The development of local
policies should take account of infection prevention and control advice given by relevant expert or advisory
bodies or by the ICT, and this should include provision for liaison between the members of any ICT and the
persons with overall responsibility for the management of the service user’s environment. Policies should address
but not be restricted to
Cleaning services
Building and refurbishment, including air-handling systems
Waste management
Laundry arrangements for used and infected linen
Planned preventative maintenance
Pest control
Management of drinkable and non-drinkable water supplies
Minimising the risk of Legionella by adhering to national guidance
Food services, including food hygiene and food brought into the care setting by service users, staff
and visitors.
Cleaning services the arrangements for cleaning should include:
Clear definition of specific roles and responsibilities for cleaning;
Clear, agreed and available cleaning routines;
Sufficient resources dedicated to keeping the environment clean and fit for purpose;
Consultation with ICTs or equivalent local expertise on cleaning protocols when internal or external
contracts are being prepared; and
Details of how staff can request additional cleaning, both urgently and routinely.
Decontamination:
The decontamination lead should have responsibility for ensuring that policies exist and that they take account of
best practice and national guidance. They may wish to consider guidance under the following headings:
Decontamination of the environment – including cleaning and disinfection of the fabric, fixtures and
Page 38 of 48
fittings of a building (walls, floors, ceilings and bathroom facilities) or vehicle.
Decontamination of equipment – including cleaning and disinfection of items that come into contact
with the patient or service user, but are not invasive devices (e.g. beds, commodes, mattresses,
hoists and slings, examination couches).
Decontamination of reusable medical devices – including cleaning, disinfection and sterilisation of
invasive medical devices.
Reusable medical devices should be reprocessed at one of the following three levels:
• sterile (at point of use);
• sterilised (i.e. having been through the sterilisation process);
• Clean (i.e. free of visible contamination).
The decontamination policy should demonstrate that
It complies with guidance establishing essential quality requirements and a plan is in place for
progression to best practice;
Decontamination of reusable medical devices takes place in appropriate facilities designed to
minimise the risks that are present;
Appropriate procedures are followed for the acquisition, maintenance and validation of
decontamination equipment;
Staff are trained in cleaning and decontamination processes and hold appropriate competences for
their role; and
A record-keeping regime is in place to ensure that decontamination processes are fit for purpose and
use the required quality systems.
Criterion 3
Provide suitable accurate information on infections to service users and their visitors areas relevant to the
provision of such information include:
General principles on the prevention and control of infection and key aspects of the registered
provider’s policy on infection prevention and control, which takes into account the communication
needs of the service user;
The roles and responsibilities of particular individuals such as carers, relatives and advocates in the
prevention and control of infection, to support them when visiting service users;
Supporting service users’ awareness and involvement in the safe provision of care;
The importance of compliance by visitors with hand hygiene;
The importance of compliance with the registered provider’s policy on visiting;
Reporting failures of hygiene and cleanliness;
Explanations of incident/outbreak management.
Information should be developed with local service user representative organisations, which could
include Local Involvement Networks (LINKs) and Patient Advice and Liaison Services (PALS)
Criterion 4
Provide suitable accurate information on infections to any person concerned with providing further support or
nursing/medical care in a timely fashion. A registered provider should ensure that:
Accurate information is communicated in an appropriate manner;
This information facilitates the provision of optimum care, minimising the risk of inappropriate
management and further transmission of infection; and
Where possible, information accompanies the service user.
Provision of relevant information across organisational boundaries is covered by the regulation
requirement ‘Co-operating with other providers’. Due attention should be paid to service user
confidentiality as outlined in national guidance and training material
Criterion 5
Ensure that people who have or develop an infection are identified promptly and receive the appropriate
treatment and care to reduce the risk of passing on the infection to other people.
Registered providers, excluding personal care providers, should ensure that advice is received from
suitably informed practitioners and that, if advised, registered providers should inform their local
health protection unit of any outbreaks or serious incidents relating to infection.
Arrangements to prevent and control infection should demonstrate that responsibility for infection
Page 39 of 48
prevention and control is effectively devolved to all groups in the organisation involved in delivering
care.
Criterion 6
Ensure that all staff and those employed to provide care in all settings are fully involved in the process of
preventing and controlling infection.
A registered provider should, so far as is reasonably practicable, ensure that its staff, contractors and
others involved in the provision of care co-operate with it, and with each other, so far as is necessary
to enable the registered provider to meet its obligations under the Code.
Infection prevention and control would need to be included in the job descriptions and be included in
the induction programme and staff updates of all employees (including volunteers). Contractors
working in service user areas would need to be aware of any issues with regard to infection
prevention and control and obtain ’permission to work‘. Confidentiality must be maintained.
Where staff undertake procedures, which require skills such as aseptic technique, staff must be
trained and demonstrate proficiency before being allowed to undertake these procedures
independently.
Criterion 7
Provide or secure adequate isolation facilities.
A healthcare registered provider delivering in-patient care should ensure that it is able to provide, or
secure the provision of, adequate isolation precautions and facilities, as appropriate, sufficient to
prevent or minimise the spread of infection. This may include facilities in a day care setting.
Policies should be in place for the allocation of patients to isolation facilities, based on a local risk
assessment. The assessment could include consideration of the need for special ventilated isolation
facilities. Sufficient staff should be available to care for the service users safely.
Registered providers of accommodation should ensure that they are able to provide or secure
facilities to physically separate the service user from other residents in an appropriate manner in
order to minimise the spread of infection.
Criterion 8
Secure adequate access to laboratory support as appropriate
A registered provider should ensure that laboratories that are used to provide a microbiology service
in connection with arrangements for infection prevention and control have in place appropriate
protocols and that they operate according to the standards required by the relevant national
accreditation bodies. In adult social care, the service user’s General Practitioner will arrange such
testing when necessary for the treatment and management of disease.
Protocols should include:
A microbiology laboratory policy for investigation and surveillance of healthcare associated
infections;
Standard laboratory operating procedures for the examination of specimens.
Criterion 9
Have and adhere to policies, designed for the individual’s care and provider organisations that will help to prevent
and control infections.
A registered provider should, in relation to preventing, reducing and controlling the risks of infections,
have in place the appropriate policies concerning the matters mentioned in a to y below. All policies
should be clearly marked with a review date.
Any registered provider should have policies in place relevant to the regulated activity it provides.
