Quality Report October-December 2015 - Southwark CCG · Chair Dr Jonty Heaversedge Chief Officer Andrew Bland The best possible health outcomes for Southwark people 6 Patient experience

Chair Dr Jonty Heaversedge Chief Officer Andrew Bland

The best possible health outcomes for Southwark people 1

Quality Report

October-December

2015



Contents

Introduction ……………………………………….. 3

Executive summary…………………………….... 4

Quality and Safety Committee…………………. 5

Patient experience……………………………….. 6

Patient safety……………………………………… 8

Clinical effectiveness……………………………. 12

General practice…………………………………. 14

General engagement feedback……………….. 15

Continuing care………………………………….. 16

Quality alerts…………………………………….. 18

Glossary………………………………………….. 23



1. Introduction

1.1 NHS Southwark Clinical Commissioning Group (CCG) is responsible for ensuring commissioned providers consistently deliver safe, high quality, clinically effective services.

1.2 The CCG Quality Report complements the CCG’s Integrated Performance Report by providing local intelligence about quality issues affecting the health economy.

1.3 The CCG Quality Report is informed by contributions from commissioners, practices (via quality alerts), the CQC, Southwark Healthwatch, the South East Commissioning Support Unit and national data collections where relevant.

1.4 The report collates information to give a view on how the CCG’s providers are delivering services for the Southwark population that are clinically effective, safe and give patients a good experience.

1.5 The report has added information about items covered by the Quality and Safety sub-Committee during the last quarter.



2. Executive summary

Issues to highlight in this report include:

Anti-microbial stewardship work being led by the CCG across primary and secondary care

The high number of Never Events (12) which have occurred at Guy’s and St Thomas’ Hospital NHS Foundation Trust (GSTT) since April 2015

Closure of the Camberwell Green care home and associated transition plan for patients

During Q3 the CCG participated in a CQC Thematic Review for end of life care. The CQC highlighted a number of areas of good practice within the initial feedback on the review



Quality and Safety sub-committee Agenda items covered during the quarter include:

Infection control and anti-microbial stewardship

Patient safety and serious incidents

Quality in primary care

Patient experience monitoring

Equality and diversity update

CCG Quality Framework review

Local Incentive Scheme (LIS) & Service Development Improvement Plan progress

London Ambulance Service CQC update Additionally the committee received summary reports from the Clinical Quality Review Group meetings (CQRG) for King’s College Hospital, Guy’s and St Thomas’, South London and the Maudsley, and London Ambulance Service, most of which are held monthly. The minutes of all QSC meetings are reported to the CCG’s Integrated Governance and Performance committee (IGP). Summary reports from the CQRG meetings are also provided to the IGP for information. Highlights

The Committee were alerted to the responsibility the CCG has for anti-microbial stewardship in primary care and requested an audit of high prescribers.

The Committee heard the Public Health team were compiling a business case for resources as they were short of capacity to fulfil their CCG responsibilities regarding infection control

The Committee were updated on serious incidents and patient safety themes with a report that demonstrated how the CCG took assurance beyond numbers. They were assured that the CCG’s main providers had a number of robust forums to discuss and learn from incidents, at which the CCG was well-represented. The QSC Chair had attended the Safer Care Forum at KCH and was impressed by the discussion. It had raised his awareness of catheter associated UTIs and the potential for intervention in primary care to minimise these.

The committee heard about the progress of KCH and GSTT regarding the local incentive schemes (LIS), an in-year alternative to CQUIN. Both Trusts are progressing well. Highlights include the leadership and enthusiasm being demonstrated at KCH for the delivery of the Health Promoting Hospital (HPH) LIS, and the work of the diabetes team at GSTT to deliver and train other departments in collaborative care planning.

Sources: CCG QSC papers



Patient experience Guy’s & St Thomas’ Hospital NHS Foundation Trust (GSTT)

Patient experience was the main agenda item at the December 2015 CQRG. The service Director described a range of ways by which the Trust are canvassing patient opinion in order to improve their experiences

An information pack has been developed for patients and families, the Yellow Badge campaign (“My name is xx”), “You said, we did” posters, and Nurse in Charge armbands have been introduced as a result of patient feedback. In response to noise on the wards at night a sleep pack has been added to the patients’ welcome pack

Discharge information was acknowledged by the Trust to be lacking. A project has been running at the Trust since spring 2015 to improve information on discharge letters for both patients and medics. In October the Trust went through a ‘platinum command’ week to focus on patients awaiting discharge for over 14 days and reasons why.

GSTT has put considerable effort and have made progress regarding the time taken to close complaints though the median of 38 days is still above their internal target of 25 days. This has reduced from a median of 49 days earlier in 2015/16.

South London and the Maudsley NHS Foundation Trust (SLaM)

PALS and Complaints

The Q3 PALS report is consistent with previous quarters where over half of contacts (64%) were requests for information. Going forward as the Trust implements ‘Best Practice for involving people who use our services and their friends, families and carers’ this information will be part of the rich source about the experience of people who use our services, their friends, families and carers. The number of crisis calls received by PALS should fall as a result establishing the new 24 hour Mental Health Support Line. The SLaM PALS team will continue to work closely with the Mental Health Support Line team to ensure good working relationships.

