Musgrove Park Hospital NHS Foundation Trust
COUNCIL OF GOVERNORS’ QUALITY AND PATIENT EXPERIENCE GROUP
Wednesday 4 November 2020, 2.00 – 4.00 pm Microsoft Teams Agenda
14:00 1. Welcome and apologies: Verbal Apologies have been received from Neil Thomas
2. Draft minutes of the meeting held on 4 August 2020 Enc A
3. Review of the action log and matters arising Enc B
4. To ratify the appointment of: JG Enc C Vice-Chairman Mental Health Act Committee representative
FOR DISCUSSION
14:15 5. Patient and Public Involvement Manager’s Report HH Enc D – To follow Complaints and PALS Manager report Recent national survey results Patient section of the Performance Report Enc E
14.45 6. Raising Awareness of Suicide Prevention and AVL Enc F Presentation Mental Health Transformation Update Enc F1 Report In attendance: Alison Van Laar, associate director of mental health and learning disability care
15:15 7. QPI Review 2020/21 ST Verbal KPI Setting 2021/22
15:20 8. Workplan Review and Meeting Dates for 2021 All Enc G
FOR INFORMATION
15:25 9. Community support for families/children – The Big Report Enc H Tent
10. Good to Know Log JG Enc I
11. Feedback from the Quality and Governance JG Enc J Committee
12. Feedback from the Mental Health Act Committee PB Enc K
13. Report from the Signage and Wayfaring Committee KB Enc L
14. Carers and Triangle of Care Report HH Enc M – To Follow
15. Any communication issues arising out of items on All Verbal the agenda
16. Future agenda items All Verbal
17. AOB JG Verbal The chair should be advised of any matters to be raised under Any Other Business in advance of the meeting.
18. Date of Next Meeting: Tuesday 9 February 2021, 10:00 – 12:00 via Microsoft Teams
Topics for possible inclusion on the agenda: Topic Source Meeting date 1. Objective 2: To deliver care closer to home in a Workplan for May Aug neighbourhood setting, with an emphasis on supporting people to stay well and manage their conditions/health. To give equal priority to physical and mental health and value all people alike
2. Terms of reference – 6 months review Worplan for May Autumn 3. Update on Outpatient Improvement Board Per PCG 08/19 August/Autumn 4. Maternity Survey Moved from the February section on workplan 5. Serious Incidents Update (NEW) Gary Risdale to be approached ?deaths from CV Autumn 6. Rapid Response Team report – Shaun Carthew November 2019 meeting Anyt time 7. Tissue Viability update Karen Triggs emailed on 11 02 20 to say that two Autumn members of the patient board group asked if she could come back and speak to the group. She didn’t know who it was that she spoke to. She asked if she could come after mid-April when she would have a years’ data to discuss
Actions from the February meeting Agenda item Action Action to be taken 1. Review of action log Serious incident report – look at themes over the last six ?Verbal update from Hayley H. See item 6 months to see what is happening above. Do we need Gary Risdale to come along. 2. Complaints and Concerns Following the merger of the two organisations PB and HP to Phil Brice and Hayley Peters Joint Policy reflect on changes for meetings and structures which are not yet reflected in the policy. Any changes to be circulated.
JB to reflect on issue of lack of reference to ‘please give your Julie Browne patient a ring’. HH joint policy. Will work slightly separately for a while. By time come back will have moved on. New directorate structure and CV holding things up. – on back brner to directorate structure in place.
HH one person started. Another due to start in next weeks. Quite difficult to train new people. Need to sit beside them. Dot want to do that rigt now. Got a slightly dif way of doing things. Don’t want to expose clinicians looking at complaints – focus on clinical work, extension on current and new complaints. Everything is slight different to usual. Once all over will be fully staffed (complaints) Jg are you letting patients know Hh yes. Every curet and future complaint will have a letter sent explaining whilst delayed. PHSO are doing the same.
3. Paediatric Mental Health Big Tent – future agenda item. HP to find out who to invite Hayley Peters Referrals Report JG ? Big Tent on hold. Keep on agenda. 4. Quality Accounts Process It was suggested that mapping agenda items around the Jg: this last 1,000 days - what pressures on quality improvement priorities would be a good idea* system due to CV. ST: Charlie doing work. Afterwards when has time he can look at how it went he can look at this after. 5. Patient Experience Report Recovery College – A report to come back to a future Approach Alison van Laar – keep on agenda meeting (6/12 = August 2020) ST saw a good presentation Hayley did on this. Powerful for governors. ?Development day – good news story. 6. AOB: Car parking for patients who are frail Carol L to email Phil Shelley
*Quality Account priorities Managing frailty Enabling people to stay well & increase their independence
Stolen years Increase life expectancy of people with mental illness through treatment of co-morbidities and prevention and modification of risk factors
Last 1,000 days Optimise people’s precious time in last part of life by ensuring we only do what is important to them
Connecting us Improving outcomes for people with high use of healthcare services
Function First Increase time in school for children with persistent physical symptoms
COUNCIL OF GOVERNORS’ THE QUALITY AND PATIENT EXPERIENCE GROUP Minutes of the Meeting Held on 4 August 2020 at 14:00 – 15:00 Via GoToMeeting
Present: Jane Armstrong (JS) Public Governor (Somerset West and Taunton) Erica Adams (EA) Public Governor (Somerset West and Taunton) Kate Butler (KB) Public Governor (Somerset West and Taunton) Judy Cottrell (JC) Public Governor (Somerset West and Taunton) Melanie Devine (MD) Public Governor (Somerset West and Taunton) Stephen Fowler (SF) Public Governor (Mendip) Judith Goodchild (Chair) (JG) Public Governor (Sedgemoor) Ian Hawkins (IH) Public Governor (Somerset West and Taunton) Mike Hodson (MH) Public Governor (Sedgemoor) Owen Howell (OH) Staff Governor Phil Hodgson (PH) Staff Governor Philip Jackson (PJ) Public Governor (Mendip) Julie Jones (JJ) Staff Governor Jeanette Keech (JK) Public Governor (Somerset West and Taunton) Jos Latour (JL) Partnership Governor (Universities of Plymouth, Bournemouth and Bristol) Eddie Nicolas (EN) Public Governor (Sedgemoor) Peter Reed (PR) Public Governor (Sedgemoor) Phil Shelley (PS) Staff Governor Tim Slattery (TS) Public Governor (Somerset West and Taunton) Sue Steele (SS) Public Governor (South Somerset) Caroline Toll (CT) Carers UK Gill Waldron (GW) Public Governor (South Somerset) Margaret Worth (MW) Public Governor (Somerset West and Taunton) Sumitar Young (SY) Public Governor (Somerset West and Taunton) Apologies: Hayley Peters (HP) Chief Nurse Paddy Ashle (PA) Public Governor (South Somerset) Phil Brice (PB) Director of Governance and Corporate Development Julie Browne (JB) Complaints and PALS Manager Ria Zandvliet (RZ) Secretary to the Trust
Attendees: Hayley Hughes (HH) Associate Director of Patient Centred Care Alison Wootton (AW) Deputy Director of Patient Care Steve Thomson (ST) Associate Director of Integrated Governance Carol Lydiate (CL) Governor and Membership Support Officer and PA to the Chairman (Notetaker) Alex Pryde (Item 5) (AP) Outpatient Services Manager Simon Needham (Item 5) (SN) Digital Project Lead
Draft Minutes of the Quality and Patient Experience Group – 4 August 2020 Quality and Patient Experience Group Meeting A 4 November 2020 1
ITEM WELCOME AND APOLOGIES 1 Due to social distancing restrictions following the impact of the COVID-19 pandemic, this meeting was held virtually for the first time and had a reduced agenda.
Judith Goodchild (Chair) gave a special welcome to Stephen Fowler, for whom this was his first meeting since elected as a public governor.
2 MINUTES OF THE LAST MEETING
The minutes of the meeting of the Joint Quality and Patient Experience Group held on 18 February 2020 were approved as a true and accurate record of the meeting. The meeting which was due to be held on 7 May was cancelled due to the pandemic.
3 REVIEW OF THE ACTION LOG AND MATTERS ARISING
The action log was reviewed and the Chair updated new governors on what lay behind some of the areas on the log.
The ‘drop off’ area on the Musgrove site: The chair did not think that it was generally known that there was an area at the Beacon Centre which could be used. Judith Cottrell also suggested that there was an area by the Discharge Lounge that might be usable as a drop off point. In acknowledging that there was also an issue around wheelchair availability, the Chair stated that this issue would need to be followed up. Action: CL
Community Mental Health Survey: In response to a query by Mike Hodson about how he could get hold of the remit for the survey, Steve Thomson offered to send it on via Carol Lydiate. Action: ST.
4 PATIENT AND PUBLIC INVOLVEMENT MANAGER’S REPORT
The patient experience report was circulated to governors within the papers for the meeting. Within the report the Hayley Hughes, Associate Director of Patient Centred Care, reported that during the COVID-19 pandemic there had been many challenges in respect to supporting patients, their families and carers. Teams across the organisation needed to be flexible and creative in their approach in order to maintain services. It was acknowledged that many patients will have felt disappointed and frustrated by the cancellations of planned procedures. There has been a significant reduction in bed occupancy and Wards and services were changed to meet the needs of patients in the safest possible way.
The investigation of formal complaints was paused in March as recommended by NHS England and the Parliamentary Health Service Ombudsman in order to protect the time of frontline staff. The Friends and Family test reporting was also suspended.
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The PALS service continued to provide advice, support and resolution for patients and relatives.
Visiting to the hospital was suspended for all other than for parents of children; for partners of women in maternity; for those receiving supportive end of life care and those with dementia.
Hayley Hughes reported that teams and services have been flexible and responsive to meet the needs of their patients in the most challenging of times and although the Trust has not always got it right, positive changes have been made that will remain for the long term.
The following discussion points arose out of the report: The Family Liaison and Messaging Service: In response to comments from Kate Butler regarding how successful this service has been during the pandemic, Hayley Hughes was asked about plans to continue this in the future? Hayley Hughes confirmed that the current plan is to carry the service on until the end of the financial year and that she has been in discussion with the Chief Nurse and Deputy Chief Nurse regarding making this a potentially long-term service. It was felt that the service would help to keep complaints and concerns low within the Trust. A business case would need to be prepared and further work undertaken before the service could be established long-term.
Red Tray system for feeding patients: Jeanette Keech raised a question about a reference she had picked up in an inpatient survey with regards to the poor service of food in the wards or the lack of timing or support for patients who needed assistance with feeding and asked if the red tray system was still being used? Hayley Hughes confirmed that the red trays are still in place on the wards and stated that it is unusual that complaints around this subject are received. She had not noticed a theme amongst the concerns received about patients who were not being fed and assured the Group that she would raise this issue with the service and team leads if it was highlighted as a regular area of concern.
Halting of the PALs service during COVID-19: Judith Goodchild noted that the PALs service had been suspended during the lockdown and asked what kind of backlog of concerns the team have had to deal with? In response Hayley Hughes stated that there was a small backlog, which they are working through quickly She advised the Group that despite the hold-ups the team have achieved 100% compliance with target to respond within 14 working days. Judith Goodchild congratulated the team on this result.
Discharge complaint example: Hayley Hughes assured the Group that the specific complaint case about a discharge, which was highlighted in her report, has been fully addressed. Hayley Hughes acknowledged that the mixed messages from the Government during the lockdown period had left many people confused as to what was happening. The position now is a lot clearer.
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Ian Hawkins mentioned that he felt that the report was weighted towards Musgrove Park Hospital. In response Hayley Hughes stated that although the report did cover the whole organisation’s performance, she did note the observation and would give more reference to mental health and community in future reports.
Judith Goodchild, on behalf of the governors, expressed their thanks for all work she has done and for catching up so well on the backlog.
Due to time restraints the patient section of the performance report was not discussed at this meeting, but was circulated for information only on complaints responses.
5. OUTPATIENT APPOINTMENT DEVELOPMENT In attendance: Alex Pryde, Outpatient Services Manager and Simon Needham, Digital Project Lead
Judith Goodchild updated the new governors on the oversight the TST patient experience group has had on the outpatient appointment system over the previous 12-18 months, and in particular the ongoing work on updating hospital letters. She welcomed Alex Pryde and Simon Needham to the meeting to give an update on the developments in outpatient appointment management during the COVID-19 pandemic.
Alex Pryde’s presentation outlined the four main areas which needed to be managed around patient appointments following the UK going into lockdown in March 2020. These were:
To manage GP demand – reducing appointment availability; To reduce outpatient activity – due to staffing and safety. Over 50,000 appointments were cancelled; To implement telephone clinics – using technology to help the Trust continue caring for patients; To implement Video Clinics using Attend Anywhere (this was an NHS England directive for all trusts). The roll-out has been split into two sections: 1) Musgrove Park (acute), 2) Community and mental health services. This has worked well across the Trust. Between March and mid-July over 60,000 patients still had an appointment, either through telephone or video consultation.
Alex Pryde stated that the pandemic coincided with the merger of the two Trusts, which brought new challenges to the work of the team as it moved from being part of the medical directorate to the surgical directorate. This meant adjusting to new structures and management teams at the same time as managing the impact of COCID-19.
In June 2020, as the lockdown began to ease, the focus was on beginning to plan for the re-opening of outpatient clinics and prioritising patients and clinics. Through July telephone and video clinics continued and urgent, then less urgent, patients began to be seen.
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Working through the lockdown months has created a new and different ‘Business as Usual’, with digital solutions coming to the forefront. The Trust is taking the new way of working very seriously and sees it as a real opportunity for the future.
Initial limitations due to hardware availability (headsets and webcams) in order to implement digital working have largely been overcome across the organisation, but clinical space is still a concern as clinicians still need a private area in order to carry out virtual consultations. Options are being considered, eg working off site.
Clinician engagement in the new way of working has been good and their initial fears about video consultations have been allayed. It is acknowledged that this is a major culture change for both clinicians and patients and it will take time to absorb.
Alex Pryde shared the following statistics to demonstrate the work that has been undertaken in outpatients since the lockdown between April and mid- July:
Community/mental health: 43 live services; 9,729 video appointments; 3,500 hours of consultation via video; 82% of patients rated their video experience as excellent or very good.
Acute: 15 live services; 37 further services planned; 875 video appointments; 239 hours of consultation via video; 80% of patients rated their video experience as excellent or very good.
For the future, consideration is being given to ways of expanding the video experience, eg, bringing the GP or community worker into the appointment with the patient to reduce the number of appointments.
In outlining the outpatient strategy, the short-term aim is to continue to reduce the backlog of appointments and then to continue the focus on developing efficiency and productivity of the appointment system to ensure that every appointment counts, eg to reduce DNAs and improve the quality of appointment letters. In response to a question from Mike Hodson about the partial booking system. Alex Pryde responded that the problem with the old system of booking appointments up to 12 months in advance, it was inevitable that around 25% of those appointments were likely to be cancelled at some point, eg. Cancellation of clinics due to a clinician’s annual leave. Partial booking essentially allows the amount of time that a patient books the appointment in advance to six weeks prior to the appointment. This has been tested nationally and it has been proven to improve performance.
Jeanette Keech raised concern about whether the shift towards digital consultations is driven by finance, IT or clinicians as she believes that GPs can tell a lot about their patient’s problems by seeing them face-to-face. In response Alex Pryde commented that the guidance from the NHS is that roughly 50% of appointments would be delivered face-to-face and 50% would
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be delivered virtually and that this would be a good balance dependent on the circumstances and what the patient prefers.
In response to a question from Stephen Fowler about the main challenges for moving towards a more digitalised way of working, Alex Pryde responded that it will be important to have discussions with the clinicians in the different services to talk through what would work for them and how they would like to proceed with digital clinics in order to keep the momentum going.
Margaret Worth asked what had reduced the number of DNAs over the last few months? Alex Pryde responded that the patients they have been seeing over the last few months had been the more urgent cases and they tend to honour their appointments more than the more routine cases. Therefore, the DNA rate has dropped during this period.
Simon Needham, digital project manager, confirmed that those departments which have been using the digital format are seeing the benefits of it. There has been positive feedback from patients and the Trust is now rolling it out to remaining departments as quickly as possible.
To meet the need for more outpatient clinic space, Jos Latour asked if one option would be for consultants to see patients at the GP surgery? Alex Pryde stated that it was something to consider, but that currently they were working with the community hospitals rather than anywhere else. GPs themselves were struggling for space in their surgeries anyway. It was noted that major benefits would be seen by collaborating with GPs.
In commenting about digital appointments for patients with mental health needs, Owen Howell stated that he was wary of this becoming the ‘norm’ as these patients do not respond well to video appointments. Certainly from a diagnostic point of view it is always best to speak face to face. Some of his colleagues are also concerned that they will have to go down the digital route, but he recognised the need to be flexible.
The Chair thanked Alex Pryde for his comprehensive presentation and noted how much had changed since he came to present six months ago and voiced her appreciation for all the hard work his team has had to undertake to manage the appointment backlog. The Chair also suggested that Alex Pryde returns to update the group in six months on how the new appointment system has been working and how this may have impacted on DNA’s. Action: Workplan February 2021.
FOR INFORMATION
6. GOOD TO KNOW LOG
The Chair informed the new governors of the purpose of the Good To Know Log and encouraged them to share any issues that they pick up from members of the public with Carol Lydiate. It was noted that the concern raised by Melanie Devine has been responded to.
The Good to Know Log was noted.
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7. FEEDBACK FROM THE QUALITY AND GOVERNANCE COMMITTEE
The Chair informed the new governors that she represents the governors on the Quality and Governance Committee. Unfortunately, she was unable to fully attend the last meeting due to technical issues and was therefore unable to bring any feedback this time.
8. FEEDBACK FROM THE MENTAL HEALTH ACT COMMITTEE
The report was noted.
A discussion arose around mental health awareness and the following points were made: Mental health first aid course: Margaret Worth suggested that governors would find this helpful. Action: CL to discuss with RZ Mental health to be included as an agenda item for a future governor development session: Action: IH/KB/CL Kate Butler advised that she was in discussion with Barbara Clift, NED and Chair of the Mental Health Committee, as to how to bring more awareness to governors about this subject. Stephen Fowler offered to help as he has some experience/background in this area.
9. REPORT FROM THE SIGNAGE AND WAYFINDING GROUP
There was no report this quarter.
Judy Cottrell advised the group that from an environmental perspective new sports water bottles and water stations have been installed around the hospital. This has saved 500 plastic bottles per week from being thrown away. She also reported that there are some resident hedgehogs resident in the biodiversity garden at the back of the maternity unit.
10. CARERS AND TRIANGLE OF CARE REPORT
There was no report this quarter.
11. ANY COMMUNICATION ISSUES ARISING OUT OF ITEMS ON THE AGENDA
None.
12. FUTURE AGENDA ITEMS
None.
13. ANY OTHER BUSINESS
Patient letters: Jeanette Keech emphasised that the Group should
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continue to keep pushing with regards the issue of the quality of patient letters as it has been on the agenda for such a long time. The Chair suggested inviting Karen Holden back to a future meeting to see how things have improved. Action: To be noted on the Workplan 2021. Performance report (patient section): Kate Butler noted that even though there had not been time to discuss the performance report there were quite a few things which governors needed to keep an eye on, eg falls and medication. She suggested that at the next meeting it would be helpful to see a comparison between the report which was circulated this meeting and the next one. Action: HH.