Each policy should indicate ownership (i.e. who commissioned and retains managerial
responsibility), authorship and by whom the policy will be applied. Implementation of policies should
be monitored and there should be evidence of a rolling programme of audit and a date for revision
stated
a. Standard infection prevention and control precautions
b. Aseptic technique
c. Outbreaks of communicable infection
d. Isolation of service users with an infection (see also criterion 7)
e. Safe handling and disposal of sharps
Page 40 of 48
f. Prevention of occupational exposure to blood-borne viruses (BBVs), including prevention of sharps
injuries
g. Management of occupational exposure to BBVs and post-exposure prophylaxis
h. Closure of rooms, wards, departments and premises to new admissions
i. Disinfection
j. Decontamination of reusable medical devices
k. Single-use medical devices
L. Antimicrobial prescribing
m. Reporting of infections to the Health Protection Agency or local authority
n. Control of outbreaks and infections associated with specific alert organisms:
MRSA
• Clostridium difficile
• Glycopeptide resistant enterococci (GRE)
• Acinetobacter, extended-spectrum beta lactamase (ESBLs) and other antibiotic-resistant bacteria
• Viral haemorrhagic fevers (VHF)
• Creutzfeldt-Jakob disease (CJD), variant CJD (vCJD) and other human prion diseases
• Relevant policies for other specific alert organisms
o. CJD/vCJD – handling of instruments and devices
p. Safe handling and disposal of waste
q. Packaging, handling and delivery of laboratory specimens
r. Care of deceased persons
s. Use and care of invasive devices
t. Purchase, cleaning, decontamination, maintenance and disposal of equipment
u. Surveillance and data collection
v. Dissemination of information
w. Isolation facilities
x. Uniform and dress code
y. Immunisation of service users
Criterion 10
Ensure, so far as is reasonably practicable, that care workers are free of and are protected from exposure to
infections that can be caught at work and that all staff are suitably educated in the prevention and control of
infection associated with the provision of health and social care. Registered providers should ensure that policies
and procedures are in place in relation to the prevention and control of infection such that:
All staff can access occupational health services or access appropriate occupational health advice;
Occupational health policies on the prevention and management of communicable infections in care
workers are in place;
Decisions on offering immunisation should be made on the basis of a local risk assessment as
described in Immunisation against infectious disease (‘The Green Book’). Employers should make
vaccines available free of charge to employees if a risk assessment indicates that it is needed
(COSHH Regulations 2002);
There is a record of relevant immunisations;
The principles and practice of prevention and control of infection are included in induction and
training programmes for new staff. The principles include: ensuring that policies are up to date;
feedback from audit results; examples of good practice; and action needed to correct poor practice;
There is appropriate ongoing education for existing staff (including support staff, volunteers,
agency/locum staff and staff employed by contractors), which should incorporate the principles and
practice of prevention and control of infection.
There is a record of training and updates for all staff; and
The responsibilities of each member of staff for the prevention and control of infection are reflected in
their job description and in any personal development plan or appraisal.
Occupational health service: Occupational health services for staff should include
Risk-based screening for communicable diseases and assessment of immunity to infection after a
conditional offer of employment and ongoing health surveillance;
Page 41 of 48
Offer of relevant immunisations;
Having arrangements in place for regularly reviewing the immunisation status of care workers and
providing vaccinations to staff as necessary in line with Immunisation against infectious disease
(‘The Green Book’) and other Department of Health guidance.
Occupational health services in respect of BBVs should include:
Having arrangements for identifying and managing healthcare staff infected with hepatitis B or C or
HIV and advising about fitness for work and monitoring as necessary, in line with Department of
Health guidance;
Liaising with the UK Advisory Panel for Healthcare Workers Infected with Blood-borne Viruses when
advice is needed on procedures that may be carried out by BBV-infected care workers, or when
advice on patient tracing, notification and offer of BBV testing may be needed;
A risk assessment and appropriate referral after accidental occupational exposure to blood and body
fluids; and
Management of occupational exposure to infection, which may include provision for emergency and
out-of-hours treatment, possibly in conjunction with accident and emergency services and on-call
infection prevention and control specialists. This should include a specific risk assessment following
an exposure prone procedure.
Appendix 4
Infection Prevention and Control Operational Group
Terms of reference
Accountability
The group is organised and administered by the Infection Prevention & Control Lead who chairs the
meetings (or nominated deputy) and reports to the Trust Infection Prevention & Control Committee,
which meets on a quarterly basis.
The group will have operational responsibility for delivering the Annual Plan; meeting Infection
Prevention and Control targets and achieving compliance with the Hygiene Code. To fulfil its
assurance function named leads from each provider services are required to nominate a senior
representative who is responsible for reporting on Trust wide activities for infection risk minimisation,
including: infection risk incidents and surveillance, policy development, audits, training, antibiotic
prescribing, environmental hygiene, waste disposal, water safety, projects and maintenance: A report
should be provided in line with the collective evidence reporting guidelines.
Purpose of the Group
The purpose of the Infection Prevention & Control Operational group is to oversee all activities for
effective prevention and control of infection across the organisation to ensure:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Agree the annual infection prevention and control programme, agreeing priorities
Review the progress of the programme, support the implementation and review the outcomes
To advise the IP&C Team and ensure compliance with the Code of practice for Infection
Prevention and Control
Promote a culture of ownership and embedding infection prevention and control into everyday
practice leading to service improvement
Oversee all infection control activities
Consider reports on infections, outbreaks and infection control problems
Oversee the development of infection prevention and control policies
Monitor the education and development plan for Infection Prevention and Control
Monitor the implementation of Essential Steps and Saving Lives
Monitor the implementation and effectiveness of the Clean Your Hands campaign
Review Root Cause Analyses and incidents related to infection prevention and control
Review progress against KPI’s
Produce quarterly and an annual report
Annual review of performance against the Terms of Reference, Membership and Attendance.
Members will be expected to always send a Deputy if unable to attend.
Membership
Infection Prevention & Control Lead (Chair)
Director of Nursing MHS (Nominated Deputy)
Infection Control Nurses
Health & Safety Manager
Page 43 of 48
Matrons (inpatient facilities, adult services, children services)
Tissue Viability Lead
Podiatry Representative
Community Dental Services Representative
Speech & Language Therapy Representative
Physiotherapy Representative
Community Leaning Disability Team Representative
Education & Training Lead
Medical Representative
Occupational Therapy Lead
Head of Estates
Facilities Manager
Head of Procurement
Occupational Health representative
Pharmacy Lead
Quality & Safety Representative
Additional members as appropriate:
Local Health Protection Units representatives
Representation from local Environmental Health Officers
Representation from local PCTs
Frequency of meeting
Meetings to be held on a bi-monthly basis.
Quorum
A quorum will consist of the Infection Prevention & Control Lead/or deputy, plus six others members.
