GHA Board Report – July 2019-September 2019

GHA BOARD MEETING AGENDA

Venue: Charles Hunt Room, John Mackintosh Hall

Wednesday 17th June 2020 at 11.00hrs

1. Apologies for absence

2. Minutes of the meeting held on 31st July 2019

3. Matters arising

4. Statement by the Minister for Health

5. Matters for the report

5.1 Report: Medical Director and Executive Summary

5.2 Report: Director of Public Health

5.3 Report: Head of Estates and Clinical Engineering

5.4 Report: Director of Nursing Services

5.5 Report: Human Resources Manager

5.6 Report: Hospital Services – General Manager

5.7 Report: Primary Care Services – Deputy Medical Director

5.8 Report: Mental Health – General Manager

5.9 Report: Director of Information Management and Technology

5.10 Report: School of Health Studies

6. Date and time of next meeting

7. In-Camera session

GHA Board Report – July 2019-September 2019

5.1 Executive Summary – Medical Director

Please see 2019 Quarter 4 Board Report for Executive Summary

GHA Board Report – July 2019-September 2019

5.2 Director of Public Health

This has been a busy time, despite the fact that summer is traditionally quiet. The Island Games created both opportunities and pressures on resources but has helped us continue to develop good relationships across many sectors. The hospital remains a focus of intense activity in terms of infection control. A Hospital is a safe environment for sick people, and therefore they should be protected from infections that could be prevented.

Activities of the Health Promotion Department July – September 2019

Main Public Health Events of this Quarter

Building Health & Wellbeing data

Sun Safety at Gibraltar Calling Music Festival

Mental Health Campaign

Public Events

. Island Games: Health Promotion supported the Island Games during the week commencing 6th July 2019. The provision of sun cream was welcomed by organisers, participants and visitors to events.

. Health and Wellbeing workshop at Dr Giraldi Home: The HPOs organised and conducted a workshop on health concerns of service users and families of Dr Giraldi Home; data collected was collated and will be used to guide the formulation of the forthcoming health and wellbeing strategy for Gibraltar.

. Child Friendly City: the HP team are working with Dr Annie Dai and other core members of CHAMP to look at obtaining UNICEF’s ‘Child-Friendly Status’ for Gibraltar.

. World Mental Health Day Campaign: HPOs have contacted GHA staff and met with several interested charities to co-ordinate efforts for WMHD, the focus being suicide prevention. Also contacted GFA to discuss collaborative health promotion:

GHA Board Report – July 2019-September 2019

. Gibraltar Football Association: The HP team met with Steven Gonzalez from the GFA, discussed collaborative working on production of media clips involving the team members on suicide and other relevant health issues for the next year.

. Hot School Lunches: The Health Promotion team attended presentations by a number of applicants for the provision of hot school lunches in schools. HP also worked with the Dietetic Department to create a nutritional standard for schools.

. Organ Donation: The Health Promotion team met with members of the Gibraltar Cardiac and Dialysis Association to discuss future campaigns in regard to organ donation

. Department of Education: The HP team remains in communication with Ms Kerri Scott in regard to having a presence in schools on a regular basis.

. Suicide Prevention Week: HP joined several other local charities to support GibSams on Saturday 31st August at their awareness event at Casemates.

. Gibraltar Calling Music Festival (Sep 7th,8th): The HP department once again joined UNITE the Union to promote sun safety at the music festival at Europa Point.

. Flu Campaign: The HP team is currently working with several other departments to prepare for the forthcoming Flu season. New leaflets have been designed, radio ads have been commissioned and an infomercial is in production.

. Meeting with Radio Gibraltar Team: The HP team met with Ian Daniels and Joanne Wilson from GBC to discuss development of radio ads and jingles with key health messages. A short radio ad on the forthcoming flu season is already on air.

GHA Board Report – July 2019-September 2019

. Facebook posts attracting most attention: o Feeling the heat, take care of yourself (619 reach, 3 shares) o Enjoy a healthy summer (1632 reach, 14 shares) o NatWest Island Games Sun Safe (166 reach, I share) o Sun safety at Gibraltar Calling (4515 reach, 1 share) o Organ Donation Week (149 reach, 4 shares) o WHO Vaccines save lives (157 reach, 1 Share) o WHO Healthy Lifestyles (316 reach, 1 share)

. Health Promotion at Private Companies: o HP were invited to a lunch and learn event at Hambros Bank to discuss general health and well-being issues. o HP joined the Advantage Insurance Wellfest event and presented key issues regarding healthy lifestyles, blood pressure & cholesterol, diabetes and sun awareness.

. Articles for the Gibraltar Chronicle included: o Stay healthy this summer

New Resources

. Table /stand and 2 new pop up banners (CHAMP and healthy lifestyle)

. Radio: o Purchased a block of slots on Rock Radio to relay a variety of health messages for the forthcoming year. Sent material for ads covering Breastfeeding, Sexual Health, Flu, Diabetes, Physical Activity, and Mental Health. o Agreed purchase of slots on GBC TV & Radio for the forthcoming year. Working on ads for Bowel Screening and preparing for Flu.

. Leaflets: revamp of leaflets used by the Child Health Department o Rotavirus o Meningitis o MMR o 6-in-1 vaccine o HPV vaccine o Flu (2)

On-going

. Public Health Website . . Health and Well-being Strategy . Meeting with CHAMP core meeting to discuss aims for future and event for 2020. . Infomercials under production –

GHA Board Report – July 2019-September 2019

o Healthy Portion Sizes o Suicide prevention o flu campaign

Training/CPD . Digital Media Course ongoing . In-house – Non-Invasive Ventilation, Basic Life Support, Infection Control . Seminar of Dyslexia . Dementia Awareness conference

Infection Prevention and Control Report

July – Sept– 2019

Infection Prevention and Control board report for the period form the 1st July – 30th Sept 2019.  Daily surveillance of MRSA, CRE & ESBL. All patients are returning from tertiary Hospitals are screened for MRSA and CRE.

o 6 monthly screening undertaken on long stay wards. Positive patient decolonised.

 1st July- Known CRE+ positive patient taken to theatre from A&E with # NOF. Theatre staff followed Infection Control practitioner instructions to declutter theatres and remove all none essentials. Staff followed IC theatre flowchart and post op cleaning and fogging arranged.

 30th July – CRE+ (urine & rectal swab) patient identified in VMW. Patient isolated and contact tracing undertaken on all patients on that ward. Through contact tracing 3 other patient were identified as positive. Decision to cohort 3 + patients was taken after discussion with consultant Microbiologist due to lack of side-room availability. Staff were briefed on importance of using contact precautions PPE and Hand hygiene. Contacts monitored throughout August as per PHE guidance tool –no further contacts found to be positive.

GHA Board Report – July 2019-September 2019

 Training:

o Mandatory Training for sessions;

o 9th July & 10th July –GHA staff. o 19th July – Bleak House –Dr Giraldi staff. o 21st August –Bleak House-Dr Giraldi staff. o 6th Sept- GHA staff. o 13th Sept – Bleak House- Dr Giraldi staff.

 Attended meetings;

o Infection Control Committee meetings (Monthly) o Nursing Clinical Governance meeting (Monthly). o Public Health Meetings (weekly). o Influenza Campaign meetings (on going with all stakeholders).

 Attended 6 Hats thinking Seminar.

 Monthly BBV clinic held twice a month with visiting consultant Dr Garcia. Reviewing HIV patients and Hep C patient to see if require treatment.

 Following plan of CRE + patient in community, currently homeless with no fixed abode. Third and fourth screen undertaken both- Negative. Patient currently in Ocean views.

 Environmental re-audits for Cochrane and Calpe ward were also undertaken;

o Calpe ward- 61% Minimal Compliance initial audit- Re-audited-.4th July - 95% Compliance.

o Cochrane Ward- 61% Minimal Compliance initial audit- Re-audited- 4th July- 92% Compliance

o Rainbow ward-81% Partial Compliance second audit- 3rd Re audited 9th July -93% Compliance.

o John ward – 79% Partial Compliance initial audit- Re audit- 24th July-96% Compliance.

o A&E- 80% Partial Compliance initial audit- Re audit 24th July 91% Compliance.

GHA Board Report – July 2019-September 2019

 Environmental audits carried out on floor 1,2.3 & Jewish Home & Theatre.

o Floor 1- 99%Compliance o Floor 2- 97% Compliance o Floor 3- 97% Compliance o Jewish Home- 97% Compliance o Theatre audit - undertaken- findings still pending to be reported.

 August- Influenza Campaign (On going) - Preparations for 2019/2020 GHA Influenza Campaign. Weekly meeting to discuss strategy for delivery of Influenza vaccine with stakeholders in order to obtain accurate data on uptake from staff and community. This year’s campaign will be consisting of offering;

o Adjuvanted trivalent flu vaccine (aTIV) - This is licensed for people aged 65 years and over and is the vaccine recommended by the Joint Committee on Vaccination and Immunisations (JCVI) for this age group.

o Quadrivalent vaccine (QIV) - This is recommended for children aged from 6 months to 2 years and in adults from 18 years to less than 65 years of age who are at increased risk from flu because of a long term health condition.

o Fluenz Tetra Nasal spray suspension Vaccine (live attenuated nasal) – will be offered for the first time in Gibraltar to children aged from 2, 3 & 4 years old will be offered.

 2nd August- IT developed programme to raise ALERTs of micro resistant organisms on HIS so patient highlighted in case needed admission or went for surgery. All MRSA colonisers, C.Difficile and CRE imputed on alert system.

 6th August – Infection Control Practitioners underwent “FIT testing course” to become accredited to train staff. Fit testing we were assessed and trained using Draegar masks which have various sizes and our accreditation only covers the use of these masks.

 7th August- Stock control of personal protective equipment undertaken to establish numbers remaining and whether fit for purpose. PPE count;

GHA Board Report – July 2019-September 2019

SIZES Suits with Suits without Goggles Overshoes Boots Boots

XXXL 89 XXL 50 66 XL 75 64 L 69 28 M 66 35 S 72 42 535 350 (approx) TOTAL 332 324 535 350 (approx)

Grand 656 Total

o Fluid repellent coverall suits, anti-fog goggles and over shoe covers that we bought for the Ebola crisis in 2014.

o Anti-Fog goggles have an expiry date (and they expired in 2017).

o Organisation needs to consider changing our FFP3 respirators as the one we use now (Meddop) is one size only and we cannot offer an alternative size if this does not fit.

 20th August- Endoscopy final rinse water issues raised as in breach of best guidance and placing patients at risk, as not being undertaken for last 8-9 months. No clear definition of whose role and responsibility it was to undertake water sampling. Same has now been addressed and agreement reached by Endoscopy team, Public analyst and Clinical Engineering who have agreed to undertake water sampling every Wednesday morning. Endoscopy to submit SOP for water sampling to present to ICC and governance.

 28th August - Mattress audit undertaken by ICP and practice development nurse and TALLY representative. (Audit report attached). Same to be presented at next ICC meeting.

GHA Board Report – July 2019-September 2019

 11th August - BAL from patient positive for MTB – Rifampacin sensitive. PHx – Admitted via A&E 26/06/2019 – poly trauma call after falling from a window. Intubated in A&E – CT scan performed and there were changes? cavitation on Chest. Patient conveyed to Quiron Malaga via ambulance with escorts. 6 weeks in Malaga and repatriated back to SBH. Patient with trachy and ventilated; respiratory precautions and isolation maintained since admission Quiron Malaga was contacted via email from Dr Nick Cortes (06/08/2019) alerted Quiron Palmones to contact Malaga to alert staff of result. Contact tracing was carried out on all staff who undertook airway management. All staff deemed at risk were Mantoux tested- results all negative and BCG will be offered.

 21st 25th Sept- Infection Prevention Society annual conference- Both Infection Control Practitioners attended IPS conference in Liverpool for insight into updated practices and equipment.

