Somerset Partnership Nhs Foundation Trust

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SOMERSET PARTNERSHIP NHS FOUNDATION TRUST

QUALITY REPORT

Report to the Trust Board – 21 July 2015

• are they safe?

• are they effective?

• are they caring?

• are they well-led?

• are they responsive to people’s needs?

• there was an decrease in the number of falls, andthepercentage of falls resulting in harm during June2015;

• therewas a decrease in the overall number of recorded medication incidents during June 2015 compared to May 2015. There wereno incidents resulting in harm to the patients;

• the number of reported incidents relating to prescribing and administration decreased during June 2015 compared to May 2015. There were no incidents resulting in harm to patients;

• there was one incident of an avoidable pressure ulcer reported within District Nursing during May 2015;

• the number of ligature incidents showed a decrease compared to May2015. In all of the incidents staff responded appropriately and removed the ligatures. Therewere no incidents involving ligature points in June2015;

• incidents of physical violence to patients by other patients increased during June 2015. There were three incidents resulting in minor harm to the patients;

• the number of instances of Absence Without Leave increased in June 2015 compared to May 2015;

• the number of incidents relating to the use of seclusion showed a decrease in June 2015 when compared to May 2015;

• use of restraint showed a decrease in June 2015 compared to May 2015. The majority of the restraint incidents were within adult mental health inpatient wards;

• the mandatory training rate for February 2015, being latest information available showed a compliance rate of 92.0%;

• the overall response rate for the Friends and Family Test for community hospitals forJune 2015 was 46.0%. 96.4% of respondents confirmed that they would ‘extremely likely’ or ‘likely’ recommended the community hospital to their friends and family;

• the overall response rate for the Friends and Family Test for minor injury units for June 2015 was 26.6%. 95.8% of respondents confirmed that they would ‘extremely likely’ or ‘likely’ to recommend the minor injury unit to their friends and family;

• the Friends and Family Test has been implemented within the Trust’s mental health inpatient wards. Of clients who provided a response during June 2015,85.7% would recommend the ward to their friends and family;

• the Friends and Family Test has been implemented within the Trust’s community services. Of clients who provided a response during June 2015, 96.9% would recommend the ward to their friends and family;

• Harm Free Care for June 2015 was 89.2%,and New Harm Free Care was 97.7%;

• the sickness rate for May 2015 being latest available information showed an decrease when compared to April 2015;

• there were no breaches of privacy and dignity in respect of sleeping accommodation.

SOMERSET PARTNERSHIP NHS FOUNDATION TRUST

QUALITY REPORT: JUNE 2015

1. PURPOSE

1.1Somerset Partnership is committed to making more information available about the quality of care that it delivers.

1.2The Trust’s Quality Report is structured around the five key questions which the Care Quality Commission will consider when reviewing and inspecting services. These are:

1.3The information provided in relation to each of these areas is as follows:

Are they safe?

• safer staffing;

• slips, trips and falls;

• medication incidents;

• prescribing and administration errors;

• pressure ulcers;
• incidents involving ligatures and ligature points;

• incidents involving actual physical violence to patients;

• incidents relating to clients being absent without leave whilst under the Mental Health Act;

• unexpected deaths;

• use of seclusion;

• use of restraint;

• infection control;

• patient safety walkrounds;

• sign up to safety;

• never events; (exception only).

Are they effective?

• NICE guidance;

• audits and cycles of improvement;

• Positive and Proactive Care (Restraint);

• policiesapproved.

Are they caring?

• Friends and Family Test – Community Hospitals;

• Friends and Family Test – Minor Injury Units;

• Friends and Family Test – Mental Health Inpatient Wards;

• Friends and Family Test – Community Services

• Clinical Incident Data (Harm Free Care);

• Mixed Sex Accommodation (exception reporting only);

Are they well-led?

• staff sickness absence rates;

• whistleblowing;

Are they responsive to people’s needs?

• complaints and commendations;

• PALS activity/patient engagement.

2. ARE THEY SAFE?

2.1Safer Staffing

Reporting period 1 to 30 June 2015

In accordance with guidance issued by NHS England and in response to the Francis report, the Trust has committed to publishing the staffing levels for each of its wards on its public website. The monthly Safer Staffing report forms a separate report for consideration by the Trust Board in the public session of the Board meeting. The report shows the percentage of time that actual staffing levels were the same as, or higher than the recommended staffing levels. Full details can be found on the Trust’s public website:

2.2Slips, Trips and Falls

Number of Incidents Recorded

Reporting period 1 July 2013 to 30 June2015

2.2.1Commentary

• Figure 1 above details the number of incidents reported over the last eight full quarters being the period between 1 July 2013 and 30 June 2015;