Date agreed & approved by:
16th February 2012 / Infection Group
Review date:
16th February 2013
Page 44 of 48
Terms of Reference
Infection Prevention and Control Group
Name of Committee
Infection Prevention and Control Group
Purpose
To ensure compliance to the legislative requirements (Health Act
2008) in relation to Infection Control and to monitor the infection
prevention and control work programme
Accountable to
South West Essex Community Services Integrated Governance
Committee
Chair
Director of Infection Prevention and Control
Membership
Director Infection Prevention and Control
Nurse Consultant Infection Prevention and Control
Lead Infection Prevention and Control Nurse
Infection Control Doctor
Service Directors or delegated deputy
Integrated Governance Manager
Head of Community Nursing
Head of Therapies
Occupational Health Adviser
In-patient medical representative
Representative from Essex Health Protection Unit
Estates and Facilities Manager
Training and Education Manager
Community Hospital representative
Nurse Consultant Specialist Services or Delegated deputy
Head of Unplanned care or deputy
Co-opted members as required
Frequency
Bi – Monthly (minimum)
Quorum
6 (minimum (1 service directors, 1 Infection Control Nurse plus
4 other members)
Responsibilities
Agree the annual infection prevention and control programme,
agreeing priorities
Review the progress of the programme, support the
implementation and review the outcomes
To advise the IP&C Team and ensure compliance with the Code
of practice for Infection Prevention and Control
Consider reports on infections, outbreaks and infection control
problems
Page 45 of 48
Oversee the development of infection prevention and control
policies
Monitor the education and development plan for Infection
Prevention and Control
Monitor the implementation of Essential Steps and Saving Lives
Monitor the implementation and effectiveness of the Clean Your
Hands campaign
Review Root Cause Analyses and incidents related to infection
prevention and control
Review progress against KPI’s
Produce quarterly and an annual report
Annual review of performance against the Terms of Reference,
Membership and Attendance.
Members will be expected to always send a Deputy if unable to
attend.
Approval Date
June 2012
Review Date
June 201
Page 46 of 48
Infection Prevention and Control Operational Group
Terms of reference
Accountability
The group is organised and administered by the Infection Prevention & Control Lead who chairs the
meetings (or nominated deputy) and reports to the Trust Infection Prevention & Control Committee,
which meets on a quarterly basis.
The group will have operational responsibility for delivering the Annual Plan; meeting Infection
Prevention and Control targets and achieving compliance with the Hygiene Code. To fulfil its
assurance function named leads from each provider services are required to nominate a senior
representative who is responsible for reporting on Trust wide activities for infection risk minimisation,
including: infection risk incidents and surveillance, policy development, audits, training, antibiotic
prescribing, environmental hygiene, waste disposal, water safety, projects and maintenance: A report
should be provided in line with the collective evidence reporting guidelines.
Purpose of the Group
The purpose of the Infection Prevention & Control Operational group is to oversee all activities for
effective prevention and control of infection across the organisation to ensure:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Agree the annual infection prevention and control programme, agreeing priorities
Review the progress of the programme, support the implementation and review the outcomes
To advise the IP&C Team and ensure compliance with the Code of practice for Infection
Prevention and Control
Promote a culture of ownership and embedding infection prevention and control into everyday
practice leading to service improvement
Oversee all infection control activities
Consider reports on infections, outbreaks and infection control problems
Oversee the development of infection prevention and control policies
Monitor the education and development plan for Infection Prevention and Control
Monitor the implementation of Essential Steps and Saving Lives
Monitor the implementation and effectiveness of the Clean Your Hands campaign
Review Root Cause Analyses and incidents related to infection prevention and control
Review progress against KPI’s
Produce quarterly and an annual report
Annual review of performance against the Terms of Reference, Membership and Attendance.
Members will be expected to always send a Deputy if unable to attend.
Membership
Infection Prevention & Control Lead (Chair)
Infection Control Nurses
Head of Nursing (Nominated Deputy)
Health & Safety Manager
Matrons (inpatient facilities, adult services, children services, Urgent care, integrated care)
Tissue Viability Lead
Audiology Manager
Podiatry Representative
Community Dental Services Representative
Page 47 of 48
Speech & Language Therapy Representative
Physiotherapy Representative
Community Leaning Disability Team Representative
Education & Training Lead
Medical Representative
Occupational Therapy Lead
Estates & Facilities Manager
Occupational Health representative
Pharmacy Lead
Additional members as appropriate:
Local Health Protection Units representatives
Representation from local Environmental Health Officers
Representation from local PCTs
Frequency of meeting
Meetings to be held on a quarterly basis.
Quorum
A quorum will consist of the Infection Prevention & Control Lead/or deputy, plus six others members.
Page 48 of 48
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AGENDA ITEM 10 – PATIENT EXPERIENCE SURVEYS
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
Report by:
Chief Nurse and Executive Director of Integrated Care (Essex)
Subject:
Patient Experience Surveys
PURPOSE OF THE REPORT:
To inform the Trust Board of the latest results of the Patient Experience surveys across the Trust.
EXECUTIVE SUMMARY
Patient surveys are a vital source of feedback to us on areas in which our clinical services are doing
well and areas which need to be improved. An overview of survey results is provided below.
How likely is it that you would recommend this service to friends and family if they
needed similar care or treatment?
Survey name
Mental Health
Inpatient
CQUIN target to
measure Service
User satisfaction
with inpatient care
Home Treatment
Team
CQUIN target to
measure Service
User satisfaction
with HTT care
Date
Q1
Q2
Q3
Q4
Over all
Q1
Q2
Q3
Q4
Over all
Survey
returns
148
141
254
256
799
Discharge
Response
%
Extremely
likely
290
337
351
307
1285
51%
42%
72%
83%
62%
37%
41%
35%
39%
38%
Likely
Combined
38%
35%
41%
34%
37%
75%
76%
76%
73%
75%
39%
43%
41%
89%
86%
88%
Survey started September of Q2
237
316
553
369
391
760
64%
81%
73%
50%
43%
47%
Survey name
Inpatient Carers
CQUIN target to
measure Carers
satisfaction with
Inpatient Services
Date
Q1
Q2
Q3
Q4
Over all
Home Treatment
Q1
Team Carers
CQUIN target to
Q2
measure Carers
Q3
satisfaction with
Q4
Home Treatment
team services
Over all
London Community Services
Survey name
Long Term
Conditions
CQUIN target to
measure patient
satisfaction with
Integrated Case
Management,
Therapies, Long
term Conditions
and Community
Treatment Team
Community
Yearly community
survey
Inpatient Discharge
Walk in Centre
Date
Survey
returns
Discharge
14
33
30
48
16
31
20
28
36
59
Response Extremely
%
likely
42%
23%
63%
51%
52%
15%
71%
23%
61%
28%
Likely
Combined
54%
77%
21%
72%
38%
53%
54%
77%
42%
70%
8
26
27
29
37
47
47
47
22%
55%
57%
62%
33%
58%
33%
36%
17%
25%
41%
36%
50%
83%
74%
72%
56
94
60%
35%
39%
73%
Discharge
Response
%
Extremely
likely
Survey
returns
Likely
Combined
Q1
Q2
Q3
Q4
244
211
126
600
600
600
41%
35%
21%
66%
69%
74%
29%
26%
26%
95%
95%
100%
Over all
581
1800
32%
70%
27%
97%
792
70%
25%
95%
9
33%
56%
89%
42%
57%
33%
45%
39%
28%
87%
96%
61%
78%
86%
82%
19%
14%
17%
97%
100%
99%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Over all
62
70
132
Q1
Q2
Q3
Q4
Over all
140
21
161
316
350
666
20%
20%
20%
Essex
Survey name
5x5 questionnaires
Improvement
targets. Each
service undertakes
telephone survey
asking 5 questions
to 5 patients.