Sandra Netto Nathan Lightbody Infection Prevention and Control Department

Cancer Screening Programmes delivered by Public Health

Colorectal Cancer Screening Programme

During the period spanning the months of July to September 2019, a total of 779 invitations were mailed to eligible participants inviting them to take part in the Colorectal Cancer Screening Programme. During this same period 798 test-kits were prepared and mailed to the participants and 382 samples were returned to the hospital laboratory for analysis. The breakdown of the results is as follows:  317 Negative for occult blood results  20 Inconclusive for occult blood results  15 Spoilt / Technical fail  30 Positive for occult blood results Of those participants invited to participate, 5 categorically refused to participate in the screening programme. In accordance with the protocol, the individuals will be re- invited to participate in two years. Of the 32 invitations extended to eligible participants residing in Spain, 6 individuals expressed interest in participating in the screening programme. During this time frame, 4 individuals aged over 74 and therefore not a routinely invited group, approached the screening office requesting to be included electively in the Bowel Screening programme.

GHA Board Report – July 2019-September 2019

During these months the Screening Office has received 0 reports from the Endoscopy / Surgical Out-Patient Department with regards the screening colonoscopy outcomes performed on Bowel Screening participants.

The bulk of visits have related to the requesting of replacement test-kits or enquiries related to the sample collection method. During this time frame a number of initiatives have been commenced with the hope that these could elevate the current level of participation. These measures include:  The Screening Administrator continues to affix inspirational testimonials to the outer surface of the test-kits as a means of enticing invitees to participate in the programme.  The invitation letter has been redrawn, keeping the text more streamlined, making it easier to read. For the last 3 months, participation has risen to 47.9% compared to 38.0% in the last quarter. The initiatives undertaken over this period may have contributed to the apparent rise in the participation rate, though trends will have to be maintained over time to confirm this.

Abdominal Aortic Aneurysm Screening Programme

During the period of July - September 28 invitation letters were mailed to eligible participants and 17 accepted their invitations. In addition, 13 gentlemen accepted their invitation after receiving reminder correspondence over a 6-month period. The participation rate for 2019 currently stands at 69.0%. All these participants were issued with ultrasound appointments. A total of 39 reconsider letters were issued to participants who did not reply. 0 expressed an explicit refusal to participate in the AAA programme during this period. However, 35 invitees, who did not respond to either the invitation letter or the reconsider letter were marked as ‘Inactive’ and notified. 0 requests were received from individuals aged 66-74+ years (outside the invitation range) to take part in this initiative as elective cases. During this period, 46 men were screened and 41 Normal Aorta results were issued. 3 known small aneurysm were re-tested on a yearly basis. Following protocol, the gentlemen who were retested for a small aneurysm will be issued with an appointment to be tested once again in 12 months’ time. In order to boost participation rates, champion requests continue to be issued to all participants that are currently taking part in the programme. In addition testimonials are now included with the initial invitation letter as well as any reconsider letters issued.

Respectfully Submitted

Dr Sohail Bhatti Director of Public Health 12

GHA Board Report – July 2019-September 2019

5.3 Estates and Clinical Engineering

1. Department Strategic Plan.

Over the last few years the department has shifted from a level where we were developing a quality manual based on ISO9001:2008 requirements and building a department looking to ensure quality and excellence across all areas and disciplines, to a department struggling even to meet our operational requirements. This has been largely due to the lack of succession planning through a period where we have seen very experienced engineers retire without the ability/opportunity to pass on their valuable knowledge and skills to younger engineers coming through. As a result we have only been able to concentrate on delivering our statutory and reactive duties operationally, therefore strategically we have been working hard to try and at least re-establish our full complement of technical staff.

Within the first quarter of this year the Estate and Clinical Engineering Department, in its entirety, officially moved across to the Gibraltar Electricity Authority. This has presented some additional challenges to us operational, but has also given us the opportunity to raise awareness about our viability to operate as a department moving forward; given our reduced numbers and ever decreasing level of expertise. I am therefore pleased to report that within this quarter the CEO of the GEA has been able to release all of our vacancies, with permission to advertise outside of the limited GEA pool of engineers. One area of expertise we have been struggling to find engineers for is within our clinical engineering team, where we need multidisciplinary engineers with an Electrical/Electronics background with the ability to diagnose faults accurately and quickly; as the work is primarily complex high risk medical devices.

2. Medical Devices.

Capital for FY 2019/20 has now been released, and within this quarter the medical devices committee has met to determine what budget will be available for both new equipment and critical ‘Life Cycle Replacement’; particularly in terms of key high to medium risk medical devices requested within our estimates.

GHA Board Report – July 2019-September 2019

Unfortunately over the last couple of years the hospital has been building an ever increasing list of equipment that requires replacement, the effect of this is three-fold; risk to patients, risk to service continuity, and increased capital budget requirements.

With regards to the FY 19/20 budgets, the committee has asked for the medical devices (new equipment/lifecycle) budgets to be ‘ring fenced’ so that the committee can prioritise the purchase of critical new equipment, and the life-cycling of old equipment in accordance with the risk. Further to this, for items that become critical and in desperate need for replacement the committee has added an impact risk assessment for each item.

From our recent meeting it was determined that capital budgets were one again extremely stretched and the committee were restricted to a limited budget for critical items only. On this basis the committee has been determining priorities for immediate purchase.

3. Clinical Engineering –

Over the last three months, the Clinical engineering section has been heavily involved in the commissioning and setup of medical devices to equip the new child CPCC (CHC) and the PCCC, adult primary care units.

Our team has also been assisting our specialist dental suppliers during and after working hours on the setup of systems for all 7-Suite Dental clinics and their respective plant rooms.

Further to this we have also managed to assist our specialist medical gas suppliers with the pipework and pendent installation for medical gases within the new theatre 5 suite, along with the build and installation of other system within the suite, including a new surgeon’s panel and LED theatre light.

The extra workload relating to projects has impacted on both the department’s operational productivity, and its ability to perform critical planned preventive maintenance. It has not been possible to maintain critical equipment and this has unfortunately resulted in an increase to our backlog maintenance. IT must be highlighted that increased backlog unfortunately leads to increased risk to our patients.

GHA Board Report – July 2019-September 2019

As already highlighted strategically the current situation in terms of our inability to recruit suitable engineers has a bearing on our viability as a clinical engineering department, and we are being forced to work outside the box in order to function day to day.

However the department continues to perform to the best of its ability to meet all the reactive works, unfortunately at the cost of planned preventative maintenance. This lack of manpower and decreasing level of skills set is forcing us to look at outsourcing more and more maintenance, and in light of BREXIT this strategy its own risks (due to us being more reliant on Spanish expertise) .

During this period little progress has been made on departmental development in order to improve operational efficiencies and standard of work. Due to the lack of personnel on the ground it has also remained extremely difficult to ensure CPD and training is implemented effectively. However with the potential for new staff coming on board, following the current recruitment drive, training will, and must be, fundamental in bringing the skills sets and expertise back up to acceptable levels.

Medical Device Alerts and Recalls Attended in the last 3 Months –

Equipment Affected Description of problem Philips TC50 ECG Risk of Batteries Overheating or Igniting Locking Plate Inspection – Arrangement made with Omni Diagnost Eleva Philips UK for upcoming Visit Weak Construction of Bezel posts. May Break and result Alaris Pumps Module in inaccurate dosage Pulse rate Software upgrade – Arrangement made with Philips VS3/4 Vital signs Monitors Philips Iberia for Upcoming Visit

External Service Provider – Completed PPM’s –

Service Provider Equipment completion Date GE Healthcare Ultrasounds Machines July

Atlas Copco Medical Air Compressors August Envair Cytotoxic Dispenser Cabinet Philips UK Radiology Modalities

Steris Iberia Autoclaves and Washer Disinfectors September

GHA Board Report – July 2019-September 2019

External Service Providers - Corrective Maintenance –

Service Provider Equipment Repairs Month Atlascopco Medical Air Compressor 1 July Steris Autoclave 1 Olympus Endoscopes 2 Philips UK Radiology Equipment 2 Philips Iberia Monitoring Equipment 1

Steris Sterilizers 2 August Philips Iberia Monitoring Equipment 1 Siemens Ultrasound Machine 1

Philips Iberica Monitoring Equipment 4 September Graham Parsons Dental Equipment 2 Autoclaves and Washer Steris Disinfectors 4 Topcon Ophthalmic Equipment 1 GE Healthcare Anaesthetic Machine 1

Medical Device Alerts and Recalls Attended in the last 3 Months –

Equipment Affected Description of problem Status Stryker Lifepak-15 May fail to work after first delivery shock Resolved Defibrillator Encor Breast Biopsy Risk of Leak onto the driver and Minimal Resolved Probe Suction

Philips TC50 ECG Risk of Batteries Overheating or Igniting In-Progress

Locking Plate Inspection – Arrangement Omni Diagnost Eleva In-Progress made with Philips UK for upcoming Visit Weak Construction of Bezel posts. May Break Alaris Pumps Module In-Progress and result in inaccurate dosage Philips VS3/4 Vital signs Pulse rate Software upgrade – Arrangement In-Progress Monitors made with Philips Iberia for Upcoming Visit

In-House Scheduled Maintenance –

PPM Status Completion Date Patient Lungs Ventilators completed June Syringe Drivers completed June Suction Pumps completed June

Reactive works attended over the period covered by this report –

GHA Board Report – July 2019-September 2019

Carried % Over Differenc Ticketin Phon Email Call- Total from Complete Pendin e from g e s Out Breakdow Previou d Jobs g Jobs Previous System Jobs Jobs s n s Quarter Quarter 0% 68 420 21 55 56 552 554 66

Commissioning of Medical Equipment - Qty Equipment Date 1 Low Profiling Beds July 1 Optical Testing Chair 1 AED 2 Static Bike August 2 Manual Wheelchairs 4 Nebulizers 10 Tympanic Thermometers 14 Examination Couches September 2 Manual Wheelchairs 2 Surgery Trolleys 2 VAC Units 1 Therapy Chair 4 TC50 ECGs

Projects and Departmental Developments -  CPCC a) Acceptance and Commissioning of Medical Equipment well Progressed. The duplex AGSS for the new dental (7 off Suites) is currently on transit - Due to arrive by mid next week.

 PCCC a) Acceptance and commissioning of Medical equipment are being carried out as they are received – In Progress (Early Stages).

 Theatre 5 a) Surgical Lamp has been sent twice with wrong configuration – Waiting for the 3rd attempt from Steris. b) Steris have supplied Pendant on site. AGSS was found to be not compatible with our system – Currently liaising with Steris and Midland Medical to resolve this issue ASAP. 18

GHA Board Report – July 2019-September 2019

c) The material for the Medical Gas Installation was shipped from UK on Monday 1st July. d) Manufacturing of Surgeon Panel is pending arrival of the digital and analogue clock from the same supplier. We are expecting a two-week lead time after receiving these items.

 CCU Isolation Rooms (PPVL - Positive Pressure Ventilated Lobby) a) 6 off Lockable line isolation valves to be fitted at the supply line for the isolation rooms. Datix – We have been responding to Datix as and when appointed as handlers, this is an extremely good system for ensuring that investigations are governed correctly and that route cause analysis is employed and followed through.

4. Electrical Engineering –

During this quarter we have carried out a very limited amount of scheduled maintenance. Although we have been involved with an extensive amount of new works they have not generally interrupted our daily routines as these have mainly been completed after hours. The department’s main output activity this quarter has predominantly been dealing with reactive maintenance issues. Unfortunately a limited amount of hours have been dedicated to preventative maintenance. Staff manning levels remains a concern as another member of the team retired within this quarter (Manning levels are down to three electricians) with two others to follow within the next quarter. As per the rest of the department’s recruitment issues there has been no opportunity for succession planning and as a result we have lost the opportunity for retiring staff to pass on their valuable site and systems knowledge. The on-call roster of one in four has one week without cover due to the retirement of one operative. So there is one week in four without electrical on call cover. For this next period will see a second retirement and the cover will be reduced further resulting in two out of four weeks covered with the electrical on call staff only.