There was an increase in the number of complaints received across the Trust during Q3 with 26 in total. The themes including attitude and behaviour of staff, communication with patients who are deaf or hard of hearing, coordination of care.

Mental Health Older Adults

The Southwark and Lambeth Memory Service (SLMS) have significantly reduced waiting times from GP referral to first appointment from 11 weeks (Q2) to 7 weeks in Q3.

The CCG and Council are undertaking a review of the dementia pathway in Southwark to ensure a streamlined, integrated route from initial detection of symptoms, to diagnosis, post diagnostic support and end of life care. This work involves stakeholders from SLaM, KCH, GSTT, social care, community nursing teams and the voluntary sector with the view to developing a dementia hub in 2017/18.

The MHOAD CAG has highlighted the need to reduce spend across the Trust by 5% (£1.6m). They are proposing a CIP involving transfer of specialist care provision from Ann Moss Way - primarily funded by Southwark - to Greenvale in Lambeth. This will



also generate an in-year 2016/17 QIPP. The CCG will assess current market provision, and the potential to invest into alternative models of care across four boroughs. This may include building capacity of the Care Home Intervention Team and working in CCG-Council partnership with charitable and independent care home providers.

King’s College Hospital NHS Foundation Trust (KCH) Developing Patient Experience information

KCH will provide the CCG with raw data of patient feedback from across the Trust down to departmental level. This is being requested for a three month period whilst the CCG compare analysis methods in order to improve information on patient experience.

Friends and Family Test (FFT) Inpatient (IP)

Both Denmark Hill (DH) and Princess Royal (PRUH) sites continued to achieve the Trust’s targets for Inpatient Friends and Family test (FFT). 95% of patients would recommend DH for IP care, much higher than in November 2014 (61%). 95% of patients would recommend PRUH for IP care, also much higher than November 2014 (63%).

Maternity Birth care setting

KCH (Trust wide) achieved good scores from patients recommending the Trust for birth care (92%) with slightly better performance at DH (97%) compared to PRUH (91%).

There has been an improvement in response rate at KCH Trust wide (36.3%, 10.2% at DH, 90.5% at PRUH) in November. This is higher than GSTT (28.4%) and the England average (23.4%).

Postnatal ward setting

KCH (Trust wide) has a marginally higher number of patients (87%) who would recommend postnatal ward care service to their friends and family if they needed similar care or treatment than compared to GSTT (86%) in M8.

The percentage of patients that would not recommend postnatal ward care at KCH Trust wide has remained at 3% over the last 3 months, lower than GSTT (6%), just above England average of 2%.

Antenatal care setting

The percentage of ante-natal patients ‘Not Recommending’ maternity services at KCH was 12% in October and 13% in November, significantly higher than the London average (1%) and other Shelford group members (0% at GSTT).

This situation is mainly due to the PRUH site (6% in October, 21% in November). The Trust is looking at practice at GSTT and elsewhere to see what lessons can be learned in improving both the recommendation and response rates.

NHS Southwark CCG Complaints

The PALS and Complaints service for CCG directly commissioned services is managed by the South East Commissioning Support Unit (SECSU). The CCG’s Quality Team oversee the service which covers complaints, PALs and MP enquiries. In Q3 19 PALS enquiries and 7 Complaints were recorded and 2 MP enquiries – however only 1 of the 7 complaints was directly related to a CCG commissioned service.

Sources: CQC website, KCH Board papers, CSU Integrated Quality & Performance Report, Southwark CCG Integrated Report, GSTT Integrated performance & Quality report, CQRG Papers, Insight Dashboard, Southwark Healthwatch



Patient safety Guy’s & St Thomas’ Hospital NHS Foundation Trust (GSTT) Serious Incidents (SI) & Never Events

GSTT notified commissioners of a total of 15 SIs in Q3, 6 of these involved Southwark residents (N.B. all SIs occurring at GSTT are managed by NHS Lambeth CCG under lead commissioner arrangements). Of the 15 SIs notified, 5 of these were Never Events which include two incidents of misplaced naso-gastric tube, a retained guidewire, wrong site surgery, and wrong route administration of IV medication. GSTT reported 12 Never Events between April and December 2015 which is of significant concern. Investigations are underway by the Trust to understand how these incidents occurred and the necessary system wide changes required to prevent them happening again.

The CCG Head of Quality and GP Lead for Quality have started attending a senior internal GSTT meeting, the Serious Incident Assurance Panel (SIAP), to get better assurance of the rigour of RCA investigations. Lambeth CCG are holding GSTT to account for an agreed action plan regarding improved incident management.

Concern regarding the number of Never Events, and the time taken to complete all serious incident investigations, has been raised to the highest levels within the Trust. GSTT have engaged a world expert in safer healthcare to advise them on a long-term arrangement.

Pressure Ulcers (PU)

A very comprehensive presentation was given to CQRG by the Lead Tissue Viability Nurse (TVN) who had been influential in promoting zero tolerance and reducing incidences of pressure ulcers. A Zero PU campaign and outreach service provided by GSTT to nursing homes has been very successful; 13 nursing homes across Lambeth and Southwark were noted to have had between 200 and 630 days without a pressure ulcer occurring.