Date
Q1
Q2
Q3
Q4
Over all
Survey
returns
Response
Discharge
%
Survey started June
142
2013
644
Nov and Jan not
reported due to
technical problems
216
559
1561
Extremely
likely
Likely
Combined
65%
62%
28%
33%
93%
95%
67%
65%
65%
29%
30%
30%
96%
95%
95%
Community
Key performance
Indicator to
udnertake annual
patient satisfaction
survey
Q1
Q2
Q3
Q4
850
66%
30%
96%
Inpatient
Q1
Q2
Q3
Q4
Over all
1
1
38
153
192
0%
100%
71%
77%
83%
100%
0%
24%
22%
15%
100%
100%
95%
99%
98%
93%
7%
Minor Injuries Unit
Q1
Q2
Q3
Q4
93
292
290
582
13%
53%
33%
ACTION PLANS:
Services are required to develop action plans for any area where patient satisfaction is low.
Adherence to action plans generated as a result of surveys is monitored through operational
management structures.
FINANCIAL IMPLICATIONS
There are financial penalties in relation to the non-achievement of CQUIN measures which are
attached to some surveys.
RISK IMPLICATIONS
As noted above.
Results may highlight concerns around patient safety
EQUALITIES AND HEALTH AND SAFETY IMPLICATIONS
None known
ACTION REQUIRED
For the Trust Board to take note of this update and report Trust Board.
PATIENT EXPERIENCE SURVEY REPORT
PURPOSE OF THE REPORT:
To inform the Trust Board of the latest result of the Patient Experience surveys across the Trust.
Mental Health Services:
Inpatient Survey
Particularly high levels of satisfaction (over 90%) were achieved for:
• Being made to feel welcome by staff
Mental Health Wards are scoring more than 20% above the national average in:
• Staff knew about previous care and treatment
• Care taken of physical health problems
• Staff took home and family situation into account when planning discharge
We are scoring above the national average in all areas, but access to daytime activities is only
marginally above the National average. This has been addressed in an action plan:
You said:
• Only a quarter of you felt there were always enough activities during the day
We did:
• We carry out monthly group monitoring and group evaluations as part of Star Wards cycle
• Several of our wards are now using volunteers to support their group programme
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 38% of respondents said extremely likely and 37% said likely.
Comments The following is a selection of comments from the comments field on the
questionnaire:
• The staff have been amazing. They are all so nice and always make sure you are OK. Ask
how you are, chat, cheer you up. I cannot thank the staff enough. You are a great team
here
• I believe the NHS is providing an excellent service at Goodmayes. There are plenty of staff
and they are all very approachable and amenable. The facilities are satisfactory and the
hygiene standards are OK. The patients I met are on the whole extremely unwell and
without such a facility I wonder how they would cope. The only criticism I have is that
activities during the day were a bit lacking, however it is not easy to run activities in such
an environment. All nurses were excellent helpful in every way they could be. THANK YOU
ALL
• At times I felt very uneasy in the presence of other patients after one came into my room in
the night. I do not know how long she was there before she woke me. Finally and much to
my relief a nurse came.
• Low fat meal options would improve the meals.
• Great! having a private room with ensuite was excellent in keeping me safe.
50 most commonly used words used in comments field of Mental Health Inpatients Patient
Satisfaction Questionnaire
Home Treatment Team Survey
Particularly high levels of satisfaction (over 90%) were achieved for:
• Being given information about the service
• Being treated with respect and dignity.
Home Treatment Teams are scoring more than 30% above the national average in:
• Views taken in to account in deciding care plan
• Care taken of physical health needs
• Relatives encouraged to be involved in treatment and care.
The priority improvement was care taken of physical health needs. This was addressed in an
action plan and a 38% improvement was achieved by Q4
You said:
• Less than half of you felt that enough care was taken of any physical health problems you
had
We did:
• We provided physical health training for all Home Treatment Team staff
• We trained our staff in how to use the Modified Early Warning Scoring System (MEWS)
tool to monitor changes in physical health
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 46% of respondents said extremely likely and 41% said likely.
Comments The following are a selection of comments from the comments field on the
questionnaire:
• I’d like to thank all the home treatment team for getting me back to normal again
• Ensure patients are notified about discharge beforehand, not on day of discharge
• Did not spend enough time, visits were quick. Should have seen the doctor more than I did
• At first I thought the team were joking me. Now I think the team help and they are polite.
50 most commonly used words used in comments field of HTT Questionnaire
Carers Inpatient Survey
High levels of satisfaction (over 80%) were achieved for:
• Found carers assessment helpful
Lower levels of satisfaction (under 40%) were achieved in:
• Staff valuing their contribution
• Being encouraged to share their views and knowledge
• Staff valuing suggestions and comments made
• Being invited to take part in discussions
• Being given a carers information pack
• Being offered a carers assessment
• Being supported to consider their own health needs
A carers action plan is being implemented
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 37% of respondents said extremely likely and 33% said likely.
Comments The following are a selection of comments from the comments field on the
questionnaire:
• Concerns about time patients are left on their own. staff are in the office and tell me they
check every 10 minutes, but in 10 minutes things can happen..
• Excellent for activities, calm atmosphere. People were relaxed.
• It did not seem with me personally I had interaction from staff in discussions with person I
care for. I gained all the information about the person I care for from them themself. I had
no communication apart from greeting and goodbye with the staff.
• Keep families informed of what goes on, on day today basis. Respect the carers/families
views.