GHA Board Report – July 2019-September 2019

Internal Planned Preventative Maintenance - Planned maintenance activity in the quarter has been minimal due to the high levels of reactive calls, along with critical projects. Planned maintenance this quarter has been restricted to the following:

Service Provider System Month Otis Lifts & Escalator July

Otis Lifts & Escalator August

Otis Lifts & Escalator September UPSMEIER UPS & IPS

Reactive Works Reactive maintenance is ongoing and will increase if planned maintenance regimes are not undertaken. Reactive works this quarter are as follows:

Ticket Phone Email Month Call-Outs Total Breakdown System Jobs Jobs

July 70 - - 13 83

August 42 - - 12 54

September 47 - - 13 60

Projects / New Works –

Location July – September 2019 Projects St Bernard Secure level 2 corridor with access control St Bernard New infection control area outside ITU St Bernard Porta cabin Installation for records completion St Bernard Outpatients modifications for new PCC requirements St Bernard OP/TH 5 Project & plant room works St Bernard Medicom Nurse call system upgrade St Bernard Grd, 1st, 2nd B4 floors removal of services for new PCCC project. St Bernard Dialysis Conversion/Expansion on-going St Bernard A+E Containment suite access control and electrical services St Bernard Basement Access via lift lobbies access control 20

GHA Board Report – July 2019-September 2019

St Bernard Stores Conversion, lighting and access control, on-going St Bernard Facilitate the replacement of the Hospital front (circular) doors St Bernard UPS installation works for new PCCC & CPCC

Electrical Training - To date, technical training of the electrical department staff has been virtually non- existent. However two members of the team have participated in the BS ISO 7671 IEE Regs 18th edition course this year to date (Q1).

Technical Training Required: in keeping with progress and new technology, and the consequential upgrade to hospital’s systems year on year, there is a need to organize a number of courses for our staff which include the following;

• First aid at work (electrical) in accordance with HTM06-02 • Fire Safety in accordance with HTM05 • AutoCAD • UPS/IPS systems in medical locations to HTM06-02 • Data Centre Course • UPS design for IM&T in accordance with HTM06-02 and BS7671 • Electrical Authorized Person (AP) HTM06-02 • Lifts trapped passengers to HTM08-02 • Electrical testing in accordance with BS7671 IEE 17th Edition • PAT testing • GENT fire systems in accordance with HTM05 • CEM access control (technical) • Austco Nurse Call system (programming) to HTM08-03 • Lift management (AP) to HTM08-02 • Solar Power systems

Degree courses in hospital engineering foundation are also something that we would like to aspire to in the future.

GHA Board Report – July 2019-September 2019

5. Mechanical Engineering –

Within this quarter the division has generally concentrated its time between projects and maintenance works. As the completion dates for each phase of the projects approaches, this exacerbates the need to sacrifice maintenance work for project works. This coupled with our staff shortages (annual and sick leave) inevitably results in staff pressure, and areas of important planned maintenance being deferred.

A good 80% of our work is currently of a REACTIVE nature; careful analysis of this work reveals that there is a close correlation between reduced planned maintenance works and the types and number of callouts we receive. Equipment and/ or system serviced or maintained at the correct frequency will break down more often and usually with a more severe consequence.

Within the quarter we have had one member of staff retire, with two members expressing a request to transfer within the GEA. This is extremely concerning, with no light at the end of the tunnel in terms of succession planning and / or recruitment.

Jobs raised as on-line tickets -

Total tickets Tickets completed Tickets Pending received April 26 26 0

May 5 5 0

June 16 14 0

Total 47 47 0

Jobs raised by Phone call -

Jobs Raised Jobs Completed Jobs Pending April 3 3 0 May 2 2 0 June 1 1 0 Total 6 6 0 Jobs raised by verbal reports -

Jobs Raised Jobs Completed Jobs Pending April 7 7 0 May 6 6 0

GHA Board Report – July 2019-September 2019

June 7 7 0 Total 20 20 0

Out of Hours Callouts -

number of callouts April 13 May 22 June 24 Total 59

Ward filter cleaning /Replacement -

number of filters cleaned April 268 May 277 June 292 Total 837

Other Reactive works carried out -

 Replacement of Drive belts ongoing.

 Ongoing AHU Pre filter replacement.

 A total of 11 Clinical beds have been assembled and dismantled by Danny on behalf of Cancer.

 Relief Service.

 Ongoing Fan deck replacement.

Planned Preventative Maintenance -

 24 Air Handling units have been serviced and we are almost to schedule.

 We are slowly bringing the Fan coil servicing up on line started mid- September and we have carried out - total of 18 units.

 Ward filter cleaning is ongoing.

 Inlet station chlorine tank and injection point service ongoing.

 We have been assisting our specialist HVAC contractors with the annual checks of ductwork fire dampers, and the AHU plant verification reports.

GHA Board Report – July 2019-September 2019

Projects -

 There has been a lot of works involved with enabling B4 for the PCCC - in terms of removing redundant mechanical services.

 A&E containment suite is progressing well, we are currently commissioning the HVAC for this area.

 Ongoing Theatre 5 works – installation of laminar flow hood and plant room ductwork.

 Dialysis – works is progressing well; the new plant is installed and we are about to commission the 8 bed temporary area from the new plant room. We are awaiting delivery and installation of the new isolation room AHU.

 Family’s room outside Critical Care unit has had a DX Air-conditioning unit installed.

Specialist Visits -

 Fresenius on various occasions to install the new dialysis water plant and advise us.

 AirisQ came to inspect our Fire Dampers and carry out some validation work

 Wheis Klimatec for theatre 5 project will need to visit again.

Fuel Oil -

The fuel is monitored on a daily self-built programme, this is now starting to bear fruit and we are slowly building up a historical record of consumption, which can then be reconciled with delivery data.

Fuel oil consumption -

Total for the month Average consumption per day July 19676 litres 634.7L/day August 19093 litres 615L/day September 21324 litres 710.8L/day Total 60093 litres We had 2 fuel deliveries, on the 30th Aug and 02 Sep 2019 a total of 66,000 litres were purchased

GHA Board Report – July 2019-September 2019

6. Projects Completed and On-Going – (main projects only – this does not include strategic reactive projects)

A huge amount of our time has been invested this quarter managing the three significant primary care projects; including the new children’s hub in building 9 ground floor, the new 3 level extension to block 4 (south) to house adults primary and community care, and a new 2 level extension to the north of block 4 to enable a separate entrance to the new PCCC. Also related to these projects there has been some sub-projects which include the moving of records into porta-cabins between blocks 1 and 3, this was to enable pharmacy to move out of the ground floor of block 4 and enable the continuation of primary care services within the ground floor (consisting of registration, lymphedema clinic, the ulcer clinic, PCCC admin and community OT).

I am pleased to say that significant milestones have been achived this quarter in terms of these projects, with the opening of the CHC (CPCC) within block 9, the moving of records in its entirety, and the completion of both the PCCC entrance extension and practical completion of the main PCCC building. A MASSIVE ACHIEVMENT.

Opening of the new Children’s Health Centre (CHC) on July 16th.

GHA Board Report – July 2019-September 2019

A massive achievement by my team, the design and management of the dental infrastructure systems to facilitate the moving of our pharmacy to the second floor of block 4.

7. New dental clinics within the CHC.

As part of the B4 works we included the installation of a large air conditioned and secure space to house our patient records. This was to facilitate the moving of our pharmacy to the second floor of block 4.

The Children’s Health Centre (CHC) opened on 16th July.

GHA Board Report – July 2019-September 2019

The Adults Primary Care Centre is opened on Monday 14th October.

New Theatre 5 – Theatre 5 will be located within main theatres and within the West wing, mirroring the position of theatre 3. This theatre is being built as a Laminar Flow theatre and will only consist of a main theatre with separate scrub.

This project is under way; we anticipate the theatre to become operational by early next year. This project is a challenge in terms of engineering due to the limited space within the plant room above, and the ceiling void within the proposed space. To this end we are adopting German technology which will provide a state of the art compact solution.

GHA Board Report – July 2019-September 2019

New MRI suite – This is a complex project that requires careful consideration in terms of its location and proximity to other services that may have a detrimental to performance. This is ‘turn-key’ project; procurement, design and installation. We are currently in the design stage of the project with the preferred supplier.

Enabling works have commenced in order to prepare the space. The enabling works involve the stripping out of old services and the waterproofing of the road above the space; located within block 2 within the basement area, ideally suited for this type of equipment. This project is likely to commence within the next few months.

Cardiac Catheter suite – Like the MRI project we are working with three suppliers in terms of feasibility, location and logistics. Again this is a highly complex project which required careful consideration, particularly in terms of adjacent services. This is also likely to be a ‘turn-key’ project. An ideally suited location has yet to be finally agreed and confirmed. It is hoped that this project will also commence before the end of the financial year.

GHA Board Report – July 2019-September 2019

Dialysis Expansion – due to pressures in terms of the number of patients requiring dialysis we have been asked to look into the expansion of the department. This is another challenging project which will require several critical stages in order to enable the continuation of the service throughout the works.

Phase 1 – installation of new water treatment plant capable of expansion to up to 25 stations.

95% complete

Phase 2 – the creation of a temporary dialysis suite for use during the expansion of the existing space. This also involves the moving of infection control and the dialysis staff facilities to create the space.

40% complete

Phase 3 – removal of the existing water treatment plant and the creation of an expanded ward.

0% complete

Phase 4 – removal of the temporary ward and the creation of an isolation room, along with dialysis staff facilities.

0% complete

Dialysis Associated Works –

Works were required within MIU to create temporary space for Infection Control and Dr Simon Lines, who needed to move out of Dialysis during the expansion works.

A new space for Infection Control will be created in the old relative’s room at the entrance to ICU. The relatives room has now been relocated, so this works is ready to commence.

Whilst doing these works we created more space for visiting consultants.

100% complete 29

GHA Board Report – July 2019-September 2019

A&E Containment/Isolation Suite – We have commenced the building of a new containment suite within A&E, this is for the isolation of patients with suspected contagious diseases. This is designed to cope with all possible scenarios providing negative pressure isolation for up to CAT4 level. Although not built in accordance with HBN4 it provides a negative pressure suite of rooms with the capability of controlled containment pre diagnosis.

Oxygen generator/concentrator – in light of Brexit we have investigated and subsequently procured a new oxygen generation plant. This system will supplement the existing VIE and reserve backup systems and provide an ‘island mode’ capability such that we would not be relient on liquid oxygen deliveries from Spain. Although we will need to retain the current bulk storage and rotate the storage capacity this new plant will provide much greater resilience in terms of our oxygen supplies (Bulk Storage Only; although we would also have the capability to fill cylinders, due to legal implications this would only be used in extreme emergencies).

GHA Board Report – July 2019-September 2019

2 x 6.1 x 4.2 m

Cabins Housing

Duplex Oxygen Generators

Projects – Presently at Design / Feasibility stages -

 SBH A+E Phase 3, Ambulance entrance Canopy – These works are required to ensure protection of patients and the department from severe weather, particularly westerly and south westerly storms.

This project has been presented to planning and is in the final stages of approval prior to tender and financing.

SBH Sponsored Patients – Redevelopment of unit, to improve patient access and data protection. Currently on hold pending funds and a permanent location.

Electrical and Mechanical Resilience - We continue to look at ways of increasing resilience for our electrical infrastructure; particularly in terms of UPS provision and the protection of vital electrical components. To this end have been looking at installing a 80 KVA UPS as part normal lifecycle replacement within one of our critical server rooms.

6 No. additional Solar PV arrays - to reduce our demand on the grid, our carbon footprint, and reduce our revenue spend on electricity. A business case has been prepared within the previous quarter and submitted to both the ministries for health and the environment.

GHA Board Report – July 2019-September 2019

Block 1 Podium Overhang Extension – Planning permission was submitted and approved in 2015 to fill in the overhang between podium level and first floor level. Various options are being considered for this extension but it is likely to become a permanent solution for Ambulance Services. It is likely that this project will commence before the end of this year.

Expansion and relocation of ENT department – this is planned to go within the new extension of block 4 on the 1st floor, this will house all ENT services including adults and children.