Falls

The CQRG received a presentation from the Falls Team who highlighted a big reduction in falls with harm over the past 3+ years (from 38 to 21 to 11). They noted the Older Persons’ unit had not experienced any falls with harm between April and October 2015 (date of the meeting). Environmental work to minimise risks such as softer flooring, dementia and delirium awareness, posters highlighting “Call don’t fall!” had contributed to this. The Trust acknowledged some falls assessments were late or of inadequate quality however and an audit had shown a gap in training and ownership. A new system has been introduced to counter this.

Hospital follow ups

Some incidents had occurred which showed not all GSTT departments were adhering to the Trust’s policy on list management with the potential that patients could inadvertently be lost from waiting lists. The Trust had done an investigation and are working to rectify the situation by February 2016.

South London and the Maudsley NHS Foundation Trust (SLaM) CQC Inspection

Positive Feedback - The CQC inspection included review of over 70 services by 120 inspectors. Community teams were rated Good overall with some Requires Improvement



against inpatient units. Specialist and acute services - AL1 and Hayworth are working well. There is a specific requirement for improvement of nutrition for this client group and it will be acted upon. Ann Moss Way received positive feedback for noticeable improvements in terms of medication and pharmacy, and compassionate and caring staff.

Areas of concern - The CQC inspection highlighted issues with electronic record keeping (EPJs), risk assessments and staffing issues. Problems were highlighted with the Bethlam and Croydon sites due to staffing and appropriate access to physical health. Deprivation of Liberty Safeguards (DoLS) was raised along with environment and food.

There were issues raised regarding Community MH Team compliance to standards and inpatient services (three acute and specialist care). The MHOAD CAG has been operating with some staff shortages which had influenced the situation, the Home Treatment Team and Care Home Intervention Teams had Team Manager vacancies. The CCG provided funding to recruit an additional Psychiatric Liaison Nurse to support KCH. SLaM is working on a recovery plan to address quality of care and treatment as a result of low staffing levels.

Serious Incidents & Never Events

In total SLaM declared 18 serious incidents during Q3, two of which were for Southwark residents in services which NHS Southwark CCG manages. A further SI was declared for a Southwark resident in a service managed by Specialised Commissioning (NHS England).

One SI notified under the Behavioural & Development Psychiatry (BDP) CAG’s Community Forensic Team was categorised as an Incident threatening organisations ability to continue to deliver an acceptable quality of healthcare services. It was discovered that a patient’s section 3 of the Mental Health Act had lapsed upon transferring a patient onto Psychiatric Intensive Care Unit (PICU), the patient was immediately assessed and placed on section 5 (2), Duty of Candour was fulfilled.

All SIs are reviewed by the CCG’s clinical, service and quality representatives to ensure learning is derived and the Trust make necessary adjustments. Common themes in SIs were also picked up by the CQC inspectors – poor documentation and risk assessments.

King’s College Hospital NHS Foundation Trust Pressure Ulcers

Pressure ulcer prevention was reviewed at the CQRG. Acute incidence of Pressure Ulcers has remained below 1% for the last 5 years which is a very positive achievement. There is a lot of work taking place across the Trust to embed into practice lessons learnt, including supporting clinical teams to rapidly make changes, and to ensure the Tissue Viability Service (TVS) has visual presence at ward rounds. Further work to improve staff training is underway with an online app in use to allow staff to complete training via smart phones.

Safeguarding

At the October KCH CQRG, Adult and Children’s Safeguarding was an agenda item. The Trust continues to not meet the mandated 80% compliance rate target for training – the Trust agreed to review online training as a means of improving uptake.

In terms of actions identified via the CQC report, relevant divisions were required to respond regarding Mental Capacity Act (MCA) and Deprivation of Liberty (DOLs) compliance. An improvement was noted in the DOLs process; referrals are going up, with no applications rejected. This indicates the Trust is learning lessons about effective and appropriate DOLs applications which suggests training may be having an impact



Serious Incidents & Never Events

Denmark Hill notified commissioners of 19 SIs in Q3, 2 of these were Never Events. The two Never Events were a retained swab in Maternity department and a retained guidewire in a patient who underwent a chest drain procedure. Incidents occurring at the PRUH site are overseen by Bromley CCG – this was 25 SIs of which 1 was a Never Event (mis-placed naso-gastric tube). The KCH Serious Incident Committee and Safer Care Forum continue to be robust forums for scrutiny of investigation reports, which Southwark CCG attends.

Infection Control

Infection rates at KCH for C.diff were 40 cases against a target of 36 (YTD) in November 2015. KCH’s and the PRUH was over trajectory largely due to a norovirus outbreak in June 2015. Work is being carried out to improve antibiotic stewardship with Junior Doctors, including RCA sessions with microbiologists, using digital apps and identifying antibiotic champions. A new Non-Executive Director has been appointed who is a Professor of Infectious Diseases, whose expertise can be used regarding infection control.

NHS Southwark CCG Medicines Optimisation The CCG has responsibility for anti-microbial stewardship in primary care

Primary care antibiotic guidelines were updated in line with Public Health England and made available in May 2015. Practices were informed as part of audit information during prescribing review meetings and it was shared with local pharmaceutical committee (LPC).

