Argyll & Bute CHP Committee Date of Meeting: 28 April 2010 Item No. 6.1

Clinical Governance, Risk Management and Health & Safety Performance Report

Report by Pat Tyrrell, Lead Nurse Fiona Campbell, Clinical Governance Manager

The Committee is asked to:  Note the contents of the Clinical Governance, Risk Management and H&S Report.

1.0 Contribution to the Board’s Corporate Objectives

This performance report demonstrates Argyll & Bute CHP’s commitment to achieving the Board’s corporate objective – Better Care, by ensuring that the services it delivers are of a high quality and safe.

BC.1 – Individuals patients are at the centre of their own treatment and care planning and decisions

In December 2009 CHP responded to 100% of complaints within 20 working days (3 complaints), however in January only 1 of the 2 complaints received were responded to within 20 days (50%). To help support compliance with meeting the 20 day target a list of open complaints and the time elapsed is sent to Locality Managers on a weekly basis.

BC.2 – Patients experience no harm from healthcare services

Argyll and Bute CHP encourages staff to report all incidents and all incidents are reviewed and actions and learning identified. Critical incidents undergo thorough investigation and root cause analysis, an action plan is developed and monitored to minimise the risk of recurrence and lessons learned are shared as appropriate.

BC.4 – Healthcare and treatments are provided to consistent standards

Argyll and Bute CHP contributes to and supports national standards relevant to the services it delivers. NHS Highland NHS QIS Peer Review Visit took place on March 10/11 2010.

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2.0 Risk Management

2.1 Incident Data for Argyll and Bute CHP – 1st January – 28 February 2010 (finally approved)

Table 1: Incidents by Site and Grade

Very Count of Incidents by Site and Grade Low Medium High High Total Hospital - Argyll & Bute 57 54 0 1 112 Hospital - Bute - Rothesay Victoria Hospital 3 21 2 0 26 Hospital - Bute - Rothesay Victoria Hospital Annexe 4 7 0 0 11 Hospital - Campbeltown 15 8 0 0 23 Hospital - Dunoon - Community Hospital 15 16 0 0 31 Hospital - Islay - Bowmore Hospital 5 11 1 0 17 Hospital - Lochgilphead - Mid Argyll Community Hospital, Integrated Care 11 29 0 0 40 Hospital - Oban - Lorn and Islands General Hospital 18 12 1 0 31 Workbase / Office / Training - Jura - Jura Care Centre 0 1 0 0 1 GP/Healthcentre - Campbeltown - Health Centre 1 0 0 0 1 GP/Healthcentre - Dunoon - Church Street Surgery 1 0 0 0 1 GP/Healthcentre - Helensburgh - Medical Centre 1 2 0 0 3 GP/Healthcentre - Islay Port Ellen - Port Ellen Practice 0 0 1 0 1 GP/Healthcentre - Kilcreggan - Kilcreggan Health Centre 1 0 0 0 1 GP/Healthcentre - Oban - Lorn Medical Centre 0 1 0 0 1 GP/Healthcentre - Southend - Southend Medical Practice 0 2 0 0 2 Dental - Dunoon - 143 Alexandra Parade 1 0 0 0 1 Total 133 164 5 1 303