Please also see Appendix 1 which includes a full list of projects either in progress or under investigation this quarter.

GHA Board Report – July 2019-September 2019

Appendix 1 –

Capital Projects - 2019 -20

No Project Principal Contractor Status Cost Estimates Notes Risk Status Official opening for phased occupation 16th July - dental at least one clinic by 12th August, all services operational by 1st week in 1 CPCC / CHC CASAIS September 2 CHC Canopy WSRM priced by CASAIS Construction phase, internal fitout, due for 3 PCCC CASAIS handover on 16th September PCCC Main Entrance B4 Extension - shell and 4 core CASAIS 80% Complete PCCC Main Entrance B4 Extension - Ground 5 floor entrance lobby reception and link CASAIS 30% Complete Cabins and infrastructure in place 100% PCCC Main Entrance B4 Extension - Move of Complete, waiting for the transfer of records B4 records to enable pharmacy move - cabins once GDPR signed off by ministry - estimated Move of records is likely to 6 between B1 and 3 CASAIS plus Balat move date 9th August take 5-7 days PCCC Main Entrance B4 2nd floor - Installation of HVAC Services to new PCCC 7 building CASAIS 10% Complete PCCC Main Entrance B4 2nd floor - Build new 8 pharmacy B4 2nd floor CASAIS 0% Complete PCCC Main Entrance B4 2nd floor - Strip out of old pharmacy and complete ground floor 9 (registration, lymphodema, ulcer clinic CASAIS 0% Complete PCCC Main Entrance B4 1st floor extension 10 shell and core - Build new ENT department Tender 90% Complete

PCCC Main Entrance B4 1st floor extension - 1st floor moves to establish orthopedics 11 department Tender and In- house 0% Complete CASAIS looking at providing a design 12 Old PCC the ICC reinstatement build cost With CASAIS 13 New Laminar Flow Theatre 5 IAC, Midland Med, Weiss, In-house 70% Complete - HVAC 30% Complete Dialysis - Expansion of dialysis to 10 couches - pre works - 8 bed temp unit plus new PPVL New RO plant room 100% complete, temp 8 14 Isolation room, New RO plant room Fresenius, IAC and In-house bed bay and isolation room 30% complete 15 Containment Suite within A&E IAC, Site Trading and In-house 90% complete Managed Service and Turn-key 16 MRI project with Phillips Waiting for instruction Managed Service and Turn-key 17 Cardiac Cath Suite project - NOT Appointed Waiting for instruction 18 Detox Unit Design stage Waiting for instruction Move of Cardiac Rehab to enable the Detox unit - possible location basement of Atlantic 19 suites Design stage Waiting for instruction Bioquell PODs installation within ITU 100% Isolation Rooms - within ITU, Victoria and Complete, budget required for additional true 20 John Bioquell - In-house isolation (PPVL) In design stage and planning with 21 New Ambulance Centre WSRM Waiting for instruction 22 Oxygen Generator Order placed - due on site November 19 BREXIT ITEM Tender stage - Principal Contractor enable construction and appoint lift 23 Garden disabled lift contractor Waiting for instruction Design stage with Gov appointed 24 Stem Cell Cryo unit - rear garden Architects Waiting for instruction WSRM to be part of the ambulance 25 Chemo unit expansion centre extension to B1 overhang Waiting for instruction In design stage - issued drawings to 26 Chemo/Pharmacy Aseptic Suite Envair as a Turn-Key Waiting for instruction Recommendations received from PATHOLOGY - BSL3 for microbiology lab: BSL3 Nicholas Cortes - need to look at Waiting for initial design and specification for TD to prepare Spec and 27 cabinet refresh or BSL3 room & lab redesign HVAC and installation as a whole tendering Tender Pathology Lifecycle replacement of main 28 AHU Obtain a 'Flat Woods' quote 29 Coaling Island expansion works In-house Waiting for instruction With Steris - looking at a managed 30 CSSD Expansion service OFF SITE Waiting for instruction 31 Sponsored Patients expansion Waiting for instruction 32 Expansion of Opthomology Waiting for instruction 33 Move of IT to building 9 Waiting for instruction 34 Expansion of Endoscopy Waiting for instruction Resiliance in light of the Generators currently tested OFF LOAD need to recent UK network failure 35 Generator Testing 100% site load Versetec ( Emergency Generators) test them monthly ON LOAD and NHS generator failures 36 A+E Canopy Tendered - Site Trading and JBS 37 A+E Ambulance Bay Works H&S Kenneth internal Quote Waiting for instruction

Respectuflly Submitted

Tony Dolding MARU MSc, MIHEEM 33

GHA Board Report – July 2019-September 2019

5.4 Director of Nursing Services

Ambulance

Emergency Ambulance Deployments - July 2019 – September 2019

Month Total Average per day

July 491 16

August 518 17 September 491 16

Main Zone Deployments

Month Jul Aug Sep Total

Gib Port 10 10 10 30

North Area 63 62 59 184

Eastside Area 18 20 21 59

Westside Area 173 191 143 507

South District 93 115 122 330

Upper Town 31 25 28 84 Town Area 99 116 116 331

Frontier/Airport 14 12 4 30

Nature Reserve 10 4 6 20

Gib Dock 0 0 0 0

Maritime 0 2 0 2

GHA Board Report – July 2019-September 2019

Ambulance Routine Transfers Operations

Summary of Patient taken for Scans and or Transfers to Spain - July 2019 - September 2019

Destination July August September

Algeciras 75 82 94

Benalmadena 1 3 4 (Xanit)

Cadiz 0 0 1 Gibraltar 31 13 19

La Linea 3 8 2

Malaga 33 17 3

Sevilla 0 0 0

Platelets 6 1 0

Marbella 6 8 5

Totals 155 132 128

Summary of Local Patient Transfers - July 2019 – September 2019

Month Total Average per day

July 381 18

August 429 19

September 363 16

GHA Board Report – July 2019-September 2019

Breast Care

Clinical/Patient Care:  218 Patients have been seen in breast clinic in this quarter  108 New patients referred via HIS to Breast Clinic  4 New patients diagnosed primary/secondary breast cancer  90 patient contact (patient telephone calls/appointments /visits) SOPD/Ward  3 Lymphedema patient appointments + admin/ ordering garments  5 Prosthesis fitting clinic patient appointments  12 Wound care +seroma care appointments  6 Home visits  10 Patients referred with Family History concern; Questionnaire + IBIS software calculation-outcome letter and patient information posted and/or referral for additional breast screening  5 Patients seen by CNSPam Estella deemed ‘high risk’, in line with the to IBIS calculation

On-going Education CPD/Teaching/Training:  CNS Estella Online Post Graduate Diploma in oncology (Newcastle University)  Breast examination and Client Communication Course Jarvis Centre UK Dec 2019 1 week CNS Christine Gill (cancelled May 2019)

Policies/Clinical meetings:  Attendance at weekly Breast radiology MDT  Attendance at weekly Oncology MDT  Weekly patient updates with Breast consultant  Attendance Oncology Clinical Governance meetings organized by Cancer Services coordinator

Innovations:  GHA Breast Cancer Register to track patient’s pathway and follow-up.  At printers - Patient information booklet - GHA Breast Clinic Discharge Following 5 year follow-up for breast cancer.  At printers Patient information GHA Breast Cancer Related Lymphedema  Breast Cancer Family History Service

Palliative Care

Total of New Referrals to GHA Palliative Specialist Nurses: 31 in this quarter Total Nurse Specialist consults: 174 (Inpatients: 158/ Home visits: 10/ Oncology appointments: 6) Hospital deaths with specialist input: 24 Home deaths with specialist input: 2 Total: 26

GHA Board Report – July 2019-September 2019

Infection Control

Continued daily surveillance of MRSA, CRE & ESBL across SBH. All patients are returning from tertiary Hospitals are screened for MRSA and CRE, as a matter of routine.

Mandatory 6 monthly screening undertaken on long stay wards and positive patients decolonised. Raising infection control protocols and proactively manage high risk areas.

1st July- Known CRE+ positive patient taken to theatre from A&E with # NOF. Theatre staff followed Infection Control practitioner instructions to declutter theatres and remove all none essentials. Staff followed IC theatre flowchart and post op cleaning and fogging arranged.

30th July – CRE+ (urine & rectal swab) patient identified in VMW. Patient isolated and contact tracing undertaken on all patients on that ward. Through contact tracing 3 other patient were identified as positive. Decision to cohort 3 + patients was taken after discussion with consultant Microbiologist due to lack of side-room availability. Staffs were briefed on importance of using contact precautions PPE and Hand hygiene. Contacts monitored throughout August as per PHE guidance tool –no further contacts found to be positive.

On-going training:

Mandatory Training for sessions;

 9th July & 10th July –GHA staff.  19th July – Bleak House –Dr Giraldi staff.  21st August –Bleak House-Dr Giraldi staff.  6th Sept- GHA staff.  13th Sept – Bleak House- Dr Giraldi staff.

Attended meetings in line with Clinical Governance

 Infection Control Committee meetings (Monthly)  Nursing Clinical Governance meeting (Monthly).  Public Health Meetings (weekly).  Influenza Campaign meetings (on going with all stakeholders).

Attended 6 Hats thinking Seminar.

Monthly BBV clinic held twice a month with visiting consultant Dr Garcia. Reviewing HIV patients and Hep C patient to see if require treatment. Following plan of CRE + patient in community, currently homeless with no fixed abode. Third and fourth screen undertaken both- Negative. Patient currently in Ocean views.

GHA Board Report – July 2019-September 2019

Environmental re-audits for Cochrane and Calpe ward were also undertaken in this quarter:

 Calpe ward- 61% Minimal Compliance initial audit- Re-audited-.4th July -95% Compliance.

 Cochrane Ward- 61% Minimal Compliance initial audit- Re-audited- 4th July- 92% Compliance

 Rainbow ward-81% Partial Compliance second audit- 3rd Re audited 9th July -93% Compliance.

 John ward – 79% Partial Compliance initial audit- Re audit- 24th July-96% Compliance.

 A&E- 80% Partial Compliance initial audit- Re audit 24th July 91% Compliance

Environmental audits carried out on floor 1,2.3 & Jewish Home & Theatre.

 Floor 1- 99%Compliance  Floor 2- 97% Compliance  Floor 3- 97% Compliance  Jewish Home- 97% Compliance  Theatre audit - undertaken- findings still pending to be reported.

August- Influenza Campaign (On going) - Preparations for 2019/2020 GHA Influenza Campaign. Weekly meeting to discuss strategy for delivery of Influenza vaccine with stakeholders in order to obtain accurate data on uptake from staff and community. This year’s campaign will be consisting of offering;

Adjuvanted trivalent flu vaccine (aTIV) - This is licensed for people aged 65 years and over and is the vaccine recommended by the Joint Committee on Vaccination and Immunisations (JCVI) for this age group.

Quadrivalent vaccine (QIV) - This is recommended for children aged from 6 months to 2 years and in adults from 18 years to less than 65 years of age who are at increased risk from flu because of a long term health condition.

Fluenz Tetra Nasal spray suspension Vaccine (live attenuated nasal) – will be offered for the first time in Gibraltar to children aged from 2, 3 & 4 years old will be offered.

2nd August- IT developed programme to raise ALERTs of micro resistant organisms on HIS so patient highlighted in case needed admission or went for surgery. All MRSA colonisers, C.Difficile and CRE imputed on alert system.

6th August – Infection Control Practitioners underwent “FIT testing course” to become accredited to train staff. Fit testing we were assessed and trained using

GHA Board Report – July 2019-September 2019

Draegar masks which have various sizes and our accreditation only covers the use of these masks.

7th August- Stock control of personal protective equipment undertaken to establish numbers remaining and whether fit for purpose. PPE count;

Sizes Suits with Suits without Goggles Overshoes Boots boots XXXL - 89 XXL 50 66 XL 75 64 L 69 28 M 66 35 S 72 42

TOTAL 332 324 535 350 GRAND 656 TOTAL

 Fluid repellent coverall suits, anti-fog goggles and over shoe covers that we bought for the Ebola crisis in 2014.  Organisation needs to consider changing our FFP3 respirators as the one we use now (Meddop) is one size only and we cannot offer an alternative size if this does not fit.