There being no further business the meeting closed.
14. DATE AND TIME OF NEXT MEETING The next meeting will be held on Wednesday 4 November 2020, 14:00 – 16:30, the Butland Room, The Exchange, Bridgwater, TA6 4RR
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Somerset NHS Foundation Trust Quality and Patient Experience Group
Action Log – 4 August 2020
Minute Action Action Outcome By 007/11.19/ Item 7: PERFORMANCE REPORTS (PATIENT SECTION) Serious incidents – This issue to be included on the agenda planner for the group. CL COMPLETE – Included on Workplan 2021 Agenda item: Item 8 (Enc G) 05/02.20 ITEM 5: PAEDIATRIC MENTAL HEALTH REFERRALS REPORT A representative from The Big Tent to be invited to present to the CL COMPLETE - Agenda item: Item 9 (Enc H) Group at a future meeting. Report submitted tor information instead of a presentation 06/02.20 ITEM 6: QUALITY ACCOUNTS PROCESS AND KPI INDICATOR FOR 2019/20 The QPE workplan to be updated to reflect follow-up of the Quality Chair COMPLETE - Included on Workplan 2021 Priority Improvements for 2020/21. Agenda item: Item 8 (Enc G)
07/02.20 ITEM 7: PERFORMANCE REPORTS (PATIENTS SECTION) – QUARTER 3: OCTOBER-DECEMBER 2019 A representation of I-Thrive to be invited to present to the QPE at a HH Date to be confirmed future meeting.
08/02.20 ITEM 8: PATIENT EXPERIENCE REPORT Annual National Mental Health Community Survey: Alison van Chair/CL Agenda item: Item 6 (Enc F) Leer to be invited back to give an update on her work in six months.
04/08.20 ITEM 3: REVIEW OF THE ACTION LOG The ‘Drop off’ area on the Musgrove Site: Update on the drop off CL/PS Update awaited point and the position around the availability of wheelchairs to be sought.
04/08.20 ITEM 3: REVIEW OF THE ACTION LOG Community Mental Health Survey: Steve Thomson to send the link ST COMPLETE to the mental health survey to Mike Hodson.
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Minute Action Action Outcome By 04/08.20 ITEM 5: OUTPATIENT APPOINTMENT DEVELOPMENT Alex Pryde to be invited back in six months to give an update on COMPLETE - Included on Workplan 2021 the new appointment system and its impact on DNAs. CL Agenda item: Item 8 (Enc G)
04/08.20 ITEM 8: MENTAL HEALTH ACT COMMITTEE Mental Health First Aid Course: The possibility of governors CL/RZ COMPLETE – Governors attended the course on undertaking this course to be discussed with Ria Zandvliet. 5 or 8 October 2020
04/08.20 ITEM 13: ANY OTHER BUSINESS Performance Report (patient section): As there had not been time HH NB: The performance report being presented at to discuss the performance report at the meeting and there were the Trust Board meeting on 3 November will not quite a few things which governors needed to keep an eye on, eg be available until 28 October. Hayley Hughes is falls and medication it was requested that at the next meeting a on annual leave until 2 November so it may not comparison between the report which was circulated at the August be possible for a comparison to be prepared in meeting and the current one would be helpful. time for the QPE meeting on 4 November. 04/08.20 ITEM 13: ANY OTHER BUSINESS Patient Letters: Karen Holden to be invited to a future meeting to Chair COMPLETE – Included on Workplan 2021 give an update on the progress on the quality of patient letters Agenda item: Item 8 (Enc G) project.
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Council of Governors
The Quality and Patient Experience Group
Appointment of a Deputy Chair and Representative on the Mental Health Act Committee
Date of Meeting 4 November 2020
Author of Paper Carol Lydiate, Governor and Membership Support Officer and PA to the Chairman Sponsor of Paper Ria Zandvliet, Secretary to the Trust The report advises the Quality and Patient Experience Group of the process undertaken to appoint a new Deputy Chair and Summary a representative for the Mental Health Act Committee
Confidentiality Status Please tick if any of the following apply
(if confidential this paper will not Data protection – staff or patient detail go on the website, and will be dealt with under Part 2 of the Commercially sensitive Agenda) Stakeholder management Early stage of discussion – potentially prejudicial to staff morale or partnership working
Previous Consideration Not applicable.
The recommendation is to ratify the appointments as outlined Recommendation in the paper.
Action Required As above.
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Quality and Patient Experience Group Appointments
1. Background
1.1 Philippa Hawks, Public Governor, was appointed as deputy chair of the Joint Quality and Patient Experience (QPE) Group in November 2019 and was also the appointed governor representative on the Mental Health Act Committee for Somerset Partnership NHS Foundation Trust.
1.2 Following the public governor election process in July 2020, Philippa Hawks was not re-elected. Therefore vacancies arose for the above roles.
1.3 The purpose of this report is to outline the process undertaken to fill the vacancies and to ratify the appointments as outlined below.
2. The Process
2.1 The task of electing a deputy chair and representative on the Mental Health Act Committee falls to the current membership of the QPE group as outlined to the Council of Governors in September 2020. Only members of the group are eligible to stand for election or vote.
2.2 On 12 October all members were advised of the vacancies and were asked to advise Carol Lydiate by 15 October 2020 if they wished to nominate themselves for roles.
Those who nominated themselves by the deadline for the deputy chair role were:
Sue Steele
Those who nominated themselves by the deadline for the role of representative on the Mental Health Act Committee were:
Stephen Fowler Philip Jackson Neil Thomas Margaret Worth
2.4 The members were notified of the nominations and asked to email their vote to Carol Lydiate no later than 09:00 on Monday 26 October 2020. At which point the successful candidate and the remaining members were advised of the result of the ballot.
3. The Result
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3.1 Following the close of the poll the results were as follows:
Sue Steele was appointed unopposed as deputy chair. Stephen Fowler was appointed as representative on the Mental Health Act Committee.
The deputy chair appointment will be reviewed in February when the role of the Chairman will also be reviewed.
The Mental Health Act Committee role will be reviewed in 12 months’ time.
4. Recommendation
4.1 The members of the Quality and Patient Experience Group are therefore requested to ratify the above appointments.
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SOMERSET NHS FOUNDATION TRUST Council of Governors’
QUALITY AND PERFORMANCE EXCEPTION REPORT (PATIENTS)
Report to the Quality and Patient Experience Group on 4 November 2020
Sponsoring Director: Director of Finance
Author: Associate Director – Planning and Performance Senior Performance Manager Director of People and Organisational Development Deputy Chief Nurse Associate Director of Performance Executive Summary Our Quality and Performance Exception Report sets out the key exceptions across a range of quality and performance measures, and the reasons for any significant changes or trends. The COVID-19 outbreak continues to have a significant impact on a range of access standards, with numbers of patients waiting increasing, and waiting times lengthening. There have been significant reductions in the numbers of suspected cancer referrals, and also a significant reduction in the numbers of emergency attendances and admissions. Urgent and emergency patients are continuing to receive the treatments they need.
Areas in which performance has been sustained or has notably improved include: Areas in which performance has been sustained or has notably improved include: waiting times with our children and young people’s mental health services the percentage of patients on Care Programme Approach (CPA) Level 2 followed up within 7 days of discharge from our mental health services
hospital cleanliness rates
the percentage of patients who were screened for dementia during their stay on our acute wards
the percentage of mental health in-patients who received a physical health assessment within 48 hours of admission
Areas in respect of which the contributory causes of, and
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actions to address, underperformance are set out in greater detail in this report include:
the percentage of patients seen within four hours, in our accident and emergency department and minor injury units
the percentage of people waiting under 18 weeks from referral to treatment with our acute services
waiting times for our community memory assessment services
the percentage of people waiting under six weeks for a diagnostic test
the numbers of people waiting 18 weeks or more to be seen by our community physical health services, including our community dental service
inappropriate Out of Area Placements for non-specialist mental health inpatient care
the percentage of patients with a National Early Warning Score (NEWS) of 5 or more acted upon appropriately.
Performance, across a broad range of indicators, is anticipated to continue to be adversely affected over the coming months, as a result of the necessary refocusing of priorities towards the effective management of COVID-19.
Performance monitoring, and the provision of essential information to front line services, and for the purposes of governance and assurance, will continue.
During the COVID-19 outbreak, NHS England / NHS Improvement wrote to all NHS Trusts, to advise that changes had been implemented to governance and reporting arrangements, to reduce the burden of reporting and release capacity. This included the suspension of requirements to submit returns relating to a range of indicators, including the Friends and Family test, delayed transfers of care, and venous thromboembolism. This is reflected in Appendix 4, the Corporate Balanced Scorecard.
Recommendation(s): The Quality and Patent Experience Group is asked to note the report.
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Action Required (Please put a against any actions required) For approval For assurance For information For discussion
Links to the Assurance Framework and Corporate/Directorate Risk Register (Please include relevant risks and the current risk rating)
Risk: Risks Associated with COVID-19 Pandemic: IF Risks Associated with Covid 19 Pandemic aren't managed effectively (mitigating controls, action plans etc.). This will affect the Trust’s ability to deliver services, THEN The Trust’s ability to deliver services will be severely adversely affected: 25
Risk: RTT Strategic Risk: IF we do not have sufficient capacity and resource currently allocated to meet the demand for non-admitted and admitted care, THEN we will continue to be in a position where waiting times lengthen. Over time, this will take us to a position where patient safety is compromised and regulatory action will be taken against the Trust as a provider: 16
Risk: Cancer Standards: IF we continue to fail to meet the 62-day GP Cancer Standard, THEN this could result in adverse patient experience / outcomes, regulatory action and reputational damage, and also potential financial penalties in future years: 16
Risk: Diagnostic Waiting Times Performance: IF we continue to experience growth in demand running at a greater rate than our ability to supply capacity for key diagnostic modalities, combined with workforce shortages, THEN we will fail to meet national standards for diagnostic waiting times (the risks for patient outcomes and experience are described separately per individual modality). As a consequence, there are risks of reputational damage, potential regulatory action and failure of other key performance standards (e.g. cancer / RTT): 16
Risk: Waiting Times: IF we are unable to provide sufficient capacity to enable us to meet clinically acceptable waiting times for patients for non-admitted and admitted care, including follow up intervals, THEN this has the potential to impact on the clinical outcomes for patients. We will also fail to achieve our RTT recovery trajectory: 15
Risk: RTT: IF we are unable to provide sufficient capacity to enable us to meet the demand for non-admitted and admitted care, THEN we will fail to achieve our RTT recovery trajectory, and patients will continue to wait longer than 18 weeks for treatment. This could lead to regulatory action (including CQC following recommendations from recent inspection). This has the potential to impact on the clinical outcomes and have an adverse effect on patient confidence in the trust: 15
Risk: Dorset Dental General Anaesthetic Paediatric List: IF the waiting list exceeds waiting targets, THEN health outcomes and patient experience will be adversely affected: 20
Quality and Performance Report (Patients) QPE – 04 11 20 - 3- E
Financial, Staffing, Legal/Statutory Implications/requirements (Please indicate whether there are any financial and/or legal/statutory implications by putting a against the relevant box. (Please also provide the necessary details) Financial
Staffing The report provides an update on issues relating to staffing, in Section 1 and also in Appendix 4.
Equality The Trust wants its services to be as accessible as possible, to as many people as possible. Please indicate whether the report has an impact on the protected characteristics and put a against one of the two options set out below 1. This report has been assessed against the Trust’s Equality Impact Assessment Tool and there are no proposals or matters which affect any persons with protected characteristics or 2. This report has been assessed against the Trust’s Equality Impact Assessment
Tool and there are proposals or matters which affect any persons with protected characteristics and the following is planning to mitigate any identified inequalities:
Public/Staff Involvement History (Please indicate if any consultation/service user/patient and public/staff involvement has informed any of the recommendations within the report) No recommendations are being made, other than to discuss and note the report.
Quality and Performance Report (Patients) QPE – 04 11 20 - 4- E
SOMERSET NHS FOUNDATION TRUST
QUALITY AND PERFORMANCE EXCEPTION REPORT: SEPTEMBER 2020
1. PURPOSE
1.1 Our Quality and Performance exception report sets out the key exceptions across a range of quality and performance measures, and the reasons for any significant changes or trends.
1.2 The report presents information relating to the five key questions which the Care Quality Commission considers when reviewing and inspecting services:
Are they safe?
Are they effective?
Are they caring?
Are they well-led?
Are they responsive to people’s needs?
1.3 The exception reports include run charts, produced using Institute for Healthcare Improvement (IHI) methodology, and in consultation with the Academic Health Sciences Network. An explanation of how to interpret these charts is attached as Appendix 1.
1.4 A summary of our current Care Quality Commission ratings, which relate to our two predecessor organisations, is included as Appendix 2.
1.5 A summary of the monthly data and run charts for our key quality measures is attached as Appendix 3.
1.6 Our Corporate Balanced Scorecard is attached as Appendix 4. The measures included in the Corporate Balanced Scorecard may change during the year as new priority areas are identified.
1.7 Supporting information relating to referral levels, activity levels, lengths of stay, tumour-site-specific activity and performance, and other key measures for our services is included in Appendix 5.
Quality and Performance Report (Patients) QPE – 04 11 20 - 5- E Overview
The table below provides a summary of key successes, priorities, opportunities, risks and threats in relation to our current levels of performance.
Successes Priorities
during September 2020 we continued successfully to meet continue to maintain safe services and optimise the the challenges presented by COVID-19 to patients and staff. provision of care to patients, in the context of effectively ‘Attend Anywhere’ technology, continues to enable patients managing pressures associated with COVID-19. Ensuring to be seen remotely and receive advice and support, urgent cases are treated as quickly as possible within the continues to be well received. context of the challenges COVID-19 brings. urgent and emergency patients are continuing to receive the bring additional capacity on-line as quickly as possible to treatments they need. restore capacity to pre-COVID-19 levels and address when required, all neutropenic sepsis patents received backlogs. antibiotics within 60 minutes. work with the Somerset system to encourage continued the standard of end of life care planning remains high, as referrals and presentations at hospital where this is needed evidenced by our audit which measures treatment escalation and appropriate, especially in respect of urgent or plans and guidance being present in the notes. emergency care. our Talking Therapy (IAPT) service continues to maintain continue to support with enabling an agile culture where recovery rates significantly above the national standard. colleagues are encouraged to work differently as we resume services. Opportunities Risks and Threats progress the health and wellbeing plans for our colleagues at COVID-19 continues to have a significant impact on pace; this includes the psychological support offered performance against all national access standards, with alongside practical aspects of support such as free car infection control measures put in place to manage patients parking, accommodation provision, and nutrition. safely and keep staff safe, reducing available capacity. new ways of working, particularly through the use of nursing vacancy levels remain challenging. Sickness / technology, presents an opportunity for us to consider how absence due to COVID-19 presents a challenge for we provide care appropriately and effectively to patients colleagues within some critical areas, and we need to following the COVID-19 outbreak. ensure that we continue to support colleagues accordingly. continue to adapt our recruitment practice, developing more failure to implement collaborative approaches across health innovative ways and reducing time to hire significantly. and social care could impact adversely on patient care.
- 7 - Quality and Performance Report November 2020 Public Board G Safe Infection Prevention and Control (IP&C) performance is assessed by means of the numbers of key healthcare associated infections (Trust apportioned) against agreed thresholds. These are: MRSA bloodstream infections (BSI): zero tolerance, Clostridium difficile (C. diff) infection (CDI): 36 cases, MSSA BSIs: 10 cases E.coli BSIs: 38 cases.
Current performance (including factors affecting this) Line/Bar Charts No MRSA blood stream infections (BSIs) were reported in September 2020. There Clostridium Difficile (post) cumulative cases against internal trajectory - April 2020 to March 2021 were 11 Trust-attributable C. Diff cases in September 2020, nine hospital-onset 40 healthcare associated infection (HOHA) and two community-onset healthcare associated infections (COHAs). 35 Of 28 C.Diff cases, 22 reviews have been completed, with three lapses in care 30 25 identified, related to inappropriate antimicrobial prescribing and low compliance 11 with environmental cleanliness. 20 15 There were five MSSA BSI cases in September 2020. Post-infection reviews have 9 10 been completed for nine cases to date, with one lapse in care identified relating to 7 17 6 5 Peripheral Venous Cannula (PVC) care. 8 3 4 5 There were two E. Coli BSIs in September 2020, bringing the total for the year to 0 0 1 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 date to 15. Post-infection reviews have been completed for all cases to date, with one lapse in care identified relating to a delay in catheter removal and inappropriate Cumulative HOHA cases Cumulative COHA cases Cumulative trajectory antibiotic prescribing. MSSA BSI cumulative Trust attributable cases against internal trajectory - April 2020 to March 2021 There were no COVID-19 hospital onset cases or ward outbreaks in September 2020. The last new inpatient case was admitted on 20 October 2020 (community 12 onset). 10 Focus of improvement work 9 The colleague Influenza vaccination programme is in place and as of 19 October 8
2020, 33% of frontline staff had been vaccinated. 6 C. diff numbers are significantly above the trajectory, a trend also being seen in 4 4 4 other Trusts. Reviews show that most cases are due to antibiotic pressure. This is 3 3 2 likely to be due to the impact of COVID on antibiotic use during the first wave of the 2 pandemic. There are several aspects to this that could be implicated including: 0 o Higher use of broad spectrum antibiotics to reduce the risk of co-infection in Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20 Jan-21 Feb-21 Mar-21 COVID patients. o Potential increased numbers of patients receiving “just in case” antibiotics. Cumulative post cases Cumulative trajectory o Potential increased use of antibiotics for dental care as dental services could Recent performance not be accessed. Area Apr May Jun Jul Aug Sept The C diff Improvement Group has been reinstated to review possible reasons for MRSA 0 0 0 0 1 0 our increase in numbers and instigate additional controls to manage our numbers. C.Diff 0 4 6 2 5 11 This needs a system wide approach. MSSA 2 1 0 1 0 5 E.coli 2 2 4 2 3 2
Quality and Performance Report - 8 - November 2020 Public Board G Safe VTE risk assessments: our aim is for at least 95% of patients to have the appropriate venous thromboembolism (VTE) assessments completed within 24 hours of admission. (Acute services only)
Current performance (including factors affecting this) Bar Chart During September 2020, performance decreased compared to August 2020, and remained below the 95% VTE risk assessment - Acute services standard. 100.0% Of 5,901 admissions, 5,095 had a recorded assessment
within 24 hours of admission. The reasons for 80.0% performance falling below the compliance standard included: o an issue in the assessment, or recording of 60.0% assessments, for surgical admissions (Montacute ward) and medical admissions (Barrington ward). 40.0% o a change in the admission processes and staff involved in data collection.