TTTable 2 : Incidents by Category and Grade

Very Count of Incidents by Category and Grade Low Medium High High Total Absconder/Missing Patient 5 16 0 0 21 Access/Admission 2 1 0 0 3 Accident 3 4 0 0 7 Blood Transfusion 0 2 0 0 2 Clinical Assessment 0 1 0 0 1 Consent, Communication & Confidentiality 0 3 0 0 3 Disruptive, Violent, Aggressive Behaviour 21 27 0 0 48 Documentation/Clinical Information 1 2 1 0 4 Fire 11 20 0 0 31 Infection Control 3 1 0 0 4 Investigations (Scans/X-Rays/Specimens) 5 2 0 0 7 Medical Device/All Equipment (except radiation equipment) 4 2 0 0 6 Medication (including vaccines) 5 4 0 0 9 Moving & Handling 1 5 0 0 6 Radiation (Exposure to radiation outwith the therapeutic dose) 1 0 0 0 1 Road Traffic Accident (RTA) 2 1 0 0 3 Security 4 2 0 0 6 Self Harming Behaviour 4 4 0 1 9 Sharps 1 2 0 0 3 Slips, Trips & Falls 48 37 1 0 86 Staff Availability 8 11 1 0 20 Test Results & Reports 1 0 0 0 1 Transfer/Discharge 2 14 2 0 18 Treatment Procedure 1 3 0 0 4 Total 133 164 5 1 303

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2.2 Key Actions Relating to Incidents:

2.2.1 Slips, Trips and Falls

Various strands of work relating to slips, trips and falls both in the Community and in hospital settings is continuing to be progressed. In addition an audit proposal is being developed to understand the reasons for admissions relating to falls and the management of this group of patients, and to review records of patients who fell in hospital to assess implementation of the MORSE risk assessment, and quality of care planning to minimise the risk of falls.

2.2.2 Violence and Aggression

See 6.2 below

2.2.3 Absconding Patients

Analysis of absconding patient incidents is being undertaken. Policies and procedures relating to absconding patients have been requested from all sites. Documents received demonstrate that there are procedures in place which outline actions to be taken when patients are discovered to be missing. Some work is required to ensure that assessment of the risk of patients absconding and preventative measures are robust.

2.2.4 Medication Safety

A&B CHP Medicines Safety Group continues to support improvements in medication safety. The next meeting takes place on 30 April 2010.

The group is initially focusing on: increasing medication incident reporting; reviewing recent incident reports; dosing errors; drug allergies; anticoagulation; NPSA competencies and Scottish Patient Safety Programme Medicines Management bundle. A Key Lessons Bulletin to share learning from reported incidents has been introduced and the first issue has been circulated.

2.2.5 Fire

Fire incidents were the third highest incident type during January – February 2010. The most common reason for reported incidents was unauthorised smoking by patients at . Although initially In Patients responded very well to the reduction / cessation of smoking in hospitals policy, more recently there has been a significant increase in patients smoking in inappropriate areas of the hospital. This is being addressed by staff within the hospital at present. New Fire Alarm system is being installed in Cowal Ward - one of the new alarm points was being inappropriately activated by one of the patients. This has been remedied by the further installation of an additional protective cover (which does not compromise the function of the alarm)

2.2.6 Staff Shortages

More information is available, in Tables 3 to 6 below, on the numbers, locations, causes and impacts of reported staff shortages.

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Table 3: Staff Availability Number of Incidents by Site and Date

Total May Aug Sep Nov Dec Mar Feb Jun Jan Apr Oct Jul

Count of Incidents by Site and Incident date

(Month) Hospital - Argyll & Bute 1 0 5 1 1 1 7 1 3 0 10 0 30 Hospital - Bute - Rothesay Victoria Hospital 2 2 0 3 2 6 2 1 0 2 0 0 20 Hospital - Bute - Rothesay Victoria Hospital Annexe 0 0 0 0 0 1 0 0 1 0 0 0 2 Hospital - Campbeltown 0 0 0 5 8 0 2 0 5 1 2 0 23 Hospital - Dunoon - 1 1 0 2 0 0 0 2 1 0 0 0 7 Hospital - Islay - Bowmore Hospital 0 0 1 0 1 1 0 0 1 0 0 0 4 Hospital - Lochgilphead - Mid Argyll Community Hospital, Integrated Care 1 4 1 0 0 0 0 0 0 0 0 0 6 Hospital - Mull - Dunaros Hospital 0 0 0 0 0 1 0 0 0 0 0 0 1 Hospital - Oban - Lorn and Islands District General Hospital 2 2 0 2 2 2 1 0 0 2 0 0 13 GP/Healthcentre - Rothesay - Bute Practice Health Centre 0 0 0 0 1 0 0 0 0 0 0 0 1 GP/Healthcentre - Seil - Easdale Medical Practice 0 0 1 0 0 0 0 0 0 0 0 0 1