20th August- Endoscopy final rinse water issues raised as in breach of best guidance and placing patients at risk, as not being undertaken for last 8-9 months. No clear definition of whose role and responsibility it was to undertake water sampling. Same has now been addressed and agreement reached by Endoscopy team, Public analyst and Clinical Engineering who have agreed to undertake water sampling every Wednesday morning. Endoscopy to submit SOP for water sampling to present to ICC and governance.

28th August - Mattress audit undertaken by ICP and practice development nurse and TALLY representative. (Audit report attached). Same to be presented at next ICC meeting.

11th August - BAL from patient positive for MTB – Rifampacin sensitive.

PHx – Admitted via A&E 26/06/2019 – poly trauma call after falling from a window. Intubated in A&E – CT scan performed and there was changes? cavitation on Chest. Patient conveyed to Quiron Malaga via ambulance with escorts. 6 weeks in Malaga and repatriated back to SBH. Patient with trachy and ventilated; respiratory precautions and isolation maintained since admission Quiron Malaga was contacted via email from Dr Nick Cortes (06/08/2019) alerted Quiron Palmones to contact Malaga to alert staff of result. Contact tracing was carried out on all staff who undertook airway management.

GHA Board Report – July 2019-September 2019

All staff deemed at risk were Mantoux tested- results all negative and BCG will be offered.

21st 25th Sept- Infection Prevention Society annual conference- Both Infection Control Practitioners attended IPS conference in Liverpool for insight into updated practices and equipment.

Practice Development

Mandatory training session attendance (medial, nursing and AHPs)

Infection control: 35 Moving and handling: 24 Blood transfusion safety: 21 Pain and dementia: 21 Palliative hour revision sessions: 13 Paediatric masterclass: 27 3-day paediatric update: 25 Paediatric medical emergency training: 14 Adult medical emergency training: 159 Talley group pressure area care: 13 EPALS: 12

Moving and handling: 8 members of staff, 1x OT, 1x physio, 1x MET, 5x nurses successful completed a 5 day moving and handling course enabling them to deliver in moving and handling training throughout the GHA and provide support at clinical level.

Nursing assistants: All the April 2019 nursing assistant intake allocated to SBH & PCC have successfully completed their 12-week induction programme and competency booklet.

Tracheostomy care: Online modules from tracheostomy.org.uk have been made available to all staff alongside clinical support from PD and the weekly altered airway round. Mattress audit: The first hospital mattress audit was completed with assistance from the Talley group

Stoma care: Access to online training course arranged via stoma specialist nurse Post on-line completion practical sessions on going

On-going projects:

Working groups established for documentation and fluid administration

GHA Board Report – July 2019-September 2019

Resuscitation Officer

Basic Life Support (BLS) is a mandatory requirement for all grades of clinical staff. In the period July to September 2019 159 staff have attended a 2 hour Adult BLS course with a further 14 the Paediatric BLS one. EventBrite is being used so that staff may book these sessions more easily.

7 doctors and five nurses successfully completed the European Paediatric Life Support Course (Resuscitation Council UK) with 3 of the medical staff chosen to become Instructors in the future.

One Paramedic attended the Generic Instructors Course run by the Resuscitation Council UK in order to instruct on the Advanced Life Support Course in Gibraltar.

A simulated cardiac arrest was run in the Children’s Health Centre to identify areas of risk and training needs.

ENT Consultant, Speech & Language Therapy, Matron, Practice Development Sister and Resuscitation Officer have initiated a weekly Altered Airway Round where inpatients with a tracheostomy are reviewed and plans of care updated as appropriate.

The Resuscitation Officer has a regular involvement in multidisciplinary team meetings (MDT) in order to give advice on resuscitation decisions and treatment escalation planning.

The Resuscitation Officer sees both patients and relatives to discuss Do Not Attempt Resuscitation (DNACPR) decisions.

DNACPR policy has been reviewed and will be considered by the Resuscitation Committee in October.

Audit and debrief of emergency calls/ cardiac arrests is now a routine occurrence.

Emergency equipment has been reviewed and the Emergency Trolleys will be updated in October.

Ambulance Patient Record Forms are now reviewed whenever a patient has suffered an out of hospital cardiac arrest or the A&E department has been alerted prior to arrival that the patient is seriously unwell.

GHA Board Report – July 2019-September 2019

Matrons

‘Safeguarding Adults’ training on basic awareness continues to be a success with GHA staff attending on a monthly basis. Furthermore, it has been included in the Mandatory training policy that all staff must attend and will updated on a three-year cycle.

The Matrons conducted a Ward Accreditation Audit in line with Essence of Care benchmarks. The Audit has shown that the Hospital Wards did not meet the relevant benchmarks. As a result, an action plan has been drawn up with the Ward Managers to ensure all Wards can work towards becoming compliant. Measuring the quality of the Nursing Care that is being delivered means that we can cross reference this with evidence based practices as patient safety and quality assurance is the one of the GHA’s core principles.

The Matrons continue to be part of the Datix Incident Grading group. Datix is a patient safety quality improvement tool that produces incident reporting and risk management for the GHA. Datix is widely used by staff, including clinicians, to report all clinical incidents. Staff are trained in using Datix as part of the GHA’s Mandatory Training policy. The system can be used to manage incident reporting, risk registers, complaints, claims, requests for information, safety alerts and benchmark against standards in the UK.

The Matrons continue to attend the Maternity Clinical Risk monthly meetings. A case is reviewed and statistics are benchmarked against UK.

Matron Orfila-Gonzalez organised the Workplace and Wellbeing interviews. A visiting team from UK met up with Nurses to discuss their experience and career journey with the GHA. This is part of the GHA’s Values strategy.

Charge Nurse Salcedo has put together the Pressure Ulcer Steering group. All pressure ulcer reports are investigated and measures are put in place to minimise the risk of the patient developing any further injuries. The group will be presenting a new pressure ulcer prevention tool to aid the nurses in assessing patients and identifying those patients at risk.

Matron Orfila-Gonzalez has written a new Transfer and Escort of Patients Policy. The purpose of this policy is to provide a standard GHA-wide procedure that will ensure the safe transfer of all patients internally between departments. The level of escort provision that is necessary for effective risk management and the care of patients is also defined in this policy.

In conjunction with the in-patient Falls policy, Charge Nurse Salcedo is establishing a falls pathway for A&E with the Community Occupation Therapists primarily focusing on patients who have fallen, people who are a falls risk and are being discharged from A&E. This initiative will safeguard this group of patients which are currently falling through the gaps.

GHA Board Report – July 2019-September 2019

Matron Orfila-Gonzalez attended the Pressure Area Workshop delivered by the Talley rep. A mattress audit was conducted following this workshop. Matron Ag Salcedo teamed up with Lea Fountain, Communications Manager, to deliver the Values workshops. This initiative will be part of the GHA communications strategy.

The Difficult Airway round was established following the rise in patients with tracheostomies within SBH. This was set up by Dr Danino (ENT Consultant) with an MDT approach. The airway rounds are conducted on a weekly basis with Dr Danino, Matrons, Practice Development Nurse, Resus Officer, Physios, Dietitians, Occupational Therapists and the Speech and Language team. All patients are assessed with their parent team and an action plan is conveyed to all members of the MDT.

The Matrons set up the quarterly DNS, PD, Matrons and Ward Managers meeting. All Quality Improvement projects are discussed in this meeting. The Ward Managers use this forum to discuss any concerns or initiatives that they have.

Charge Nurse Salcedo has been working alongside the Hospital Social workers and Rainbow Ward Sister to devise a document called ‘Passports’ for those patients who are unable to communicate effectively their medical conditions. These passports are then uploaded onto Symphony in A&E to ensure the nursing team are informed.

On-going projects:

 Majax Planning Group – reviewing the clinical guidelines  NOF pathway – introduction and monitoring compliance  Domestic Abuse Policy – multi agency project  PCC relocation – working in partnership with the PCC to ensure a smooth transition takes place when the PCC move into their new site  Palliative care workshop – patient pathway  Antibiotic Stewardship Group – introduce Point of care testing at the PCC  Electronic document management system (EDMS)  NEWS 2 – launch NEWS 2 and MEOWS  Outreach and NEWS team  Language Line – telephone interpretation awareness  Holistic nursing care project – remove task orientated care on the wards.  Self-discharge Policy  Consent Policy  Record keeping / documentation and Kardex project  NMP – scope of practice  Quality Improvement initiate in theatres – KPI, case reviews and audits

GHA Board Report – July 2019-September 2019

Medical Directorate

Victoria Ward:

 July 2019 seen Victoria undergo the re-audit of the Environmental audit report, the score reached was 97% and therefore, fully compliant (as per IPS scoring system) with most aspects of the Environmental Audit. The team can be congratulated in their compliance to the GHA uniform & bare below the elbow policy. They continue to work extremely well in raising the ward’s compliance by ensuring all staff working in Victoria as well as visitors are conscious of the GHA’s infection control policy, the foodborne infection Policy, with displayed instructions for relatives/patients and staff on how to label and date food as well as the acceptable use of the kitchen area.

Victoria Ward Activity:

July August September Admissions 2 13 11 Discharges 3 6 7 RIP 0 4 5 New Staff * 0 0 0

Maternity:

Between July and September an increase has been noted to the admission rate into the EPAU: A total of 12 admissions, all early miscarriages were delivered by medical management. One 33-week gestation of twins & a pneumothorax neonate transferred to Cadiz.

Study days utilised by the Midwives between July and September:

Course Staff Attendees Adult safeguarding 2 NLS resit 2 Management master classes 3

 K2: all midwives have access and is on-going

No new initiations have been commenced in the unit, although the team continue to await Ministerial consideration to consider an effort to improve current services.

GHA Board Report – July 2019-September 2019

Maternal Statistics:

July August September Total Total % Total Total Tota Total % % l Total births 31 100 39 100 36 100 Male 15 48.4 23 59.0 19 52.7 Female 16 51.6 16 41.0 17 47.2 Premature <37 2 6.5 2 5.1 0 0 IOL 5 16.1 9 23.1 10 3.6 Epidural 3 9.7 3 7.7 4 11.1 EM LSCS 3 9.7 0 0.0 1 2.7 URG LSCS 1 3.2 2 5.1 1 2.7 EL LSCS 4 12.9 5 12.8 6 16.6 Total LSCS 8 25.8 8 20.5 12 33.3 Ventouse 2 6.5 2 5.1 0 0 Forceps 2 6.5 2 5.1 2 5.5 Breech LSCS 1 3.2 1 2.6 0 0 Episiotomy on SVD 3 9.7 3 7.7 3 8.3 Episiotomy total 7 22.6 6 15.4 5 13.8 PET/PIH 2 6.5 2 5.1 1 2.7 Diabetes 1 3.2 2 5.1 2 5.5 PPH <1500mls 5 16.1 10 25.6 0 0 PPH >1500mls 1 3.2 0 0.0 3 8.3 MROP 1 3.2 1 2.6 1 2.7 SVD 19 61.3 27 69.2 25 69.4 Transfer to Spain in Utero 0 0 1 2.7 Transfer to Spain 0 0 1 2.7 Neonates SCBU Admissions 2 0 2 5.5

GHA Board Report – July 2019-September 2019

Paediatric Services – Rainbow:

Between July & September has seen staff move on to new horizons – Paediatric Diabetic Nurse Specialist Cynthia Maoko transferred her services the new Child Health Centre.