• the number of incidents reported during the first quarter of 2015/16, 1April to 30 June 2015 shows a reduction in the number of falls and those resulting in harm;

Number of Incidents and Percentage Resulting in Harm

Reporting period 1 July 2013 to 30 June 2015

• Figure 1a above details the number of incidents reported, with each bar showing the number of incidents occuring in the twelve months ending in the month indicated (i.e. the bar for the month of June 2015, shows the number of falls occurring between 1 July 2014 and 30 June 2015). This enableslonger term trendsto be identified;

• the total number of falls recorded over the period 1 July 2014 to 30June 2015 has reduced when compared to the earlier reported periods. The number resulting in harm has also steadily decreased over the last three periods being reported;

• for the period 1 July 2013 to 30 June 2014 the rate per 1,000 bed days was 2.694 compared to a rate of 2.575 incidents per 1,000 bed days for the period 1July 2014 to 30 June 2015;

• during June 2015 there were 61 fall incidents reported, a decrease when compared to May 2015 when 70falls were reported;

• of the falls reported during June 2015, 15 (24.6%) resulted in harm to the patients. Of the number recorded as resulting in harm, two cases were recorded as moderateharm to the patients; the remaining 13 incidents were recorded as minor harm to the patients.

• there were no incidents recorded in June 2015 of patients suffering serious harm;

• during June 2015 harm recorded to patients per 1,000 bed days was 1.451 compared to a rate of 1.546 per 1,000 bed days in May 2015;

• during May 2015 there were two incidents resulting in the patients substaining broken neck of femur which were reported as Serious Incidents Requiring Investigation (SIRI). Both incidents have been allocated to a case worker and investigations have commenced;

• Figures 1band 1bi are scatter graphs, each of which shows the relationship between the number of slips, trips and falls reported by each of the Trust’s community hospitals and older personsmental health wards, and the average number of occupied beds at each hospital/ward during the reporting period;

• the traffic-lighting applied to the graphs is for illustrative purposes only, to denote where comparative high and low rates per occupied bed are situated across the Trust, rather than being an indicator of high or low rates in absolute terms. This is because the comparison is being made only on the basis of internal benchmarking, rather than against the rates reported by other Trusts;

• Figures 1b and 1bi illustrate the position in respect of community hospital fall incidents for the period 1 April to 30 June 2015 and the corresponding months in 2014/15;

• as shown Figure 1b Chard Community Hospitaland Magnolia ward are shown to be an outliers for the period 1 April to 30 June 2015, compared to the corresponding months of 2014/15.

Chard Community Hospital

• between 1 April to 30 June 2015 Chard Community Hospital recorded a total of 25 falls compared to eight falls recorded during the corresponding months of 2014/15;

• during June 2015 a total of 14 falls were recorded, although none wasreported as resulting in harm to the patients. Eight falls were attributable to one patient;

• the July 2015 Falls Local Action Group meeting will review these falls in detail to identify any new actions. Initial evaluation has confirmed that 16 falls took place between 17.00 and 05.30 hours and has also indicated a number of reported issues with the use of fall alarms that will need to be resolved.

Magnolia Ward

• between 1 April to 30 June 2015 Magnolia ward recorded a total of 21 falls compared to five falls recorded during the corresponding months of 2014/15. No falls were recorded in June 2015;

• of the 21 falls, eight were reported as resulting in harm to the patients. Four of the incidents were classifed as moderate harm to patients and the other four cases being recorded as minor harm;

• following detailed review of each incident report by the Falls and Bone Health Co-ordinator and the multidisciplinary Falls Local Action Group at Magnolia it was noted that the patient group during this period was complex, with an increase in associated physical/medical factors;

• all but two of the ‘moderate’ harm ratings have been revised to minor harm. The remaining two moderate incidents involved the same patient and were a head injury and dislocated shoulder - all actions have since been taken to minimise the risk of further harm for this patient;

• 13 falls resulted in no injury, with the remainder resulting in minor harm including lacerations, skin tears and a sprained wrist;

• the 21 falls involved eleven patients, six of whom were men and five of whom were women, with 16 of the 21 falls taking place during the evening and nighttime when staffing levels are lower. There was also an increase in the number of agency staff on duty at night during this period who were unfamiliar with the patient;
• three patients were at the end-of-life stage of their dementia, which corresponds with an increase in agitation at the same time as a deterioration of physical function and mobility;

• a factor with dementia patients becoming more agitated and restless during the sundowning (evening) period coincides with the challenge of administering medicines to reduce their symptoms whilst at the same time managing the increased risk of falls from the medicines prescribed;

• the implementation of a ‘patient out of bed’ system to alert staff is still being refined to ensure that the alarm responds appropriately;

• staff report having limited access to physiotherapy support for patients who have no rehabilitation potential and will be discharged to nursing care environments but are a high risk of falling;

• work is onging to reduce the risk of patients falling.