Indicators for the Prescribing Incentive Scheme 2015/16 – practices will be measured on 2 indicators (included in the Quality Premium) to support clinicians in promoting quality improvement by reviewing antibiotic prescribing within their practice:

i. Antibiotic items/STAR PU – aims to reduce the overall volume of prescribing by 1% or

5% from the CCG average in 2014/15 (baseline value).

ii. Percentage broad spectrum antibiotics – to reduce by 10% (from 2014/15) the total number of co-amoxiclav, cephalosporins and quinolones prescribed as a percentage of the total number of selected antibiotics OR achieve the national target of 11.3% or less

Mandatory audit - Southwark Practices are required to carry out a mandatory antibiotic audit as part of 2015/16 prescribing incentive scheme which gives opportunity to improve their quality of prescribing by reviewing current prescribing practice against our local guidelines. The audit will contribute positively to the practice of antibiotic prescribing in primary care and support the antibiotic prescribing elements of the 2015/16 national Quality Premium set by NHS England. There are 2 audits available – the first focusses on reducing the number of antibiotic prescriptions, and the second focusses on reducing the use of broad spectrum antibiotics. Practices were allocated the audit according to analysis of their prescribing data.

Antibiotic Prescribing in Care Homes – Care homes pharmacists have been auditing antibiotic prescribing in the four Southwark Care Homes (all looked after by one GP practice). This took place in November 2015 and will be re-audited in March/April 2016. In addition, a questionnaire will be conducted to identify attitudes of prescribers and care homes staff towards the use of antimicrobials and identify factors that influence antibiotic prescribing in care homes.



Further audit work in top 5 prescribers of broad spectrum antibiotics The top 5 Southwark practices identified as having a particularly high proportion of broad spectrum antibiotic prescribing will be audited further. A member of the Medicines Optimisation team will be reviewing their 2015/16 broad spectrum antibiotic prescribing data to assess compliance with the local guideline and provide feedback. It is anticipated that this will support them to make improvements in their prescribing.

1. Data (NB: There is a time lag in data availability)

GP practices are measured on highlighted indicators, values highlighted in red indicate prescribing higher than the QP target Table 1: data for 2015/16

Indicator Indicator unit of measurmnt

Value for Southwark CCG 2015/16 by quarter

Value for South London 2015/16 by quarter

Value for London by quarter 15/16

Value for England 2015/16 by quarter

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

3 Days courses of antibiotics

ADQ/item 5.94 5.83 6.26 6.08 6.37 6.20 6.03 5.89

Co-amoxiclav, Cephalosporins & Quinolones

% Items

13.35 12.08 12.28 11.73 12.87 12.55 10.64 10.81

Minocycline ADQ/1000 Patients

7.92 8.12 12.26 11.88 11.96 11.68 11.15 10.40

Antibacterial items/STAR PU 0.19 0.18 0.23 0.21 0.22 0.20 0.26 0.24

Table 2: data for 2014/15

Indicator Indicator unit of measurement

Value for Southwark CCG 2014/15 by quarter

Value for South London 2014/15 by quarter

Value for London by quarter 14/15

Value for England 2014/15 by quarter

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

3 Days courses of antibiotics

ADQ / item 5.86 6.00 6.01 5.91 6.37 6.27 6.22 6.25 6.46 6.40 6.36 6.36 6.13 6.02 6.00 6.03

co-amoxiclav, cephalosporins & quinolones

% Items 12.8 13.6 12.3 12.3 12.9 13.5 11.8 11.8 13.7 14.4 12.1 12.1 11.2 11.9 10.1 9.9

Minocycline ADQ / 1000 Patients

13.5 13.4 11.9 11.6 14.1 13.7 13.8 13.1 14.3 14.0 13.6 12.9 13.6 13.2 12.5 11.8

Antibacterial Items / STAR PU

0.22 0.20 0.25 0.24 0.25 0.23 0.29 0.28 0.24 0.22 0.28 0.27 0.28 0.26 0.32 0.32

Graph 1: Trend in prescribing of broad spectrum antibiotics



Sources: KCH Board papers, CQRG papers, CSU Integrated Quality & Performance Report, GSTT Integrated Performance & Quality Report, GSTT SI Review Meeting, Medicines Management Committee;

Clinical effectiveness South London and the Maudsley Hospital NHS Foundation Trust (SLaM) CQUINS

All were met for Q3 including Outcomes, Inpatient Experience and Physical Health with compliance across all metrics including lifestyle, smoking status, blood pressure and BMI.

Guy’s and St Thomas’ Hospital NHS Foundation Trust (GSTT) Referral to Treatment times (RTT)

The CQRG were alerted to the potential negative affect the Junior Doctors’ strikes will have on RTTs. The Trust flagged that the cap on agency spend introduced by the Government will also affect RTT clearance lists as these are often staffed by agency and locum workers.

Community Nurse recruitment

GSTT have made significant progress in this area however in December 2015 District Nurse vacancies were still running at 26%. This was likely to reduce to 21% if all pending appointments occurred. It is acknowledged to be a difficult area for recruitment due to the age profile of District Nurses throughout the country. GSTT have used some innovative recruitment methods which appear to be successful.

King’s College Hospital NHS Foundation Trust (KCH) Workforce

At the November KCH CQRG, the main discussion focused on Workforce. A significant amount of international recruitment is underway to address the vacancy rate. The Trust reported the introduction of rotational and joint posts in an attempt to improve the disparity in vacancy rates across Trust sites. The Trust is slightly above its internal vacancy rate target (<8%), with worse performance at the PRUH than the DH site. Information received from Exit Interviews cited a lack of promotion opportunities as one reason for staff leaving the Trust.