Total 7 9 8 13 15 12 12 4 11 5 12 0 108

Table 4: Staff Availability Number of Incidents by Site and Time

07:59 17:59 23:59 00:00 08:00 18:00 Total - - -

Incidents by Site and Time of Incident Hospital - Argyll & Bute 1 11 11 23 Hospital - Bute - Rothesay Victoria Hospital 2 10 3 15 Hospital - Bute - Rothesay Victoria Hospital Annexe 2 0 0 2 Hospital - Campbeltown 9 7 5 21 Hospital - Dunoon - Cowal Community Hospital 0 5 1 6 Hospital - Islay - Bowmore Hospital 0 1 2 3 Hospital - Lochgilphead - Mid Argyll Community Hospital, Integrated Care 1 1 4 6 Hospital - Mull - Dunaros Hospital 0 1 0 1 Hospital - Oban - Lorn and Islands District General Hospital 4 6 1 11 Total 19 42 27 88

4 Argyll & Bute CHP Committee Date of Meeting: 28 April 2010 Item No. 6.1

Table 5: Staff Availability Number of Incidents by Site and Cause

Agencies Other Sickness Staff Nurse Availability Doctor Needs Patient Additional Other Total

Incidents by Site and Cause of Incident

Primary Care 2 (Social Care) 2

Hospital - Argyll & Bute 20 10 30

Hospital - Bute - Rothesay Victoria Hospital 8 10 2 20

Hospital - Bute - Rothesay Victoria Hospital Annexe 1 1 2

Hospital - Campbeltown 6 7 10 * 23

Hospital - Dunoon - Cowal Community Hospital 1 5 1 7

Hospital - Islay - Bowmore Hospital 3 1 4 Hospital - Lochgilphead - Mid Argyll Community Hospital, Integrated Care 2 4 6

Hospital - Mull - Dunaros Hospital 1 1

LIH Oban 5 8 13

Total 2 47 5 32 22 108

Table 6: Staff Availability Number of Incidents by Site and Impact of Incident

Staff Pressureon Increased Staff Agency of Employment PatientCare quality Reduced recorded Noimpact Other Total

Incidents by Site and Impact of Incident

Primary Care 2 2

Hospital - Argyll & Bute 8 19 2 1 30

Hospital - Bute - Rothesay Victoria Hospital 18 1 1 20

Hospital - Bute - Rothesay Victoria Hospital Annexe 2 2

Hospital - Campbeltown 16 7 23

Hospital - Dunoon - Cowal Community Hospital 5 2 7

Hospital - Islay - Bowmore Hospital 3 1 4 Hospital - Lochgilphead - Mid Argyll Community Hospital, Integrated Care 1 1 4 6

Hospital - Mull - Dunaros Hospital 1 1 Hospital - Oban - Lorn and Islands District General Hospital 3 7 3 13

Totals 56 20 25 5 2 108

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Points to note from this information are:

 There are different thresholds at which an incident report for staff shortage is generated and this leads to inconsistencies across the CHP

 Apart from two, all incidents related to staff shortages are reported from in patient hospital services and over 95% of the total number are related to nurse staffing.

 The times of the incidents are largely related to day time shifts when activity levels are usually higher

 Argyll and Bute hospital is the exception to this and this is attributable to the number of reports submitted where non contract agency staff had been recruited to cover night shifts

 Some of the reported incidents are isolated events that have been dealt with effectively at local level.