Rainbow Ward Statistics:

July August September Total Paed Medical 44 46 38 128 HDU 1:1 2 3 5 10 ENT 6 7 2 15 Dental 8 5 5 18 Ortho 2 7 9 18 Eye 0 0 0 0 Surgical 9 3 5 17 Adult Patients 16+ 4 2 0 6 Total Admissions 75 73 64 212 Ward Attenders ** 72 68 89 229 Total Ward Activity 147 141 153 441 (Admissions & Ward Attenders) SCBU 1:1 0 0 1 1 Clinics * 191 164 129 484 Total Departmental Activity (Total 338 305 282 925 Ward Activity & Total Clinic Activity)

Course Staff Attendees EPALS 3 Paediatric 3 day course 4+1 Bank RSCN Paediatric 1 day course 3 Management master class 2

* Clinics: Rapid access, Learning, Multi-disciplinary, Diabetes, Down Syndrome, Visiting Consultants: Neurologist, Endocrine, Psychiatrist, Genetics (15-90 minute slots) All admin completed by nursing staff (notes / results / issuing appointments etc.)

** Ward Attenders: Skin prick testing, events monitoring, surgical pre-assessment, Dr review (emergency GP / urgent follow-up), jaundice screen, bloods, wound checks, procedures under sedation, injection administration, MCUG catheterisations, replacing NGT / gastrostomy devices, flushing of CVAD, ECG’s (15-90 minute slots) 47

GHA Board Report – July 2019-September 2019

Accident & Emergency:

Attendances:

 Total Number of attendances in A&E: 8129. Admissions:  General Medicine - 353.  Gynaecology - 3.  General Surgery - 140.  Orthopaedic – 44.  ENT – 6.  Paediatrics – 79.  Anaesthetics – 0. Referrals to other specialities.  Trauma Clinic – 246  Mental health – 83 Courses:

DATE NAME COURSE 10/07/2019 Raquel Gavira Blood Transfusion Update 10/07/2019 Jordanna Clinton Workforce and Wellbeing Strategy Meeting 10/07/2019 Calynn McLaren Workforce and Wellbeing Strategy Meeting 25/07/2019 Laura Valcarcel Blood Transfusion Update 18/07/2019 Justine Rovegno Triage course Joanna Muñoz Ferran Cañadillas 02/09/2019 – 04/09/2019 KJ Salcedo Paediatric Course Tara Ferrary Jordanna Clinton Stephanie Stevens Maria Rodriguez 05/09/2019 Sean Whitfield Paediatric Course Rafael Leon Calynn McLaren Cristina Vega Elaine Ferro Nuclear Response KJ Salcedo Training Natalie Dignam Nurse Prescriber 23-24/09/2019 Stacie Rothwell EPALS Fernando Lara

GHA Board Report – July 2019-September 2019

Staffing:

 KJ Salcedo was acting Matron finishing period on 18/08/2019, during that time A&E Acting S/R post covered by: o Justine Rovegno finished acting period on 06/07/2019. o Jordanna Clinton started acting on 07/07/2019 finished 18/08/2019.  Maternity: o Maria Cantador was on Maternity Leave and on 04/08/2019 started Unpaid Leave o Maryanne Dunham and Cherylanne Sheppard have been on Unpaid Leave after Maternity. o Melissa Lucas started Maternity leave on 25/08/2019  1 Staff Nurse covering Night Sister as an Acting Post.  1 Enrolled Nurse transferred to St. Anne’s School on 08/09/2019. Events support.

A&E nursing and Medical staff has supported several events (Monkey Rocks Festival, Andrea Bocelli Concert, Island Games, GFA matches) with Polyclinics in situ.

Developments:

 Pending finish of Isolation Area (Observation Bay 2)

Surgical Directorate

Dudley Toomey Ward

There continues to be no cancellations of elective surgery as a result of our bed management practices which continue to have a positive impact on scheduled elective surgery, patient-flow and the discharge process.

The staff continues to identify critically ill patients early on and transfer to CCU in a timely manner. Changes in working practices and skill mix have moved us away from task-orientated care towards a more patient-centred care.

With regards to succession planning, we currently have 5 senior staff nurses acting as Sister / Charge nurse on a rotational basis, as part of a development programme to replace SR Sandra Dean and Caron Fennelly. They have all attended a series of leadership and management master classes developed by Dr Jacqueline Leigh from the University of Salford in conjunction with the Gibraltar School of Health Studies. Interviews for the Sister/Charge Nurse post will take place this month.

Captain Murchison Ward

The rehabilitation/stroke unit is not only alleviating beds within the acute setting but is also providing safe and timely discharges. The staff rotation system together with the training and development program continues to ensure staff develops the necessary skills to care for our stroke and rehabilitation patients. The Ward 49

GHA Board Report – July 2019-September 2019

Managers have also commenced the much awaited appraisal system/performance management in order to meet individual staff personal/professional development needs.

Operating Theatres

Major works continue underway to create a new trauma theatre. This will create more opportunities to increase the throughput of surgical cases and conduct two orthopaedic lists simultaneously.

Day Surgery Unit

The Day Surgery Unit continues to undertake on average 90% – 95% of all elective patients requiring surgical procedures of all sub specialities with even more complex surgical procedures. There are on-going discussions to incorporate elective cardiology patients through a streamlined DSU Care Pathway.

Dialysis . Phase two of major works is complete with the Dialysis expansion project. Following careful consideration to risk and infection control management, patients continue to receive their treatments in the department with adjustments to the patient flow/traffic through the department. The extension of opening times for Dialysis provides greater flexibility to patients who require dialysis treatments. This has resulted in service users having better balance between their clinical needs and their daily lives. Stoma Care Nurse specialis

Stoma Services Our Stoma Nurse Specialist has filled a much needed gap in the service provisions for our patients with stomas.

The current services the stoma team highlighted as providing: • Pre assessment citing & education (before elective stoma surgery) ensuring that the stoma is placed in the best area • Post-operative follow ups- teaching patients how to apply their bag, education on diet, exercise and going back to work • Daily Stoma management (new appliances, tissue viability) • Stoma complications (e.g formation of hernia, refashioning of wound) • Check-ups (daily, weekly month and yearly reviews) • Home visits sometimes (elderly or immobile) • Education to GHA Staff

Out patients Orthopaedics

A spinal clinic initiative aimed to reduce the waiting times has commenced. These clinics are aimed to eliminate waiting times for those patients that are awaiting spinal review. waiting

GHA Board Report – July 2019-September 2019

Endoscopy Unit

Recent statistics collated by Mr Aidan Lane (SRN, NP, Jag accredited Endoscopist) demonstrate a sharp increase in the throughput of patients undergoing endoscopic procedures.

Outpatient Services

The recent data collated illustrates that the repatriation of services has resulted in an increase in service demand and patient throughput in the outpatient clinic setting over the last three years.

GHA Board Report – July 2019-September 2019

Bed Management

Below you can find a snapshot of how the Nurse Management team are capturing the daily Bed Census.

GHA Board Report – July 2019-September 2019

The Clinical Nurse Managers have been actively involved with our EHT Officers in the re-design of the electronic Bed Management Programme to tie in with the Hospital at night initiative and documentation in line with Clinical Governance standards.

PCC

Child Health Nurses

The Child Health Team Have Successfully moved to the Child Health Centre and are running all clinics. The have been preparing for the new Influenza initiative which commences late October for 2-4 year olds. Additionally: • They have introduced an 18-month assessment • Had a further BCG catch up • Developed a new system on E-MIS • Organised appointments on E-MIS for all Reception children

District Nurses

Dementia Conference held on September 30th: Rebecca Parslow Ann Marie Hemmi Selena Victory

GHA Board Report – July 2019-September 2019

Dermatology

CNS Nuria Campos has completed all of her written assignments and is waiting for the external boards final marking for the prescribing programme. She has presented the matrons with her Intended Scope of Practice for the first year. Staff Nurse Theresa Cardoso is the successful candidate for the succession planning for CNS Castro who finishes early 2020. Two weeks ago Theresa Cardoso commenced 2 days a week training in Dermatology as part of the succession planning. Waiting to be released full time. EN Ilyanna Ramirez Has passed her competency training for both patch testing and Cryotherapy for benign lesions already diagnosed by a member of the team. She runs small clinics alongside the CNS clinics. She is also running patch test clinics as required.

Well person unit

Staff Nurse Laura Netto continues with her on-going training as part of a Professional Developmental Programme to equip her to become a specialised sexual health nurse.

Following the successful completion of the STIF foundation course and BASHH Sexual Health Course, she is still waiting to see if she will be considered to enrol on a non-medical prescribing course in March 2020. SN Netto has successfully passed her summative assessment in cryotherapy for Condylomata Acuminate and is now fully assessed NP Vannan is still pending her formative assessment. We are currently in the process of recruiting a Specialist Sexual Health Nurse that will commence on January 13th.

Community Midwife

CM Naomi Gross continues covering post-natal clinics for patients discharged from the Maternity ward and into the community. She continues to work closely with the clinical Governance team to develop care pathways for expecting mothers who are suffering from domestic violence, drug and in rehabilitation programme. The aim is to provide protection and support through their pregnancy.

At present she is working on a business case to improve and expand maternal and baby care services at the GHA. The proposal is in the early stages and costing is being prepared for the estimates.

Approved Mental Health Professionals

The Mental Health professionals continue to work hard to implement the New Mental Health Act and The Mental Capacity act and Lasting power of attorney within the GHA and ECA, under their new roles as Approved Mental Health Professionals ( AMHP-Best Interest Assessors (BIA.) Danny and Paul have been carrying out intensive Mentoring of the new recruits additional to their normal workload. 54

GHA Board Report – July 2019-September 2019

The new recruits have integrated well to the team. They are in the process of developing a New Mental Health strategy which is currently in the early stages working alongside The Clinical lead in Psychiatry, Dr Ashim Bettadapura The team are working closely with the 3 newly appointed Liaison Officers to close the gaps in waiting times and assist in early intervention. The team continue to manage the 24 HOUR Mental Health Crisis line. Also they have a new drop in service in clinic hours where they provide advice, awareness and guidance on how to access Mental Health services within the GHA.

Nurse Practitioners

Lynn Angove and Elizabeth Borges attended a prescribing up-date at SBH in April, and Elizabeth Borges attended the annual Respiratory Conference at Telford in September.

CNM Suzanne Romero

CNM Romero is currently working together with other stakeholders, co-ordinating the project management for the new adult and children PCC. The Inauguration will be held on October 7th. The Nursing strategy 2020-20-22 has been submitted.

July '19 August '19 September’ 19

Child Health Dept Attended Dr's Clinic 22 24 38 Health Visitors/Nurse team New born hearing test 35 38 36 Social services attendances 78 104 130 Primary Visits 28 28 33 HV Assessments @ 8 weeks 27 29 21 HV Assessment 8 months 22 29 31 13 month development assessment 17 14 48 No children seen in school 0 0 0 Eneuresis Clinic 0 1 3 weighing clinic, feeding advice 378 392 621 seasonal flu vaccine 0 0 0 pre-school assessments 0 0 24 Referral to clinic 10 0 0 HPV Vaccines 2 7 15 Immunisation Clinic 399 394 519 Total 1,018 1,060 1,519 55

GHA Board Report – July 2019-September 2019

Cardiar Rehab. Nurse Attended Ward visits 5 5 9 phase 2 screening clinics 12 8 12 Pre and post clinics 15 11 8 Cardiac rehab programme 78 78 90 self help group 412 367 432 community 0 0 0 Annual Reviews 4 6 4 Referrals 15 9 14 Drop in 35 40 63 Total 576 524 632

Diabetic specialist Nurse Attended ADRC 109 109 204 Other (coment/default) email 229 115 139 Diabetic Review 259 259 275 Diabetic ward patients 122 122 68 Diabetic ward/ antenatal patients 35 22 62 Diabetes education 10 10 32 Glucose 22 0 1 admin repeat prescritption 31 145 34 Emergencies 0 0 0 CDM 4 0 8 Tel consults 118 118 160 Total 939 900 1100

Nurse Practitioner Attended Smoking Cessation clinic review 16 16 17 Smoking Cessation clinic new 65 67 18 Asthma Clinic/COPD 55 25 27 Driving medical 37 33 60 Released on the day 168 131 0 Spirometry 16 13 16 Review clinic 35 0 41 Cervical Smears 176 130 193 on the day clinic 168 0 0 Telephone Consultation 17 130 0 TOTAL 753 545 372