The Trust reported a number of initiatives to boost retention including introduction of a new Band 5.5 scheme to support nurses moving towards band 6 positions, and a scheme for

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middle grade doctors from Sri Lanka particularly to support the PRUH. The impact of vacancies in pathology and diagnostics at the PRUH has a potential link with a high number of quality alerts from Bromley regarding repeat HbA1c tests for patients with diabetes.

Maternity

The number of elective C-Section procedures (<10%) was achieved in November (9.9%) for the first time in year with October (10.8%) rate just above. However the total number of C-sections remain over target (<26%) for October (26.2%) and November (27.2%) with only August being within target in year.

This remains an area of focus in the Southwark/Lambeth Maternity Joint Commissioning meeting with links to London wide practice being utilised. The overall Maternity strategy and community redesign process has been discussed in CQRG previously and is returning for review in February 2016.

Pertussis (Whooping Cough)

Guidance emerged from Public Health England late in 2015 on the proposed role of midwives in delivering pertussis immunisations to pregnant women. This is particularly pertinent following rising infection rates and confusion between who should be delivering the vaccine. Overall responsibility remains with NHS England and delivery is still through primary care via an enhanced service specification in the GMS contract. A future pathway will be agreed via the joint Lambeth and Southwark Maternity Commissioning group (for delivery through a local care network). It will take into account ante-natal screening, key performance indicators and how they are monitored, and how bloods/path lab issues will be managed.

Safer Care

The KCH Safer Care Forum looks at how the hospital can provide harm free care in areas which include Pressure Ulcers, Falls, VTE, deteriorating patients and catheter associated UTIs. The forum also oversees the presentation of serious incident investigation reports in these specific harm areas and is attend by the CCG Quality Team. It produces a ‘Fact of the Fortnight’, circulated to staff across the Trust. Topics in Q3 included ‘Do’s and Don’ts on prescribing Oxygen’, ‘Early identification of homeless patients entering Health services and ‘Managing constipation in adults and children to avoid harm’

In October 2015 KCH held their annual Safer Care event at the Denmark Hill site. It was attended by over 300 staff as well as stakeholders, visitors and the CCG Quality Team. Over ten stalls shared information about harm free care topics including medication safety, iMobile, Hospital at Night, Continence, Falls, plus many more. The event has proved to be a successful method of sharing learning and providing educational resources.

CQC Action Plan

The KCHs CQC Action Plan (overall rating ‘Requires Improvement’) is providing a helpful focus for commissioners and the Trust in terms of addressing areas of concern. The Action Plan was shared at the October CQRG meeting; it contains 25 ‘must do’ actions at the DH site, and 9 at the PRUH. There will be quarterly reporting to the Trust Board regarding monitoring the must dos with a review of progress at end January 2016.

Sources: KCH Board papers, CQRG papers, CSU Integrated Quality & Performance Report, GSTT Integrated Performance & Quality report, CCG Mental Health team



General Practice

Clinical effectiveness Patient experience Patient Safety Primary Care Co-commissioning NHS Southwark Clinical Commissioning Group (CCG) has a statutory duty to improve the quality of primary care services and to reduce health inequalities of our local population and from 1 April 2015 has been a joint co-commissioner of primary care services with NHS England. CCG Quality Assurance Framework In November 2015, the Primary Care Programme Board approved the CCG’s Quality Assurance Framework for primary care. The CCG will progress practice visits which will focus on areas within the assurance framework. It has also been jointly agreed with the LMC, the CCG, NHS England and GP Federations that Primary Care Dashboard indicators will be reviewed to support practice improve quality in priority areas. This will be linked to changes in GP practice contracts. Care Quality Commission (CQC) From 1 April 2015 the CQC began inspecting GP practices in Southwark. To date 8 have been inspected and reports published. SELDOC, the out of hour’s provider has also been inspected. Full reports are available on the CQC website. Following a second inspection, Borough Medical Centre (Dr Sharma) and the Acorn Surgery have been rated as ‘Good’ in all areas. After the CQC’s first visits both practices required improvements under the ‘Safe’ criteria. Falmouth Road Group practice, which has been in Special Measures since their first CQC visit, has an improvement action plan in place in preparation for their second CQC visit. The CCG and NHS England met with the practice in November 2015. It was noted that good progress had been made but more work is still to be completed. The CQC visited the practice again on 5 January 2016 and the CCG is awaiting the outcome of that visit. Extended Primary Care Service The CCG commissioned an Extended Primary Care Service via neighbourhood groups of practices which delivers additional healthcare advice and appointments for local patients 7 days a week, 8am to 8pm. Patients can access the service via telephone management from their GP practice or SELDOC out of hours. Patients are given advice on the phone, booked an appointment at their practice, or offered an appointment at an Extended Primary Care Access Clinic. The CCG has monthly contract monitoring meetings with both federations, including a review of quality and patient satisfaction. GP Federations In August 2015, the CCG issued a remedial notice to the South GP Federation Improving Health Ltd (IHL) due to repeated service breaks. Action was completed and there have been no breaks in service since. The Service Improvement Plan is monitored through the monthly contract meetings. The CCG undertook a quality assurance site visit to the South service in October 2015. Generally the CCG noted the safety and quality of services delivered by IHL was good. There were specific actions for IHL to follow up from the visit, which are being monitored through the monthly performance meetings. In December 2015 12% of patients seen at the North service provided feedback to Quay Health Solutions (QHS), the GP federation. 90% of patients said that they would be ‘extremely likely’ or ‘likely’ to recommend the service to their friends or family. IHL (South) are working to increase the numbers of patients that respond to their patient survey as part of their service improvement plan.