 Argyll and Bute Hospital has the highest reported incidence of staff shortage and this is attributable to their use of non contract agency to provide cover when it has been required. The impact of the staff shortages in these situations had greater financial than clinical significance, as capacity to deliver care was not effected. It is anticipated that there will be a significant decrease in the use of both bank and agency staff on this site as a result of the changes in ward configuration.

 Because of the variations in service demand, and the integrated model of service delivery across community hospitals, there are inevitably peaks and troughs in activity levels. This can cause pressure for staff at times and does require flexibility and movement of staff throughout the hospital to target areas of demand. Some of the incident reports relate to this movement and resulting pressure on staff. In most of these cases there is no report of negative impact on patient care. This is especially the case for Victoria Hospital in Rothesay and .

 The recent review of the nursing establishments across all hospitals in Argyll and Bute (apart from mental health which will be completed at a later date) has identified where the staffing levels have been inappropriate, both in relation to numbers and skill mix of staff. Implementation of the recommendations from the review is now underway and, once completed, it is anticipated that there will be a reduction in the number of staff shortage reports.

 Training in use of Datix and reporting of incidents, as well as ongoing monitoring and feedback by Locality Managers and Lead Nurse will help address the inconsistencies in reporting of staff shortages.

6 Argyll & Bute CHP Committee Date of Meeting: 28 April 2010 Item No. 6.1

2.3 Incident Management System

All sites have now received training on reporting and reviewing incidents using Datix-web, further local ‘mop up’ sessions are planned and NHSH-wide training sessions will be able to be accessed on an ongoing basis for new starts.

It is expected that all CHP incidents will be reported directly via the web-system by the end of April 2010.

Currently there a small number of GP Practices within A&B CHP which complete IR1 Forms. The Datix system is available for use by NHSH GP Practices but further work is required to identify appropriate routes for review and approval of incidents.

2.4 Critical Incident Reviews

There were six critical incident reviews held in the CHP in March. These focussed on a number of aspects of clinical care including HAI, tissue viability, surgery and patient transfers. Each review, which involved multi disciplinary team who delivered the care as well as clinical and professional leads from CHP, identified number of areas of good practice as well as key actions and learning points. Implementation of action points and monitoring of the action plans will be overseen by the CHP Clinical Governance and Risk Management Group. Many of the areas for action identified have significance beyond the locality in which the incident occurred and central to the review process is the sharing of the learning beyond the immediate clinical environment.

3.0 Complaints

3.1 Complaints Volume and Performance Against the 20 Day Target – Highland wide and by Argyll and Bute CHP

This information is based on the complaints received in the calendar month shown

Table 7: Compliance with Response Times, Highland

Response in Number 20 days or Highland received less % Jan-09 32 18 56% Feb-09 33 18 55% Mar-09 33 20 61% Apr-09 25 19 76% May-09 30 17 57% Jun-09 44 27 61% Jul-09 26 20 77% Aug-09 27 17 63% Sep-09 25 15 60% Oct-09 14 10 71% Nov-09 28 18 64% Dec-09 33 28 85% Jan-10 19 12 63%

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Figure 1: Complaint Performance, Highland

Highland Wide Complaint Performance

50 120% 45 40 100% 35 80% 30 25 60% 20 15 40% 10 20% 5 0 0% Jul-09 Jan-09 Apr-09 Jun-09 Jan-10 Oct-09 Nov-09 Feb-09 Mar-09 Aug-09 Sep-09 Dec-09 May-09

Number received % responded to within 20 working days

Table 8: Response Times Argyll and Bute CHP

Response in Number 20 days or received less A&B % Jan-09 8 5 63% Feb-09 3 3 100% Mar-09 2 2 100% Apr-09 4 4 100% May-09 7 7 100% Jun-09 8 6 75% Jul-09 3 2 67% Aug-09 4 1 25% Sep-09 2 1 50% Oct-09 1 1 100% Nov-09 6 4 67% Dec-09 3 3 100% Jan-10 2 1 50%

