Performance, Quality and Outcomes Report: Position Statement
Governing Body meeting
F10 January 2019
Author(s) Jane Howcroft, Programme and Performance Assurance Manager Rachel Clewes, Senior Programme and Performance Analyst
Sponsor Directors Brian Hughes, Director of Commissioning and Performance Mandy Philbin, Chief Nurse
Purpose of Paper
To update Governing Body on key performance, quality and outcomes measures.
Key Issues
1. Areas of concern, which remain under review
A&E 4 hour waits: The proportion of Sheffield CCG’s adult patients admitted, transferred or discharged within 4 hours of arrival at Sheffield Teaching Hospitals NHS Foundation Trust’s (STHFT) A&E, continues to remain below the Constitutional standard of 95% and the interim improvement target of 90% for Quarter 3. The CCG will co-ordinate city wide escalation during the winter months, including pre-agreed actions for times when escalation is needed.
These actions include: an option for care home staff to get direct clinical advice via 111 in order to avoid unnecessary trips to hospital or admissions; a protocol is in place whereby if any if ambulance crews have capacity they are diverted to support discharge processes, and ensuring that all care homes are aware of the YAS Emergency Care Practitioner service to assess and treat the patient in situ.
Delayed Transfers of Care (DTOC):.A ‘delayed transfer of care’ occurs when a patient is ready to leave a hospital or similar care provider but is still occupying a bed. This issue remains a key priority for the CCG and our partners across the city, with additional capacity being created in a number of services, particularly those which enable patients to be transferred back home with support to regain independence.
Closure of the Hadfield Building at STH (Northern General site)
Building work on the Hadfield Building at the Northern General Hospital commenced in mid November. The work is necessary following some exploratory inspection work on the walls of the building, which prompted STH to seek advice from South Yorkshire Fire Service about fire prevention measures inside the walls.
The Fire Service advised that STH need to do further work on prevention measures within the walls and that this work should be undertaken as a priority. This advice is not due to any new sudden increased risk of a fire starting in the building; it is more concerned with fire protection measures inside the walls which would limit the impact of a fire.
The work will inevitably cause a level of disruption which cannot be avoided and following advice from the Fire Service patients and staff have been re-located.
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During the period it will take to relocate patients, STH are also enhancing fire prevention and protection measures, such as onsite trained fire safety officers, regular checks and they will continue to have support from the fire service.
The beds usually located within the Hadfield Building have been opened in other parts of the STH estate, this means that there is no potential for any further capacity to be created over the winter period. The CCG is liaising closely with the Trust regarding how we manage the potential impact on both elective and unscheduled care.
2. Care Quality Commission (CQC) inspections in Sheffield
Sheffield Teaching Hospitals NHS Foundation Trust
The CQC undertook and inspection of STH this autumn and published their report in November; the Trust was again rated as “good” for the domains of safety, effectiveness, caring and a well-led organisation. STH was seen as “outstanding” in terms of being responsive to patients.
The Northern General hospital was rated as Good overall as both urgent and emergency care and end of life had improved. Responsiveness was outstanding at this site which was an improvement.
Sheffield Special Educational Needs and/or disabilities (SEND) Inspection
A separate briefing paper has been prepared for Governing Body on this topic by the CCG’s head of Commissioning for Children’s Services.
3. Performance and quality highlights
Diagnostics: STH delivered the 6 week waiting time standard for diagnostics in October, ahead of the date they were forecasting, having implemented speciality specific recovery plans, eg in echocardiography.
Elective referral to treatment times (RTT): The CCG again delivered the 18 week standard for the waiting times from referrals to treatment in October, as did both our local providers.
Health care associated infections: there were no MRSA bacteraemia infections in November.
Is your report for Approval / Consideration / Noting
Consideration
Recommendations / Action Required by Governing Body
The Governing Body is asked to discuss and note: Sheffield performance on delivery of the NHS Constitution Rights and Pledges Key issues relating to Quality, Safety and Patient Experience
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Governing Body Assurance Framework
Which of the CCG’s objectives does this paper support?
1. To improve patient experience and access to care 2. To improve the quality and equality of healthcare in Sheffield
Specifically the risks:
2.1 Providers delivering poor quality care and not meeting quality targets
2.3 That the CCG fails to achieve Parity of Esteem for its citizens who experience mental health conditions, so reinforcing their health inequality and life expectancy
Are there any Resource Implications (including Financial, Staffing etc)?
Not applicable at this time
Have you carried out an Equality Impact Assessment and is it attached?