In November 2015, 27 patients responded to their patient survey, all expressing satisfaction with the service. GP Patient Survey Results January 2016 The latest national GP Patient Survey (GPPS) results were published in January 2016. The results combine two waves of questionnaires (January-March and July-September 2015), providing practice-level data. In Southwark 17,063 questionnaires were sent out and 4,455 returned – a response rate of 26%. Areas where there has been a minor decrease in performance include:

overall experience

ease of getting through on the phone

success of making an appointment

overall experience of making an appointment The CCG will be reviewing and analysing the results in more depth and this will form part of the proposed agenda at practice quality visits. The GPPS results are discussed at the extended primary care services (EPCS) performance meetings as the service and utilisation impacts on patient access and experience.

General engagement feedback

Clinical effectiveness Patient experience Safety Primary Care

Waiting times for appointments continues to be an issue raised by patients in most forums, including locality PPGs, EPEC, other outreach meetings including Tenants and Residents Associations (October 2015)

Some good feedback has been received from people who have used EPCS (‘smooth service’, ‘brilliant’), although travel issues have also been raised by one resident in Dulwich and one in Blackfriars area. CCG is organising a focus group for locality PPG members to gain their input in developing the independent evaluation of service.

Latin American community and Southwark Deaf Forum have highlighted a number of primary care including registration and interpreting services. Healthwatch also raised issues around access to interpreters. The CCG is reviewing the primary care interpreting service this year and will use intelligence already gathered as well as carrying out further engagement to inform the review and future service. The CCG is exploring, with Healthwatch and other partners, developing a train the trainer care navigation programme for community leaders.

A number of issues relating to access came up at the CCG’s Equalities and Human Rights workshop including those listed below. The CCG is considering how it might address these :

o disability access to GP premises, including perceptions and being seen more as a disabled person rather than as the presenting ill health issue

o lack of space in reception areas to have confidential conversations o lack of awareness of gender identity issues

Community Services

Podiatry service – it was raised at the North Southwark Locality PPG and Engagement and Patient Experience Committee (EPEC) in September that there were concerns about contacting the service and the ability to make appointments. The Head of Service attended the November PPG meeting to discuss access issues at the Walworth Road clinic. The service presented options for improving access and raised the on-going operational issues at this particular site. An option to disperse the activity across other clinics in Lambeth and



Southwark to improve overall access was well received. The group recommended the service spoke to affected practices and PPGs.

Healthwatch Southwark (HWS)

HWS continue to receive many contacts about GP registration, with some callers expressing frustration at the catchment system and inability to register with surgeries quite nearby, and questioning whether patients have any choice but to register with practices rated poorly on NHS Choices. HWS received 3 contacts this quarter about inability to get timely GP appointments.

Interpretation services: HWS conducted focus groups with Vietnamese/Vietnamese Chinese mental health service users, and a Bengali women’s group. As has been a common theme, access to interpretation was found to be the most significant barrier to accessing good care, with some surgeries not offering this.

HWS ran an information session with the Somali community, attended by 13 people. All were registered with a GP but many did not feel they could trust their GP as they did not always see the same doctor, and did not understand the medication they were taking and how to take it. HWS ran another session with older people attending a gardening project, attended by 10 people. At both of these signposting sessions attendees said they would fear being treated badly if they made a complaint to their GP surgery.

HWS conducted a visit to Evelina Children’s Hospital outpatients waiting room and spoke to 6 families. Generally they were very positive about the service including friendly, competent staff, good communication about treatment, and a pleasant environment. 5 of 6 rated the service as ‘Excellent’ and 1 did not rate it as they were not sure when they would be seen. Some patients had faced minor delays but been kept well informed; one family however had been waiting several hours after their appointment time and received conflicting information and were very frustrated. There were few other suggestions for improvement but car parking costs and not being able to access refreshments while waiting were raised.

HWS logged 3 problems from patients in getting through to GSTT services by telephone. HWS attempted to contact PALS at St Thomas and was unable to get through by phone or leave a message. This was flagged with the service who said they would resolve it.

Continuing care

Clinical effectiveness Patient experience Safety

Summary During Q3 the CCG participated in a CQC Thematic Review for end of life care. CQC highlighted a number of areas of good practice within the initial feedback on the review including:

being highly impressed with the CCGs continuing care fast track process suggesting was the best they had come across

commending Southwark on the very genuine partnership working between the CCG and providers of end of life care in the borough, saying it was not something that they had seen replicated across the country

being particularly impressed with the model of MDT working in the nursing homes in Southwark, that the CCG had proactively managed the primary care support to these homes, resulting in them all being registered with one practice



Barriers to high quality end of life care for hard to reach groups identified during the review included:

patients not identified early enough and greater gaps with non-cancer diagnosis

lack of confidence among some professionals in discussing advance care planning

cultural or personal reasons preventing some patients accessing services, e.g. STAG, homeless and people with no recourse to healthcare services

information sharing

workforce challenges The CCG continues to address these through the Lambeth and Southwark End of Life Strategy Group.

