Agenda item

Report of the Associate Director of Nursing (Patient Safety and Governance)

The Associate Director of Nursing (Patient Safety and Governance) submitted a report (previously circulated) to update Members on the progress of improvements against the agreed priorities for 2018/19 during the period April 2018 to September 2018 outlined in the Quality Accounts briefing (previously circulated).

 

Members were advised that the Quality Accounts for County Durham and Darlington NHS Foundation Trusts include indicators set by the Department for Health and local priorities agreed through consultation with staff, governors, local improvement networks, commissioners, health Scrutiny Committees and other key stakeholders.

 

Patient Safety

 

Patient Falls

 

Members were pleased to note that target work continues to reduce falls across the organisations with the introduction of the Trust Falls Strategy and the multi agency action plan has been mapped out and agreed.

 

Members discussed the non-slip red sock scheme on each ward to avoid patient falls and the sensory training to enhance staff perception of risk of falls.

 

Care of Patients with Dementia

 

Members welcomed the continued development and roll out of the dementia pathway alongside monitoring of patients with dementia and that all work streams were in place and being delivered.

 

Healthcare Associated Infections

 

MRSA - Members noted that there had been two cases reported since April 2018 and although within the national average, Members confirmed the threshold of zero tolerance.

 

Clostridium Difficile (C-Diff) – the target for C-Diff is 18 and the trust had reported 13 cases since April 2018.  Members questioned the role of the Infectious Disease Control Team within the community and their work in Care Homes and with the General Practitioners.

 

Members also noted that the Trust were fully compliant with maintenance of Venous thromboembolism risk assessment.

 

Pressure Ulcers

 

Members noted that the Trust was striving for zero tolerance and that there had been one avoidance grade 3/4 pressure ulcers reported in acute service and three cases reported in community services. Members also noted that there was good reporting of skin damage.

 

Discharge Summaries

 

Members noted that the Trust target was 95 per cent completion within 24 hours and were making good progress towards this target with a task and finish group now reviewing quality of discharge summaries and a deep dive audit had been undertaken regarding quality of discharge summaries.

 

Rate of Patient Safety Incidents Resulting in Severe Injury or Death

 

National Reporting and Learning System (NRLS) shows the Trust remains within the 50 percentile of reporters of incidents however it was the aim of the Trust to reach 75^th percentile.

 

Members discussed Near Miss reporting in place within the Trust.

 

Improve Management of Patients Identified with Sepsis

 

Members were pleased to note the roll out of the sepsis screening tool via electronic system and the implementation of the sepsis care bundle across the Trust.  Screening was compliant however Members were disappointed to learn that the time to administer antibiotics required further improvement.

 

Local Safety Standards for Invasive Procedures (LoCSSIPS)

 

The Trust had formed a LoCSSIP Implementation and Governance Group bringing together Members of the Corporate Governance body with Care Group representatives and the Trust was on tract and recognised as good practice by NHS Improvement.

 

Experience

 

Nutrition and Hydration in Hospital

 

Members welcomed the aim to promote optimal nutrition for all patients with the introduction of a finger food menu and following the pilot to move the nutritional assessment tool to Nervecentre to improve quality metrics for nutrition for all patients, this was now ready to roll out. 

 

The Associate Director of Nursing offered Members an invitation to see the Nervecentre in operation.

 

End of Life and Palliative Care

 

Members noted that the Trust now had an effective strategy and measures for palliative care and that there were no concerns and the End of Life Steering Group was now embedded to ensure the agenda moves forward.

 

The Chair referred to a Review Group established by this Committee to look at End of Life Care for those with Dementia.

 

Responsiveness to Patients Personal Needs

 

Members noted that the results were not yet available.

 

Percentage of Staff who would recommend the trust to family and friends needing care

 

Members noted staff survey results were not yet available.

 

Percentage of staff experience harassment, bullying or abuse from staff in the last 12 months

 

Members noted staff survey results were not yet available.

 

Percentage of staff believing that the Trust provides equal opportunities for career progression or promotion

 

Members noted staff survey results were not yet available.

 

Friends and Family Test

 

Members noted an increase in the number of staff recommending the Trust to friends and family from 62 per cent to 66 per cent although there had been a slight increase in those not recommending from 11 per to 13 per cent.

 

Clinical Effectiveness

 

Hospital Standardised Mortality Ratio (HSMR) and Standardised Hospital Mortality Index (SHMi)

 

Members were advised that this priority was as expected.  Weekly mortality reviews were held led by the Medical Director and any actions highlighted were monitored through Care Group Integrated Governance Reports.  The Trust continues to benchmark both locally and nationally with organisations of a similar size and type.

 

Reduction in 28 day readmissions to hospital

 

Members noted that the goal was set at 7 per cent but the Trust were now at around 12 per cent readmission with a realisation that the goal had been set too low. Information will be submitted to the national database so that national benchmarking can continue and results will be monitored via Trust Board using the performance scorecard and any remedial actions measured and monitored through the performance framework.

 

Reduce the Length of Time to Assess and Treat Patients in Accident and Emergency Department

 

Members were informed that at Quarter 1 performance was 91.2 per cent compared to Quarter 2 at 89.1 per cent.  Members were advised that there were a number of projects in operation to improve current performance including a change to shift patterns at times of surge and Ambulatory Rapid Access Teams.

 

Patient Reported Outcome Measures

 

Members noted that the results were not yet available.

 

Maternity Standards

 

Members were pleased to note that compliance with key indicators was on track and priorities of ‘Each Baby Counts’ policy was in place.

 

The Trust continue to monitor for maintenance and improvement in relation to breastfeeding, smoking in pregnancy and 12 week booking; and to monitor actions taken from gap analysis regarding ‘Saving Babies Lives’ report.

 

Paediatric Care

 

Members noted that the Trust continue to develop more direct and personal relationships with individuals within Primary and Secondary care by building on the work already undertaken.

 

Excellence Reporting

 

Members were advised of this new indicator to ensure that CDDFT continues to embed learning from excellence into standard culture and practice through excellence reporting.

 

Members also discussed the four Never Events that had been reported since April 2018 and the actions taken.

 

RESOLVED – (a) That the report be noted.

 

(b) That the Associate Director of Nursing (Patient Safety and Governance) be thanked for her informative report.