Please attach if completed. Please explain if not, why not No - none necessary
Have you involved patients, carers and the public in the preparation of the report?
It does not directly support this but as a public facing document is part of keeping the public informed.
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Performance, Quality & Outcomes Report
2018/19: Position statement using latest information
for the 10 January 2019 meeting of the Governing Body
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Highest Quality Healthcare NHS Constitution Measures Performance Dashboard
Performance Indicator Target
CCG
Quarterly
Q2 18/19
CCG Latest monthly
Position
CCG
Performance
against standard
(latest 6 months)*
Latest Provider Total Monthly Position
Sheffield
Teaching
Hospital
Sheffield
Children's
Hospital
Sheffield
Health &
Social Care
Yorkshire
Ambulance
Service * Mental Health CPA 7 day followup & Cancelled Operations (28 days) trend lines are using latest quarterly (not monthly) data.
Referral To Treatment
waiting times for non-urgent
consultant-led treatment
All patients wait less than 18 weeks for treatment to start 92% 94.25% Oct-18 92.55% 93.39%
No patients wait more than 52 weeks for treatment to start 0 1 Oct-18 0 0
Diagnostic test waiting
times
Patients wait 6 weeks or less from the date they were referred 99% 99.90% Oct-18 99.96% 99.50%
A&E Waits
Patients are admitted, transferred or discharged within 4 hours of arrival
at A&E 95% 90.14% 89.29% Nov-18 86.83% 97.04%
No patients wait more than 12 hours from decision to admit to
admission 0 0 Nov-18 0 0
Cancer Waits: From GP
Referral to First Outpatient
Appointment (YTD)
2 week (14 day) wait from referral with suspicion of cancer 93% 95.46% 95.45% Oct-18 95.64%
2 week (14 day) wait from referral with breast symptoms (cancer not
initially suspected) 93% 93.03% 94.34% Oct-18 94.64%
Cancer Waits: From
Diagnosis to Treatment
(YTD)
1 month (31 day) wait from referral with suspicion of cancer to first
treatment 96% 95.38% 95.78% Oct-18 93.42%
1 month (31 day) wait for second/subsequent treatment, where
treatment is anti-cancer drug regimen 98% 100.00% 100.00% Oct-18 100.00%
1 month (31 day) wait for second/subsequent treatment, where
treatment is radiotherapy 94% 93.78% 93.62% Oct-18 94.03%
1 month (31 day) wait for second/subsequent treatment, where
treatment is surgery 94% 93.33% 92.98% Oct-18 87.80%
Cancer Waits: From
Referral to First Treatment
(YTD)
2 month (62 day) wait from urgent GP referral 85% 82.24% 72.03% Oct-18 67.55%
2 month (62 day) wait from referral from an NHS screening service 90% 87.04% 86.67% Oct-18 88.52%
2 month (62 day) wait following a consultant's decision to upgrade the
priority of the patient
(85%
threshold) 86.05% 76.19% Oct-18 71.43%
Ambulance response times
Category 1 (life threatening) calls resulting in an emergency response
arriving within 7 minutes (average response time) 7 mins 7 mins 1 sec Nov-18 7 mins 1 sec
Category 2 (emergency) calls resulting in an emergency response
arriving within 18 minutes (average response time) 18 mins
20 mins 30
secs Nov-18
20 mins 30
secs
Category 3 (urgent) calls resulting in an emergency response arriving
within 120 minutes (90th percentile response time) 120 mins
118 mins 19
secs Nov-18
118 mins 19
secs
Category 4 (less urgent) calls resulting in an emergency response
arriving within 180 minutes (90th percentile response time) 180 mins
226 mins 51
secs Nov-18
226 mins 51
secs
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Apr
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Highest Quality Healthcare NHS Constitution Measures Performance Dashboard
Performance Indicator Target
CCG
Quarterly
Q2 18/19
CCG Latest monthly
Position
CCG
Performance
against standard
(latest 6 months)*
Latest Provider Total Monthly Position
Sheffield
Teaching
Hospital
Sheffield
Children's
Hospital
Sheffield
Health &
Social Care
Yorkshire
Ambulance
Service
Ambulance handover / crew
clear times
Ambulance Handover - reduction in the number of delays over 30
minutes in clinical handover of patients to A&E
Local
Reduction 6.93% Oct-18 13.26% 0.00% 6.93%
Ambulance Handover - reduction in the number of delays over 1 hour in
clinical handover of patients to A&E
Local
Reduction 0.87% Oct-18 0.55% 0.00% 0.87%
Crew Clear - reduction in the number of delays over 30 minutes from