Focus of improvement work 20.0% Work is being finalised to identify and exclude the endoscopy cases from the reporting cohort. Retrospective amendments to compliance levels may be possible 0.0% A detailed review of areas of low compliance, focusing on Montacute and Barrington wards, led by the VTE lead. VTE risk assessment - Acute services Standard The information related to the ‘Getting it Right First Time’ (GIRFT) programme has now been submitted. GIRFT is How do we compare supported by junior doctor data entry, and work will be Compliance during September 2020 remained below the mandated 95% undertaken to raise awareness further as COVID-19 standard. priorities adjust. Ongoing discussion with the digital team about the Recent performance opportunity to digitise assessment. Area Apr May Jun Jul Aug Sept % of All outlined actions are presented to, and monitored via, a Reporting assessments 84.6% 87.3% 86.3% VTE Group chaired by a Consultant Haematologist. suspended completed The VTE Group are working with CCU, Montacute and Barrington to address the recording issues.
Quality and Performance Report - 9 – November 2020 Public Board G Safe Out of Area Placements – The Five Year Forward View for Mental Health stated that placing people out of area for non-specialist acute mental health inpatient care due to local bed pressures was to be eliminated entirely by no later than 2020/21.
Current performance (including factors affecting this) Bar Chart During September 2020 three patients were placed ‘out Inappropriate 'Out of Area' placements: Monthly number of patient of area’ for a total of 30 days. days out of county At the time when the patients required admission, 60 Holford ward was unable to accept them due to clinical
and patient safety considerations. 50 Two patients have since been repatriated and subsequently discharged into the community. The other patient remains in an ‘out of area’ placement 40 due to patient safety concerns. Regular reviews are
being undertaken to establish when it is appropriate for 30 the patient to be admitted onto Holford ward.
Focus of improvement work 20 We continue have amongst the lowest levels of
inappropriate ‘out of county’ placements of all providers 10 of mental health services nationally. With only 10 Psychiatric Intensive Care Unit (PICU) beds available, there are occssions when, due to clinical 0 acuity or gender, it would be unsafe to admit a patient. During COVID-19, to maintain required isolation arrangements, there remains the possibility that a patient How do we compare will need to be placed out of county. We continue have amongst the lowest level of inappropriate ‘out of area’ When a patient is so placed, a key worker is immediately placements of all providers of mental health services nationally. assigned to maintain daily contact with the patient until the patient is either transferred back to our wards, Recent Performance discharged, or moved to secure services. The The monthly numbers of patients who were placed ‘out of area’ and the placements sought are always as close to Somerset as numbers of patient days spent ‘out of area’ since February 2020 were: posssible. Area Apr May Jun Jul Aug Sept Many episodes relate to patients awaiting transfer to Number of Days 5 0 45 0 0 30 secure services. Working closely with other NHS Number of patients 1 0 2 0 0 3 providers, we are exploring opportunities to ease such transfers and cohort such patients.
Quality and Performance Report - 10 – November 2020 Public Board G Safe Mixed sex accommodation: our aim is to eliminate mixed sex accommodation (ESMA) breaches to ensure patients’ dignity and respect.
Current performance (including factors affecting Bar Chart this) During September 2020, there were two breaches in Mixed sex accommodation breaches respect of mixed sex accommodation, both occurring 10
with our Cardiac Catheterisation (Cath) Lab. 9 These breaches occurred as a result of Musgrove Park Hospital being in OPEL 3 status (Operational 8 Pressures Escalation Level 3, which requires further 7 urgent actions by all system partners to reduce 6 pressures and impact). There was no available cardiology capacity within the 5
Integrated & Urgent Care Directorate. 4 To ensure there was sufficient bed capacity for cardiology emergencies, two patients requiring 3 procedures the following day were transferred to the 2 Cath lab as this was the safest and most pragmatic option. One patient was male, one patient was 1 female. 0 As part of usual practice the patients were fully
informed of the rationale and screens were used to Mixed sex accommodation breaches maintain privacy and dignity.
Focus of improvement work How do we compare Monitoring of general and speciality bed capacity is There were two breaches reported during September 2020, the first such undertaken, with the early formation and development incidents since February 2020. of escalation and action plans. Recent performance Area Apr May Jun Jul Aug Sept No of breaches 0 0 0 0 0 2
Quality and Performance Report - 11 – November 2020 Public Board G Safe Percentage of patients with a National Early Warning Score (NEWS) of 5 or more acted upon appropriately: Core Nursing Metrics Measurements (CNMM). Our aims are to achieve and maintain compliance rates of at least 95%, to ensure patients receive appropriate treatments.
Current performance (including factors affecting this) Line Chart During September 2020, compliance increased to 81.8% Percentage of patients with a NEWS of 5 or more acted upon from 77.8% in August 2020, against a standard of 90%. appropriately (CNMM) 100.0%
Focus of improvement work 90.0% We are collecting weekly data and empowering the ward 80.0% mangers to take immediate action if the patient has not been escalated or managed according to the protocol. 70.0%
Electronic observations were implemented trustwide 60.0% between January and April 2020. The next stage, to review the escalation process, commenced in July 2020. 50.0% It is estimated that the review process will take 40.0%
approximately six months. 30.0% The deteriorating patient team are working with the digital team on a more visual solution to make staff 20.0% aware of the most unwell pateints in their area. 10.0%
The team are also conducting audits to see what we can 0.0% learn from the new way of recording electronic Jun-20 Jul-20 Aug-20 Sep-20 observations and the devices that are used. Training updates are being offered, incorporating Percentage of patients with a NEWS of 5 or more acted upon appropriately (CNMM) Standard electronic observations and escalation processes. The deteriorating patient and digital teams are working How do we compare towards being able to use the data that is being collected Compliance during September 2020 rose when compared to August 2020 to generate real-time reports and feedback about the frequency of observations and how many patents we Recent Performance have with a NEWS of 5 or above. The monthly compliance since April 2020 was as follows: Area Apr May Jun Jul Aug Sept % Monthly Reporting 75.3% 80.4% 78.8% 81.8% compliance changed
Quality and Performance Report - 12 – November 2020 Public Board G Safe Percentage of patients screened for sepsis, and the percentage of patients who with red flag sepsis given antibiotics within 60 minutes of the time of the National Early Warning System (NEWS) assessment. Our aims are to achieve and maintain compliance rates of at least 90%, to ensure patients receive appropriate timely treatments.
Current performance (including factors affecting this) Line Chart During the period 1 July to 30 September 2020 a total of Percentage of patients screened and treated for sepsis 89 patients were screened for sepsis, out of 101 who
should have been screened. 100.0% The Emergency Department (ED) screened 100% of 90.0% eligible patients; inpatients screened 76% of eligible patients, an increase from 63% in Quarter 1. 80.0%
For the same period, four out of five patients with red 70.0% flag sepsis were given antibiotics within 60 minutes of the NEWS assessment. It should be noted that this is 60.0% only a sample, and is based on only five patients. 50.0% Percentage of patients screened for sepsis
40.0% Percentage of patients receiving antibiotics within Focus of improvement work one hour of red flag diagnosis of sepsis 30.0% A new sepsis application is currently being tested within Standard the Ditigal team and once this has been completed it will 20.0%
be tested within the live environment of two wards 10.0% identified for the trial, those being Coleridge ward and the Surgical Admission Unit (SAU). 0.0% In ED a multidisiplinary audit is undertaken. Patients who do not receive antibotics within one hour are reviewed and feedback is given to the team in real time. Weekly training is available for all colleagues. How do we compare A new user-friendly sepsis screening tool was launched Compliance for the period 1 July to 30 September 2020 increased in respect during June 2020, which facilitates the recording of of both indicators compared to the period 1 April to 30 June 2020. information for all users. Robust use of this is being Recent Performance supported. Area Apr May Jun Jul Aug Sept % of patients screened 77.7% 88.1% who required screening % of patients receiving 57.1% 80.0% antibiotics within 60 mins
Quality and Performance Report - 13 – November 2020 Public Board G Safe Direct admissions of patients to a Stroke ward: our aim is to ensure that at least 90% of all stroke patients are admitted onto the designated stroke ward within four hours of admission.
Current performance (including factors affecting this) Line Chart During August 2020, the latest data available, 75.3% of patients % Stroke Patients direct admission to stroke ward in 4 hours were admitted within the four hour standard. 100.0% Of 81 patients admitted during August 2020, there were 23 breaches of the four hour standard. Of these: 90.0% o 10 patients had a clinical presentation that did not suggest 80.0%
stroke on admission. 70.0% o 6 patients were admitted out of hours, and there was 60.0% therefore no stroke input in the Emergency Department (ED) until a stroke was confirmed. 50.0% o 3 patients were ED admissions who sadly passed away in 40.0% the department, being unstable and inappropriate to move. 30.0%
o 2 patients were breaches of the four hour standard as no 20.0% stroke beds were available at the time required. 10.0% o 1 patient was a possible COVID case, and was admitted onto the COVID ward. 0.0% o 1 patient had a long stay in ED, requiring trauma input. % Stroke Patients direct admission to stroke ward in 4 hours Standard Focus of improvement work: Discuss with ED colleagues varied presentations when strokes may be diagnosed. Support with any additional teaching How do we compare elements that would support juniors within the ED team. During August 2020, the latest data available, compliance Data input errors to be rectified. decreased compared to July 2020. Recent audit findings to be reviewed and implemented to Recent Performance improve stroke criteria guidelines. Our performance in recent months is as follows: The recent data review highlighted a number of patients who, for clinical, reasons breached appropriately as they required Area Mar Apr May Jun Jul Aug additional input. % of direct Reporting 81.7% 81.8% 75.3% admissions suspended
Quality and Performance Report - 14 – November 2020 Public Board G Responsive The Accident & Emergency (A&E) 4-hour standard is a measure of the length of wait from arrival in an Emergency Department (ED) to the time the patient is discharged, admitted or transferred to another provider. The target is that at least 95% of patients will wait less than four hours in the Emergency Department.
Current performance (including factors affecting this) Line Chart A&E 4-hour performance was 85.3% for the Musgrove site during A&E 4 - hour performance September 2020, which was above our draft planning trajectory of Acute services
81.0%. With Minor Injury Units included, the overall performance 100.0% was 93.0%, below the 95% national standard. A&E attendances were 10.2% below the trajectory level, due to the 95.0%
continuing impact of COVID-19. Emergency admissions were 15% 90.0% down on the same period last year. Performance against the 15-minute triage time for patients arriving 85.0%
by ambulance remains below the 95% standard at 85.6%, which 80.0% represents a reduction on the improved levels seen in May and June 2020 when levels of ambulance arrivals were much lower. 75.0%
97.2% of all patients were triaged within 30 minutes of arrival during 70.0% September 2020, maintaining performance above the 95% standard. Performance against the A&E 4-hour standard, and other key 65.0%
performance indicators of urgent care management, has generally 60.0% been maintained at a higher level since COVID-19 began, even though the Emergency Department (ED) attendances are now % inside 4 hours Standard almost back up to pre-COVID-19 levels. However, staffing gaps in + the ED rota remain which continue to present challenges. How do we compare
National average performance for Trusts with a major Emergency Focus of improvement work Department was 81.6% in September 2020. Our performance was The pre-booked appointment pathways (111 First) are due to be 85.3%. We were ranked 45 out of 114 trusts. With Minor Injury Unit launched in November 2020 to support awareness of urgent activity attendances included, we were ranked 24, with performance of flow into the department. 93.0%. The ED is revising the bed requesting and allocation process to reduce any delays with admitting patients from ED. Recent performance and trajectory The ED Improvement plan also contains further actions under way to support the delivery of quality and safety within the department. Area Apr May Jun Jul Aug Sept Trajectory 79.0% 81.0% 79.0% 80.0% 82.0% 81.0% Actual 91.4% 91.4% 91.5% 90.5% 86.9% 85.3%
Quality and Performance Report - 15 – November 2020 Public Board G Responsive Referral to Treatment Time (RTT) is a measure of the length of time a patient waits from the point of referral through to receiving treatment. The target is for at least 92% of patients, who have not yet received treatment, to have been waiting less than 18 weeks at the month-end. Trusts should have no patients waiting over 52 weeks for treatment.
Current performance (including factors affecting this) Line Chart All aspects of acute trust RTT performance continue to be 18 week RTT heavily impacted by the recent COVID-19 outbreak, mainly due Acute services to capacity being reduced through being repurposed to manage 100.0% COVID-19 and implementing additional infection control 90.0%
measures, a shortfall of staff, and social distancing. 80.0%
The percentage of patients waiting under 18 weeks RTT 70.0% increased from 42.2% in August 2020 to 48.7% in September 60.0% 2020, reflecting a significant reduction in over 18 week waiters. The over 18-week backlog reduced by 1,731 pathways in 50.0% September 2020. The total waiting list size also decreased, by 40.0% 659 pathways to 20,929. 30.0%
RTT clock starts (i.e. referrals) in September 2020 were 37% 20.0%
lower than in September 2019. The number of referrals was 10.0% similar to the last two months, reflecting cancer/urgent referrals 0.0% having returned to more normal levels but routine referral volumes remaining low even though patients are being seen at usual levels in General Practice. RTT incomplete pathway performance Standard 52-week waiters increased from 1,524 in August 2020 to 1,639 in September 2020, again due to patient choice not to attend and the necessary prioritisation of urgent patients. How do we compare The national average performance was 53.6% in August 2020. Our Focus of improvement work performance was 42.2%. National performance improved by 6.7% The emphasis during the COVID-19 outbreak is to keep patients between July and August 2020, with the number of 52-week safe, with patients with urgent conditions being prioritised. waiters across the country increasing significantly, from 83,203 to Additional capacity is continuing to come on line, including 111,026. increasing use of the Independent Sector and planned Performance trajectory: 52 week wait performance expansion of facilities for video/telephone consultations. Repurposed capacity, such as the use of theatres for critical Area Apr May Jun Jul Aug Sept care and use of Outpatient Department space, is being restored Trajectory 0 0 0 0 0 0 where this is possible and/or alternative spaces exist. Actual 118 270 502 1,299 1,524 1,639 Ways of safely minimising capacity lost due to social distancing and infection control measures continue to be progressed. Appendix 5a provides a breakdown of tumour-site level performance.
Quality and Performance Report - 16 – November 2020 Public Board Responsive Waiting Times – One of our key priorities is to ensure that patients are able to access our services in as timely a manner as possible, and without unnecessary delays. Our aim is to reduce the number of people waiting over 18 weeks from being referred to having treatment. The data shown relates to our Somerset and Dorset Dental services, specifically children and young people waiting 18 weeks or more for an appointment to have a procedure requiring a general anaesthetic (GA).
Current performance (including factors Bar Chart affecting this) Dental Service – number of young people waiting 18 weeks or more As at 30 September 2020, 557 young people for a general anaesthetic appointment date, from assessment had waited 18 weeks or more for an 700 appointment date, a decrease of 29 on the 618 previous month. 600 571 586 557 555 569 557 Of the 557 patients waiting, 405 related to our 519 531 499 Dorset service (down from 423 as at 31 August 500 490 478 2020), and 152 related to our Somerset service 464 408 414 401 (down from 163 as at 31 August 2020). 400 Prior to the implementation of arrangements to 335 manage COVID-19, the Dorset service had 300 276 made considerable progress in reducing the numbers of children and young people waiting, 202 200 through its Vanguard waiting list initiative, which 158 came to an end in December 2019. 123 117 100 94 Due to current pandemic protocols, all routine 67 appointments were suspended, which has impacted significantly impact on the waiting 0 times and numbers waiting.
Focus of improvement work How do we compare Numbers of GA lists available to the service are The number of young people waiting 18 weeks or more as at 30 September 2020 starting to increase although demand and capacity decreased by 29 compared to 31 August 2020. challenges are expected to remain. Musgrove Park Recent Performance Hospital lists have returned to pre-COVID levels The numbers of young people waiting 18 weeks or more at the month end in recent with additional lists being provided as available. months were as follows: Work is ongoing with Dorset County Hospital, Area Apr May Jun Jul Aug Sept where a reduced number of lists are taking place, Number waiting 401 478 569 618 586 557 and with Yeovil District Hospital to expedite a % > 18 weeks 61.8% 73.7% 90.5% 100% 98.2% 97.2% restart of GA lists there.
Quality and Performance Report - 17 – November 2020 Public Board G Responsive Older Persons Mental Health Waiting Times: One of our key priorities is to ensure that patients are able to access our services in as timely a manner as possible, and without unnecessary delays. Our aim is to ensure that at least 90% of people are seen by our mental health services within six weeks of being referred.
Current performance (including factors affecting Bar Chart this) Older Persons Mental Health Services – percentage of people As at 30 September 2020, 194 / 231 people waiting 6 weeks or less for first appointment (84.0%) waiting to be seen by our older persons 100.0% 93.1% 91.0% 90.9%89.2%89.9% 89.9%91.0% 90.3% 90.5%89.3% 85.7% mental health services were reported as waiting 90.0% 85.4% 86.9% 84.5% 83.5% 84.4%84.0% under six weeks, against a required standard of 77.6% 79.0% 81.8% 80.0% 90%. 68.5% Performance for mental health services for older 70.0%
adults continues to be particularly affected, due to 60.0% the memory assessment service, which often 50.0% requires that people are seen for the first time, face 43.2% to face. 40.0% Compliance in respect of the six week standard by 30.0% service area was as follows: o Older adults: 90.5% 20.0%
o Memory Assessment: 80.9% 10.0%
Focus of improvement work 0.0% Appointments continue to be held on a clinical risk- assessed basis. Services continue to contact non-urgent patients How do we compare via telephone or video virtual clinic, ‘Attend The latest NHS Benchmarking Network data shows our median waiting time for older Anywhere’, wherever appropriate. people’s community mental health services to be near the best quartile nationally. Until normal arrangements are re-established it is Recent Performance expected that the waiting list position will continue The total numbers of people waiting, and the percentages of people waiting six to need to be managed closely. weeks or more to be seen by our mental health services at the month end in recent months were as follows: Area Apr May Jun Jul Aug Sep Number waiting 125 130 148 196 205 231 % < 6 weeks 43.2% 68.5% 81.8% 85.7% 84.4% 84.0%
Quality and Performance Report - 18 – November 2020 Public Board G Responsive Waiting Times – One of our key priorities is to ensure that patients are able to access our services in as timely a manner as possible, and without unnecessary delays. Our aim is to reduce the number of people waiting over 18 weeks from being referred to having their first appointment. The data shown relates to our community physical health services, including dentistry.