Commissioned home care


Summary

To improve the quality of care experienced by people at the end of their lives, the CCG has agreed a new way of working with the provider, with end of life care patients receiving weekly visits from a Senior Quality Assessor who provides oversight from a provider perspective and monitors for changes in the patient’s condition.

The Safeguarding Adults Board Self-Assessment Framework has been sent to the provider for completion by end February and a challenge event will be held by the Board for all providers to attend once analysis of audits is complete.

Two Quality Alerts were raised in the quarter, one relating to poor standards and the other relating to a missed visit. These concerns have been addressed by the provider. There were no safeguarding referrals.

Care homes


Summary

Camberwell Green Nursing Home closed during the first week of January 2016, the final CQC inspection of this service highlighted that the home was failing to meet quality standards. The Local Authority, CCG, HC-One, who managed the home, Sternhall Lane GP Practice and GSTT Community Health Services worked together to manage the transition of residents from the home. Of the three fully-funded clients in the home two have transferred to Tower Bridge Care Centre and the third died at Camberwell Green prior to the home closing.

Embargoes on placements have been lifted at Tower Bridge Care Centre and Burgess Park Nursing Home due to the CCG and Local Authority being satisfied that improvements had been made. However both services continue to be rated as Inadequate by CQC and this rating will remain in place until the next scheduled inspection.



St Christopher’s Hospice


Summary As its CQUIN for 2015/16 St Christopher’s developed an inter-cultural spiritual care directory including guidance on end of life care for all faith groups. A first draft has been completed and sent to the CCG for comment. Summary of Incidents

Southwark

Duty of Candour 0

Never Events 0

Complaints Substantiated 0

Partially 0

Unsubstantiated 1

Falls 1

Safeguarding 0

DoLS 0

MCA Assessments 3

Training Of 204 clinical staff, 154 (74.9%) have completed training in safeguarding. The remaining 50 have until 31/3/16 to complete this training. Our Safeguarding Lead has undergone advanced training. 177 (87%) of clinical staff have received training on MCA and DoLS Drug Errors There were 43 drug errors and incidents reported, a Southwark breakdown of these is not available. All were rated as green



Quality Alerts


The CCG’s quality alert system was re-launched in April 2015. Practices were encouraged to highlight concerns about quality or safety which were not complaints or serious incidents, but indicated areas where there may be a systemic problem. See Appendix 1 for the most recent ‘You said, we did’ document circulated to practices (Q2). Q3 will be circulated after agreement with the providers and CCGs.

Quarter 3 127 alerts were submitted in Q3. 48 for services across GSTT, 54 for services within KCH, 4 for SLaM, 5 for community providers (not GSTT), and 6 others.

Quarter 2 86 alerts were submitted. This represented 53 for services in GSTT and 33 for services in KCH. Two reverse quality alerts were also left.

Quarter 1 51 quality alerts were raised. 28 for services in GSTT and 23 for KCH. Difficulties with poor clinical care and communication were the top categories followed by appointments issues.

Q3 2015 Quality Alert Report

Appoints E-referrals

Clinl Care Comms Discharge

Patient Exp Prescribing Referrals Results Other Total

Community Provider (eg GPwSI) 0 1 0 0 0 1 0 3 0 0 5

GP Practices 2 0 2 1 0 0 0 1 0 4 10

GSTT Community 1 0 4 1 1 1 0 2 1 2 13

GSTT (Acute) 7 0 5 4 3 1 2 9 3 1 35

KCH 6 1 3 21 8 2 4 3 5 1 54

SLaM 1 0 0 1 0 0 0 2 0 0 4

Lewisham Hospital 0 0 0 0 1 0 0 0 0 0 1

Other 0 0 1 0 0 0 1 0 0 3 5

Total 17 2 15 28 13 5 7 20 9 11 127

Themes from Q3

Referrals (n=20) remain a highly reported theme. Work is being picked up in the KHP Discharge working group and is due to report back in quarter 4. Issues include late or incomplete discharge summaries, medicine reconciliation problems, and inadequate communication of discharge planning.

Communication (n=28) issues with particular services such as MCATTs and ENT are being taken up with the services. Issues with CAMHS referrals including out of area have been picked up within the contract meeting.

Clinical care issues include District nursing and these are being reviewed by the primary care team and service. Delayed 2 week wait cancer referrals have been robustly discussed with GSTT. (See Appendix 1)



Appendix 1

Quality Alerts Feedback to General Practice: July – Sept 2015

You said: GSTFT/KCH did:

You said: GSTFT did:


You said: KCH did: KCH did:

You said: KCH did:


Discharge information

often inadequate delayed

or sent to wrong practice

Referrals/appointments

missing and delayed have

increased

Poor communication

between patients/

surgeries and MCATTs, and

issues of missing

appointments

Delay in death notifications

which are sent by post from

KCH rather than urgent e-

mail and/or phone message

Hospital Consultants ask

GPs to make onward

referrals, arrange diagnostic

tests or chase tests

organised by the hospital

including 2 wk waits

Screening and diagnostic Improvement group

established by commissioners to improve pathways

within KCH. Communications will be sent regularly

throughout KCH to reinforce secondary care

responsibilities.