clinical handover of patients to A&E to vehicle being ready for next call
Local
Reduction 3.07% Oct-18 3.42% 1.79% 3.07%
Crew Clear - reduction in the number of delays over 1 hour from clinical
handover of patients to A&E to vehicle being ready for next call
Local
Reduction 0.20% Oct-18 0.34% 0.00% 0.20%
Mixed Sex Accommodation
(MSA) breaches
Zero instances of mixed sex accommodation which are not in the
overall best interest of the patient 0 0 Oct-18 0 0 0
Cancelled Operations
Operations cancelled, on or after the day of admission, for non-clinical
reasons to be offered another date within 28 days
Local
Reduction 12
*
12 0
No urgent operation to be cancelled for a 2nd time or more Local
Reduction 2 Oct-18 2 0
Mental Health People under adult mental illness specialties on CPA (Care Plan
Approach) to be followed up within 7 days of discharge (YTD) 95% 88.52%
*
100.00%
Highest Quality Healthcare Mental Health / DTOC Measures Performance Dashboard
Early Intervention in
Psychosis (EIP)
Proportion of EIP patients seen in 2 weeks 53% 78.43% 75.00% Oct-18 100.00% 66.67%
Improved Access to
Psychological Therapies
(IAPT)
Number of patients receiving IAPT as a proportion of estimated need 4.8% (Qtr
target) 4.80% 1.61% Sep-18 1.64%
Proportion of IAPT patients moving to recovery 50.00% 49.47% 49.40% Sep-18 50.00%
Proportion of IAPT patients waiting 6 weeks or less from referral 75.00% 88.74% 89.66% Sep-18 88.76%
Proportion of IAPT patients waiting 18 weeks or less from referral 95.00% 99.01% 98.85% Sep-18 97.75%
Dementia Diagnosis Estimated rate of prevalence of people aged over 65 diagnosed with
dementia 71.5% 79.70% Nov-18
Delayed Transfers of Care
(DTOC)
Total number of delayed days (from acute and non-acute) when a
patient is ready for discharge but is still occupying a bed 4,306 (Qtr
target) 7,419 2,935 Oct-18 2,644 209
No individual provider targer for DTOC bed days
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Highest Quality Health Care NHS Constitution Measures Performance Dashboard: Actions
Area Action being taken Expected timeframe for
improvement
Action requested of
Governing Body
RTT 52 week For October, one patient was showing as waiting over 52 weeks – this is We will continue to monitor None
waits the same patient who was showing as a breach last month at Northern
Lincolnshire and Goole NHSFT (in ‘Other’ speciality). The Trust have
informed us that the patient was due to be treated on 14th November
2018. The treatment had been delayed due to capacity issues.
this patient until they have
been seen.
Diagnostic Diagnostic waits continue to be monitored through monthly Contract STH met the six week To endorse the approach of
Waits - STHFT Management Group (CMG) meetings; as can be seen, the Trust met the
required national standard in September and October, a month ahead of
the forecast trajectory.
There were only 2 patients waiting over 6 weeks at STH during October,
both in Echocardiography, this is in line with the recovery action plans
devised by STH. This success reflects significant effort on behalf of the
Trust.
standard in September and
October. The CCG will
continue to monitor, in order to
ensure that this improvement
is maintained.
monitoring STHFT achievement
of diagnostic waiting times and
any necessary mitigating
actions, through monthly PCMB
meetings with the Trust.
A & E Waits STH's performance in November was 86.8%, a decrease from the reported
October position of 89.4%. The interim target of 90% for Quarter 3 will not
be met, despite concerted efforts and additional staff. A wide range of
actions are being taken by the Trust, as part of their "Action 95" plan and a
series of local actions agreed across the city health and social care system
are being signed off by the Operational Resilience Group (a sub-group of
the UECTDB, chaired by the CCG) to help mitigate the impact of winter
pressures. STH's Trust Executives meet with A&E each month to monitor
progress on the detailed "Action 95" improvement plan, and the CCG
receives an update each week on progress of implementing the actions.
The Trust is implementing its
detailed Action Plan and is
working towards achieving the
interim performance target of
90% in Quarter 3, in line with
the NHS Improvement / NHS
England trajectory. Achieving
the 90% target presents a
challenge in the context of
winter pressures.
