Agenda item

Presentation by Director of Quality Governance, Tees, Esk and Wear Valleys NHS Foundation Trust

The Director of Quality Governance, Director of Operations, Durham and Darlington and Associate Director of Strategic Planning and Programmes, Tees, Esk and Wear Valley NHS Foundation Trust gave a presentation outlining the progress made on the Quality Account improvement metrics and priorities for 2021/22.

Members were advised that the three quality improvement priorities for 2021/22, Care Planning, Safer Care and Compassionate Care, were supported by 50 actions, 36 of which had been achieved and 14 had not been achieved.

It was reported that Care Planning was a key priority area which was overseen by the Project Management Board; and a number of actions under this priority had been extended to quarter 4 due to staff deployment as a response to COVID-19. Reference was made to the new framework, dialogue; that this would be aligned to the new patient record system, cito that was due to go live in Autumn 2022; and that the work undertaken as part of this priority would be delivered to this timeline.

Members were advised of the work undertaken as part of the Safer Care priority with reference made to the focus on organisational learning including the implementation of patient safety briefings, a learning library containing ‘learning lessons from serious incidents’ and a weekly lessons learned bulletin.

Details were provided of the work being undertaken as part of the patient safety campaign; and Members noted that whilst the family conference was not held due to covid and business continuity pressures, work was undertaken with patients and carers focusing on the serious incident process, with an action plan produced.

In relation to the Compassionate Care priority Members noted that a revised policy for managing informal concerns and complaints was due to go live in quarter 4; and bespoke empathy training had been delivered to the complaints team to help develop an empathetic approach.

The presentation provided information in relation to the nine quality metrics as at 31 December 2021, of which three of were reporting Green, those being Metric 2 - number of incidents of falls (level 3 and above) per 1000 occupied bed days (OBDs) –for inpatients, Metric 4 -  Existing percentage of patients on Care Programme Approach who were followed up within 72 hours after discharge from psychiatric inpatient care and Metric 5 -  Percentage of Quality Account audits

completed; and that six quality metrics were reporting Red.

 In relation to Metric 1- Percentage of patients who report ‘yes, always’ to the question ‘Do you feel safe on the ward?, it was reported that whilst still below the Trust target of 88 per cent, Durham and Darlington were performing better than the Trust overall.

In relation to Metric 2 - Number of incidents of falls (level 3 and above) per 1000 occupied bed days (OBDs) for inpatients, Members noted that this target was being met. It was reported that there had been one Level 3 fall; and Members were informed of a pilot due to begin in mental health services for older people of Circadian Lighting which was designed to reduce stress and falls.

In relation to Metric 3 - Number of incidents of physical intervention/ restraint per 1000 occupied bed days, Members noted that Durham and Darlington’s position was above the target of 19.25 and the reasons for the performance were outlined.

In relation to Metric 6 - Patients occupying a bed over 90 days, Members noted that the target of 61 days or less had not been met and work was being undertaken with mental health services for older people to facilitate discharges.

In relation to Metric 7 – Percentage of patients who reported their overall experience as excellent or good, Metric 8 – Percentage of patients that report that staff treated them with dignity and respect and Metric 9 – Percentage of patients that would recommend our service to friends and family if they needed similar care or treatment, Members noted that whilst the target of 94 per cent had not been met, the metrics were improving and were performing close to the target.

Members were advised that a Quality Programme  Group was in place, and were developing ideas for the 2022/23 priorities for improvement; discussions were ongoing regarding an engagement event to agree the priorities; and details were provided of the timeline for the draft Quality Account document.

Members entered into a discussion regarding the derivation of the targets and acknowledged the Trusts progress against the priorities, in a particularly challenging year.

IT WAS AGREED  – That the Director of Quality Governance, Director of Operations, Durham and Darlington and Associate Director of Strategic Planning and Programmes, Tees, Esk and Wear Valley NHS Foundation Trust be thanked for their informative update.