Current performance (including factors affecting Bar Chart this) Community services (physical health)- number of patients waiting As at 30 September 2020, the number of patients 18 weeks or more from referral to first appointment waiting 18 weeks or more decreased slightly to 2460 2,311, down by three compared to the position as 2255 75 87 at 31 August 2020. 87 4120 348 42 107 77 Dental services Podiatry 45 Our Somerset and Dorset dental service had 2050 82 Children and Young People’s Therapy Service MSK Physio 2,105 patients waiting 18 weeks or more to be 1845 seen, up from 2,071 patients as at 30 September Other services 1640 73 2020 (Somerset: 1,352 patients, up from 1,332 as 4422 77 at 31 August 2020, Dorset: 753 patients, up from 1435 739 as at 31 August 2020). 1230 The number of people waiting 18 weeks or more 42 2071 2105 1025 13 1985 to be seen by our Podiatry service decreased to 1738 77 patients, from 107 in the previous month. 820 40 37 1485 58 The significant increase in numbers waiting, 17 615 3458 especially within our dental service remains 10490 2736 34 949 410 10 principally due to the measures being undertaken 1327 138 14716 610 18 643 523 23 in respect of COVID-19. 17 1245 462 56 205 12409 20 1 373 5 36 20 329 103 105 228 8 294 288 193 208 110 37 48 104 96 263 93 181 186 2 102 95 62 92 3 51 64 20 Focus of improvement work 0 40 9 14 31 38 In accordance with nationally mandated guidance
relating to the management of COVID-19, all non- urgent / emergency or essential interventions How do we compare have ceased. The number of patients waiting 18 weeks or more as at 30 September 2020 Services are continuing to contact non-urgent decreased by three when compared to 31 August 2020. patients via telephone and via video / ‘Attend Anywhere’, to provide advice and support. Recent performance The expectation is that waiting times performance The numbers of people waiting 18 weeks or more at the month end, in recent will continue to deteriorate until after usual months were as follows: arrangements have been restored. Area Apr May Jun Jul Aug Sep Number waiting 795 1,059 1,701 2,241 2,314 2,311
Quality and Performance Report - 19 – November 2020 Public Board G Responsive The two-week wait for suspected cancer is a measure of the length of wait to see a specialist following urgent referral for suspected cancer. The target is for at least 93% of patients to be seen within 14 days of referral. This standard is the first step in the 62-day GP cancer pathway standard.
Current performance (including factors affecting this) Line Chart The percentage of patients with a suspected cancer seen within 14 days of GP referral was 71.1% in August 2020. 2 week cancer performance The number of 2-week wait referrals in April and May 2020 100.0% fell dramatically due to the COVID-19 outbreak. Demand has 90.0% slowly increased and is now around 95% of pre-COVID levels. 80.0% We continue to have slightly reduced diagnostic and 70.0%
outpatient capacity due to infection control measures and 60.0% social distancing in waiting areas. Urgent/cancer patients continue to be prioritised. 50.0% Colorectal makes up 73% of the capacity related 2-week wait 40.0%
breaches, due to pressures within the endoscopy and CT 30.0% colon services, as a result of steps taken to manage the COVID-19 risk and backlogs in these services needing to be 20.0% cleared. 10.0%
0.0% Focus of improvement work Telephone consultations are taking place in cases where patients do not need to be seen face-to-face. Cancer - max. 2 week wait from GP referral (suspected cancer) Standard In services where patients need to attend a face-to-face appointment or for a diagnostic test, precautions are being How do we compare taken in physically distancing patients in waiting areas and National average performance in August 2020 was 87.8%. Our performance was limiting the number of clinics run at any one time. 71.1%. We were ranked 123 out of 132 providers. Please refer to the Diagnostic exception report for further Recent Performance detail on the actions being taken to increase CT and endoscopy capacity. Area Mar Apr May Jun Jul Aug % seen 2 weeks 80.9% 79.2% 94.1% 86.0% 75.7% 71.1% Patient choice breaches 44 18 9 6 19 31 Other breaches (including 131 69 27 99 195 220 capacity, delayed blood tests)
Quality and Performance Report - 20 – November 2020 Public Board G Responsive 31-day decision to treat to cancer treatment is a measure of the length of wait from the patient agreed decision to treat, through to treatment. The percentage performance standard to be met varies according to whether this is first definitive treatment or subsequent treatment.
Current performance (including factors affecting this) Line Chart The 31-day subsequent surgery and subsequent radiotherapy standards were not met in August 2020, with performance of Cancer - max. 31 day wait for subsequent treatment - surgery 87.5% and 93.9% respectively against the 94% standards. Eight 100.0%
patients were not treated within 31 days, across the two 95.0% standards. The 31-day first definitive standard was also not met in August 90.0%
2020, with performance of 93.8% against the 96% standard and 85.0% eight patients not treated within 31 days. The main reasons for the two 31-day subsequent treatment and 80.0%
31-day first definitive standards not being met in the month were 75.0% a shortfall of capacity, related to COVID, and patients needing to be delayed for medical reasons. 70.0%
65.0% Other national cancer standards The 62-day screening standard was not met in the period, with 60.0% performance of 20.0% against the 90% standard. Four patients
were not treated within 62 days of referral, all on bowel screening Cancer - max. 31 day wait for subsequent treatment - surgery Standard pathways. Three patients were not treated within 62 days as a How do we compare result of screening outpatient appointment delays related to National performance for 31-day subsequent surgery was 87.3% in August COVID-19. As a result, one of these patients was transferred late 2020. Our performance was 87.5%. The national average for 31 day to another provider for treatment. One patient was also subsequent radiotherapy was 96.1% in August 2020. Our performance was transferred to the Trust late and could not therefore be treated by 93.9%. day 62. Recent performance
Focus of improvement work Area Mar Apr May Jun Jul Aug Please refer to the 62-day GP Cancer exception report. 31-day subs 96.8% 88.2% 85.7% 90.9% 85.0% 87.5% surgery 31-day subs 96.0% 95.0% 74.6% 81.0% 88.5% 93.9% radiotherapy 31-day first 99.1% 95.4% 91.5% 96.3% 96.8% 93.8% definitive 62-day 82.9% 70.0% 66.7% 40.0% 66.7% 20.0% screening
Quality and Performance Report - 21 – November 2020 Public Board G Responsive The 62-day cancer waiting time standard is a measure of the length of wait from urgent referral by a GP for suspected cancer, to the start of first definitive treatment. The target is for at least 85% of patients to be treated within 62 days of referral.
Current performance (including factors affecting this) Line Chart The percentage of cancer patients treated within 62 days of referral by their GP was 75.0% in August 2020, just below the national average. 62 day GP cancer performance The number of patients treated in August 2020 was at near normal levels 100.0% reflecting services, including diagnostics, running at higher levels of 95.0% capacity than during the peak of COVID, but there also being reduced levels of referrals. A quarter of all breaches of the standard related to 90.0%
patients treated for colorectal cancers, reflecting the reduced capacity for 85.0% endoscopy and CT colon tests during the COVID peak. Four patients were treated in August 2020 on or after day 104 (the 80.0% national ‘backstop’). Three were assessed as having unavoidable 75.0% delays. Two patients had treatment delayed for clinical reasons. One 70.0% patient was delayed due to an extended wait for a diagnostic test as a result of COVID-19. One patient was transferred late to a specialist 65.0%
centre following a wait for a surgical consent appointment with a specific 60.0% surgeon, and had a further wait for treatment at the treating trust. Performance in the coming months will continue to be impacted by COVID-19 due to patient choice not to have investigations and reduced Cancer - max. 62 day GP wait Standard diagnostic capacity during the height of the pandemic. Focus of improvement work How do we compare Patients are continuing to be prioritised for cancer treatment, in line with the national prioritisation codes and timescales. National average performance for providers was 77.9% in August 2020. The small number of ‘suspended’ patients remain on the waiting list so Our performance was 75%. We ranked 97 out of 147 providers. that the next steps in their pathways can be booked once it is safe to resume their tests and/or treatment. Recent performance and trajectory The majority of patients with delayed pathways have been referred with 62 day GP cancer performance suspected lower GI cancers. Faecal Immunochemical Testing was Area Mar Apr May Jun Jul Aug undertaken to determine the likelihood of a cancer diagnosis and which Trajectory 84.0% N/A N/A N/A N/A N/A patients should be prioritised for urgent diagnostics. Actual 80.7% 82.8% 66.0% 81.7% 68.0% 75.0% Appendix 5a provides a detailed breakdown of tumour-site level performance.
Quality and Performance Report - 22 – November 2020 Public Board G Responsive The Diagnostic 6-week wait is a measure of the length of wait from referral through to diagnostic testing being carried out. This standard is applied to the top 15 national high volume tests. The target is for at least 99% of patients to have been waiting less than 6 weeks for a test at month-end.
Cu Current performance (including factors affecting this) Line Chart All aspects of diagnostic performance continue to be impacted by the Diagnostic 6 week wait performance recent COVID-19 outbreak. 100.0% The percentage of patients waiting under 6 weeks for their diagnostic test increased for the fourth month in a row, rising from 49.8% in August 2020 90.0% to 60.8% in September 2020. 80.0% The number of patients waiting over 6 weeks decreased from 3,809 at 31 70.0% August 2020 to 2,731 as at 30 September 2020; the highest numbers of 60.0%
patients were waiting for CT (down from 664 to 365), ultrasound (from 599 50.0%
to 319), echo (increased from 593 to 611), and MRI (from 567 to 405). 40.0% The total waiting list size was 6,958 in September 2020 compared with 30.0% 7,589 in August 2020. Focus of improvement work 20.0% Capacity has been increased, but social distancing, Personal & Protective 10.0% Equipment (PPE) and cleaning measures put in place to manage patient 0.0% care during the COVID-19 outbreak continue to impact on throughput. The emphasis continues to be to keep patients safe, with patients with Diagnostic 6-week wait Standard urgent conditions being prioritised. How do we compare Additional CT capacity is now available, with the completion of the National average performance for NHS providers (i.e. excluding upgrade of CT2 and an additional CT van now being on site, taking Independent Sector providers) was 61.1% in August 2020. Our scanning capacity from 3 to 5 scanners, from 17 August 2020. performance was 49.8%. We were ranked 130 out of 165 Trusts. Two additional MRI vans will be available in October 2020, helping to For endoscopy procedures our performance is recovering more replace capacity lost through the upgrade of an on-site scanner. quickly; we were ranked 74 out of 133 providers for the percentage Additional endoscopy sessions are being run with the use of Day Surgery of patients waiting under 6 weeks for a colonoscopy, 39 out of 133 theatres and weekend waiting list initiatives; in addition a number of for flexi sigmoidoscopy and 18 out of 133 for gastroscopy. appointments have been made to the team, to replace gastroenterology consultants who have left, or are due to leave. Recent performance Locums continue to be booked and sought to increase echo capacity; Area Apr May Jun Jul Aug Sept waiting list initiatives also continue to be run. Actual 41.6% 33.5% 37.0% 42.9% 49.8% 60.8%
Quality and Performance Report - 23 – November 2020 Public Board Responsive This shows the trend for the percentage of inpatient scan requests turned around in under 24 hours. Our aim is to minimise delays in turnaround times, and ensure that at least 96% of scan requests are turned around within 24 hours.
Current performance (including factors affecting this) Line Performance has been below the green threshold for the last five months, with compliance in September 2020 % Inpatient scan requests turned around in less than 24 hours reported at 92.1%. 100.0% Radiology capacity continues to be adversely affected by 90.0%
additional infection control measures being taken to reduce 80.0% the risk of COVID-19 transmission, although inpatient scanning turn-around times remain similar to those 70.0% achieved in 2019/20 and better than in 2018/19. 60.0% One of our MRI scanners broke down during the period, 50.0% with a 10 day outage. Inpatient scans continued to be prioritised. 40.0% 30.0% Focus of improvement work 20.0% Overall scanning capacity will increase in the next month, which will help to reduce inpatient scanning delays; our CT 10.0% scanning capacity increased from three to five scanners 0.0% from the week commencing 17 August 2020, with the
completion of the replacement of CT2 and the use of a % Inpatient scan requests turned around in less than 24 hours Standard mobile scanning van. A further mobile MRI scanning van has also been sourced, in addition to the one already planned, which will help to increase capacity from mid- How do we compare October 2020 whilst one of our on-site scanners is being Performance fell by 1.0% in September 2020, to 92.1% when compared upgraded. to August 2020. There will be a continued focus on ensuring sustainable staffing levels are in place. Recent performance Work is also being undertaken to support effective patient Area Apr May Jun Jul Aug Sept flow through the scanners, to optimise available physical % inside 96.3% 94.9% 94.7% 94.0% 93.1% 92.1% scanning capacity 24 hours
Quality and Performance Report - 24 – November 2020 Public Board G Responsive This shows the trend for the percentage of histopathology requests turned around within seven days. Our aim is to minimise delays in turnaround times, and ensure that at least 71% of histopathology cases are reported within seven days of receipt.
Current performance (including factors affecting this) Line Performance against the seven day turnaround standard Histopathology - % cases turned around in 7 days (receipt to was 67% in September 2020, against a standard of 71%. results) This followed six consecutive months of performance being 100.0% above the compliance standard, reflecting lower levels of 90.0%
activity across the Trust, during the main COVID-19 80.0% outbreak. 70.0% The recent deterioration in performance is related to an increase in histopathology workload, as additional clinics 60.0% and theatre lists have been put in place as part of elective 50.0%
recovery, including additional endoscopy lists at the 40.0% weekend. The patients being seen are the more urgent patients who are also more likely to need biopsies. The 30.0% current turnaround times are better than this time last year. 20.0%
Histopathology laboratory staff were retrained and were 10.0% deployed to support the 24-hour COVID-19 testing rota, and 0.0% were not taking annual leave at that time. They were still on this testing rota in September 2020 as the elective work increased. Histopathology - % cases turned around in 7 days (receipt to results) Standard There are currently also consultant vacancies.
Focus of improvement work How do we compare No histopathology laboratory team members now remain on Performance fell by 13% in September 2020, to 67.0%. the COVID-19 testing rota. New staff have commenced in post, but are training. Recent performance Some staff are working at weekends to help clear the Area Apr May Jun Jul Aug Sept existing backlog. % inside 24 83.0% 87.0% 91.0% 85.0% 80.0% 67.0% hours
Quality and Performance Report - 25 – November 2020 Public Board G Responsive
Our aim is to ensure that at least 90% of the complaints we receive are responded to within 40 working days.
Current performance (including factors affecting this) Line Chart During September 2020, 16 out of 24 closed complaints (66.7%) were responded to within the 40 working day standard. Percentage of complaints responded to within 40 working days 100.0% Delays occurred due to a combination of reasons including: 1. Consultant availability to investigate a complaint. 90.0% 2. Delay due to the availability of dates for a resolution meeting. 80.0% 3. The complaint not being fully addressed in the first instance 70.0%
and being returned to the directorate with further questions. 60.0%
4. The quality of the response needing improvement and being 50.0% returned to the directorate for further work. 40.0% The significant complaints workload has also contributed to some of the delay. The backlog of complaints which had been ‘on hold’ 30.0% during April, May and June 2020 and a significant increase in new 20.0% complaints in September 2020 was further exacerbated by staffing 10.0%
challenges due to long term sickness in the complaints/PALS 0.0% team.
Complaints breached against deadline Standard Focus of improvement work: The complaints team continue to work with directorates to improve How do we compare response times, working with Associate Directors of Patient Care, During September 2020 the percentage of complaints responded to who have responsibility for the oversight of directorate complaints. within 40 working days decreased compared to August 2020. The patient experience team is planning to link with each directorate to offer ongoing support with achieving the 40 working Recent Performance day response time. Our performance in recent months is as follows: It is also planned, when capacity allows, to re-establish complaint workshops for staff to improve the quality of responses. Area Apr May Jun Jul Aug Sep There is a plan for a monthly report for each directorate to present % within 40 at Governance meetings, which will include an overview of open working days 60.0% 85.7% 100% 61.1% 70.0% 66.7% complaints and PALS including the due dates.