To continue to endorse the
CCG's ongoing monitoring of
STHFT's progress towards
achievement of the A&E
standard and the delivery of any
necessary mitigating actions, as
agreed through the Performance
Contract Management Board.
Cancer Waiting STH continues miss the delivery of the 31 and 62 day targets; this is due to The Cancer Alliance is To note the continued work
Times - 62 day the ongoing high volume of patients, particularly in Urology and the addressing the capacity and undertaken locally and across
waits complexity of treatment in Head and Neck cancer sites, and Urology.
As previously outlined, in Head and Neck, there are long term issues
relating to patient choice delays. Patients often need extra time to make
decisions around when considering complex surgery with life changing
consequences.
Increased referrals into Urology for prostate cancer continue and as
patients convert to surgical waiting lists the pressures on robotic capacity
at STHFT increase. Additional funding in the region will support current
planned activity but not address the robotic surgery capacity shortfall fully.
There is no clinical concern identified in regard to these waiting time
breaches.
In addition to the actions outlined in this report previously the Cancer
Alliance are leading an exercise to identify opportunities to increase activity
across all cancer sites to improve overall performance in quarter 4 and
associated funding requirements, STHFT have provided a number of
opportunities.
demand issues which affect
STH and neighbouring
providers' issues through joint
action. Despite concerted work
to manage capacity across the
system and additional support
from NHS England it is
probable that these issues will
not be fully resolved until
quarter 2 2019/20, work is
underway to review the
recovery trajectory based on
latest capacity and demand
information. Potential
initiatives in quarter 4 2018/19
may improve this trajectory
sooner but have yet to be
confirmed.
the Cancer Alliance to address
immediate capacity issues and
also to develop integrated
pathways to sustain service
delivery and performance. To
continue to monitor progress
against internal improvement
plans and escalate to the PCMB
as appropriate.
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Highest Quality Health Care NHS Constitution Measures Performance Dashboard: Actions
Area Action being taken Expected timeframe for
improvement
Action requested of
Governing Body
Ambulance Yorkshire Ambulance Service is continuing to participate in NHS England’s Progress continues to be None this month.
Response Ambulance Response Programme (ARP) pilot and has now moved to the closely monitored by the
Times next stage, Phase 3. YAS are reporting on the new standards, which
replaced the previous way of measuring performance.
YAS remains unable to report the performance data at CCG level, so the
Sheffield data is still not available. However, it can be reported that in
comparison with other ambulance trusts nationwide, YAS is the top
performing service for call answer, the second best for early identification
of life threatening calls and third top performing service for hear and treat.
Work is ongoing with regards to training staff, re-designing services,
ensuring that vehicle fleet is modernised to enable YAS to meet all the
targets and an integrated workforce work stream is now established.
Oversight and management of business cases for YAS service
development is being co-ordinated by the Lead Commissioner Wakefield
CCG.
Urgent Care Team, Urgent
and Emergency Care
Transformation Delivery Board
and at the Yorkshire & Humber
999/111 Contract
Management Board meeting.
Ambulance Whilst ambulance handover performance for STH has seen a small The CCG continues to To continue to endorse the
handover / crew improvement, handover times are still too long (some days have had facilitate meetings between approach of monitoring
clear times delays over 1 hour). STHFT is one of the three acute Trusts highlighted as
a continuing concern within Yorkshire and Humber.
There has however been improvement in crew waiting hours - this has
gone down from an average of 10.5 hours a day in August to 7.08 in
November. Even more positively for this month, the rolling 30 day position
(up to the 6th of December) showed this has further reduced to 3.22 lost
hours per day which shows great progress. It is possible that this progress
may not be maintained over the next few months, given the additional
pressures of winter and the closure of the Hadfeld wing at the Northern
General.
The CCG and STH have agreed a new clinical protocol which enables YAS
to convey patients directly to the Walk In Centre, thereby relieving
pressure on A&E.
STH & YAS to discuss
measures to improve
performance moving forward.
ambulance handover
performance, the monitoring of
any necessary mitigating actions
through monthly Contract
Management Group meetings
with the Trust and support the
decision by the UECTDB that
this be an area of significant
system focus moving forward.
Cancelled There were 12 operations of this type cancelled during Quarter 3, all were Ongoing monitoring. None requested.
Operations - (on at STHFT. The cancellations were caused by capacity issues in critical
day of care over the summer period; these improved in September, and the
admission) number of cancellations reduced.
Cancelled 2 patients had their urgent operations cancelled for a second time in Ongoing monitoring. None requested.