50 most commonly used words used in comments field of Inpatient Carers Questionnaire
Carers Home Treatment Team Survey
High levels of satisfaction (over 80%) were achieved for:
• Being provided with information
Lower levels of satisfaction (under 40%) were achieved in:
• Being invited to take part in discussions
• Feeling staff valued suggestions and comments
• Being given a Carers information pack
• Being offered a Carers assessment
A carers action plan is being implemented
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 41% of respondents said extremely likely and 33% said likely.
Comments The following are a selection of comments from the comments field on the
questionnaire:
• There was not much support for me or my children who live with the person I care for
• HTT is very helpful to my son always respectful and thoughtful. They always encourage
him to take his medicine. He could easily have had a relapse
• We found that anything we did say, was somehow twisted and reported on incorrectly. We
felt by some that anything we wish to discuss was treated as stupid
• Brilliant , Excellent always
• Thank you to the Home Treatment Team I would recommend them.
50 most commonly used words used in comments field of Home Treatment Team Carers
Questionnaire
London Community Services:
Long Term Conditions CQUIN – Quarter 4
http://www.bbc.co.uk/news/entertainment-arts-27654804
Services demonstrated overall levels of satisfaction above 90% in all but one area. Over 95% was
scored in the following areas:
• Being seen on time
• Being given enough time in the appointment
• Healthcare professional introducing themselves
• Being communicated with confidentially
• Being able to understand information given to them
• Being listened to
Lower scores were received from patients in the following areas:
• Being given information to read (57%)
Access to information is a recurrent theme in surveys and a team on the NELFT Leadership
programme have started to progress this
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 74% of respondents said extremely likely and 26% said likely.
•
•
•
•
•
•
•
Comments The following are a selection of comments from the comments field on the
questionnaire:
I think it does not need any change
Ensure that the patient knows the time of visits- and is informed when they are changed
Wait for key safe for 2 days and stair rail so I can get up and down stairs
Physiotherapist came to visit, assess me, told me someone else will come and help me do the
exercises. Could not tell me what exercise , did not explain.
Quite happy with present arrangement
Poor communication from acute sector to primary care. No discharge summary
Changeover time 8-9am. Messages left don’t get through to day staff but is an excellent service.
50 most commonly used words used in comments field of Long Term Conditions CQUIN
questionnaire
Community:
Particularly high levels of satisfaction (above 95%) were reported in the following areas:
• Being given enough time in appointment
• Having treatment explained clearly
• Healthcare professional introducing themselves
• Being communicated with in a confidential manner
Lower scores (below 80%) were received from patients in the following areas:
• Being given information to read
As previously, information is a recurrent theme
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 70% of respondents said extremely likely and 25% said likely.
Comments The following are a selection of comments from the comments field on the
questionnaire:
• The quality of care in Grays Court needs to be investigated by Matron - approach to patients
• with dementia, more TLC, encouragement
• Everything was fine
• It's been good to me all times
• The road outside and parking services could be improved other than that everything else is
very good.
• Good service. No need to improve.
50 most commonly used words used in comments field of Community questionnaire
Inpatient:
Particularly high levels of satisfaction (above 95%) were reported in the following areas:
• Being made to feel welcome
• Having confidentiality respected
• Being treated with dignity and respect
• Having privacy maintained
• Feeling safe
• Having family and home life taken into account on discharge
Lower scores (below 80%) were received from patients in the following areas:
• Being told about the daily routine of the ward
• Being encouraged to ask questions
• Being involved in care planning
• How clean the ward was
• The quality of the food
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 43% of respondents said extremely likely and 49% said likely.
Comments The following are a selection of comments from the comments field on the
questionnaire:
• All the staff are good. I enjoyed my stay
• All staff have been very good to me
• We cannot thank all staff enough for their kindness shown to our mother
• I feel the ward was vastly undermanned and seemed to lack senior judgement
• During my 5 week stay I have had 3 meals I had to throw away because they were uneatable.
• Maintenance needs improving. Doors and Beds need lubricating. Rails in Bathrooms need fixing
All lights need to be switched off at night in corridor. On site gym would be beneficial
Most commonly used words used in comments field of Inpatient questionnaire
Walk in Centre:
Particularly high levels of satisfaction (above 95%) were reported in the following areas:
• Being communicated with in a confidential manner
Lower scores (below 80%) were received from patients in the following areas:
• Being encouraged to ask questions about treatment
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 82% of respondents said extremely likely and 17 % said likely.
Essex Services:
5 x 5 questionnaires:
Results from 1st June 2013 to 31st March 2013;
• Did you find it easy to access this service? 95%
• Did staff introduce themselves to you? 98%
• Did staff explain what they could or couldn’t do for you? 97%
• Did the service you received meet your expectations? 98%
This has stayed steady in every area since the last report.
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 64% of respondents said extremely likely and 31% said likely.
Comments The following are a selection of comments from the comments field on the
questionnaire:
• Service is brilliant
• Exceeded our expectations
• Over and above. All the nurses who visit are excellent
• Once the right person was involved, then yes. Based on the most recent contacts it is very
good and meeting all my expectations
• Staff don’t carry the right equipment and has to get masks from London hospital
50 most commonly used words used in comments field of Essex 5x5 questionnaire
Community:
Particularly high levels of satisfaction (above 95%) were reported in the following areas:
• Being treated with respect
• Being given the opportunity to ask questions
• Having confidentiality respected
Lower scores (below 80%) were received from patients in the following areas:
• Length of time to get an appointment
• Being seen on time
• Feeling involved in planning of treatment
• Being asked for permission before receiving treatment
• Rating of patient transport
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 66% of respondents said extremely likely and 30% said likely.
Comments The following are a selection of comments from the comments field on the
questionnaire:
• Have found the community matron scheme to be very responsive, caring and wonderful
support to my mother
• Overall excellent service thank you. Was late due to car parking
• Phone booking system could be better. Seems to take a long time to get through to make
an appointment
• I was disappointed to find promised medication referral letter to my GP had not been sent.
Two subsequent phone calls to resolve the matter were very time consuming
• Nothing to improve. Top marks.
50 most commonly used words used in comments field of SWECS Community questionnaire
Inpatient:
Particularly high levels of satisfaction (above 95%) were reported in the following areas:
• Being made to feel welcome
• Having confidentiality respected
• Being treated with dignity and respect
• Having privacy maintained
• Being listened to
• Feeling safe
• Having home situation taken into account
Lower scores (below 80%) were received from patients in the following areas:
• Quality of the food
• Cleanliness of the ward
•
Being told how to help in an emergency after discharge
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 75% of respondents said extremely likely and 23% said likely.
Comments The following are a selection of comments from the comments field on the
questionnaire:
• Most of the staff are good. A few try to voice their opinion and will not listen. The two
doctors are very good indeed and very helpful
• Very impressed by the care, competence and friendliness of the staff
• Would like to say how very well I have been looked after during my stay
• Listen to your patients. NOBODY can speak for another and understand how they feel.