Quality and Performance Report - 26 – November 2020 Public Board G Appendix 1 - Procedure for Interpreting Run Charts
Special Cause Variation Rules
1. A single point outside the control limits
2. A run of eight or more points in a row above (or below) the centreline
3. Six consecutive points increasing (trend up) or decreasing (trend down)
4. Two out of three consecutive points near (outer one-third) a control limit
5. Fifteen consecutive points close (inner one-third of the chart) to the centreline
- 24 - Quality and Performance Report November 2020 Public Board G APPENDIX 2
CARE QUALITY COMMISSION RATINGS FOR OUR PREDECESSOR ORGANISATIONS
Our current Care Quality Commission ratings are as follows:
Somerset Partnership Taunton and Somerset
NHS Foundation Trust NHS Foundation Trust
Overall rating for the Trust Good Good
Are services safe? Requires improvement Requires improvement
Are services effective? Good Good
Are services caring? Good Outstanding
Are services responsive? Good Good
Are services well led? Good Good
- 25 -
SOMERSET NHS FOUNDATION TRUST
QUALITY MEASURES - 2020/21
Area Ref Measure Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 30
Data Data 1 Number of medical outliers in acute wards 4 13 23 29 18 9 4 1 0 1 15 awaited awaited 0 Oct-19 Feb-20 Jun-20
2
Admissions of under 16 year olds to adult mental 2 000010000000 1 health wards 0 Oct-19 Feb-20 Jun-20
8
3 Acute wards 073040000002 4
0 Admissions Mixed sex accommodation Oct-19 Feb-20 Jun-20 breaches
Community and 4 000000000000 mental health wards
180
Number of patients transferred between acute 5 39 47 54 67 30 46 46 52 23 20 20 22 90 wards after 10pm 0 Oct-19 Feb-20 Jun-20
August 2020 to be Reporting of new Trust of whole period to commence from 31 October 2020. 6 Hospital Standardised Mortality Ratio (HSMR) 126.6 120.4 reported after Currently only possible to report from June to July 2020 October 2020
Reporting of new Trust of whole period to commence July 2020 to be reported 7 Summary Hospital-level Mortality Indicator (SHMI) from 31 October 2020. Currently only possible to report 102.2 102.4 101.9 after October 2020 from April to June 2020 Mortality (acute services)
4
No of Serious Incidents Requiring Investigation Data Data Data 8 0 0 3 3 0 0 1 1 0 2 (SIRIs)/Never Events - acute services awaited awaited awaited 0 Oct-19 Feb-20 Jun-20 Incident reporting
- 26 - SOMERSET NHS FOUNDATION TRUST
QUALITY MEASURES - 2020/21
Area RefMeasure Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 6 Number of recorded Serious Incidents Requiring Data Data Data 3 Incident reporting Incident 9 Investigation - community and mental health 211322012 awaited awaited awaited services 0 Oct-19 Feb-20 Jun-20
8 Clostridium Difficile cases HOHA cases (Hospital Onset Hospital Acquired) 10 1232220462511 4 and Control Infection Infection COHA cases (Community Onset Hospital Acquired) 0 Oct-19 Feb-20 Jun-20
11 MRSA bacteraemias (post) 000000000010 Infection Control (acute services) (acute Control Infection SOMERSET NHS FOUNDATION TRUST
QUALITY MEASURES - 2020/21
Area RefMeasure Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 8
12 E. coli bacteraemia 123361224232 4
0 Oct-19 Feb-20 Jun-20
6
Infection Control (acute services) (acute Control Infection 13 Methicillin-sensitive staphylococcus aureus 221141210105 3
0 Oct-19 Feb-20 Jun-20
4
14 No. of still births 000020130302 2
0 Oct-19 Feb-20 Jun-20
4 Maternity Data Data 15 No. of babies born in unexpectedly poor condition 0000000000 2 awaited awaited 0 Oct-19 Feb-20 Jun-20
160
Data Data Data 80 16 Number of patient falls - acute services 108 152 132 121 110 112 104 100 103 awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
14.000
Rate of falls per 1,000 occupied bed days - acute Data Data Data 17 6.706 9.128 7.944 6.863 7.062 8.657 12.309 8.812 7.994 7.000 services awaited awaited awaited 0.000 Oct-19 Feb-20 Jun-20
40
Data Data Data 18 Number of falls resulting in harm - acute services 22 23 36 27 27 29 24 23 12 20
Falls awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
3.000
Rate of falls resulting in harm per 1,000 occupied Data Data Data 19 1.366 1.381 2.166 1.531 1.733 2.242 2.84057 2.027 0.931 1.500 bed days - acute services awaited awaited awaited 0.000 Oct-19 Feb-20 Jun-20 SOMERSET NHS FOUNDATION TRUST
QUALITY MEASURES - 2020/21
Area RefMeasure Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 90
Number of patient falls - community and mental Data Data 45 20 70 70 67 56 61 62 61 89 70 59 health wards awaited awaited 0 Oct-19 Feb-20 Jun-20
12.000
Rate of falls per 1,000 occupied bed days - Data Data 21 7.686 8.081 7.408 6.123 7.028 7.512 10.521 11.296 9.183 7.548 6.000 community and mental health wards awaited awaited 0.000 Oct-19 Feb-20 Jun-20
30
Number of falls resulting in harm - community and Data Data 22 20 28 21 27 15 29 22 25 20 11 15
Falls mental health wards awaited awaited 0 Oct-19 Feb-20 Jun-20
4.000
Rate of falls resulting in harm per 1,000 occupied Data Data 23 2.196 3.233 2.322 2.952 1.728 3.514 3.794 3.173 2.624 1.407 2.000 bed days - community and mental health wards awaited awaited 0.000 Oct-19 Feb-20 Jun-20
14
Data Data Data 24 Acute wards - number of incidents 6 12 3 4 6 3 2 1 2 7 awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
0.800
Rate of pressure ulcer damage per 1,000 acute Data Data Data 25 0.373 0.721 0.181 0.227 0.385 0.232 0.118 0.053 0.155 0.400 ward occupied bed days awaited awaited awaited 0.000 Oct-19 Feb-20 Jun-20 SOMERSET NHS FOUNDATION TRUST
QUALITY MEASURES - 2020/21
Area RefMeasure Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 12
Data Data Data 26 Community hospitals - number of incidents 10 2 5 6 2 5 3 3 3 6 awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
2.00
Rate of pressure ulcer damage per 1,000 Data Data Data 27 1.84 0.39 0.92 1.10 0.39 1.02 0.91 0.63 0.69 1.00 community hospital occupied bed days awaited awaited awaited Pressure ulcer damage ulcer Pressure 0.00 Oct-19 Feb-20 Jun-20
60
Data Data Data 28 District nursing - number of incidents 44 52 37 41 37 33 34 42 55 30 awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
2.00
Rate of pressure ulcer damage per 1,000 district Data Data Data 29 1.41 1.75 1.26 1.37 1.36 1.23 1.40 1.61 1.86 1.00 nursing contacts awaited awaited awaited 0.00 Oct-19 Feb-20 Jun-20
8
30 No. ward-based cardiac arrests - acute wards 042142173442 4
0 Oct-19 Feb-20 Jun-20 Cardiac Arrests Cardiac 70
Data Data Data 31 Total number of incidents 32 17 28 27 17 38 54 49 30 35 awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
22.000
Data Data Data 32 Restraints per 1,000 occupied bed days 8.705 4.831 7.819 7.278 4.773 11.411 21.574 15.817 9.144 11.000 awaited awaited awaited 0.000 Oct-19 Feb-20 Jun-20
14
Data Data Data 33 Number of prone restraints 4 6 4 13 7 7 10 10 7 7 awaited awaited awaited 0 Oct-19 Feb-20 Jun-20 Restraints (mental health wards) health (mental Restraints SOMERSET NHS FOUNDATION TRUST
QUALITY MEASURES - 2020/21
Area RefMeasure Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 5.000
Data Data Data 34 Prone restraints per 1,000 occupied bed days 1.088 1.705 1.117 3.504 1.965 2.102 3.995 3.228 2.133 2.500 awaited awaited awaited 0.000 Oct-19 Feb-20 Jun-20
60
Data Data Data 35 Total number of medication incidents 51 52 38 56 28 44 37 26 38 30 awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
wards 2
Data Data Data 36 Medication incidents resulting in harm 110200111 1
Medication incidents - incidents Medication awaited awaited awaited 0
community and mental health health mental and community Oct-19 Feb-20 Jun-20
70
Data Data Data 37 Ligatures: Total number of incidents 33 23 60 31 14 15 25 40 2 35 awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
12
Data Data Data 38 Number of ligature point incidents 460252910 6 mental health wards health mental awaited awaited awaited 0 Oct-19 Feb-20 Jun-20 Ligatures and ligature points - points ligature and Ligatures
30
Violence and Aggression: Number of incidents Data Data Data 39 16 9 16 10 18 5 12 7 15 15 patient on patient (inpatients only) awaited awaited awaited 0 Oct-19 Feb-20 Jun-20
wards 6
Violence and Aggression: Incidents resulting in Data Data Data 40 524131011 3 harm - patient on patient (inpatient only) awaited awaited awaited
Violence and Aggression - Aggression and Violence 0
community and mental health health mental and community Oct-19 Feb-20 Jun-20
100
Violence and Aggression: Number of incidents Data Data Data 41 68 53 73 70 65 38 74 75 72 50 patient on staff awaited awaited awaited 0 Oct-19 Feb-20 Jun-20 services Violence and Aggression - Aggression and Violence community and mental health health mental and community SOMERSET NHS FOUNDATION TRUST
QUALITY MEASURES - 2020/21
Area RefMeasure Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 22 services Violence and Aggression: Incidents resulting in Data Data Data 42 20 9 13 14 10 8 7 13 11 11 harm - patient on staff awaited awaited awaited
Violence and Aggression - Aggression and Violence 0
community and mental health health mental and community Oct-19 Feb-20 Jun-20
10 Unexpected Deaths: Total number of incidents to Data Data Data 43 be investigated - community and mental health 292555373 5 awaited awaited awaited
deaths services 0
Unexpected Unexpected Oct-19 Feb-20 Jun-20
22
44 Number of Type 1 -Traditional Seclusion 10 6 10 7 4 3 12 18 19 15 15 9 11
0 Oct-19 Feb-20 Jun-20
wards 18
45 Number of Type 2 -Short term Segregation 409212223344 9
Seclusion - mental health health -mental Seclusion 0 Oct-19 Feb-20 Jun-20 SOMERSET NHS FOUNDATION TRUST
CORPORATE SCORECARD 2020/21
Links to Theme No. Description corporate Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Thresholds objectives Accident and 1 Accident and Emergency / Emergency 2, 4, 6, 8 2.2% 3.3% 3.4% 2.5% 2.1% 1.2% 0.9% 0.5% 0.4% 1.5% 1.0% 1.4% Minor Injury Units: department (ED) <=5%= Green Percentage of patients who >5% =Red 2 left without being seen Minor Injury Units 2, 4, 6, 8 1.3% 1.1% 1.2% 1.1% 1.4% 1.1% 0.3% 0.4% 0.6% 1.2% 1.1% 1.2%
ED: Percentage of patients triaged within 15 >=95%= Green 3 minutes (patients arriving by ambulance) - acute 2, 4, 6 83.4% 82.0% 84.9% 88.1% 75.6% 83.6% 86.4% 88.6% 88.5% 86.4% 85.5% 85.6% >=90% - <95% =Amber services <90% =Red Accident and 4 Emergency 2, 4, 6, 8 80.8% 72.9% 74.3% 74.5% 79.1% 84.3% 91.4% 91.4% 91.5% 90.5% 86.9% 85.3% department (ED) Accident and Emergency / >=95%= Green 5 Minor Injury Unit 4-hour Minor Injury Units 2, 4, 6, 8 99.6% 99.4% 99.4% 99.5% 99.7% 99.9% 100.0% 99.6% 99.3% 99.3% 99.3% 99.2% >=85% - <95% =Amber performance <85% =Red
6 Trust-wide 2, 4, 6, 8 91.1% 86.9% 87.7% 88.0% 90.5% 92.6% 95.5% 95.4% 95.4% 95.3% 93.7% 93.0%
New Emergency Department Treatment within a median reporting <=60 minutes= Green 7 2, 4, 6 27 30 35 41 50 52 waiting time (minutes) , to >60 minutes =Red commen Unplanned re-attendance at an Emergency <=5%= Green 8 2, 4, 6 2.9% 3.4% 3.3% 3.4% 0.7% 2.4% 3.0% 3.0% 4.1% 3.2% 3.9% 3.5% Department within 7 days >5% =Red
Number of 12-hour trolley waits in Accident and 0 = Green 9 2, 4, 6 0 0 0 0 0 0 0 0 0 0 0 0
Emergency >0 = Red Access and Operations
>=90%= Green All mental health 10 4, 6, 8 92.1% 91.3% 85.1% 90.0% 92.9% 85.2% 67.7% 83.0% 91.0% 94.0% 93.2% 92.7% >=80% - <90% =Amber services <80% =Red >=90%= Green Adult mental health 11 4, 6, 8 91.2% 90.1% 83.4% 86.5% 93.7% 86.7% 86.1% 91.7% 97.8% 98.7% 97.7% 96.5% >=80% - <90% =Amber Mental health primary care services <80% =Red referrals offered first appointments within 6 weeks Older Persons >=90%= Green 12 mental health 4, 6, 8 91.0% 90.3% 83.5% 90.5% 89.3% 79.0% 43.2% 68.5% 81.8% 85.7% 84.4% 84.0% >=80% - <90% =Amber services <80% =Red >=90%= Green Children's mental 13 4, 6, 8 98.8% 98.9% 96.6% 100.0% 98.9% 98.5% 100.0% 100.0% 96.6% 100.0% 92.7% 98.4% >=80% - <90% =Amber health services <80% =Red
0= Green 15 52 week RTT breaches - acute services 4, 6, 8 31 32 43 46 69 118 270 502 906 1,299 1,524 1,639 >0 = Red SOMERSET NHS FOUNDATION TRUST
CORPORATE SCORECARD 2020/21
Links to Theme No. Description corporate Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Thresholds objectives Waiting times: number of people waiting over 18 < 82 patients (2017/18 outturn) = Green 16 weeks from referral to first appointment - 4, 6, 8 121 185 188 122 184 488 795 1,059 1,701 2,241 2,314 2,311 >=82 - <86 = Amber community services including dental >86 = Red
Community dental services - Child GA waiters 0 = Green 17 4, 6, 8 158 67 94 123 117 276 401 478 569 618 586 557 >=0 - =<50 =Amber waiting 18 weeks or more >50 =Red
Community 18 RTT incomplete pathway 4, 6, 8 99.7% 99.8% 99.6% 99.6% 99.7% 99.6% 98.1% 97.6% 98.5% 97.3% 96.9% 96.2% services performance: percentage of >=92%= Green people waiting under 18 <92% =Red 19 weeks Acute services 4, 6, 8 70.6% 71.6% 72.3% 72.8% 71.0% 68.8% 59.8% 50.4% 40.7% 35.6% 42.2% 48.7%
Early Intervention In Psychosis: people to begin >=56%= Green 20 treatment with a NICE-recommended care package 4, 6, 8 68.2% 75.0% 72.2% 87.5% 86.4% 90.9% 92.3% 90.5% 83.3% 76.9% 76.2% 75.0% <56% =Red within 2 weeks of referral (rolling three month rate) Improving Access to Psychological Therapies >=75%= Green 21 (IAPT) RTT : percentage of people waiting under 6 4, 6, 8 95.8% 94.0% 96.1% 94.4% 91.7% 93.9% 90.2% 90.1% 88.1% 86.0% 88.6% 88.4% <75% =Red weeks Improving Access to Psychological Therapies >=95%= Green 22 (IAPT) RTT: percentage of people waiting under 18 4, 6, 8 100.0% 99.3% 99.6% 99.7% 99.6% 98.6% 99.5% 99.0% 99.8% 99.3% 100.0% 99.7% <95% =Red weeks
Percentage of operations cancelled at the last- <=0.8% = Green 23 4, 6 1.8% 1.6% 1.7% 1.9% 0.8% 3.4% 1.6% 0.3% 0.3% 0.8% 0.8% 0.7% minute for non-clinical reasons (acute services) >0.8% = Red
Cancer - maximum 2-week wait from GP Data >=93%= Green 24 4, 6 90.0% 85.7% 87.0% 72.2% 88.2% 100.0% 40.0% 80.0% 83.3% 83.3% 100.0%
Access and Operations (symptomatic breast) awaited <93% =Red
Cancer - maximum 2-week wait from GP referral Data >=93%= Green 25 4, 6 90.6% 87.6% 84.9% 77.6% 81.8% 80.9% 79.2% 94.1% 86.0% 75.7% 71.1% (suspected cancer) awaited <93% =Red
Cancer - maximum 62 day wait from referral by Data >=90%= Green 26 4, 6 85.1% 85.7% 81.0% 70.0% 89.7% 82.9% 70.0% 66.7% 40.0% 66.7% 20.0% NHS screening service awaited <90% =Red
Cancer - maximum 62 day wait from urgent GP Data >=85%= Green 27 4, 6 75.9% 76.4% 78.9% 69.8% 78.6% 80.7% 82.8% 66.0% 81.7% 68.0% 75.0% referral awaited <85% =Red
Cancer - maximum 31 day wait for subsequent Data >=98%= Green 28 4, 6 100.0% 100.0% 99.4% 98.4% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 98.6% treatment - drug awaited <98% =Red
Cancer - maximum 31 day wait for subsequent Data >=94%= Green 29 4, 6 90.7% 89.7% 90.8% 90.7% 100.0% 96.0% 95.0% 74.6% 81.0% 88.5% 93.9% treatment - radiotherapy awaited <94% =Red
Cancer - maximum 31 day wait for subsequent Data >=94%= Green 30 4, 6 97.1% 96.0% 90.5% 92.6% 93.6% 96.8% 88.2% 85.7% 90.9% 85.0% 87.5% treatment - surgery awaited <94% =Red SOMERSET NHS FOUNDATION TRUST
CORPORATE SCORECARD 2020/21
Links to Theme No. Description corporate Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Thresholds objectives
Cancer - maximum 31 day wait from diagnosis to Data >=96%= Green 31 4, 6 98.9% 96.8% 97.6% 94.4% 97.4% 99.1% 95.4% 91.5% 96.3% 96.8% 93.8% first treatment awaited <96% =Red
Cancer: 62-day wait from referral to treatment for Data 0= Green 32 urgent GP referrals – number of patients treated 4, 6 5 5 9 9 9 7 3 5 8 14 4 awaited >0 = Red on or after day 104
Diagnostic 6-week wait (formerly 'Diagnostic >=99%= Green 33 4, 6 88.2% 86.5% 85.5% 86.8% 91.1% 85.9% 41.6% 33.5% 37.0% 42.9% 49.8% 60.8% >=98% - <99% =Amber Performance') - acute services <98% =Red
Percentage of inpatient scan requests turned >=96%= Green 34 4, 6 94.2% 94.3% 93.0% 92.8% 89.7% 94.1% 96.3% 94.9% 94.7% 94.0% 93.1% 92.1% >=90% - <96% =Amber around in under 24 hrs (acute services) <90% =Red
Histopathology - percentage of cases turned >=71%= Green 35 4, 6 47.0% 72.0% 50.0% 68.0% 67.0% 74.0% 83.0% 87.0% 91.0% 85.0% 80.0% 67.0% >=50% - <71% =Amber around in 7 days (receipt to results) <50% =Red
Improving Access to Psychological Therapies >=50%= Green 36 4, 6, 9 56.8% 55.3% 62.2% 59.3% 63.2% 54.2% 52.1% 62.1% 62.0% 62.2% 60.9% 58.3%
(IAPT) Recovery Rates <50% =Red Access and Operations Percentage of patients on Care Programme >=95% = Green 37 Approach (CPA) Level 2 followed up within 7 days 4, 6 100.0% 98.0% 96.6% 98.4% 100.0% 98.6% 100.0% 97.6% 100.0% 100.0% 100.0% 98.1% <95% = Red of discharge - all mental health services
38 Weekend discharge rate (acute services) 4, 6, 7 16.8% 20.3% 19.8% 16.7% 20.5% 19.1% 19.0% 23.6% 20.1% 17.6% 23.9% 19.1% TBC
Inappropriate Out of Area Placements for non- 0= Green 39 specialist mental health inpatient care (monthly 4, 6, 7 22 0 12 31 27 9 5 0 45 0 0 30 >0 = Red number of patient days)
40 Acute services 4, 6, 8 96.0% 97.0% 97.0% 97.0% 97.0% 97.0% 98.0% 99.0% 99.0% 99.0% 99.0% 99.0% >=95%= Green Cleanliness audit - wards >=90% - <95% =Amber Community and <90% =Red 41 mental health 4, 6, 8 98.9% 98.7% 98.4% 98.8% 98.8% 98.5% 99.2% 98.7% 98.7% 98.8% 98.6% 98.3% services
Percentage of patients who rate the acute hospital >=90%= Green 42 4, 6 85.3% 86.8% 82.0% 79.9% 85.1% Reporting suspended >=80% - <90% =Amber as very clean <80% =Red Percentage of patients who were happy with the >=95%= Green 43 level of involvement in decisions about care and 4, 6 95.7% 96.5% 96.0% 95.4% 96.6% Reporting suspended >=80% - <95% =Amber
Quality treatment - acute services <80% =Red Percentage of patients who have been spoken to >=60%= Green 44 by a member of staff about plans for discharge - 4, 6 94.2% 93.5% 94.5% 94.2% 94.4% Reporting suspended >=50% - <60% =Amber acute services <50% =Red
Percentage of patients who felt always treated with >=95%= Green 45 4, 6 92.7% 92.8% 91.9% 91.0% 91.4% Reporting suspended >=80% - <95% =Amber respect and dignity - acute services <80% =Red Quality SOMERSET NHS FOUNDATION TRUST
CORPORATE SCORECARD 2020/21
Links to Theme No. Description corporate Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Thresholds objectives Percentage of patients who report staff are always >=90%= Green 46 4, 6 89.0% 89.1% 86.9% 84.4% 87.6% Reporting suspended >=80% - <90% =Amber kind and sensitive to their needs - acute services <80% =Red Percentage of audited deceased patients who had >=90%= Green 47 a Treatment Escalation Plan in place - acute 4, 6 98.8% 98.8% 99.0% 98.8% 98.7% 100.0% 100.0% 100.0% 100.0% 100.0% 97.4% 97.8% >=80% - <90% =Amber services <80% =Red Percentage of audited deceased patients with End >=60%= Green 48 of Life Care Planning guidance in notes - acute 4, 6 78.6% 71.3% 70.0% 72.9% 76.0% 76.5% 75.0% 80.9% 69.4% 83.7% 87.2% 71.7% >=50% - <60% =Amber services <50% =Red
Percentage of patients who were screened for >=90%= Green 49 4, 6 93.7% 92.3% 93.2% 93.8% 93.9% 92.6% 90.2% 90.7% 92.4% 90.3% 90.8% 93.6% dementia during their stay - acute services <90% =Red
>=90%= Green Percentage of stroke patients with direct admission Data 50 4, 6 60.8% 60.0% 68.1% 50.0% 68.2% 81.7% Reporting suspended 81.8% 75.3% >=75% - <90% =Amber to an acute stroke ward within 4 hours awaited <75% =Red Percentage of patients where ongoing need for a >=90%= Green 51 catheter has been assessed and recorded daily - 4, 6 93.5% 91.4% 88.5% 88.9% 91.5% Reporting suspended >=80% - <90% =Amber acute services <80% =Red