8 Argyll & Bute CHP Committee Date of Meeting: 28 April 2010 Item No. 6.1

Figure 2: Complaints performance Argyll and Bute CHP

A&B Complaint Performance

9 120% 8 100% 7 6 80% 5 60% 4 3 40% 2 20% 1 0 0% Jul-09 Jan-09 Apr-09 Jun-09 Jan-10 Oct-09 Nov-09 Feb-09 Mar-09 Aug-09 Sep-09 Dec-09 May-09

Number received % responded to within 20 workign days

3.2. Issues and Outcome

This information is based on the complaints received in the calendar month shown and includes all complaints responded to by the date this report is produced (1 March 2010). Graphs will be shown if there are 4 or more categories reported.

Table 9: Issues and Outcomes, Highland

Partly High Level Issue 1 Upheld upheld Not upheld Treatment 1 1 1 Staff - Communication (oral) 1 1 Wait Times 1 Delays 1 Environ/Dom 1 Procedural Issues 1 Staff - Attitude / behaviour 1 Staff - Communication (written) 1 Staff - Competence 1 Staff - Shortage / availability 1 Total 4 4 5

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Table 10: Issue, Outcomes and Staff Group, Argyll and Bute CHP

Staff Group High Level Issue 1 Upheld Partly upheld Not upheld

Nursing Treatment 1

4.0 NHS Reviews

4.1 NHS QIS Clinical Governance and Risk Management Standards

NHS Highland NHS QIS Peer Review Visit took place on March 10/11 2010. Feedback was provided as follows:

Standard 1: Safe and effective care and services

Strengths

• Use of risk registers to inform the strategic framework

• Commitment to progression with business continuity agenda

• Establishment of the quality and patient safety framework

Challenges

• Continued systematic evaluation of risk management

• Continuing to refine the approach to business continuity planning in a proactive manner

 Ensure cross system learning from the operational units activity in clinical effectiveness

Standard 2: The health, wellbeing and care experience

Strengths

• Local solutions to local problems

• Commitment to training within equality and diversity

• Use of modern technology in internal communication

Challenges

• The reality of access, referral, treatment and discharge in NHS Highland

• Progress with roll-out of performance assessment framework for equality and diversity

• Assess the impact of changes in internal communication

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Standard 3: Assurance and accountability

Strengths

• Culture of quality improvement in clinical governance arrangements, fitness to practise and performance management

• Press office business partners in local operational units

• Improvement committee

Challenges

• Communicating strategic vision comprehensively to staff, service users and the public

• Maintaining the high quality of the arrangements for clinical governance, fitness to practise and performance management

The NHS Highland local report will be sent to the Board to check for factual accuracy w/c 3 May 2010 and the National overview will be published October 2010

4.2 NHS Highland QIS Anaesthesia, Care before, during and after Anaesthesia Report The Follow-up report based on the 10 November 2009 peer review visit was published in March 2010 and is available at: http://www.nhshealthquality.org/nhsqis/files/ANAES_LREP_HIGH_MAR10.pdf

A meeting is planned to review the Lorn and Islands action plan and to identify the barriers relating to full implementation of the standards.

4.3 Health Facilities Scotland Food in Hospitals Audit

Actions are underway to progress the key actions which address:

- Full implementation of MUST - Implementation of Raigmore analysed menus - Implementation of dietetic codes and education of nursing and catering staff - Patient and medical representatives identified for all FFNC groups - Agreement regarding the supply of therapeutic meals

The next national audit will take place in June 2010.

5.0 Health and Safety

5.1 Moving and Handling Training

The approach to be taken to increase the CHP capacity to provide training is continuing to be explored and a report will be available shortly.

5.2 Violence and Aggression Training

A programme of training is continuing to be delivered across the CHP and to provide the new trainers with support.