GHA Board Report – July 2019-September 2019

Practice Nurses Attended Phlebotomy Clinic 1,354 1,100 1,224 Ear Syringing Clinic 86 77 66 ABPM Clinic 15 12 18 ECG Clinic 116 90 125 House calls 185 154 151 General wound 234 188 223 Lymphoedema clinic 22 25 42 Leg Ulcer Clinic 165 216 176 Doppler Clinic 25 37 14 Blood pressure check 39 5 26 Hypertension clinic 315 312 310 Blood Glucose 21 19 38 Admission to A/E 23 40 40 Telephone results 251 212 199 Triage 784 809 81 injection clinic 396 459 475 urinalysis 182 140 681 Nebulisers 11 9 12 oral med 13 10 8 Tel sick note line consults 424 333 323 Flu vaccines/PNEMOCCOCCAL 4 2 3 Referrals from hospital 0 1 0 Referrals from A/E 1 2 1 Referrals from consultants 8 4 15 Discharge from wound clinic 24 0 27 Total 4,698 4,256 3,055

Dermatology team Attended Cryotherapy 323 390 397 light therapy 2 8 7 photos clinic 0 0 0 Clinical Meeting 2 42 0 Dermatology CDM 91 97 94 Ancillary see and treat 14 24 17 Telephone consultations 8 17 14 Minor-ops Hyfrecator 10 2 1 Patch testing 2 0 12 Dermoscopy 33 14 23 MDT meeting 52 19 42 Email consultation 1 1 3

GHA Board Report – July 2019-September 2019 wound care (New) 41 19 21 Nursing Administration (New) 60 19 22 Blood pressure check (New) - 0 1 Preganancy Test (New) 2 1 1 TOTAL 641 634 655

AMHP Attended Average calls 81 77 69 Mental Health Act assessment 11 12 16 Mental Capacity Act Assessment 11 8 9 A/E GHA Assessment 2 0 2 Police Assessments 9 9 6 Walk in - PCC 43 42 29 AHMP community visit 10 10 8 AHMP community clinic 0 0 0 Government offices/public services 4 4 5 MDT/Follow ups: SBH 0 8 10 MDT/Follow ups: Prison 3 2 3 MDT/Follow ups: Police 8 7 7 MDT/Follow ups: CMHT 7 12 9 MDT/Follow ups: Ocean Views 11 9 11 MDT/Follow ups: Social services 5 7 5 MDT/Follow ups: ERS,Hillside,BV 4 12 9 TOTAL 207 219 198

District Nursing Team Attended Diabetic/Insulin 104 124 100 Dressings 290 254 242 Injections 62 20 33 Visits- Support/Monitoring 91 95 95 Terminal Care 38 10 18 Catheter Care 2 8 2 INR and Blood Samples 77 96 84 Admissions 13 6 12 Discharges 6 3 4 Support/Palliative 96 45 65 ear syringing 0 0 0

GHA Board Report – July 2019-September 2019

Flu Vaccinations 0 0 0 Total 779 661 655

Well person clinic Attended Early pregnancy assessment 42 49 41 post natal checks 5 0 14 Health Check screen 37 30 30 Sexual Health Nurse 100 108 104 Reproductive health doctor 70 51 25 Worklist 24 84 80 TOTAL 278 322 294 DNA Sexual Health Clinic - 16 16 DNA Reproductive Health Doctor - 6 2 DNA Health check screen - 6 7 DNA Community Midwife - 5 2 Total - 33 27

Grand Monthly Total 9,889 9,121 8,480

Respectfully submitted Ms Sandra Gracia Director for Nursing Services

GHA Board Report – July 2019-September 2019

5.5 Human Resources

This quarter marks the department’s first, since relocating to new premises, located at Suite 7.3.3 Europort.

Throughout this quarter, the department has held successful interview boards across the spectrum of healthcare professional grades, most notably within nursing and administrative support grades.

Nursing has seen successful interviews in specialist areas such as Mental Health, Dialysis, Paediatrics and Practice Development. Whereas within administrative grades, 14 Junior GHA Clerks have been appointed throughout GHA areas, following successful interviews, held in July. Furthermore, successful interviews were also carried out within diverse departments, which offer specialist support, such as Information Management & Technology and Catering.

Within Medical Grades, successful interviews have been carried out in junior grades within General Surgery and Orthopaedic & Trauma, as well as for the position of Clinical Fellow in Anaesthesia and that of Consultant Psychiatrist. This quarter has also seen notable medical appointments as Clinical Fellows in Anaesthesia, Registered Medical Officers in General Surgery and in Orthopaedic & Trauma, as well as the GHA’s first Consultant Cardiologist, which marks another substantial step in the GHA’s repatriation of services.

Within Allied Health Professionals, successful interviews have been carried out, also aligned with the GHA’s repatriation of Chemotherapy Services and selective appointments have been made within Physiotherapy, Psychology, Counselling and Speech and Language Therapy.

This quarter has also seen promotions within the GHA’s Ambulance Service, where 3 Ambulance Care Assistants have been promoted to Emergency Medical Technicians and within Information Management & Technology, where 2 Senior Electrical Health Technicians have been promoted to Information and Communications Technology Manager and Information Systems Manager, respectively.

The GHA’s 2019 Staff Awards were also ably delivered by our department during this quarter, where after painstaking and meticulous planning, the award ceremony, which took place at The Rock Hotel, was a huge success, joyfully attended and celebrated by GHA staff from all professional groups.

GHA Board Report – July 2019-September 2019

The department’s heartfelt congratulations go out to all award winners, nominees and long service award recipients, for their sterling professionalism and deserved recognition.

Respectfully submitted

Mr Christian Sanchez Human Resources Manager

GHA Board Report – July 2019-September 2019

5.6 Hospital Services

This board report covers the 3rd Quarter period of the 2019 from July to Sept and the 2nd Quarter of the Financial Year 2019-2020

During this third quarter we have continued with on-going improvements and refurbishment programs within St. Bernard’s Hospital and worked on contingency plans for Brexit expected on 31st October 2019. The teams have also been actively working with the commissioning of the new Children’s Health Centre and new Primary Care Centre. The Medical Records Library and Release of Records Office was successfully relocated during September to the temporary facility within the St. Bernard’s courtyard. This allowed works to continue for the new Primary Care and preparation of the area for the new Pharmacy and Palliative Departments. St Bernard’s Hospital now has two new external lifts that has improved access for visitors and staff with mobility issues in particular. The lifts together with the escalators enable visitors and staff to ascend from the pavement level to the podium level of the hospital. This is part of on-going improvements in accessibility infrastructure.

The teams continue to work on the refurbishment of the General Stores Department and the creation of satellite stores in the main wards as part of wider stock management programme in conjunction with Guys & St. Thomas. Completion of waterproofing works at St. Bernard’s Hospital still on track to be completed by end of this 3rd quarter as delays were experienced has to attend to other priority projects. Other improvements and infrastructure developments for clinical services that are currently being undertaken include the complete refurbishment and expansion of the Dialysis Unit, the creation of a 5th Theatre and new Infection Control Unit. The team is also assisting with following major projects; New Primary Care Centre, Children’s Primary Care Centre, the new Ambulance Services Facilities, A&E Isolation Suite, expansion of Dialysis Services, an additional Operating Theatre, and installation of single patient pods in Critical Care Unit, Hospital Pharmacy and refurbishment of CMHT amongst others. The team continues to be involved in the feasibility studies for MRI, Catheterisation Laboratory and Aseptic Suite services to be introduced at St. Bernard’s Hospital. The digitization of the current medical records is planned to commence in the 1st Qtr of 2020. This will be a major project within the digital transformation programme to move towards a paperless document management environment.

GHA Board Report – July 2019-September 2019

A new oxygen generation plant has been procured and preliminary civil works will begin in October in preparation for the arrival of the unit towards the end of this year.

Respectfully submitted,

Mr D Figueredo General Manager – Hospital Services

GHA Board Report – July 2019-September 2019

5.7 Primary Care Services

1. Executive summary

This quarter has again been dominated by the opening of the new Children’s Centre on 17 July 2019, and the planning and preparation for the inauguration of the new Primary Care Centre in October 2019. a. Note Scanning Project

Micro Business Systems (MBS) continue to scan the primary care paper notes and to provide a member of MBS staff to the PCC, dedicated solely to uploading files. To date over 93,000 pdf files have been uploaded on to EMIS. b. Staffing Issues

This quarter has also been notable for the significant fluidity in staffing levels, in particular with the GPs. Maternity leave and dedication of time to key projects such as the Substance Misuse service, have been managed well, with no disruption in the availability of GP appointments.

Interviews were held on 1 and 2 August 2019 for GHA junior clerks to replace those successful in their applications for promotion to AA, and to replace transfer requests. In total 6 GHA junior clerks were employed and have already started working with a great deal of success in their roles.

Mrs Soraya Galliano, typist, retired after over forty years of service to the Health Authority. c. Children’s Centre

Three clerks have been allocated to provide administrative support to the Children’s Centre.

Five GPs with an expressed interest in Paediatrics carry out clinics one day a week in the new Children’s Centre, working closely with a Consultant Paediatrician, to deliver more specialised type care for children. The relevant GPs are Dr Thoppil, Dr Flores, Dr Martyn, Dr Montero and Dr Perez. d. Patient Registration with an Individual GP

The second phase of this project is on-going. To date almost 14000 patients are now registered to the GP of their choice.

GHA Board Report – July 2019-September 2019

2. Sub Departments and Key Activities Statistics

(a) Training

The following courses have been attended by clinical and administration staff over the last quarter:

 Safeguarding Children  Understanding Autism  Child Sexual Exploitation  Managing Challenging Behaviour in Individuals in Autism  Rebound Therapy for Children with Complex Needs.  Dementia  Paediatric Intermediate Life Support (ILS)  Adult ILS  Palliative Care Workshop and Course  Paediatrics Course

Three Administrative Assistants, appointed in June, attended a Customer Care Course in September.

(b) Key Activities Statistics

Services Jul 19 Aug 19 Sept 19 Totals Calls to 20052441 Offered 11044 9876 10604 31524 Answered 5305 4992 4848 15145 Terminated 1369 1288 1247 3904 Abandoned 4370 3596 4509 12475 Administration Repeat Prescription 569 548 520 1637 Results phone calls 251 212 199 662 Audiology Attended 173 160 175 508 Did Not Attend 19 11 1 31 (6%) Dental Attended 1827 1447 1707 4981 Did Not Attend 470 301 547 1318 (26%) Derm Cons + GP Attended 184 365 360 909 Did Not Attend 27 32 0 59 (6%) Dermatology Nurse Attended 654 634 655 1943 Did Not Attend 85 43 0 128 (6%) Diabetic Nurse Attended 1136 1088 1216 3440 Did Not Attend 151 65 4 220 (6%)

GHA Board Report – July 2019-September 2019

Dieticians Attended 141 141 135 417 Did Not Attend 42 38 34 114 (27%) General Practitioners Attended 9170 8690 9495 27355 Did Not Attend 434 297 177 908 (3%) Advance Appointments 282 425 579 1286 Evening Clinic 309 253 358 920 See and Treat Clinic 1 698 425 198 1321 See and Treat Clinic 2 359 671 524 1554 Under 16's 936 872 1047 2855 (10% of all attendances) Home Visits 218 193 208 619 Avge Wait Time (mins) 9.49s 9.52s 10.12s 9.43s Telephone Sick Notes 424 333 323 1080 Unused appointments 1390 1193 1003 3586 (daily average) (45) (38) (33) (39) Nurse Practitioners Attended 585 457 612 1654 Did Not Attend 68 32 10 110 (7%) Occupational Therapy Attended 111 70 36 227 Did Not Attend 0 0 0 0 Comm Physiotherapy Attended 208 197 138 543 Did Not Attend 5 8 14 27 (5%) Speech & Language Attended 120 191 202 513 Did Not Attend 33 45 19 97 (18%) Women Health Attended 337 353 337 1027 Did Not Attend 47 20 6 73 (7%) Well Person Unit Attended 137 88 70 295 Did Not Attend 19 9 6 34 (11%)

Respectfully submitted

Dr Krishna Rawal Deputy Medical Director

GHA Board Report – July 2019-September 2019

5.8 Mental Health Services

Community Mental Health Team (CMHT) – Patient contact/staff activity The Mission of our Community Mental Health Team is to focus not only upon people's deficits and disabilities (an illness perspective), but also upon their strengths, capacities and aspirations (a recovery perspective). Services and supports thus aim to enhance a person's ability to develop a positive identity, to frame the illness experience, to self‐manage the illness, and to pursue personally valued social roles.