Neutropenic Sepsis: Antibiotics received within 60 >=90%= Green 52 4, 6 93.0% 90.0% - 91.0% 96.0% 90.0% 94.0% 73.0% 92.0% 90.0% 100.0% 100.0% >=80% - <90% =Amber minutes - acute services <80% =Red
Percentage of emergency patients screened for >=90%= Green 53 4, 6 87.0% 83.0% 77.7% 88.1% >=49% - <90% =Amber sepsis - acute services <49% =Red Percentage of patients receiving antibiotics within >=90%= Green 54 one hour of red flag diagnosis of sepsis - acute 4, 6 55.0% 100.0% 57.1% 80.0% >=49% - <90% =Amber services <49% =Red >=90%= Green Quality Percentage of patients with a NEWS of 5 or more 55 4, 6 New reporting criteria commenced from 1 June 2020 75.3% 80.4% 78.8% 81.8% >=75% - <90% =Amber acted upon appropriately - acute services <75% =Red
WHO checklist (theatres): percentage compliance - Reporting changes >=95%= Green 56 4, 6 71.1% 79.7% 88.2% 89.2% Reporting measure being reviewed >=90% - <95% =Amber acute services being implemented <90% =Red Fracture Neck of Femur – Best Practice Tariff 100% =Green 57 access to theatres within 36 hours, ortho- 4, 6 73.3% 80.0% 81.5% 76.2% 95.7% 76.9% Reporting measure being reviewed <100% =Red geriatrician review - acute services
58 Acute services 4, 6, 8 95.2% 95.3% 94.4% 95.3% 95.1% 94.5% Reporting suspended 84.6% 87.3% 86.3% >=95%= Green VTE risk assessment: >=85% - <95% =Amber percentage compliance Community and <85% =Red 59 mental health 4, 6, 8 98.3% 97.7% 97.9% 98.3% 98.8% 98.3% 97.3% 98.0% 98.9% 97.0% 98.4% 97.4% services
Medicines Management: percentage of patients <=1% = Green 60 4, 6 2.7% 2.6% 3.4% 2.2% 3.0% 4.9% 6.3% 7.9% 6.5% 1.5% 1.3% 1.6% with missed doses - acute services >1% - =<3% =Amber >3% =Red Quality
SOMERSET NHS FOUNDATION TRUST
CORPORATE SCORECARD 2020/21
Links to Theme No. Description corporate Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Thresholds objectives Percentage of mental health inpatients receiving a >=95%= Green 61 physical health assessment within 48 hours of 4, 6, 8 95.3% 95.8% 98.8% 98.6% 100.0% 98.2% 100.0% 100.0% 100.0% 98.6% 100.0% 96.6% >=85% - <95% =Amber admission <85% =Red
Patient survey: percentage of patients rating care >=80%= Green 62 4, 6 74.4% 73.1% 71.3% 69.3% 75.1% Reporting suspended >=75% - <80% =Amber received as excellent - acute services <75% =Red >=80%= Green 63 Catering satisfaction scores - acute services 4, 6 80.8% 82.2% 81.7% 79.5% 84.7% Reporting suspended >=75% - <80% =Amber <75% =Red
Percentage of complaints responded to within 40 >=90%= Green 64 2, 4 76.3% 55.9% 76.2% 64.0% 83.3% 73.9% 60.0% 85.7% 100.0% 61.1% 70.0% 66.7% >=75% - <90% =Amber working days - Trust-wide >75% =Red >=80% = Green Quality Reported incidents managed within 10 days - Reporting being reviewed due to 65 4, 6 71.8% 71.4% 68.1% 69.3% 66.3% 69.4% 74.7% 78.3% 81.2% >=50% - <80% Amber acute services new system (RADAR) <50% = Red
Data Quality Maturity Index: Mental Health >=95%= Green 66 4 95.5% 95.6% 95.6% 95.6% 95.2% 95.4% 95.0% 95.2% 95.9% 95.9% 96.0% 96.4% Services Dataset score <95% =Red
>=95%= Green 67 Former T&S 1, 2, 4, 10 92.8% 92.7% 92.8% 92.5% 92.7% 92.1% 92.4% 92.6% >=85% - <95% =Amber New reporting arrangements implemented for the merged <85% =Red Trust Mandatory training: 68 Former Sompar 1, 2, 4, 10 95.3% 94.7% 95.1% 95.1% 95.1% 94.8% 93.3% 91.4% percentage completed All courses >=90%= Green Overall rate <80% =Red Any other position = Amber Somerset NHS FT 1, 2, 4, 10 New reporting system from June 2023 80.6% 78.1% 83.4% 85.9%
Vacancy levels - percentage difference between <=5%= Green 69 contracted full time equivalents (FTE) in post and 2, 4, 10 7.1% 6.3% 6.1% 6.7% 5.1% 4.2% 5.2% 4.1% 4.2% 3.3% 2.7% 3.2% >5% to <=7.5% =Amber budgeted establishment (Trust-wide) >7.5% =Red
<=4%= Green People 70 Sickness absence levels (Trust-wide) 2, 4, 10 4.3% 4.3% 4.4% 4.4% 4.4% 4.4% 4.5% 4.5% 4.4% 4.4% 4.4% 4.3% >4% to <=6% =Amber >6% =Red
Reduce the number of working days lost due to Monitored using Special 71 2, 4, 10 309 351 398 328 273 351 355 357 398 412 398 383 Cause Variation Rules. stress and anxiety (Trust-wide) Report by exception. =<12%= Green 72 Retention / turnover rates (Trust-wide) 2, 4, 10 12.3% 12.4% 12.3% 12.3% 12.1% 11.8% 11.7% 11.3% 10.7% 10.9% 10.5% 10.5% 12% to <15% =Amber >15% =Red
Career conversations (12 months) - formerly Required changes to be implemented to enable combined reporting of appraisal information. Prior to the merger, the two 73 2, 4, 10 'Performance review (12-month)' predecessor organisations operated different systems. The changes are to be implemented over the next few months. Appendix 5a – Specialty and tumour-site level performance
Table 1 – Performance against the RTT performance standard in September 2020, including the number of patients waiting over 18 weeks, the number of patients waiting over 52 weeks, and the average (mean) number of weeks patients have waited on the Trust’s waiting list Average weeks Over 18 week Incomplete pathways RTT specialty Over 52 week waiters Incomplete pathways waited (incomplete waiters performance pathways) General Surgery 1171 201 2,805 58.3% 20.1 Urology 379 78 1,003 62.2% 18.9 Trauma & Orthopaedics 1364 184 2,200 38.0% 26.5 Ear, Nose & Throat (ENT) 1150 111 1,902 39.5% 25.5 Ophthalmology 1845 469 3,262 43.4% 26.0 Plastic Surgery 0 3 100.0% 3.8 Cardiothoracic Surgery 4 0 17 76.5% 12.6 General Medicine 0 13 100.0% 5.0 Gastroenterology 352 36 1,101 68.0% 16.6 Cardiology 364 8 1,066 65.9% 16.1 Dermatology 10 0 72 86.1% 8.4 Thoracic Medicine 230 6 601 61.7% 16.6 Neurology 349 13 705 50.5% 21.0 Rheumatology 258 15 442 41.6% 24.1 Geriatric Medicine 44 1 156 71.8% 15.0 Gynaecology 536 22 1,285 58.3% 17.8 Other 2684 495 4,296 37.5% 27.3 Total 10740 1639 20,929 48.7% 23.0
Table 2 – Performance against the 62-day GP cancer standard in August 2020
No of Trust Tumour site breaches performance Breast 2.0 83.3% Colorectal 4.0 42.9% Gynaecology 0.0 100.0% Haematology 0.0 100.0% Head & Neck 3.0 64.7% Lung 2.0 50.0% Sarcoma/Cancer Unknown 2.0 60.0% Primary/Testicular Skin 0.5 80.0% Upper GI 0.0 100.0% Urology 2.5 76.2% Total 16.0 75.0%
Operational context Community Physical Health: This section of the report provides a high level view of the level of demand for the Trust’s services during the reporting period, compared to the previous months and prior year.
Community service referrals Summary: (physical health) 14000 External referrals for the period from 1 April to 30 September 2020
12000 were down by 23.5% compared to the same months of 2019. Attendances for the same period decreased by 23.8% when 10000 compared to the corresponding months of 2019.
8000 Community service caseload levels slightly increased as at 30 September 2020 and, for the first time since the COVID outbreak, 6000 were comparable with numbers for the corresponding month of 2019. 4000 The reductions seen in all three measures are largely attributable to
2000 actions taken in response to the COVID-19 pandemic.
0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 2019/20 2020/21 Community service attendances Community service caseloads (physical health) (physical health) 90000 60000
80000 50000 70000
60000 40000
50000 30000
40000
20000 30000
20000 10000
10000
0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 2019/20 2020/21 2018/19 2019/20 2020/21
Assurance and Leading Indicators This section of the report looks at a set of key community hospital (excluding stroke beds) and Minor Injury Unit indicators, which helps to identify future or current risks and threats to achievement of mandated standards.
Minor Injury Unit attendances Summary:
12,000 The number of Minor Injury Unit attendances decreased in September 2020, compared to August 2020. Overall Minor Injury
10,000 Unit attendances between 1 April and 30 September 2020 fell by 33.0%, compared to the same months of 2019/20; unplanned 8,000 attendances decreased by 33.2%. 99.4% of patients were discharged, admitted or transferred within four hours of 6,000 attendance, against the national standard of 95%. Attendances since March 2020 have significantly reduced due to COVID-19. 4,000 The average length of stay in our community hospitals in September 2020 was 27.2 days, the highest level since 2,000 September 2019.
0 The community hospital bed occupancy rate for non-stroke Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar patients in August 2020 (the latest data available) was 73.9%. 2018/19 2019/20 2020/21 Community Hospital - average length of stay days (excluding Community Hospital - average bed occupancy (excluding stroke stroke beds) beds) 35.0 100.0%
30.0 90.0%
80.0% 25.0 70.0%
20.0 60.0%
50.0% 15.0 40.0%
10.0 30.0%
20.0% 5.0 10.0%
0.0 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2018/19 2019/20 2020/21 2018/19 2019/20 2020/21
Assurance and Leading Indicators This section of the report looks at a set of key community hospital indicators relating to stroke patients, which helps to identify future or current risks and threats to achievement of mandated standards.
Community Hospital Stroke Beds - average length of stay days Summary:
70.0 The average length of stay for stroke patients in our community 60.0 hospitals during September 2020 was 37.2 days, an increase compared to August 2020. 50.0 Stroke bed occupancy for August 2020 (the latest data available) 40.0 increased slightly to 82.8%, from 82.1% in July 2020. During September 2020 there were 18 discharges of stroke 30.0 patients, an increase compared to August 2020. 20.0
10.0
0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 2019/20 2020/21 Community Hospital Stroke Beds - number of discharges during Community Hospital Stroke Beds - average bed occupancy month 35 110.0%
100.0% 30
90.0% 25 80.0%
70.0% 20
60.0%
50.0% 15
40.0% 10 30.0%
20.0% 5
10.0% 0 0.0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2018/19 2019/20 2020/21 2018/19 2019/20 2020/21
Operational context Community Mental Health services: This section of the report provides a high level view of the level of demand for the Trust’s services during the reporting period, compared to the previous months and prior year.
Community service referrals Summary: (mental health) 3500 Between 1 April and 30 September 2020, external referrals 3000 reduced by 7.9% when compared to the same months of 2019. Attendances for the same period increased by 31.8% when 2500 compared to the corresponding months of 2019, mainly as a
2000 result of appointments being undertaken, where appropriate, via video and telephone. 1500 Mental health community service caseloads as at 30 September
1000 2020 decreased by 5.2% when compared to 30 September 2019. The reductions seen in respect of referrals and caseloads since 500 March 2020 are mainly attributable to actions taken in response to the COVID-19 pandemic. 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 2019/20 2020/21 Community service caseloads Community service attendances (mental health) 18000 (mental health) 30000
15000
25000 12000
20000 9000
15000 6000
10000 3000
5000 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
0 2018/19 2019/20 2020/21 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 2019/20 2020/21
Assurance and Leading Indicators This section of the report looks at a set of leading metal health ward indicators, which helps to identify future or current risks and threats to achievement of mandated standards.
Mental Health wards - average length of stay Summary:
70.0 The average length of stay in our mental health wards during 60.0 September 2020 was 53.3 days. Similarly to August 2020, the increase was mainly attributable to a long stay patient who was 50.0 discharged from Ash Ward, our low secure facility. This patient’s 40.0 total length of stay was 907 days. The mental health bed occupancy rate during September 2020, 30.0 on the basis of both excluding and including leave, increased
20.0 compared to August 2020. During September 2020, a total of 75 patients were discharged, a 10.0 reduction compared to September 2019.
0.0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 2019/20 2020/21 Mental Health wards - average bed occupancy Mental Health wards - number of discharges during month
110.0% 120
105.0%
100.0% 100
95.0% 80 90.0%
85.0% 60
80.0%
40 75.0%
70.0% 20 65.0%
60.0% 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Excl leave 2018/19 Excl leave 2019/20 Incl leave 2018/19 Incl leave 2019/20 Excl leave 2020/21 Incl leave 2020/21 2018/19 2019/20 2020/21
Operational context Acute services: This section of the report provides a high level view of the level of demand for the Trust’s services during the reporting period, compared to the previous months and prior year.
Acute service - Accident and Emergency attendances Summary: 8000 Between 1 April and 30 September 2020, attendances to Accident
7000 and Emergency were 19.7% lower than the same months of 2019. Attendance levels in September 2020 were 8.6% lower than 6000 September 2019. During September 2020, 85.3% of patients were 5000 discharged, admitted or transferred within four hours of
4000 attendance, against the national standard of 95%. GP and Dental referrals between 1 April and 30 September 2020 3000 decreased by 44.6% compared to the same months of 2019. 2000 Outpatient attendances during September 2020 reduced
1000 compared to August 2020, with attendances from 1 April to 30 September 2020 being 12.7% lower compared to the 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar corresponding period in 2019. The reductions seen are mainly
2019/20 2020/21 attributable to actions taken in response to COVID-19.
Acute service - GP and Dental Referrals received Acute service - Outpatient attendances 6000 40000
35000 5000
30000 4000 25000
3000 20000
15000 2000
10000
1000 5000
0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2019/20 2020/21 2019/20 2020/21 Operational context Acute services: This section of the report provides a summary of the levels of day case, elective, and non elective activity during the reporting period, compared to the previous months and prior year.
Acute service - daycase activity Summary: 4000 The number of day cases undertaken by our acute services
3500 during September 2020 increased for the fifth consecutive month but remained 43.1% lower for the year to date than the same 3000 months of 2019. 2500 Elective admissions similarly increased although activity levels for 2000 the period from 1 April to 30 September 2020 were 52.2% lower
1500 than the corresponding months of 2019. Non elective admissions also showed a fifth successive monthly 1000 increase, but were down by 21.7% for the year to date, when 500 compared to the same months of 2019.
0 The reductions seen in respect of all activity since March 2020 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar are attributable to actions taken in response to the COVID-19 2019/20 2020/21 pandemic. Acute service - elective activity Acute service - non elective activity 800 5000
700
600 4000
500 3000 400
300 2000
200
1000 100
0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2019/20 2020/21 2019/20 2020/21
Council of Governors’
Quality and Patient Experience Group
Mental Health Transformation Update and Suicide Prevention Awareness
Date of Meeting 4 November 2020 Author of Paper Presentation: Alison Van Laar, associate director of mental health and learning disability care Report: Catherine Connor, Rose Firth and Kate Williams, Somerset CCG
Sponsor of Paper Summary The purpose of the report is to update the Group on progress with the adult mental health transformation programme (including crisis offers and the new community model of care) and the transformation initiatives for children and young people’s mental health services.
Confidentiality Status Please tick if any of the following apply
(if confidential this paper Data protection – staff or patient detail will not go on the website, Commercially sensitive and will be dealt with Stakeholder management under Part 2 of the Early stage of discussion – potentially prejudicial Agenda) to staff morale or partnership working
Previous Consideration February 2020
Recommendation The Group is asked to note the report
Action Required None
Suicide Prevention Awareness and Mental Health Transformation Update QPE – 04 11 20 F + F1 Raising awareness of Suicide Prevention & an overview of adult & adolescent mental health provision in Somerset FT
Alison Van Laar, associate director of mental health and learning and disability care
Enclosure F Suicide prevention
• Suicide is preventable and is everyone’s business – not just MH • Suicide is one of the biggest killers of people under 50 years old in England – this may increase in other age groups post Covid-19 • Each suicide is estimated to have an impact on 135 people • In Somerset, we are committed to reducing the numbers of suicides across all age groups
Enclosure F 29/10/2020
Suicide and Covid-19
• Covid-19 is likely to have an impact on numbers of suicides across the county • The Lancet (2020) identified 3 themes likely to lead to a deterioration in an individuals mental health & potentially increase the risk of completed suicide: 1. Risk of PTSD & long term effects of brain functioning as a result of the virus (‘Long Covid’) 2. Deterioration of MH/increased suicide risk due to lockdown measures (isolation etc) 3. Deterioration of MH/increased suicide risk as an effect of turn down in the economy & subsequent socio-economic issues
Enclosure F 29/10/2020 3 Suicide in Somerset
• The pre-covid rates of suicide in Somerset placed suicide rates as in the highest quartile nationally • In addition, a higher percentage (compared to other MH providers) of people who completed suicide had had contact with MH services • The Lancet (2020) recommend a structured approach to “protecting mental well being” including strategies to optimise positive responses and enhancing resilience • Suicide rates have been added to the CCG corporate risk register. The MH and LD integrated system huddle see suicide prevention as an immediate priority
Enclosure F 29/10/2020 4
Suicide prevention in Somerset – post Covid-19 In Somerset, strengthening our approach to suicide prevention would be by addressing three main areas MH specific opportunities – including strengthening our response to themes arising from suicide eg: involvement of carers, our response to dual diagnosis, and approaches to risk and escalation Somerset FT opportunities – as an integrated health organisation, SFT are in a unique position to “make every contact count” in relation to suicide prevention and additional resource would be used to increase awareness, improve the recognition of high risk groups, and ensuring that staff feel confident not just about how to talk about suicide but what to do if this arises System wide opportunities – as Somerset moves to be an integrated care system there will be an opportunity to ensure that suicide prevention is everyone’s business. The work developed across SFT can be used to inform and deliver across the system including; county council, education, housing, the police. The resource will need to have a clear interface with public health
Enclosure F 29/10/2020 5 What we’re doing….