Operations - October, both at STH.
(Urgent These 2 cancellations were orthopaedic patients and surgery was
operations cancelled on both occasions due to lack of theatre time (list overrun /
cancelled for overbooked). Both patients received their surgery in October 2018.
2nd time)
Mental Health The CCG continue to receive regular assurance at the monthly Contract CPA, in line with monthly To continue to receive
CPA 7 day Management Groups from Senior Operational Managers within SHSC and performance reporting, is a monitoring reports on this
follow up the Director of Operations provide regular updates and rationale
surrounding any breaches. The Trust has implemented a daily monitoring
process which alerts senior managers of any breaches. The CCG does still
have concerns over the recording of data in real time; the team have
questioned the reliability of data due to system errors. This is being
reviewed with SHSC in line with the Contract Management processes.
standard agenda item at the
Contract Management Group
(CMG). SHSC continue to
focus on improving their data
collection systems and the
CCG will expect an
improvement in order to
achieve the National target.
national target.
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Highest Quality Health Care NHS Constitution Measures Performance Dashboard: Actions
Area Action being taken Expected timeframe for
improvement
Action requested of
Governing Body
Mental Health / DTOC Measures Performance Dashboard: Actions
Improved Sheffield IAPT, remain slightly below the 50% recovery target, at 49.40% An updated position will be Governing Body is asked to
Access to for September, but as previously reported, recovery rate will always be presented to Governing Body continue to receive these
Psychological reduced for this cohort, due to acceptance of people with more complex to monitor whether the service updated position statements,
Therapies needs by Sheffield IAPT, compared to other national IAPT services. We sustains this significant until this standard is delivered
(IAPT) continue to monitor this through Contract Management Group, as the progress against the national consistently.
Recovery Rate service had reported confidence that they would achieve the target by the
end of quarter 3. However the service does overachieve on all other
targets.
target of 50% (monthly as well
as quarterly). Delivery of the
targets are also monitored as
part of the standard CMG
meetings with SHSC.
Delayed Additional actions across the system have resulted in a steady Ongoing None requested
Transfers of improvement in reducing the number of delayed days.
Care (DTOC) This includes:
- Additional assessment capacity is ensuring more patients are discharged
and assessed for longer term needs.
- Prevention and Escalation: The locality pilots are starting to show early
success in identifying and supporting some patients to return home with
support from Primary care. Going forward this will be supported by
additional voluntary sector capacity.
- Increasing the opportunity for patients to return home independently: The
voluntary sector will be commencing a range of additional services in late
December, early January that will support carers and patients to return
home and reduce readmissions.
- Increasing the support available for patients to return home with some if
required immediately or following further assessment: SCC will be
providing an additional 6% independent sector capacity throughout
December to enable more patients to be discharged home with support.
Additional equipment rounds is ensuring faster delivery of equipment.
Medically stable patients are offered the opportunity of a short stay in
offsite bed to continue their recovery until they are ready to return home.
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Highest Quality Health Care Quality Dashboard
Latest data Latest data Latest data Latest data Latest data
Q2 18/19 Target 95% 95.04%
Oct17 - Mar18 Provider Actual
previous year 37.6 40.84
Provider Actual
previous year 76.95 88.84
Provider Actual
previous year 59.87 69.79
Oct17 - Mar18 Provider Actual
previous year 0.09 0.24
Provider Actual
previous year 0.00 0.00
Provider Actual
previous year 1.18 0.81
Provider Actual
previous year 2.23 1.09
Nov-18 Plan 0 0 Plan 0 0 Plan 0 0
Nov-18 Plan 16 22 Plan 7 4 Plan 0 0
Nov-18 YTD Plan 128 140 Plan 57 58 Plan 2 5
Nov-18 4 3 0 1 0
Nov-18 YTD Target 0 2 Target 0 2 Target 0 0 Target 0 0
Patient Reported Outcome
Measures (PROMS)
Health gain (EQ-5D Index) - hip replacement surgery
(primary) Apr17-Mar18
(Aug release) England Average 0.470 0.455
Patient Reported Outcome
Measures (PROMS)
Health gain (EQ-5D Index) - knee replacement
surgery (primary) Apr17-Mar18