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5.3 Face Fit Testing and Mask Training

Health and Safety and Infection Control staff are progressing the issue of suitable respiratory protection for staff with beards. It is essential that the equipment provides a sufficient level of protection and is also easy to decontaminate. In order to ensure that the CHP is prepared for a future pandemic and to comply with the recommendations for retesting an action plan will be developed to maintain a cohort of tested staff and qualified testers in each locality.

5.4 Sypol - COSHH Assessment System

The population of the Sypol/COSHH database has now been completed by Health and Safety staff in Inverness, and the database is now live. A programme of training for line managers and others who need to use the system has been developed and will take place across the CHP during April and May 2010.

The training will demonstrate the use of the Sypol system and will also make managers aware of their duties under the COSHH Regulations.

5.5 CHASE – Safety Audit System

Two pilot internal audits have been carried out in the CHP during the past two months. The feedback from the pilot audits has been analysed and this combined with the lessons learned from the process was the subject of a development workshop for all health and safety staff throughout NHS Highland. The workshop evaluated the success of the pilots and identified areas for improvement; this has resulted in a shorter and improved question set for the audit. I has been decided that audits will be carried out at each site during the year 2010/11, a timetable for the audit programme will be in place by the end of April 2010.

5.6 Fire Safety

5.6.1 Risk Assessments All duty holder risk assessments will be completed by the end of May 2010 and work is underway to review and progress existing action plans.

6.0 Quality

6.1 Leading Better Care

This project is now progressing across NHS Highland and covers three main streams of work.

The first is the development of the role of the Senior Charge Nurse (SCN) in each ward. In recognition of the pivotal importance of this role, and the fundamental need for effective nursing leadership at this level, a national job description, KSF outline and educational framework have been developed. In NHS Highland all SCNs are undertaking a programme of education and development, supported on site by their local line manager and practice development nurses.

The second part of the project is the introduction of Clinical Quality Indicators (CQIs) in each ward. These have been nationally agreed and are evidence based, covering four key areas of Falls Prevention, Nutrition, Pressure Areas and use of early warning system (SEWS) to identify deterioration in patients’ conditions.

12 Argyll & Bute CHP Committee Date of Meeting: 28 April 2010 Item No. 6.1

Measurement systems have been developed which are focussed on the assessment process and data is recorded in an electronic database. The CQIs are still at an early stage of phased implementation but it is anticipated that progress reports will be available in the near future.

The third work stream is called Releasing Time to Care. Using service improvement methodology this Scottish version is based on a system developed by the Department of Health in England and called the Productive Ward.

Its overall aim is to enable staff within clinical environments to review their working environment, their systems and processes in order that they can identify where time can be saved to be reinvested in providing direct care to those for whom they are working – i.e. the patients and their carers/ families.

Evidence from work across many hospitals in England has indicated that by improving the efficiency and organisation within wards and clinical care environments as much as 30% additional time can be released to spend caring for patients directly.

In Argyll and Bute the Practice Development Nurse in Cowal and Bute has been trained as a facilitator and she has commenced the implementation in Dunoon Hospital. This is at an early stage of development but staff within the hospital are optimistic that the approach will be beneficial in producing positive results.

6.2 Delivering Quality, Serving Communities

International Nurses Day is on May 12th and, to co-incide with this, Argyll and Bute CHP will hold a conference for nurses and other health care professionals. The conference will bring together managers and frontline staff from across the CHP. The dual purpose will be to a) provide up to date information on all of the current quality initiatives that are in place and the impact that they are having on improving patient care and b) to plan the next stages of development so that priority is given to those initiatives that have greatest benefit for patients.

The event will be chaired by Dr Viv Shelley and keynote presentations will be delivered by Heidi May, Board Nurse Director and by Vicky Thomson, National Project Lead for Leading Better Care.

Record Keeping Audit

The results of the annual nursing record keeping and care planning audit have now been received. Although there have been improvements in some aspects of record keeping there are still obvious gaps in the results of the care planning audit and it is on this area that we will focus attention in the coming year.

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