The MH and LD directorate continues to strengthen and improve access to services, and Open @ MH (the Somerset NHS / VCS) alliance has significantly improved access and the offer that is available to people in Somerset who are distressed and experiencing mental health difficulties such as the 24 Mindline, & the SFT rapid access support for colleagues The Zero Suicide Alliance training link https://www.zerosuicidealliance.com/training has been circulated to all SFT staff & is accessible on the L&D platform The Clinical Risk training, as well as the Dual Diagnosis training for MH & LD staff has been reviewed & will be mandatory for all clinical staff at B3 & above & optional for other staff (eg clinical general staff, admin, portering etc across SFT) which also dynamically considers our responses to serious incidents across the Trust The recruitment of a 12 month secondment of a suicide prevention lead is to take place shortly
Enclosure F 29/10/2020 6 Suicide Prevention Lead 12/12 secondment opportunity:
The postholder would be required to: • Review the evidence base in relation to suicide prevention (including learning from other providers) • Review SI themes and the current suicide prevention plan; and specifically how it impacts upon patients within the MH and LD directorate • Strengthen and refresh planning relating to suicide prevention in light of the above • Alongside clinical and operational colleagues in the directorate and across Open Mental Health, deliver initiatives aimed at preventing suicide • Work with the medical lead for suicide prevention to measure the efficacy of suicide prevention initiatives • Ensure that all of the above is within a co produced model and alongside Open Mental Health
Enclosure F Enclosure F 7 Enclosure F 29/10/2020 Overview of adult & adolescent MH provision in Somerset
• See attached document ‘Transformation update’ • Any questions?
Enclosure F 29/10/2020 Mental Health Transformation: Progress Update October 2020
1 Adult services
Executive summary: The transformation programme continued throughout the COVID period, and some elements of the Long Term Plan were accelerated Excellent partnership working between NHS and VCSE partners continues Provisional reporting shows patients are being seen promptly (<95% of patients are being seen within 4 weeks) Further work required on data collection and reporting
Purpose: to update the Scrutiny Committee on progress with the adult mental health transformation programme (including crisis offers and the new community model of care) and the transformation initiatives for children and young people’s mental health services.
Background: In 2019, following a national bidding process, NHS England and NHS Improvement awarded the Somerset system CMHS trailblazer status. Our model, for adults in Somerset, brings together traditional NHS- delivered mental health services and a collaborative of voluntary sector providers. This enables a holistic support offer, including the psychosocial elements of mental health (e.g. financial difficulties, substance misuse). Collectively, these organisations operate as Open Mental Figure 1: Open MH pathway Health.
The model is represented right at Figure 1.
Mental Health Transformation: Progress QPE – 04 11 20 1 F1
Impact of COVID: We were fortunate that COVID did not cause significant disruption to the delivery of the transformation programme or services in general; indeed, Somerset benefitted from having additional capacity in place as part of the trailblazer programme to respond to the level of need. However, what did change was the method of delivering care: the bulk of activity has been delivered virtually, rather than face to face.
Progress:
CMHS:
The Open Mental Health offer is the bedrock of our new community model. There are four mental health hubs across Somerset (which our PCNs are aligned to).
Activity Activity until end July shows that there have been 6841 contacts across Open Mental Health (in addition to those seeking support via the crisis line) Staffing We are almost fully recruited across the NHS and VCSE elements of the service. Data and There have been some challenges with reporting; this is because it is reporting difficult to aggregate data across all the involved organisations who use different systems. However, the CSU are supporting with a simple reporting solution. Governance Bi-weekly Open Mental Health Steering Group in place Communication Experts by experience steering group is in place and has and informed both the model design as well as the engagement communications/branding Leaflets have been developed and shared with clinicians across the system Patient leaflets have been developed Outcomes We will be using DIALOG+ across all Open Mental Health organisations to ensure consistency in outcome reporting across the system. This is likely to be in place across all providers by end-Q3. However, anecdotally, we are receiving excellent feedback from service users, referrers and staff. Sharing We are active participants in the Kings Fund CMHS action learning learning set, which has regular sessions We have received funding from NHS England and NHS Improvement to support our evaluation. We are working with the Applied Research Collaboration (with Plymouth University) and some of the other trailblazer sites to develop a shared evaluation approach, which will then inform the overarching national evaluation. We are also providing ad hoc support to other areas whilst they develop their own plans for CMHS transformation. Next steps Development of a bespoke website Agreement of reporting metrics and route across the providers and aligned with national expectations System-wide demand and capacity modelling
Crisis alternatives:
Our CMHS transformation programme includes expansion of the range of crisis offers. In Somerset, we are meeting this ambition by developing 4 crisis community front rooms, one in each of the Open Mental Health localities.
Mental Health Transformation: Progress QPE – 04 11 20 2 F1
The Community Front Rooms provide out of hours support for adults in acute emotional distress. Two trained and experienced staff will offer non-clinical and therapeutic support between 6-11pm on Friday, Saturday and Sunday in each locality. The model has been developed collaboratively by Second-Step, Mind in Somerset (MiS), Watch CiC, Somerset Foundation Trust (SFT) and Rethink. Crisis staff will be supported by Watch CiC Peer volunteers. The impact of the service will be two-fold: positive impact on individuals’ mental wellbeing by providing them with a safe space and supporting them in the identification of ongoing support, whilst simultaneously, reducing the pressures on the wider system (i.e. ambulance call outs, 111, A&E, police).
At the present time, the community front rooms are accepting only pre-booked appointments (via the Home Treatment Teams) to reduce COVID risk.
Activity We do not yet have a validated data set for the community front rooms as they have only recently launched. Staffing These are staffed by crisis support workers employed by Mind in Somerset and Second Step, and will expand to offer peer support in this setting too (paused for management of COVID risk). Data and This work reports to the Open Mental Health Steering Group. reporting Governance A community front room subgroup reports to the Open Mental Health Steering Group. Communications We have currently not launched a county-wide communication and engagement campaign; this is to manage COVID-risk. However, we have promoted the service internally and to the ambulance service in the first instance. It is anticipated that these services will move to drop ins post-COVID. Sharing learning It is too early to have shared any learning on these elements; however, we are linked into the NHS England and NHS Improvement CMHS trailblazer network Next steps Comms and engagement campaign Winter expansion (funds permitting) Link in the peer support offer Opening to self-referrals and other referral routes
Crisis line:
As part of the COVID response, all STPs were asked to implement a 24/7 all age mental health crisis line. This was an element of the NHS Long Term Plan that was not expected to be delivered until 2023. The crisis line built on the Mindline that was already operational in early 2020. The crisis line receives calls directly from patients. “Crisis” is defined by the caller. The service is able to refer the caller to other services, including the ambulance service, the Home Treatment Teams, Open Mental Health and voluntary sector support offers as appropriate.
Activity At 4 October 2020, the crisis line has received 12,975 calls; of these, 816 were from CYP (6.3%)
Of total calls, 1,001 (7.7%) calls related to suicidal ideation, including 168 where the caller was actively suicidal with intent and means. Staffing The crisis line is operated primarily by Mindline staff. Clinical cover is available at all times. Data and The crisis line provides activity data on a weekly basis, with more reporting detailed information monthly. Governance There is a weekly meeting in place specifically for the Mindline
Mental Health Transformation: Progress QPE – 04 11 20 3 F1
Communications We have promoted the Mindline through a variety of routes, with callers and engagement reporting being directed by a healthcare professional, recommended by a family member, or finding details online. Outcomes Anecdotally, the crisis line has actively been able to de-escalate mental health crisis and work with partners to put in place regular support offers for patients. Next steps Linking the crisis line into NHS111
Other activity:
Coproduction: this is a key way of working for our new service. In this spirit, Open Mental Health has delivered training to partners across the system on what coproduction is and how to do it well. Reducing inequalities: we are reviewing how we look at inequalities, including proposals to amend how we undertake an EIA. We are also reviewing our approach to digital poverty. Supporting innovation: as part of the funding ,we hold a small innovation pot open to community providers. We are finalising the application process, but anticipate this will be open to community groups before the end of the quarter. VCSE Alliance: Work is also underway with VCSE partners outside of the Open MH collaborative to upskill, share resources and increase collaborative working.
2 Children and Young People’s (CYP) services
Executive Summary:
Services were able to adapt quickly and efficiently to align with the demands of Covid-19, including the transformation programme, moving towards a pathway model - Thriving Strengthened working between NHS and VCSE partners System-wide commitment to use the iThrive framework Increase in co-production and engagement with CYP CYP access target not met but increasing
Our model of care for CYP is shown at Figure 2.
Mental Health Transformation: Progress QPE – 04 11 20 4 F1
Figure 2: CYP Model of Care
Progress
Mental Health Support Teams (MHST) in Schools After a successful bid in 2019, Somerset gained two MHSTs, with a further two in 2020. Jointly delivered with NHS England and Improvement and the Department for Education, MHSTs provide early intervention on some mental health and emotional wellbeing issues, as well as helping staff within a school or college to provide a ‘whole school approach’ to mental health and wellbeing. The teams act as a link with CYP mental health services and are supervised by NHS staff in the Children and Adolescent Mental Health Services (CAMHS) team.
Each MHST is hosted in the PRU Schools of Somerset: Taunton Deane Partnership College, the TOR School in Mendip, South Somerset Partnership College and The Bridge School in Sedgemoor. The MHSTs are multi-disciplinary teams comprising Education Mental Health Practitioners (EMHPs) employed by Young Somerset, clinical supervision from Somerset FT and Education Psychologists.
Impact of COVID: The first two MHSTs (Taunton Deane and TOR School) went live in February 2020. Although the EMHPs were unable to see CYP face to face due to COVID, Young Somerset worked extremely hard to offer digital interventions, and were able to build the teams’ confidence working with CYP in this way. Over the summer, the MHSTs opened their access routes to GPs, school nursing and school support staff. Requests for Supports were lower at this time but an increase in demand has started to build.
Mental Health Transformation: Progress QPE – 04 11 20 5 F1
Activity 169 requests for support Staffing The MHSTs are staffed but having difficulty in recruiting clinical supervisors. This is a national problem and has been escalated. Data and Somerset CCG will receive monthly reporting and data will be submitted Reporting to the MHSDS Governance Weekly operational and triage meetings feed into the MHST Executive Group Communications Promoted internally through a number of different routes, with Somerset and Engagement Foundation Trust and Young Somerset promoting to schools. A full communication and engagement plan is in place, with the intention that CYP will design the logo for the MHSTs. Outcomes Early intervention and prevention offer with the aim to reduce the numbers into CAMHS but also provide an offer for children and young people needing low level support for mental health and emotional wellbeing Sharing Shared learning across Public Health, CAMHS, Somerset CCG and the Learning VCSE sector. Next Steps The next two MHSTs are imminently due to commence their training, amd will become operational in February 2021
The Big Tent The Big Tent is a VCSE Alliance in which mental health and emotional wellbeing services for CYP (aged 8-18 years) operate under a quality assurance framework. The Big Tent concept was created by Young Somerset, Somerset CCG and Public Health, co-produced with CYP and their families.
The aim is to broker the best deal for CYP, so they can access the right help at the right time with ease. The Big Tent operates within localities building awareness and partnership working with statutory organisations such as Primary Care Networks (PCNs), CAMHS, Schools and Colleges. There were two ‘test and learn’ pilots for the Big Tent which were formed in Yeovil and North Sedgemoor. These pilots brought together GPs, a wide range of VCSE organisations such as SPARK, RAISE, The Space in Cheddar and In Charley’s Memory, to work together, share best practice, and establish a quality assurance framework.
Young Somerset Wellbeing Service Alongside the Big Tent, Young Somerset’s CYP Wellbeing Service delivers emotional wellbeing services across the neighbourhood localities and PCNs. This will be delivered by Improving Access to Psychological Therapies (IAPT) trained and experienced Children’s Wellbeing Practitioners (CWP).
Young Somerset has increased its capacity to deliver wellbeing and mental health preventative services as a conscious function of its strategic development, recognising its role in the county in this realm. CWPs are able to offer positive activities and wider enhancement opportunities that can help sustain outcomes from young people receiving therapeutic interventions. There has also been significant increased confidence in the VCS workforce to support children and young people with mental health needs; the service builds on proposals in the NHS LTP and FFMF public consultation feedback.
Young Somerset Wellbeing Hubs The Wellbeing Hubs are designed to inform CYP and their parents/guardians of the services available to them (a Directory of Services) and help them navigate through the system to get the best support for their needs. The Hubs also provide engaging content, conversation and
Mental Health Transformation: Progress QPE – 04 11 20 6 F1 educational materials on what positive wellbeing and a healthy lifestyle looks like. The Wellbeing Hubs adapt the Social Prescribing model and empower CYP and parents/ guardians to make their own informed decisions around their support needs as it is recognised that individuals are more likely to follow through with accessing support when they have made their own decisions about their support needs.
The Hubs are supported by Young Somerset’s Wellbeing Practitioners, Youth Workers, and young people’s Peers in the role of Wellbeing Champions, offering a diverse range of professionals available to support CYP and their families through their Hub journey.
Impact of COVID: The method of delivering support changed significantly for Young Somerset. However, a virtual intervention route was set up at pace. In June Phase 1 of the Wellbeing Hubs was launched; this is accessible via Young Somerset’s Facebook and Instagram platforms, through Young Somerset’s website, and over the phone through Young Somerset’s ‘Fancy a Chat’ service.
Activity Virtual interventions and group work including parental support Staffing Young Somerset employ 12 (trainee and qualified) practitioners, a project leader and there is currently a Head of Wellbeing Services role out to advert. Data and SCCG will receive monthly reporting and data will be submitted to the Reporting MHSDS Governance Feeds into the CYP Mental Health and Emotional Wellbeing Collaborative Group (chaired by the CCG) Communications Young Somerset lead the communication through a monthly and Engagement newsletter, with the Big Tent and Young Somerset’s Wellbeing Service and Hubs promoted through area meetings and internal channels Sharing Learning Although the Big Tent concept is still in its infancy, With the skills every member of the alliance brings with them, an ‘entry level’ and ‘gold standard’ Qualitative Assurance Framework has been produced. Better understanding of the local Somerset offer and social media work has been improved, underpinned by a social media policy. Next Steps Roll out of the Big Tent to form a county-wide offer, a Big Tent website is currently in development and Young Somerset are in the process of recruiting further CWPs’.
MeeTwo MeeTwo provide specialist support to young people in areas of Somerset by creating a unique portal which sits inside the MeeTwo app. MeeTwo is a multi-award winning, fully moderated, mental help app for young people aged 11-25. The peer support model enables young people to talk about difficult things, and to help themselves by helping each other. Reciprocity allows young people to transform their own difficult life experiences into useful advice for others.
With partners in Public Health, CAMHS, Education Inclusion and Young Somerset, a pilot has been established, with MeeTwo available for people aged 11-18 in a small number of postcodes. The portal will enable young people to connect directly to the Somerset support services including Young Somerset, KOOTH, 2BU, Mindline, ChatHealth and LifeBeat. The pilot is due to conclude in December 2020, and dependent on the evaluation, will be expanded to more postcodes thereafter.
Prepared by: Catherine Connor, Rose Firth and Kate Williams, Somerset CCG
Mental Health Transformation: Progress QPE – 04 11 20 7 F1
Council of Governors’
Quality and Patient Experience Group
Draft Workplan 2021
Date of Meeting 4 November 2020
Judith Goodchild, Hayley Hughes, Steve Thomson and Carol Author of Paper Lydiate
Sponsor of Paper Summary This report outlines the workplan for 2021 for the Quality and Patient Experience Group
Confidentiality Status Please tick if any of the following apply
(if confidential this paper will Data protection – staff or patient detail not go on the website, and Commercially sensitive will be dealt with under Part Stakeholder management 2 of the Agenda) Early stage of discussion – potentially prejudicial to staff morale or partnership working
Previous Consideration November 2019
The Group are requested to review and approve the workplan Recommendation for 2021.
Action Required As above.
Draft 2020 Workplan - Quality and Patient Experience Group QPE – 04 11 20 Page 1 of 3 G
SOMERSET NHS FOUNDATION TRUST COUNCIL OF GOVERNORS
QUALITY AND PATIENT EXPERIENCE GROUP
WORK PLAN 2021 Our Clinical Objectives Getting it right for patients and carers: Objective 3: To provide safe, effective, high quality care in the most appropriate setting Objective 4: To deliver care closer to home in a neighbourhood setting, with an emphasis on self-management and prevention. Objective 5: To give equal priority to physical and mental health and value all people alike Objective 6: To improve outcomes for people with complex conditions through personalised, co-ordinated care
Topic Feb May Aug Nov Objectives Review Objective 4 Objective 5 Objective 6
Quality Accounts Process, including ADIG Key Performance Indicator for 2020/21 and quality indicators and priorities
KPI/QPI Review 2020/21 ADIG
QPI Review 2021/22 ADIG
KPI Setting 2022/23 ADIG
Annual National Mental Health ADPCC Inpatient Survey
Annual Inpatient Survey ADPCC
Maternity Survey ADPCC
Workplan Review Chair
Terms of Reference Review Chair
Serious Incidents Update Gary Risdale Rapid Response Team report Shaun Carthew Quality of Patient Letters Karen Holden Update on the new Appointments Alex Pryde system and its impact on DNAs (Report only)
Draft 2020 Workplan - Quality and Patient Experience Group QPE – 04 11 20 Page 2 of 3 G
REGULAR MEETING ITEMS
Item Responsibility Review of Draft minutes and action log / Chair Matters Arising Patient Experience Report (Objective 3) ADPCC
Complaints and PALS Manager report CPM
Feedback from the Quality and Governance Governor Committee Feedback from the Mental Health Act Governor Committee Patient Experience Framework ADPCC
Good to Know Log Governors
Report from the Signage and Wayfinding Governor Group Carers and Tringle of Care Report ADPCC
Any communication issues arising out of All items on the agenda
LEGEND CPM Complaints and PALS Manager ADIG Associate Director of Integrated Governance ADPCC Associate Director of Patient Centred Care Chair Chair of the Quality and Patient Experience Group
Draft 2020 Workplan - Quality and Patient Experience Group QPE – 04 11 20 Page 3 of 3 G
Council of Governors’
Quality and Patient Experience Group
Community Support for Families/Children - The Big Tent
Date of Meeting 4 November 2020 Author of Paper Rose Firth, Mental Health Commissioning Officer for Children and Young People, Somerset CCG
Sponsor of Paper
Summary This report outlines the workplan for 2021 for the Quality and Patient Experience Group
Confidentiality Status Please tick if any of the following apply
(if confidential this paper will not Data protection – staff or patient detail go on the website, and will be dealt with under Part 2 of the Commercially sensitive Agenda) Stakeholder management Early stage of discussion – potentially prejudicial to staff morale or partnership working
Previous Consideration November 2019
Recommendation None Action Required None
The Big Tent QPE – 04 11 20 1 H The Big Tent
The Big Tent is a Voluntary, Community and Social Enterprise (VCSE) alliance in which mental health and emotional wellbeing services for children and young people (aged 8-18 years) will operate under a quality assurance framework.