(Aug release) England Average 0.340 0.339
Friends and Family Test Response rate - A & E Oct-18 Target 20% 23.0% Children's Trust
average 7.3% 17.5%
Friends and Family Test Response rate - Inpatients Oct-18 Target 30% 26.1% Children's Trust
average 40.3% 97.2%
Friends and Family Test Number of responses - Mental Health Oct-18 Children's Trust
average 46 32
Average for Trust
last 12 montIs 171 311
Friends and Family Test Proportion recommended - A & E Oct-18 England Average 87.1% 85.5% Children's Trust
average 84.7% 79.4%
Friends and Family Test Proportion recommended - Inpatients Oct-18 England Average 95.7% 96.6% Children's Trust
average 94.4% 83.5%
Friends and Family Test Proportion recommended - Mental Health Oct-18 Children's Trust
average 89.2% 93.8%
England
Average 90.1% 99.0%
Staff Friends and Family Test Proportion recommended - as a place of work Q2 18-19 England Average 64.0% 71.7% England
Average 64.0% 62.7%
England
Average 64.0% 58.8%
Staff Friends and Family Test Proportion recommended - as a place of care Q2 18-19 England Average 80.5% 92.4% England
Average 80.5% 89.9%
England
Average 80.5% 67.5%
Patient Complaints Number of complaints responded to within agreed
timescale Various Internal target 85%
92% (Oct18 YTD)
Internal target 85% 75%
(Q4 17/18) Internal target 75%
38% (Q1 18/19)
CQC national patient survey Community Mental Health Survey 2018 - Overall
Experience Score 2018 6.6/10
Mixed Sex Accommodation Number of breaches Oct-18 Target 0 0 Target 0 0 Target 0 0 Target 0 0
Continuing Healthcare (CHC) Proportion of DST's (Decision Support Tool)
completed on patients in an acute hospital setting Q2 18-19 Target 15% 0%
Continuing Healthcare (CHC) Proportion of Referrals completed within 28 days Q2 18-19 Target 80% 96%
Jul17-Jun18 England Average 1.0035 0.9491
Up to Nov 18
YTD Target 20 wks 20wks
PATIENT SAFETY
Patients admitted to hospital who were risk assessed for venous thromboeombolism
(VTE)
Rate of reporting of patient safety incidents per 1000 bed days, using the National
Reporting and Learning System (Trusts which report a higher number of incidents
tend to have a more effective safety culture)
Performance Indicator Reporting
period
Sheffield CCG Sheffield Teaching Hospital Sheffield Children's Hospital Yorkshire Ambulance Service
Target / Average Target / Average Target / Average Target / Average Target / Average
Sheffield Health & Social Care
Proportion of patient safety incidents resulting in severe harm or death
Incidence of Healthcare Associated Infections - MRSA
Summary Hospital-Level Mortality Indicator (SHMI)
Serious Incidents - Number opened in month No target
Incidence of Healthcare Associated Infections - Clostridium Difficile (Cdiff)
HOSPITAL MORTALITY
No target No target No target No target
Serious Incidents - Never Events
PATIENT EXPERIENCE
CHILDREN & YOUNG PEOPLE
Average delivery time for Education Healthcare Plans (EHCP)
Benchmarked against other
Trusts as 'about the same'
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Highest Quality Health Care Quality Dashboard Actions
Area Commentary / Action being taken Expected timeframes Action requested of
Governing Body
Patient Safety
Healthcare Clostridium difficile Weekly monitoring. None requested.
Associated STHFT had 4 cases for November (total 58 to date) which is 1 case over
Infections the national target for November. Root Cause Analysis (RCA) review of
cases for Q1 has been undertaken and STH had 16 cases of which 6 were
assessed as lapses in care: 2 due antibiotic prescribing not within
guidelines, 1 transmission event on a ward, 1 failed audits and 2 due to
wards not completing audits within the specified time frame of 30 days
(note this has been recently changed to 30 days from 60 so may account
for the higher ratio of lapses to non lapses).
Amendment to STH October figures. STH reported 8 cases for October but
following RCA has since reclassified 1 case as carriage rather than
infection (as patient not symptomatic) so in fact they had 7 cases in
October.
SCHFT has had zero cases in November. RCAs have now been received
on all 5 and all agreed as no lapses in care/unavoidable.
NHS Sheffield CCG had 22 cases of C. difficile in November and RCAs
continue. An annual report has been presented at SMT in December and
will be presented to CCC in January (deferred by CCC from November &
December) which includes analysis of the risk factors associated with
community cases, identification of any cases where there is a lapse in
care, comparison with the previous year, as well as providing
recommendations that can be included in the CCG C.difficile Action Plan,
which is monitored by the Antimicrobial Stewardship Group on a 6 monthly
basis.