Project manager approved to lead discharge

workgroups set up following Summit. Discharges

now sent electronically. Focus training with

Junior Drs. Work has taken place in KCH with

admin to ensure correct GP sent Info. Project in

place to enable a real-time look up to the Spine

for demographics to ensure correct GP is used.

Estimated live in New Year.

The increased number of quality alerts regarding lack of

and follow up of appointments has been raised with

GSTFT and a review of the PIMs waiting list is currently

being undertaken.

There is a LIMs Recovery Plan in place working with

NHS Lambeth CCG to address the issues raised. The

introduction of e-referral impacted on referrals,

however this has now improved. The MCATS team

are actively meeting with local GP practices to go

through the LIMs referral process.

EPR team are putting in place a process to ensure

rapid notification of deaths to GPs, prevent any

backlog, and spot gaps where notifications are absent.

District nursing visits not

always taking place as

expected

A single point of access for district nursing services

in Lambeth and Southwark was launched to all

referrers on Monday 5 October. All enquiries and

referrals for Lambeth and Southwark should be

sent to: 0203 049 4020 or gst-

[email protected]. Nurses working on the Pan

Lambeth shift are scheduling their visits on the

electronic system instead of ringing the team

manager out of hours.

mailto:[email protected]

mailto:[email protected]



Q2 2015/16 Referrals Submitted by Practice

Practice Name Appointment

Choose and Book / E-

referrals Clinical Care Communication Discharge Prescribing Referrals Results

Other

please

specify

Total Per

GP

GP - 306 Medical Centre 0 0 0 2 0 0 0 0 0 2

GP - Acorn Surgery 1 0 0 0 0 1 2 0 2 6

GP - Albion Street Health Centre 10 11 8 1 0 0 0 0 2 32

GP - Aylesbury Medical Centre 1 0 0 0 0 0 1 0 0 2

GP - Bermondsey and Lansdowne Medical

Mission 0 0 0 0 1 1 0 0 0 2

GP - Blackfriars Medical Practice 0 0 0 0 1 0 0 0 0 1

GP - Concordia - Melbourne Grove - SE22 0 0 0 0 1 0 0 0 0 1

GP - Elm Lodge 0 0 0 3 0 0 0 0 0 3

GP - Lister Primary Care Centre - ARU 0 0 0 1 0 0 0 0 0 1

GP - Lister Primary Care Centre - HOSSAIN 0 0 1 0 0 0 0 0 0 1

GP - Nunhead Surgery 0 0 0 0 0 0 0 2 0 2

GP - Park Medical Centre 0 0 0 0 0 0 1 0 0 1

GP - Princess Street Group Practice 1 0 0 0 1 1 0 0 0 3

GP - Silverlock Medical Centre 0 0 1 0 0 0 0 0 0 1

GP - Sir John Kirk Close 1 0 0 0 0 0 1 0 0 2

GP - ST Giles Surgery - Dr Patel 0 0 0 0 0 0 1 0 0 1

GP - St Giles Surgery - Dr Virgi 0 1 0 0 0 0 0 0 0 1

GP - Sternhall Lane Surgery 0 0 0 3 6 0 0 1 1 11

GP - The Grange Road Practice 0 2 0 0 1 0 0 1 0 4

GP - The Hambleden Clinic 0 0 0 1 0 0 0 0 0 1

GP - The Surgery - 1 Forest Hill Road - SE22 0 0 0 0 0 0 0 0 1 1

GP - The Surgery - 12 Queens Road - SE15 0 0 0 1 0 0 0 0 0 1

GP - The Surgery - The Gardens - SE22 0 1 0 1 0 0 1 0 0 3

GP - Villa Street Surgery 0 0 0 1 0 0 0 0 0 1

Total by Category 14 15 10 14 11 3 7 4 6 84



Glossary:

A&E – Accident and Emergency

AGM – Annual General Meeting

AI – adverse incident

CCG – Clinical Commissioning Group

CQRG – Clinical Quality Review Group

DH – Denmark Hill site, KCH

DOLs – Deprivation of Liberty applications

EPEC – CCG Engagement and Patient Experience Committee

FNOF – fractured next of femur

GSTT – Guys and St Thomas’s Hospital NHS Foundation Trust

HCAI – health care acquired infection

IHL – Improving Health Limited

KCH – King’s College Hospital NHS Foundation Trust

LA – Local Authority

MCA – Mental Capacity Act

MCATT – Muscular Skeletal Assessment Team

MDT – Multi-disciplinary team

NE – Never Event

PPG – Patient Participation Group

PRUH – Princess Royal University Hospital site, KCH

RCA – root cause analysis

RTT – referral to treatment

SECSU – South East Commissioning Support Unit

SI – Serious Incident

SLaM – South London and the Maudsley NHS Foundation Trust

YTD – year to date

Documents

Quality Report October-December 2015 - Southwark CCG · Chair Dr Jonty Heaversedge Chief Officer Andrew Bland The best possible health outcomes for Southwark people 6 Patient experience