Historically the CMHT was geared towards providing a service to people with an acute, severe or chronic mental illness Most have been ill for a lengthy period of time. As the focus has shifted from mental illness to mental health, this had led to a much greater demand from people who are having complex life problems affecting their mental health. This poses greater challenges for the team as within this context there is no magic pill to sort out these issues. A noticible improvement and one that is having an impact in dealing with some of these complex cases has been the closer working relationships and greater participation from Housing, RGP ,Social Services, Employment Services and NGOs.

The period in question has seen a stabilisation of the service with new roles clearly defined for our new Psychiatrists. The addition of a part time child and Adolescent Psychiatrist has also helped in filling a big gap and the continued development of the A+E liason service has taken some of the pressure from the team

Data below presents service user contacts with nursing staff both at Coaling Island and within the community setings (this could be in town, service user home or club house facility).

July August September

Depot Clinic 55 54 56

Seen/ Contact in 365 366 364 CMHT

Domiciliary visits 283 230 291

outreach 6 2 2

Depot Clinic 709 652 713

GHA Board Report – July 2019-September 2019

PATIENTS SEEN IN CLINICS

JULY 2019 SEEN DNA Doctor Ruiz 32 9 Doctor Segovia 38 10 Doctor Bettadapura 27 24 Doctor Stavron (GYM) 12 1

AUGUST 2019 SEEN DNA Doctor Ruiz 31 13 Doctor Segovia 39 7 Doctor Bettadapura 41 8 Doctor Stavron (GYM) 16 3

SEPTEMBER 2019 SEEN DNA Doctor Ruiz 20 10 Doctor Segovia 27 7 Doctor Bettadapura 41 8 Doctor Quinlan 32 11 Doctor Stavron (GYM) 23 2

Data reflects month by month clinic appointments held in Coaling Island and Gibraltar Young Minds ‘GYM’, (our Child and Adolescent Mental health service CAMHS)

Psychology therapy offered with the mental health services.

Our team of psychologists, and counsellors manage a wide range of psychological issues referred to the department these are triaged, and appointed the relevant support, people referred with mild depression, anxiety, stress and bereavement issues are allocated for counselling, whereas the more complex presentations or those requiring specific cognitive or neuropsychological assessment would be allocated to one of the Clinical Psychologists.

The psychology services including Gibraltar Young Minds ‘GYM’, which is our Child and Adolescent Mental health service (CAMHS), are currently in the process of being reconfigured and developed further by our Clinical lead who manages both our psychiatrist and psychology teams. The aim is to ensure we are providing the best possible service to all. As a direct result of these major developments and

GHA Board Report – July 2019-September 2019 modifications, no figures or data can be presented for this quarter, but will be included in the next board report.

In-patient data and activities

Horizon - Sky / Dawn - Flats / Sunshine / ARC

Below data presents admission, diagnosis, mode of admission and mental health status. The majority of admissions for this quarter show increase in male admissions compared to the last report, with all appeals being.

GHA Board Report – July 2019-September 2019

Section / appeals / outcomes July to September 2019

Horizon / SKY

Month Number of Number of Gender Outcome patients appeals / admitted Section on section

July 2019 8 2 M:1 - F:1 Appeal withdrawn- F

Appeal won -M

August 2019 3 1 F:1 Discharged

September2019 11 4 M:4 1 x Discharged

3 x Pending outcomes

GHA Board Report – July 2019-September 2019

Rehab activities on the ward

Staff currently in Dawn ward offer support to service users attending particular groups run by the ARC such as our weekly beach outings. A number of service users require 1:1 nursing support due to physical disabilities as well as mental health issues. This has seen a remarkable improvement in service users confidence and ability to mobilise , interact and have time away from the unit.

Staff also offer extra 1:1 support in ARC bases activities to service users who otherwise would not be able to attend due to current mental health issues. On the ward staff encourage a number of ward based actiives such as colouring, art sessions, puzzle groups, board games and 1:1 time with names nurses.

Elderly care services - Sunshine ward

Sunshine ward

Sunshine ward continues to place great emphasis on both the physical and mental health care needs of all our service users

Activities within the ward

Sunshine ward continues to provide a numebr of ward based activites such as Arts and crafts, interactive board games, cognitive stimulation activites – crosswaords, word puzzles and a baking group. To add this a number of patients in particular attend the weekly beach outing facilitated by the ARC, but supported by a staff members each week. This enables service users to socialise not only with fellow service users in hospital but also the general public.

The Pawsative Pets Activity (PPA) program, where 2 members of the public bring their small dogs in to the unit to meet and interact with service users in the garden area. This has continued to have a very positive response from service users and their families who were all consulted with prior to this initatives implementation. Currently the dogs (Ant and Dec) visit us weekly, staff continue to maintain a record of service user response (positive and negative) and although this was initally implemented for our elderly service users there is a hope that this will be introduced to a wider audience at some stage in the future.

GHA Board Report – July 2019-September 2019

Chiropody appointments

Ward July Aug Sept Horizon/Sky 4 5 2 Dawn 5 3 5 Sunshine 2 4 7

Monthly sessional attendance by patients to the ARC.

The Activity and Rehabilitation Centre continues to provide activities and support to the patients at Ocean Views. The groups and activities are well attended, and many patients are supported with their activities in the community in preparation for their discharge home. Continued support is offered to patients that require Occupational Therapy input in the community. Weekly beach outings have continued throughout the summer months, many of the patients from the wards appreciate the opportunity to go to the beach. The highlighted period has seen the introduction of two new groups. ‘Breakfast Club’ has been offered to the patients in the rehabilitation flats. This offers them to opportunity to come to the OT department, make their own breakfasts, and discuss with the staff their plans for the day and week, helping to structure their days and clarify what they need to do, to progress forward with their recovery. ‘Make your own Lunch session’ has also been offered to patients on the wards. This gives them to opportunity to use the OT kitchen to make their own lunch. This helps them in many different levels, from encouraging them to organise their days, to think about what they are going to cook and shopping for the ingredients. At the same time, it is a good opportunity to assess their mental health, their concentration and functioning skills.

Monthly sessional attendance by patients to the ARC.

MONTH HORIZON DAWN SUNSHINE COMMUNITY TOTAL WARD WARD WARD Jul. 2019 24 227 50 174 475 Aug. 2019 14 184 44 119 361 Sept. 2019 18 203 60 107 388

GHA Board Report – July 2019-September 2019

Liaison Services

This period has seen the introduction of Mental Health liaison support, this offers a service to St. Bernard’s hospital 7 days a week from 8am until 8pm. Providing prompt assessment and treatment to individuals in A & E and on medical wards. They provide advice and support to medical staff, improving integrated care of physical and mental health problems, emotional support to patients on medical wards, interim support to patients who may be waiting to be seen by psychology/counselling /drug and alcohol services. Although still at its embryonic stages we continue to expand and develop the service.

Supported Housing

The Mental Health Services have a two bedroom apartment which is regularly used as part of a rehabilitation program for some of our patients who are slowly reintegrating back to the community, depending on the needs this can be either staffed 24/7 or supported by the community teams. On occasion these premises have also been used as an overflow area when in bed crisis. During the stipulated period work has been on going to look at ways of expanding staffed sheltered Mental health accommodation in Gibraltar.

Respectfully submitted

Chris Chipolina – Unit General Manager

GHA Board Report – July 2019-September 2019

5.9 Information, Management and Technology

Information Technology

Server Programme

We continue to work on the installation and configuration of a new, highly available, virtualization platform which will facilitate additional medical systems. As the GHA continues to expand on services provided, and introduces computer systems that aid the clinicians in providing the optimum patient care, these systems will be hosted on this new hardware and will ensure that they are available 24/7 365 days a year.

IT Security

All Systems implemented up to and including the third quarter of 2019, and mentioned in previous board reports, are functioning well and succeeding in protecting the GHA networks and systems from all manner of possible security attacks and breaches. We continue to working with the Cyber Security Compliance Division at the GRA to make sure the GHA is compliant with the NIS Directive (Network and Information Security Directive). The IT Team actively monitors system performance, and also security issues globally, to make sure that we are as protected as we possibly can be.

Information Systems Projects

Patient Flags on HIS

Patient Flags system has been created and is now being used by infection control to mark patients with conditions relevant to them. Clinicians get a warning if they select one of those patients on HIS.

Theatre Module on HIS

New feature for notes on the Theatres module has been developed. This allows surgeons to create surgical procedure notes electronically.

Outpatient Waiting Lists on HIS

Will be used to manage waiting lists for outpatient clinics. Links to the Frontdesk appointment system so that patients can be removed from the waiting list once they receive their appointment. Designed to help secondary care move to a 6-week partial booking system.

GHA Board Report – July 2019-September 2019

Medical Investigation Unit, Breast Clinic Referral and Sponsored Patient Episode modules on HIS

This update has brought them in line with the HIS new look and the new patient search toolbar. This update means that all HIS modules that clinicians regularly use are in the new format, ensuring a more consistent and more efficient user interface.

Respectfully Submitted,

Aaron Asquez Director of Information Management & Technology (Ag)

GHA Board Report – July 2019-September 2019

5.10 School of Health Studies

The new academic year has commenced and the School of Health Studies continues its close working relationship with a range of staff within the GHA and continues to provide programmes of study, educational activity and training events to support service delivery. Our multidisciplinary study days and accredited learning modules offered at various academic levels continue, we remain responsive to wide range of needs across the organisation.

A QCF level two vocational course for our Care Assistants has been now been developed in conjunction with our service colleagues and Pearson Edexcel with an anticipated Autumn commencement date. Our suite of units for the QCF level three has been revised and will be offered to a range of multidisciplinary staff. We are awaiting external validation for these courses.

All students undertaking the BSc (Hons) Operating Department Practitioners programme have all successfully passed the first progression point of the course. They are all progressing; they are now undertaking a range of clinical placements. The External Examiner’s report is complimentary of the provision.

The Non-Medical Prescribing students (nurses) have all successfully completed the first part of the programme. The second part of the programme is due for completion October 2019.

The SHS in conjunction with the Care Agency and St George’s University of London and Kingston University London continue to host the BA (Hons) Social Work programme. We are pleased to announce that all ten students on this programme have progressed into the second year. The annual Executive Management Group has met for the first time and has discussed preparations for the second year of the programme. The External Examiner’s report is complimentary of the provision.

The undergraduate nursing programmes are running as expected. The first year cohort has successfully progressed into the second year and the second year cohort has progressed into the third and final year of their programme of study. The external examiner’s visit over the summer and subsequent reports are very complimentary of our provision and clinical and academic support that is provided to the students. Both cohorts assisted with Island Games supporting activities. The GHA-SHS-UoG Working Group, meetings continue, overseeing the transition of the 2020 Nursing Degree programme into the University of Gibraltar. We have seconded of member of the SHS staff to the University of Gibraltar.

The MSc Leadership and Health students continue to focus on the dissertation stage of the programme. We have recruited ten students to the MSc Leadership Care and Justice programme who have commenced their study in September 2019.

GHA Board Report – July 2019-September 2019

The SHS in conjunction with University of Salford continues to offer a range of master classes in leadership and management; full day non-credit bearing sessions (six in total). Throughout, these classes have been very well subscribed to and have received very good evaluations.

Our own staff continues to receive on-going support for their personal and professional development. We continue to publish and present at conferences.

Respectfully submitted

Prof. Ian Peate

GHA Board Report – July 2019-September 2019