Consider the global picture. Every case is different.
• Could badly do with another toilet and showers for the ladies and would save the nurses
valuable time.
• I was well looked after. Within a minute of arriving I had a cup of tea and a cheese
sandwich. All the staff did my care and were really friendly. Staff always friendly to all
visitors. Always listen to me, patient and answer my calls.
Most commonly used words used in comments field of Inpatient questionnaire
Minor Injury Unit:
Particularly high levels of satisfaction (above 95%) were reported in the following areas:
• Being communicated with in a confidential manner
Lower scores (below 80%) were received from patients in the following areas:
• Bring treated with dignity and respect
Friends and Family Test: How likely is it that you would recommend this service to friends and
family? 93% of respondents said extremely likely and 7 % said likely.
NHS England Friends and Family Test Pilot
NELFT has been part of the NHS England pilot for the Friends and Family Test within Mental Health
Services and Community Services. Learning has been shared with NHS England, and will be used in
developing the national Friends and Family Test Guidance. NELFT continue to be part of the NHS
England Friends and Family test work streams for Mental Health and data collection & reporting.
Areas covered by the pilot were;
• 5x5
• Mental Health Inpatient
• Home Treatment Team
• Community Inpatients
• Minor Injuries Unit
• Walk in Centre
• Health Visiting
• Psychiatric Liaison
• Perinatal
Paper questionnaire responses from Barking Walk in Centre and Orsett Minor Injury Unit were
very low due to high patient levels and the logistics of proving printed paper questionnaires. As of
1st May 2014 electronic kiosks have been installed in these locations to overcome this problem.
Other questionnaires
Other bespoke surveys have also been untaken on a local level, including Community Dental and
discharge to Primary Care from Mental Health Services. 5x5 style surveys have been launched in
Waltham
Forest
and
Barking,
Havering
&
Redbridge.
ACTION PLANS:
In all areas, as well as the overall report, individual service reports are distributed to teams/ wards
via leadership.
Services are required to develop action plans for any area where patient satisfaction is low.
Adherence to action plans generated as a result of surveys is monitored through operational
management structures.
QUALITATIVE FEEDBACK:
All questionnaires also have a free text box where patients and carers can make any qualitative
comments. Examples of these are presented in word cloud form. These show the 50 most
commonly used words used in the comments box. The larger the word the more frequently used.
AGENDA ITEM 11 – BHR ECONOMY MANAGEMENT REPORT
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
Report by:
Integrated Care Director – Havering
Subject:
BHR economy - update
Visit from David Foster – Deputy Director of Nursing, Department of Health
David Foster, Deputy Director of Nursing and Midwifery advisor for the Department of
Health (DH) visited one of the Havering District Nurses, Liz Alderton on 3 June 2014. David
was interested in the role of the District Nurse and shadowed Liz, a Queens Nurse from the
Queens Nursing Institute (QNI), as the DH have commissioned QNI to review District
Nursing. David spent the morning with Liz and then came back to base to see how the team
was working. During the debrief he commended the service and was very impressed with
the care Liz had delivered noting her compassion and professionalism. It was noted how the
service was increasingly dealing with highly complex patients and when asked what the DH
should be sighted on, the team highlighted that the DH focus on nursing tends to lean
towards acute rather than community care and a higher profile of community nursing would
be beneficial. NELFT also shared the work we are doing to progress integration of
community services and this was well received.
Stay Safe Be Healthy in Barking & Dagenham
A highly successful multi-agency and community engagement event, ‘Stay Safe Be Healthy
in Barking & Dagenham’, has recently taken place. The event was opened by the Mayor of
London Borough of Barking and Dagenham (LBBD).The initial idea for having such an event
came from a Barking and Dagenham Health Visitor based at Orchards Health Centre after
recognising many children and young people were presenting at A&E following preventable
accidental injuries, especially those resulting in burns and scalds. Following discussion with
colleagues within LBBD, the format of the event developed further and involved
representatives from a wide range of statutory, voluntary and community groups and
professionals. Positive feedback regarding the event was received. The multi-agency
partnership working and large attendance by a cross-section of the public, including some of
our most vulnerable groups, made the day a huge success.
Redbridge Paediatric services
Work is continuing within Redbridge to review roles and processes within the children’s
services. As a part of this process the Royal College of Paediatricians have been engaged to
review the work of the Paediatricians in the borough. This review will take place on the 30
June and 1 July 2014, and the Trust will receive a report with recommendations around best
practice for the future delivery of the service. Senior management have also visited the
Hackney Ark Children’s Centre, which is acknowledged as a centre of excellence, to gather
ideas for service improvement in preparation for the move of the Child Development Centre
to Grovelands in September 2014.
HSJ Awards
NELFT has been shortlisted for the HSJ awards in a joint submission with BHR CCGs. The
submission outlined the work NELFT and the BHR CCGs have completed to date regarding
the redesign of rehabilitation and intermediate care services in the community. The
submission entitled - Shifting care from hospital to home: trialling a new model of
intermediate care in Barking and Dagenham, Havering and Redbridge was one of 5
shortlisted out of 60 applications. The winners will be announced in November 2014.
Caroline O’Donnell
Integrated Care Director
AGENDA ITEM 12 – ESSEX HEALTH ECONOMY MANAGEMENT REPORT
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
Report by:
Integrated Care Directors
Subject:
Basildon/Brentwood and Thurrock Integrated Care Directorates – Update
Essex Falls Prevention Service
In April, NELFT commenced mobilisation and operations to provide a newly specified Falls Prevention Service
for the increasing older population of Basildon, Brentwood, Castle Point and Rochford. This team aims to
identify those at risk of falling, assess their individual risk factors, implement appropriate intervention and
follow-up to monitor effectiveness. The key indicators for the service are a reduction in the number of falls and
injuries resulting from falls per year from those participants using the service.
As with all of the care and support delivered by NELFT, the Trust encourages Service Users to have their say
about quality care and how NELFT can continue to improve its offer by completing a short on-line or telephone
questionnaire. The initial responses to such surveys have been extremely positive. All patients and carers have
fed back that their concerns had been addressed and that they subsequently felt much better equipped to
avoid falls.
Some of the comments received included “think it was brilliant service…. that you were visited at your home
was very helpful”, “very satisfied – glad that she is getting help”, “very happy and pleased that we will be
contacted again in 6 months” and “everything explained, very good service”.
NELFT staff have worked extremely hard to deliver a challenging mobilisation plan and can take great pride
from the appreciation shown for what promises to be a much valued service.