Young Somerset is the largest youth work organisation in Somerset and hosts Children and Young People’s Wellbeing Practitioners (CYP-IAPT). Somerset Clinical Commissioning Group has commissioned Young Somerset to enable, facilitate and manage the Big Tent alliance of VCSE organisations offering emotional wellbeing and mental health services for children and young people.
The Big Tent is a conceptual model that brings coherency to a diverse and agile sector, ensuring a single point of contact for VCSE mental health prevision in Somerset and be an integrated part of the iThrive model, addressing unmet need and assisting with wide Access targets and pressures by enabling easy access to brokerage and triage for statutory colleagues including the formative Primary Care Networks.
Wider benefits of the Big Tent include streamlined and integrated pathways for requesting involvement and support, a coherent structure for statutory colleagues to interact and engage with the VCSE, a potential lever for external funding in support of Somerset services, and further engagement and participation by young people service-users in service design and development.
Young Somerset’s Wellbeing Service operates as part of the IAPT (Improving Access to Psychological Therapies) strategy in the UK. Children & Young People’s Wellbeing Practitioners (CWPs) operate under-supervision as part of a multi-disciplinary team, delivering high-quality, outcome-informed; focused, evidence-based interventions for children and young people experiencing, mild to moderate anxiety, low mood and behavioural difficulties.
Two ‘test and learn’ Big Tent pilots were situated in Yeovil and North Sedgemoor. Together, colleagues effectively mapped out what services were in their area, identified best practice, engaged with children and young people and created an ‘Entry Level’ and ‘Advanced’ Quality Assurance Framework; the aim to be as inclusive as possible, with Young Somerset supporting those smaller, emotional wellbeing services in Somerset.
Currently, Young Somerset are facilitating the Big Tent Executive Group, the Big Tent Network Group and are forming the Big Tent website, which is due to go live mid-November.
During the lockdown, Young Somerset mobilised quickly and safely to continue to support children, young people and their families with emotional wellbeing and mental health. Therapy was moved online, sessions adjusted, interactions led by service-users: operating to their needs, at their pace, at times that they wanted.
Young Somerset also stood up new services rapidly and in sector partnership – offering generous leadership, adaptability and agility in co-creating innovative and dynamic solutions to the difficulties of lockdown. YS has integrated its mental health and youth services to provide high quality holistic support for Somerset’s young people – and will evolve that further, with partners, in the coming months.
The Big Tent QPE – 04 11 20 2 H Young Somerset have also created Virtual Hubs. This is a safe online space for young people and parents/ guardians to find out about what Big Tent services are available to them to support with their mental health and wellbeing. There are also informative workshops every week led by the Young Somerset team, providing professional advice and guidance for young people on how to maintain positive Wellbeing and look after their Mental Health.
Young Somerset also believe in putting young people first, and feel that it’s vital that their services are co-designed for young people, with young people. Therefore, they have a developed a range of opportunities for young people to get involved with. Roles include; Hub Buddy, Wellbeing Champion and Participation Group member. Hub Buddy’s support with Wellbeing Hubs, Wellbeing Champions support with developing Social Media content, and Participation Group members have an opportunity to have a say in how services develop.
The Big Tent QPE – 04 11 20 3 H
Council of Governors’
Quality and Patient Experience Group
Good to Know Log
Date of Meeting 4 November 2020
Author of Paper Carol Lydiate, Governor and Membership Support Officer and PA to the Chairman Sponsor of Paper Report on comments made to Governors since August Summary 2020
Confidentiality Status Please tick if any of the following apply
(if confidential this paper Data protection – staff or patient detail will not go on the website, Commercially sensitive and will be dealt with Stakeholder management under Part 2 of the Early stage of discussion – potentially prejudicial Agenda) to staff morale or partnership working
Previous Consideration Quality and Patient Experience Group – 4 August 2020 Governors are asked to note the report and continue to Recommendation feedback comments to Carol Lydiate, Governor and Membership Support Officer
Action Required To note the report
Good to Know Log QPE – 04 11 20 1 I Good to Know Patient Experiences and First Impressions Log
This report covers comments made to Governors about experiences of the public attending either Musgrove Park Hospital or the community hospitals. Those reporting their concerns are always advised that if they have a formal complaint they should contact PALS.
The “Good to Know” log captures comments that fall outside of PALS (unless specifically stated that it is known that contact has been made with the PALS office) and is a regular agenda item. Therefore when concerns are presented and discussed, the Quality and Patient Experience Group are able to express the views of the public and where necessary management are able to highlight the concerns through the most appropriate channel.
Governors are therefore requested to continue to feedback information from the public to the Governor and Membership Support Officer for the “Good to Know Log”. Accurate details with as much information as possible is essential, however the log will not breach patient confidentiality. In essence the log will be brief and give an indication of trends.
The log is a useful additional intelligence tool for the hospital.
Date Item received 09 10 20 COMMENDATION – Submitted by Kate Butler
Received from RD, Stogumber
I would like to express my sincere gratitude to the Ambulance Service and the A&E Department for the care that I received yesterday (08. 10. 20) when I needed their help following a minor fall. Will you please, on my behalf pass my comments to the relevant departments.
NB: This commendation was sent on to the PALs team who forwarded it to the managers of the local ambulance service and the A & E Department at Musgrove Park Hospital.
12 10 20 COMMENDATION – Submitted by Melanie Devine
My daughter in law had a follow-up appointment with ENT this morning (the earlier one was right in the middle of the lockdown). She was very impressed that she went in on time, they repeated the earlier assessment tests, she had a meeting with the consultant and she was pleased to hear that she is now discharged. She said all the staff were very caring and considerate, but also highly professional. 12 10 20 CONCERN – Submitted by Melanie Devine
It is fair to say that I have also received a comment/complaint regarding the lack of dermatology at Musgrove Park. A gentleman who is a regular customer at the bookshop asked me whether there would ever be dermatology appointments at Musgrove as he finds getting to Bristol very difficult.
Response received from Alex Pryde, Outpatient Services Manager
Due to no interest in Dermatology consultant vacancies at Musgrove Park Hospital for many years now, there was no choice but to commission Bristol consultants to see our patients both at Bristol and here at Musgrove Park Hospital.
Good to Know Log QPE – 04 11 20 2 I Date Item received There are a limited number of follow up clinics held at Musgrove, and again this is due to the limited consultant capacity we have in this area. Patients are welcome to request a Musgrove appointment however this may increase their waiting time.
12 10 20 CONCERN – Submitted by Jeanette Keech
What is the policy regarding sending people home from hospital in the middle of the night?
This question arose out of the following experiences which came to Jeanette’s attention:
A woman was discharged from Bath Hospital at 3am having undergone numerous tests. She had no car and lived halfway between Bath and Frome. On checking whether this sort of thing happens at Musgrove I was told 'yes'. A 90 year old lady from a nursing home was discharged very late at night only to be admitted three days later with severe breathing problems. She had no transport. Very early in the morning a member of A & E staff, feeling very sorry for the patient, paid for a taxi to take him/her home.
If this sort of action is a must in order to keep the system going, why not consider providing a small room in which such patients could wait until the bus service and other transport systems start the following morning. Not everyone has easy access to 24 hour transport.
Response from Cathy Phillips, Clinical Site, Patient Flow and Security Manager
As a Trust we endeavour not to discharge inpatients later in the evening, however on some occasions this may occur. As per the discharge policy our intention is that inpatients are discharged no later than 9pm unless a patient requests this, or specific circumstances apply. Later discharges will be agreed by the patient, carers or next of kin prior to discharge, as well as ensuring the discharge destination, if not the patient’s own home, are happy with the discharge plan. If a discharge occurs later than 9pm we have a process that the discharging ward contact the Clinical Site team to provide senior nurse over view ensuring that the discharge is appropriate and safe.
The situation is slightly different for our ED department, as I am sure you can appreciate. A large majority of the patients that attend ED are able to get themselves home safely. There are some patients that are medically eligible for transport and we make every effort to ensure that we can obtain transport. If we are unable to source the correct transport for the patients requirements the patient may have to stay in hospital overnight.
For people that are not medically eligible for non-urgent patient transport they are assessed on an individual basis to see if we can support providing
Good to Know Log QPE – 04 11 20 3 I Date Item received transport. On the rare occasions these patient may wait in the ED waiting room if they are medically safe to do so to enable them to catch public transport at the earliest opportunity.
13 10 20 COMMENDATION – Submitted by Tim Slattery from a friend whose wife had been treated at Musgrove Park Hospital
‘My wife has been under the care of the Beacon Centre since last November, and the regular care and treatment she has received there has been absolutely first class.
Everyone there has been so caring and friendly that it has made what could have been stressful experiences much less so. Even yesterday when Dr Petra Jankowska had to give her the awful news that she had less than a year now, more like six months it was done in such a sympathetic way.
I myself have been a regular outpatient since January, first of all with A&E, and latterly with the Urology Dept. Both departments have provided excellent treatment in a really comforting environment.
We both have nothing but high praise for the work of MPH.
13 10 20 COMMENDATION – Submitted by Erica Adams
Two good to know items:
1. A friend went in for a scan for painful tummy and gall stones diagnosed. Referred to Endoscopy where diagnosis confirmed. Rudi (apologies I forget his surname) saw friend immediately and fitted him in for the next day when gall stones were removed. Friend immediately felt much better and was back to full good health in no time.
2. I was referred for an X-ray by my Doctor. I rang the given number and was given several dates all within a few days. I arrived early as road traffic was very light but I did not have to wait any length of time before being called. Radiographer was charming and efficient. Excellent. Also very good Covid safety signing.
13 10 20 COMMENDATION – Submitted by Richard Brown
On September 4th, we took my hundred year old Mother to West Mendip Hospital, for an emergency x-ray on her foot.
Mother was treated with respect and courtesy, by Ashley a Nurse Practitioner and Ally the Radiographer; she appreciated the care that she was given.
Good to Know Log QPE – 04 11 20 4 I
Council of Governors’
Quality and Patient Experience Group
Quality and Governance Committee Report
Date of Meeting 4 November 2020
Author of Paper Judith Goodchild, Public Governor
Sponsor of Paper The report summaries discussions at the Quality and Summary Governance Committee meeting held on 14 October 2020.
Please tick if any of the following apply Confidentiality Status Data protection – staff or patient detail (if confidential this paper will not Commercially sensitive go on the website, and will be dealt with under Part 2 of the Stakeholder management Agenda) Early stage of discussion – potentially prejudicial to staff morale or partnership working
Previous Consideration 4 August 2020
Recommendation To note the report.
Action Required For information only.
Quality and Governance Committee Report QPE Group – 04 11 20 Page 1 of 2 J
Summary of Quality and Governance Committee Meeting
The following areas were discussed at the meeting held on 14 October 2020:
1. Suicide Prevention A report on strategy to be presented to the November meeting.
2. Elective Care Recovery Pathway In the last four weeks 82% of pre-Covid level of activity has been achieved. Re-organisation of space has freed up areas for face to face consultations, which have increased. Continuing to develop video conferencing and telecom consultations. Theatre capacity has been reduced due to critical care use of theatres. There will be a modular theatre on site from March to replace this. Day case procedures are down as it was decided it was more important to support endoscopy (cancer pathway). This has now moved back to Bridgwater. Rescheduling of recovery room as a surgery to increase capacity. Elective surgery: Currently at 71% of pre-Covid activity compared to last year.
3. Long waiters The Trust is working with Yeovil District Hospital and other partners to target 52-week waiters. It is hoped to reduce this by March 2021. The Referral to Treatment (RTT) list has reduced due to fewer referrals. Clinical reviews (Safety netting and harm): Healthwatch are undertaking a 40+ week survey to see the impact of waiting on the quality of patient’s lives. All patients are being written to with a potential date for their procedure.
4. Ophthalmology The Trust is looking to adopt a single system referral for cataracts. Patients will be offered appointments with the shortest lists.
5. Diagnostics 92% of pre-Covid levels overall has been achieved. Six-week waiters have been reduced.
6. Maternity An update was received on CNST (Clinical Negligence Scheme for Trusts) standards, which were recently introduced.
7. Learning from deaths New processes are to be embedded by December 2020.
8. CQC action plan An update on the CQC action plan was received.
9. Primary Care An update on primary care is to be brought to a governors’ meeting.
Quality and Governance Committee Report QPE Group – 04 11 20 Page 2 of 2 J
Council of Governors’
Quality and Patient Experience Group
UPDATE FROM THE MENTAL HEALTH ACT COMMITTEE MEETING HELD ON 13 MAY 2020
Date of Meeting 4 November 2020 Phil Brice, Director of Governance and Corporate Author of Paper Development Sponsor of Paper The report outlines the discussions arising at the Mental Health Committee meeting held on 29 Summary September 2020.
Confidentiality Status Please tick if any of the following apply
(if confidential this paper will not go on the website, and will be Data protection – staff or patient detail dealt with under Part 2 of the Commercially sensitive Agenda) Stakeholder management Early stage of discussion – potentially prejudicial to staff morale or partnership working
Previous Consideration
Recommendation For Information
Action Required None
Report from the Mental Health Act Committee - October 2020 QPE – 04 11 20 - 1 - - 1 K
SOMERSET NHS FOUNDATION TRUST
UPDATE TO THE QUALITY AND PATIENT EXPERIENCE GROUP FROM THE MENTAL HEALTH ACT COMMITTEE MEETING HELD ON 29 SEPTEMBER 2020
1.1 At its meeting on 29 September, the Committee received reports from:
the Approved Mental Health Professional (AMHP) Lead from Somerset County Council, who described the pressures on the service and noted an increase in activity in recent weeks;
the Somerset Clinical Commissioning Group lead for children and young people’s mental health services who outlined the projects being put in place by the CCG and County Council to improve these services across the county, particularly in response to the poor SEND report issued by Ofsted/CQC recently;
SWAN Advocacy services who provide independent advocacy support to patients detained under the Mental Health Act on our wards. SWAN reported very positive relationships with the ward managers and teams and a level of increasing access and involvement since the initial COVID lockdown.
1.2 The Committee also received information and assurance on the following issues:
training and support for all relevant colleagues around the application of the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) across all our wards;
the annual report on Mental Health Act activity in the Trust which had been presented to the Integrated Quality Assurance Board. The report was subject to some further updates but had an overall “Amber” rating as actions were required to improve management of patients detained under the MHA at Musgrove Park Hospital. The Committee received an update which provided assurance that these actions were now in place;
a statistical report for the month of August which was in a new format. Details noted included:
as at 1 August there were 133 people who were subject to the Mental Health Act in Somerset (and under the care of Somerset NHS Foundation Trust) 15 people were released from their section during the month there were 13 Hospital Managers’ Panel Hearings (a review by lay members appointed by the Trust to decide whether the renewal of a person’s section is necessary, or whether the patient should, instead, be discharged from section. This applies to patients detained under s3, s37 or a CTO – see Appendix for explanation of
Report from the Mental Health Act Committee - October 2020 QPE – 04 11 20 - 2 - - 2 K
the sections); and 16 Tribunal Hearings (legal hearings before a judge where a patient can appeal against their detention).
a review of the actions following an audit of detained patients Absent Without Leave (AWOL) from adult mental health inpatient wards which identified improvements to be made in the recording of AWOLs;
the number of children and young people placed out of county who were subject to the MHA and the oversight of these patients;
a very positive outcome from the CQC remote MHA Compliance visit to Wessex House with no identified improvement actions and some best practice identified, particularly around the ward’s COVID-19 response and support for young people;
an update on recent unexpected deaths of patients detained under the MHA and the investigations which are still ongoing;
Definitions
CTO - Community Treatment Order- used when a person is being discharged from hospital from a treatment order. The person agrees to a set of conditions, compliance with which is intended to lessen the need for readmission to hospital. The person can be recalled to hospital for 72 hours should that be necessary, and the CTO can then either continue again or be revoked.
S2- a period of up to 28 days in hospital for assessment and treatment of mental disorder.
S3- a period of up to 6 months (which can be renewed for another 6 months and then annually) in hospital for treatment of mental disorder.
S5- a ‘holding power’ which can be used by doctors or nurses to prevent an inpatient from leaving the hospital, or prevent an unlawful deprivation of liberty, whilst a MHA assessment is arranged and carried out. Doctors may apply s5(2) which lasts up to 72 hours. Nurses may apply S5(4) which lasts up to 6 hours.
S19- the transfer of responsibility for a detained patient to a hospital managed by a different set of hospital managers. Transfers between hospitals managed by the Trust can be done ‘without formality’-i.e. no statutory paperwork. Since the merger this has been an area of confusion when a patient is moved from Musgrove to a MH unit, or vice versa.
S37 and S37/41- the section 37 is a period of hospital admission for treatment ordered by a court after the person has committed an offence which is punishable by prison. But the person has a mental disorder which requires treatment in hospital. The section 41 imposes restrictions on how the person may be discharged, granted leave or be transferred between hospitals- all requiring authorisation from the Secretary of State (although discharge can also be granted by a tribunal). A section 37/41 has no time limit- it only ends when proactively discharged. A section 37 can be imposed without restrictions, and then its timescales are identical to s3.
Report from the Mental Health Act Committee - October 2020 QPE – 04 11 20 - 3 - - 3 K
Council of Governors’
Quality and Patient Experience Group
Signage and Wayfaring Committee Report
Date of Meeting 4 November 2020
Author of Paper Kate Butler, Deputy Lead Governor
Sponsor of Paper
The report summarises the discussions which took place at Summary the Signage and Wayfaring meeting held on 9 October 2020
Please tick if any of the following apply Confidentiality Status Data protection – staff or patient detail (if confidential this paper will not Commercially sensitive go on the website, and will be dealt with under Part 2 of the Stakeholder management Agenda) Early stage of discussion – potentially prejudicial to staff morale or partnership working
Previous Consideration 18 February 2020
Recommendation The Group is asked to note the report
Action Required None
Signage and Wayfaring Report QPE – 04 11 20 1 L
Signage and Wayfaring Committee Report - 9 October 2020 This was the first meeting to be held since March and it was therefore agreed to prioritise the main items requiring attention. 1. Signage during future building works It was agreed that: signage during the building works needed to be regularly updated and ensure instructions to relevant departments could be easily interpreted and understood by patients and contractors Judy Cottrell, Public Governor, would undertake a walk around the site and report back to the committee. She was tasked to check on how clear the signage was to certain departments, such as different outpatient clinics x-ray, etc., and whether contractors’ signage was causing problems for visitors to the hospital. different outpatient areas will be updated on the website. It was also stressed that clear communication during these difficult times was essential, eg. patient letters. This area is being looked at under a separate committee. 2. Maps around the site These are now out-of-date and it was agreed that it is essential to update these as soon as possible. Medical photography is undertaking this task and estates will look at the cost of removing the present maps and replacing them. The outcome will be reported back at the next meeting of the committee. 3 Patients leaflets These are being redesigned by medical photography and the communications team, and it was agreed that the frames around the hospital would be used to provide information to patients during the building works. Please could Governors who have any question regarding Signage and Wayfaring send them to Carol Lydiate so that the questions can then be raised at the next meeting on 15th November 2020. Kate Butler
Signage and Wayfaring Report QPE – 04 11 20 2 L