MRSA Bacteraemia
In November there were zero cases.
Never Events Never Events are defined as Serious Incidents that are wholly preventable, Weekly monitoring. None requested.
and Serious because guidance or safety recommendations that provide strong
Incidents systemic protective barriers are available at a national level and should
have been implemented by all healthcare providers.
There were no new never events in November. The other 4 Never Events
reported in the dashboard relate to 2 that occurred in June, 1 in August
and 1 in October, the detail of which has already been reported.
Patient Experience
Friends and STHFT: STH triangulates and analyses a wide range of patient experience Ongoing. None required.
Family Test data and takes action in response to trends identified. Response rates for
FFT are good. STH closely monitors FFT response and recommendation
rates and takes action when rates drop. This includes ward level
improvement plans for inpatient areas where the proportion of people who
would not recommend the service is higher than the national average.
SCHFT: FFT response rate for A&E and inpatients has improved.
Response rate for outpatients continue to be very low. There has been an
improvement in the proportion of inpatients that would recommend the
Trust over the last two years, 83% in October 2018. The recommend rate
for A&E rate has seen a gradual reduction, dropping to 79% in October
2018
SHSCFT: The Trust continues to receive low numbers of responses to
FFT, but there has been a slight improvement over recent months with 311
responses received in October 2018.
CQC Community The CQC Survey of community mental health 2018 was published in Ongoing None
Mental Health November 2018. The survey was divided into 11 sections, focussing on
Survey 2018 different aspects of patients’ experiences. When comparing SHSC’s 2018
and 2017 results, there was no significant difference on any question.
However, in 2018 SHSC benchmarked as ‘about the same’ as other trusts
on all questions, whereas in 2017 SHSC was benchmarked as ‘worse than
other trusts’ on questions relating to organising care and reviewing care.
Therefore there has been an improvement in the benchmarked position of
the trust.
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Highest Quality Health Care Quality Dashboard Actions
Area Commentary / Action being taken Expected timeframes Action requested of
Governing Body
Patient The number of complaints responded to within agreed timescale at Ongoing. None required.
Complaints Sheffield Health and Social Care Foundation Trust is below the internal
target of 75%. The response rate has improved from 23% in Q4 to 38% in
Q1 18/19. The CCG is continuing to gain assurance that the Trust is
striving to improve this situation.
Children and Young People
Education Education Health Care (EHC) plans have been established to replace The CYP portfolio is working None requested.
Healthcare Statements of Special Educational Needs for children and young people closely with the SENDSAR
Plans (EHCP) with special educational needs.
Currently the LA maintains 3,155 Education Health Care Plans, of which
there is an education and health element of 52%, this total has remained
consistent since last year. In the last 12 months 552 new requests for
EHCP have been received, compared with 441 on the previous year – an
increase of 111 requests.
In October and November there were 96 requests for EHCP assessment;
in October 48.3% of cases were completed in 20 weeks, in November
44.3% were completed within 20 weeks. The average timescale for
EHCP completion for 2018 is now 20 weeks, this has been a gradual
improvement year on year from 2018 of 48 weeks, 2015 of 34 weeks to
2017 of 29 weeks. 29 new EHCP’s were issued in October, 37 new EHCP
were issued in November.
For November 11 cases were issued within 20 weeks, 25 cases had taken
between 20 and 40 weeks and 1 had taken 40-60 weeks. There are
currently 114 cases to be finalised (29 cases have draft plans issued with
families, 66 await agree to assess decision), 85 are within 0-20 weeks, 27
within 20-40 weeks and 2 are above 40 weeks.
1 new tribunal request was lodged in November, 0 tribunals relate to
health.
Service (previously named the
SEND team) in Sheffield LA to
support EHCP delivery and
track the overall impact of
SEND to better inform our
commission.
In November 2018, Sheffield
had its local area SEND
inspection. The joint CQC and
Ofsted report is expected
within the next 4 weeks. Work
is already being undertaken in
anticipation of the letter. More
feedback will be provided in
January’s update.
Health’s involvement into the
EHCP process requires
improvement to support
delivery of the EHCP review
process for EHCP, monitor
provision delivery and review
health reports going into
EHCP’s. The CYP&M
commissioning manager is
scoping this with the head of
SEND and a recent business
case to support this has been
approved to recruit additional
admin staff an a therapist into
the SENDSAR service at the
LA.
Safeguarding
Safeguarding Following the 2 citywide inspections re Children Looked after & SEND we
are awaiting final reports in order to formulate any required action plans
which the safeguarding team will contribute to where necessary.