Community Paediatric Diabetic Service peer review
The NHS England National Peer Review Programme takes place every six years and looks at best practice. A
review of the Paediatric Diabetes Service recently took place and they were very complimentary about our
motivated, friendly and interactive team. They were impressed with the service provided and paid particular
attention to the patient centred goals, dietetic services such as supermarket trips and coffee mornings, school
clinics and particularly liked the psychologist going into school to meet with patients. Formal outcome is
expected in July 2014.
Feedback on Barbara’s story for Dementia Awareness Week (GR)
As part of Dementia Awareness week, the three in-patient units introduced Barbara’s story to their teams.
Barbara’s story is a training programme launched by Guy’s and St Thomas’ NHS Foundation Trust to raise
awareness of how it feels to be a patient with dementia.
The training programme follows the journey of an older woman called Barbara through her healthcare journey
as her dementia gradually advances. Each film/DVD focuses on different aspects of her care and highlighted the
support we need to provide patients to achieve high standards of care for dementia patients. The feedback and
the impact of the DVD were very positive although an emotional experience.
One matron stating “Barbara’s story was extremely moving, some staff were brought to tears” .After watching
the DVD which was thought provoking, staff made a pledge to make a greater effort to put themselves in the
patients shoes when delivering care as well as to ensure they are treated as individuals in their own right.
1
As part of this pledge, staff were also encouraged to become Dementia friends as part of the National
campaign recently launched.
Essex Staff grade posts included in the East of England Deanery GP Training posts Professor John Howard,
Postgraduate GP Dean and Deputy Postgraduate Dean at Health Education, East of England has shown a very
positive response to our initiative of including the staff grade doctor posts in Community Geriatrics, Dementia
Crisis Support Team and Genito-urinary (GUM) services in Essex, into their GPVTS training program. This means
that, in future, these posts will be covered by GP trainees which will have a very positive impact on these
services. It will raise the profile of these services with Commissioners and will improve the quality of care
delivered to our patients.
Mark Woolterton, GP Program Director for Brentwood and Basildon had a very positive meeting with Dr Qazi,
Associate Medical Director for Essex. He was excited about the GP trainees receiving training within NELFT
posts in Essex, which Dr Qazi will oversee.
Brid Johnson, ICD-Basildon & Brentwood
June 2014
Michelle Stapleton, ICD-Thurrock
2
AGENDA ITEM 13 – WELC ECONOMY MANAGEMENT REPORT
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
Report by:
Integrated Care Director – Waltham Forest
Subject:
Waltham Forest/ Mental Health Inpatient Report to Board – June 2014
PURPOSE
To advise Trust Board of recent issues in Waltham Forest/ Mental Health Inpatient directorate
EXECUTIVE SUMMARY
The Board is asked to note the following issues and developments in Waltham Forest/ MH Inpatient
service areas:
•
•
•
Waltham Forest Estate Strategy
Recruitment strategy for IAPT and Community Nursing
Substance Misuse and Sexual Health Services promotional DVDs
WALTHAM FOREST ESTATES STRATEGY
Waltham Forest Leadership team has formed an Estates Strategy Group for Waltham Forest with
colleagues from the estates department. The group is developing an Estates Strategy for Waltham
Forest as part of the review of the NELFT Estate Strategy.
The emerging vision is to have three main hubs for integrated community and mental health service
provision in the borough in the north, south and centre of the borough. Each hub will comprise of a
modern, fit for purpose community health resource which will facilitate agile working with teams
working with together across traditional boundaries. The hubs will enable a rationalisation of estate
use which it is envisaged will deliver a higher quality environment for service users and patients and
will be more resource efficient. Community and mental health services are currently located on at
least 24 sites in Waltham Forest and a number of sites such, Hawkwell Court, are presently
significantly under-utilised.
Plans to develop the central hub on the Thorpe Coombes site are well underway and a pre planning
application public consultation event on the proposed development took place on the 19th May
2014. The event was well attended by local residents, service users and staff and plans will now be
refined in light of the issues and suggestions raised. A full business case for the Thorpe Coombe site
is in development and is scheduled to come to a Trust Board workshop in September for Board
approval in October.
An initial feasibility study has also been commissioned by NELFT to establish whether a North hub
community site could also accommodate an integrated frail elderly inpatient unit which potentially
would enable closer joint working between older adult mental health provision and community
health rehabilitation services.
RECRUITMENT STRATEGY FOR IAPT AND COMMUNITY NURSING
As a result of significant new investment and challenging targets in community nursing in Waltham
Forest and in IAPT in Havering, Redbridge, and Waltham Forest; the Waltham Forest Leadership
team has been working in partnership with HR colleagues on a priority recruitment programme. The
programme has involved the senior leadership team identifying recruitment as a key priority and
dedicating significant resource to its oversight and delivery. Managers have taken a local approach
to recruitment with administrative support based locally from HR. This has included: rolling adverts
and shortlisting, targeted advertising, creative partnerships. A detailed process, outlining the key
steps, to enable robust monitoring of progress was also devised.
Since its inception in April this year the following outcomes have been achieved:
•
20 trainee low intensity workers have been jointly recruited with UCL and will start a
bespoke NELFT IAPT training course on (date). All those passing the course will be
guaranteed jobs as qualified staff in our IAPT services in October. In addition to this all the
existing IAPT vacancies have been advertised
•
5 nursing and 2 AHP staff have been recruited to our Integrated Care teams in Waltham
Forest. Of these 2 nurses have started and 5 are waiting for the recruitment processes to be
completed.
•
10 new vacancies have also been created in our district nursing services from new
investment and a review of existing resources. These posts have now been advertised, 6
band 5 nurses have been appointed and the aim is to complete the process by the end of
June.
•
A further 2 band 6 nurse have been appointed and adverts are in place for 2 band 6 nurses
for the existing vacancies
As a result of the initiative staff have been appointed and started in roles in a more timely fashion.
Improvements can still be made and we will continue to do so. Plans are now in place to work to the
same model to recruit to new vacancies in our 0-19 universal children’s service.
SEXUAL HEALTH and SUBSTANCE MISUSE SERVICES PROMOTIONAL DVDs
Two DVDs to promote our services have been developed for Substance Misuse and Sexual Health
services. The sexual health 15 minute DVD is targeted at young people and was devised in
partnership with the Local Authority and features the Young Advisors, who are a team of young
people recruited to advise on services for young people in the borough. Young people were involved
in the design and making of the film, and some also featured in it.
