Annual Quality Report 2018/19 Annual Quality Report Annual Quality Report 2018/19 Chief Executive Foreword Messages from Chief Executive - DRAFT I am delighted to introduce the 7th Annual Quality Report for Southern Trust, which highlights some of the fantastic work which is underway across the Southern area and includes the key quality indicators against which we are measured. The launch of Quality 2020 by the Department of Health in 2011 described quality as excellence in safety; effectiveness and ensuring a patient & client focus on the work which we do. During 2018/19 we’ve continued to ensure we focus on all these aspects of quality and indeed how we further embed improvement of services across the Southern area. We’ve been delighted to receive transformation funding in 2018/19 to support us to develop new and innovative ways to transform how we deliver care. This will support us to address the increasing demands which we face across both acute and community services and look forward to seeing the impact that these initiatives make to local lives. We have achieved much in 2018/19 including the opening of the Direct Assessment Unit at Daisy Hill Hospital, also the opening of ‘Willows’, Maternity Bereavement Suite at Craigavon Area Hospital and relatives rooms for intensive care patients at our acute hospitals. Indeed, we are delighted that again in 2018/19 our acute hospital network was recognised at the CHKS UK Top Hospitals Awards. I would like to acknowledge the dedication of all our staff to their patients and clients, how they strive to continually improve their services and in many cases excel in delivering high, quality care on a local, regional and national basis. Shane Devlin i Annual Quality Report 2018/19 Table of Contents Chief Executive Foreword ..................................................................... i Theme 1: TRANSFORMING THE CULTURE ........................................ 1 1.1 Introduction ....................................................................................................... 2 1.2 Patient and Client Experience ........................................................................... 8 1.3 Complaints and Compliments ......................................................................... 23 1.4 Adverse Incidents / Serious Adverse Incidents (SAIs) .................................... 34 1.5 Quality Improvement ....................................................................................... 36 Theme 2: STRENGTHENING THE WORKFORCE .............................. 43 2.1 Introduction ..................................................................................................... 44 2.2 Looking After Your Staff .................................................................................. 46 2.3 Induction ......................................................................................................... 50 2.4 Corporate Mandatory Training ........................................................................ 50 2.5 Leadership Programmes ................................................................................. 61 2.6 Supervision, Coaching and Mentoring ............................................................ 64 2.7 Staff Achievements ......................................................................................... 67 2.8 Staff training .................................................................................................... 77 2.9 Revalidation of Medical and Nursing Staff ...................................................... 79 2.10 Staff Absenteeism ......................................................................................... 83 2.11 Reducing the Risk of Hyponatraemia ............................................................ 85 Theme 3: MEASURING THE IMPROVEMENT .................................... 86 3.1 Reducing Healthcare Associated Infection...................................................... 87 3.2 Safer Surgery / WHO Checklist ....................................................................... 92 3.3 Maternity Collaborative ................................................................................... 94 3.4 Paediatric Collaborative .................................................................................. 97 3.5 Falls .............................................................................................................. 120 3.6 Pressure Sores ............................................................................................. 122 3.7 Venous Thromboembolism (VTE) ................................................................. 124 3.8 Medicines Management ................................................................................ 125 3.9 Cardiac Arrest Rates ..................................................................................... 132 Theme 4: RAISING THE STANDARDS ............................................. 133 ii Annual Quality Report 2018/19 4.1 Standardised Mortality Ratio ......................................................................... 134 4.2 Emergency Re-admission Rate .................................................................... 135 4.3 Emergency Department ................................................................................ 137 4.4 Clinical & Social Care Governance Research ............................................... 143 4.5 Nice Guidelines ............................................................................................. 145 4.6 National Audits .............................................................................................. 147 4.7 Cancer Targets ............................................................................................. 152 4.8 Enhancing Social Work and Social Care Services ........................................ 154 Theme 5: INTEGRATING THE CARE ............................................... 158 5.1 Community Care ........................................................................................... 159 5.2 Mental Health ................................................................................................ 164 5.3 Children’s Social Care Services .................................................................... 173 5.4 Adult Social Care Services ............................................................................ 181 5.5 Update on Integrated Care Partnerships....................................................... 183 iii Theme 1: TRANSFORMING THE CULTURE TRANSFORMING Theme 1 THE CULTURE Theme 1: TRANSFORMING THE CULTURE 1.1 Introduction The Department of Health commissioned the Regional HSC Staff Survey in autumn 2015. Some of the findings for Southern Trust were as follows: of staff said they would recommend the Trust as a place to 67% work This is above the national NHS average of 54% of staff said that care of patients is the organisations top 76% priority This is a 15% improvement from the previous survey in 2012 of staff feel satisfied with the quality of work and patient 80% care that they are able to deliver This is above the NHS national average of 76% The Trust continues to implement the Corporate Staff Survey Action Plan which centres on the 5 key themes: Visible Leadership Staff Voice/Engagement Regaining Respect Healthy, Well & Productive Workforce Equipped Workforce Each Directorate, following staff engagement sessions, developed their own Action Plan during 2016/17 to address identified areas. Directorates are currently implementing these action plans locally. Progress during 2018/19 on the Corporate Action Plan against these 5 themes is outlined overleaf:- Page 2 Theme 1: TRANSFORMING THE CULTURE Corporate Action Plan Our Corporate Action Plan covers five key themes. Please see below: 1. VISIBLE LEADERSHIP Link to Overarching Being a great place to work, valuing our people Trust Priority Providing safe, high quality care As part of the implementation of HSC Collective Leadership Strategy the Trust participated in its Phase 1 Actions including:- Establish a core set of HSC values and associated behaviours Develop a framework that outlines the critical collective leadership capabilities needed by all our Achievements people who work in health and social care i.e. during 2018/19 Collective Leadership in Action Framework Designed a system to monitor the outcomes and review the implementation of the collective leadership strategy Embed the collective leadership framework into all leadership development activities Develop a framework that will support and enhance team working in and across the system During 2019 / 2020 the agreed regional HSC values will be launched. The focus of 2019/2020 will be to communicate these values to staff with an on-going commitment to embed these within our organisation and into everything we do. Some of the actions achieved during 2018-2019 will continue into 2019-2020 including embedding a culture of collective leadership which includes rolling Planned Actions out a Culture Assessment survey in spring 2020 to During 2019/20 provide a baseline measurement. Other actions include developing a model for team based working within the Trust and reviewing Management development programmes and training pathways. Page 3 Theme 1: TRANSFORMING THE CULTURE 2. STAFF VOICE / ENGAGEMENT Linking to Overarching Trust Being a great place to work, valuing our people Priority The Trust participated on the Regional Staff Survey Group to undertake another Staff Survey which was completed by mid-April