Ongoing Governing Body to note
Produced by
Information and Intelligence Team, NHS Sheffield CCG Page 8
Highest Quality Health Care - Provider CQC Ratings
The following table provides an overview of CQC (Care Quality Commission) inspection ratings for providers within Sheffield CCG locality. The CQC monitors, inspects and regulates health and social care services. Only providers that are
rated as either 'Requires Improvement' or 'Inadequate' in the month or have had a 'focussed inspection' will be displayed for information in the table below.
Organisation Name Provider
Name
Organisation
Inspection
Directorate
Specialism / Services
Date of
Inspection
report
Overall CQC
Rating CQC Rating Report
Alpine Lodge Alpine Health
Care Limited
Adult Social
care
Accommodation for persons who require
nursing or personal care, Dementia, Mental
health conditions, Physical disabilities,
Treatment of disease, disorder or injury, Caring
for adults over 65 yrs
25/09/2018 Requires
Improvement
Is the service safe? – Requires improvement
Is the service effective? – Requires improvement
Is the service caring? – Requires improvement
Is the service responsive? – Requires improvement
Is the service well-led? – Requires improvement
http://www.cqc.org.uk/location/1-
114994765
Diagnostic and screening procedures, Physical
Sloan Medical Centre The Sheffield
Clinic Ltd
Primary Medical
services
disabilities, Sensory impairments, Surgical
procedures, Treatment of disease, disorder or
injury, Caring for adults under 65 yrs
11/10/2018 Focussed Inspection http://www.cqc.org.uk/location/1-
274994960
Hallam Homecare Services
Ltd
Hallam
Homecare
Services Ltd
Adult Social
Care
Dementia, Learning disabilities, Mental health
conditions, Personal care, Physical disabilities,
Caring for adults under 65 yrs, Caring for adults
over 65 yrs
09/10/2018 Requires
Improvement
Is the service safe? – Requires improvement
Is the service effective? – Requires improvement
Is the service caring? – Good
Is the service responsive? – Good
Is the service well-led? – Requires improvement
http://www.cqc.org.uk/location/1-
4151895832
Nuffield Health - Sheffield
Fitness and Wellbeing
Centre
Nuffield Health Primary Medical
Services
Diagnostic and screening procedures,
Treatment of disease, disorder or injury, Caring
for adults under 65 yrs, Caring for adults over
65 yrs
16/10/2018 Focussed Inspection http://www.cqc.org.uk/location/1-
4151895832
Four Seasons Health Care
(England) Limited
Balmoral Care
Home Adult social care
Accommodation for persons who require
nursing or personal care, Dementia, Treatment
of disease, disorder or injury, Caring for adults
over 65 yrs
23/10/2018 Requires
Improvement
Is the service safe? – Requires improvement
Is the service effective? – Requires improvement
Is the service caring? – Good
Is the service responsive? – Requires improvement
Is the service well-led? – Requires improvement
http://www.cqc.org.uk/location/1-
135674276
Is the service safe? – Requires improvement
Ash House (Yorkshire)
Limited
Ash House
Residential
Home
Adult social care
Accommodation for persons who require
nursing or personal care, Dementia, Mental
health conditions, Caring for adults over 65 yrs
31/10/2018 Requires
Improvement
Is the service effective? – Requires improvement
Is the service caring? – Good
Is the service responsive? – Requires improvement
http://www.cqc.org.uk/location/1-
115440705
Is the service well-led? – Requires improvement
The following table provides an overview of CQC (Care Quality Commission) inspection ratings for all GP The following table provides an overview of CQC (Care Quality Commission) inspection ratings for all GP practices within practices within Sheffield CCG locality. The table shows the number of Sheffield practices rated under the Sheffield CCG locality. The table shows the number of Sheffield practices rated under the 4 current CQC ratings. 4 current CQC ratings.
Practice Overall Rating
Number of
Sheffield GP
Practices
Proportion of GP Practices
Outstanding 0 0%
Good 85 98%
Requires Improvement 2 2%
Inadequate 0 0%
TOTAL 87 100%
Practice Overall Rating Number of Sheffield Care Homes Proportion of Care Homes
Outstanding 1 1%
Good 85 76%
Requires Improvement 22 20%
Inadequate 4 4%
TOTAL 112 100%
Data as at Quarter 2 2018-19 Data as at Quarter 2 2018-19
Produced by
Information and Intelligence Team, NHS Sheffield CCG Page 9