The film is a virtual tour of the sexual health clinic at Oliver Road, with young people interviewing
staff and asking questions which aimed to demystify and encourage young people to be more
proactive about taking care of their sexual health
90 copies have already been given to the local authority healthy schools consultant to be delivered
in schools as part of their sex and relationship education (SRE) programme. There is also a process in
progress to recruit a young person’s lead in the service who will be further develop services include
bespoke young peoples’ clinics
A film, called Sharing Hope, has also been developed with substance misuse service users, through
the service users’ network. It consists of a series of interviews with service users about their journey
to recovery and how NELFT supported them on this journey. It covers both drugs and alcohol.
Both services are commissioned by Public Health and will be subject to competitive tendering
exercises during 2014/15.
Sue Boon
Integrated Care Director
June 2014
AGENDA ITEM 14 – APPLICATION OF THE CORPORATE SEAL
BOARD OF DIRECTORS 24 JUNE 2014
Report to:
Board of Directors
Date:
24 June 2014
Report by:
Trust Secretary
Subject:
Application of the corporate seal
PURPOSE OF THE REPORT
To notify the Board of the use of the corporate seal for the year April 2013 – March 2014
EXECUTIVE SUMMARY
As per s.16 of the Trust Constitution, the Trust has a seal which may only be affixed under
the authority of the Board of Directors.
An entry of every sealing is made and numbered in the Register of Documents Sealed. Each
entry is signed by the members who approved and authorised the document and attested
the seal.
FIT WITH ORGANISATIONAL VALUES
The report ensures the Trust complies with the relevant section of the Trust Constitution
and standing orders.
FINANCIAL IMPLICATIONS
None
ACTION REQUIRED
The Board is asked to receive the report for information.
Helen Essex
Trust Secretary
24 June 2014
Use of the Trust seal in the year April 2013 – March 2014
Document signed/sealed
Naseberry Court – Guardian Services Agreement
Signed by
(signature 1)
John Brouder
Signed by
(signature 2)
Jacqui Van Rossum
Date
Destination
22.07.13
Capsticks Solicitors LLP
Thurrock Council – s.75 agreement with NELFT
Martin Munro
n/a
15.08.13
Thurrock Council via AD Finance,
SWECS
NELFT & Goodmayes Sports & Social Club – lease
Martin Munro
John Brouder
11.09.13
Estates department
Lease and licence for alterations – first floor office
at Bernard House
London Borough of Redbridge – s.75 agreement
with NELFT
S.106 agreement – Mascalls Park, Mascalls Lane,
Great Warley, Brentood Ref: 11/1181/FUL
Martin Munro
John Brouder
11.09.13
Capsticks Solicitors LLP
Martin Munro
John Brouder
11.09.13
NELFT Borough Director, Redbridge
John Brouder
Martin Munro
16.09.13
Rochford District Council (AJ Bujega –
Head of Legal, Estates and Member
Services)
Sale of freehold land with vacant possession at
Mascalls Park
Ian Cable
Jacqui Van Rossum
30.09.13
Capsticks Solicitors LLP
Lease for Chadwell Clinic
Jacqui Van Rossum
Ian Cable
09.10.13
Beachcrofts LLP via Estates Director
Agreement for Education Project Speech &
Language Therapy service and Speech & Language
Therapy in Special Schools
John Brouder
Jacqui Van Rossum
21.11.13
Not indicated
Licence agreement for sessional use of Seminar
Room 2 ground floor of Broad St Centre
Jacqui Van Rossum
Stephanie Dawe
10.12.13
Capsticks Solicitors LLP
Lease relating to Ainslie Rehab Unit, Friars Close,
Larkshall Road, Chingford
Martin Munro
John Brouder
23.12.13
DAC Beachcroft LLP
Phoenix House lease
Martin Munro
John Brouder
23.12.13
Capsticks Solicitors LLP
Lease agreements for Ilford Lane Chambers and
Broadway Chambers
Martin Munro
John Brouder
23.12.13
Legal Services, LBR, Ilford Town Hall
Transfer (TR1), legal charge and parent company
guarantee for Mascalls Park
John Brouder
Ian Cable
24.01.14
Capsticks Solicitors LLP
Contract for supply of the young people’s
specialist substance misuse service in the London
Borough of Redbridge 1 April 2014 – 31 March
2015
John Brouder
Ian Cable
06.03.14 (and resent on 19.03.14
LBR (via Bob Edwards)
Part of Foxglove Ward Block 2, KGH, Barley Lane
Jacqui Van Rossum
John Brouder
19.03.14
DAC Beachcroft LLP
AGENDA ITEM 04a – CE REPORT, ESTATES STRATEGY UPDATE
BOARD OF DIRECTORS 24 JUNE 2014
Estates Strategy 2007-2016 - Update
A full strategy updated will be presented to the Board in November 2014. Our general strategic plan revolves
around rationalising estate, releasing older unsuitable buildings/leased buildings and moving to new fit-forpurpose owned buildings. This will use the principles of agile working to maximise the use of buildings and
minimise the Trusts reliance on buildings as fixed bases.
Thurrock
A borough strategy is being developed. We are currently looking at the potential to develop a HUB in StanfordLe-Hope with a GP practice.
Basildon & Brentwood
An overall strategy is being developed. We are currently looking at the disposal and redevelopment of
Craylands in conjunction with Basildon Council as part of their redevelopment of the area.
Redbridge
Goodmayes – plans remain to re-locate all clinical & corporate services other than inpatient and associated
services from the site and dispose of the older parts of the site for residential development and re-investing
proceeds into improved healthcare. There are current delays due to green belt planning issues. The target date
for disposal is now 2017.
The Trust is planning to develop a Child Development Centre within Redbridge which will integrate Child
Mental Health and Community Services in conjunction with Redbridge Council. Potential sites are currently
being identified; however an interim move of the CDC from Kenwood Gardens to Grovelands is planned for
September 2014.
Waltham Forest
The strategy is well-developed to rationalise services into three HUBs, the first of which is a new community
and mental health centre on the Thorpe Coombe site. This development will release two thirds of the TCH site
for residential redevelopment. A planning application is to be submitted in June 2014. A Health Centre is due
to open mid-2016.
Two other HUBs (one in North and one in South) will probably be located at either Naseberry or Hawkwell
(North) and Langthorne (South). Stonelea is not in Trust plans and is planned for disposal by early 2015.
Barking & Dagenham
An overall strategy is being developed. The Hedgecock site was disposed of in 2013. There are no current plans
for further site disposals.
Havering
An overall strategy is being developed. Plans emerging in conjunction with Havering Council for a new Older
Persons Centre for re-location of services from Victoria site. New building procured (London Road) for a new
Child Development Centre which will be an integrated service encompassing Mental Health and Community
Services, due to open autumn 2014.
Graham Thomas - Estates Director

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