• further ongoing reduction in the total number of falls across all community hospitals and the two older persons mental health wards remains challenging and actions will focus on reducing harm being sustained.

2.2.2Actions

• the Somerset Falls Pathway Group met during April 2015 to discuss the first draft of a proposed pathway. An event has been arranged for June 2015, aimed at patients, carers and health and social care staff, to review the proposed patient pathway between the various service providers in Somerset that support people who have had a fall and/or are at risk of a fall;

• the Falls Best Practice Group meets regularly to review reported incidents and develop actions to reduce the risk of falls and the resulting harm to patients;

• falls training is being rolled out across the Trust.

2.3Medication, Prescribing and Administration Incidents

Medication Incidents

Reporting period 1 July 2013 to 30 June 2015

2.3.1Commentary

• figure 2 above details the number of incidents reported over the last eight full quarters being the period between 1 July 2013 and 30 June 2015;

• the number of incidents reported during the first quarter of 2015/16, 1April to 30 June 2015 shows an increasein the number of reported incidents when compared to the previous quarter.

Number of Medication Incidents – All Settings

Reporting period 1 July2013 to 30 June 2015

Number of Medication Incidents – Inpatient Setting

Reporting period 1 July 2013 to 30 June 2015

• Figures 2a and 2b above detail the number of medication incidents reported. As with Figure 1, each bar represents the number of incidents occuring in the twelve months ending in the month indicated;

• the total number of reported incidents reflected in Figure 2a over the final period being reported 1 July 2014 to 30 June 2015 shows a decrease compared to the five previous periods reported. The numbers detailed in Figure 2b also show a decrease in the final period being reported 1 July 2014 to 30 June 2015;

• Figure 2b shows that the number incidents within an inpatient setting per 1,000 bed days between 1 July 2014 to 30 June 2015 was 3.820, a decrease when compared to the period 1 June2014 to 31 May2015 when an incident rate of 3.968 per 1,000 bed days was recorded;

• incidents within an inpatient setting between 1 July 2014 to 30 June 2015 per per 100,000 bed days was 382, compared to the 2013/14 NHS Benchmarking all trusts national average per per 100,000 bed days of 357;

• medication incident reports are received from all settings – mental health and community health, inpatient and outpatient with most reports received from inpatient wards. More reports are usually received from community health inpatients than mental health inpatients, potentially a reflection of the difference in the number of inpatient beds;

• most community (outpatient) reports come from the district nursing service. This is to be expected as the service is most involved with the admnistration of medication in a community setting;

• the total medication reports do not yet show a sustained increase in numbers. However data from the last seven months for inpatient settings suggests a shift to increased reporting.

Prescribing and Administration Incidents

Reporting period 1 July 2013 to 30 June 2015

2.3.2Commentary

• Figure 3 above details the number of incidents reported over the last eight full quarters being the period between 1 July 2013 and 30 June 2015;

Prescribing and Administration Incidents

Reporting period 1 July 2013 to 30 June 2015

• Figure 3a details the number of administration and prescribing incidents reported since July 2013. Each bar represents the number of incidents occuring in the twelve months ending in the month indicated;

• the two lines as shown in Figure 3a covered by the right-hand axis detail incidents resulting in harm occuring in the last twelve months;

• prescribing and administration incident reporting is a subset of the overall medicines incidents data showing the main groups where incidents occur. There are no significant changes to the numbers of incidents reported;

• the majority of prescibing incidents reported concern incorrected or incomplete Medication Administration Record (MAR) charts;

• in June 2015, there were no prescribing or administration incidents where severity (harm) was recorded as greater than minor;

• prescribing incidents within an inpatient setting between 1 July 2014 to 30 June 2015 per per 100,000 bed days was 73, compared to the 2013/14 NHS Benchmarking all trusts national average per per 100,000 bed days of 58;
• administration incidents within an inpatient setting between 1 July 2014 to 30 June 2015 per 100,000 bed days was 55, compared to the 2013/14 NHS Benchmarking all trusts national average per per 100,000 bed days of 144;

2.3.3 Actions

• the Medicines Incidents Review Group meets bimonthly to review incident reports and initiate actions where appropriate, including review of the appropriate grading of incidents;

• learning from incidents is passed on to the medicines management linkworkers session, andthrough regular information posters;

• the Pharmacy Team monitors all inpatient wards for medicines-related problems, each week when resource allows. Any problems or concerns identified are immediately fed back to the ward for action;

• incidents related to pharmacy suppliers are followed up by the medicines management team to check that appropriate action is taken. Incident data is reviewed with our suppliers at regular contract review meetings.

2.4Pressure Ulcer Incidents