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DATE OF MEETING: 22 January 2013 Paper Title: CKW Cluster: Quality And Performance Report Responsible Director: Executive Director of Quality and Governance Director of Performance & Commissioning Intelligence Paper Author: Natalie Ackroyd, Business Reporting/Planning Manager, NHS Kirklees Laura Elliott, Head of Quality and Engagement, NHS Wakefield Executive Summary:

Agenda Item: 08 Enclosure: CKWCB/13/16 Category of Paper Tick() Decision and Approval

Position statement Discussion Information FOI Status: Open

To inform NHS CKW Cluster Board of NHS Calderdale (NHSC), NHS Kirklees (NHSK) and NHS Wakefield District (NHSWD), PCTs’ performance against the 2012/13 NHS Operating Framework PRINCIPAL headline outcomes/measures and key quality and safety metrics:-

Any proposed changes or actions required to improve performance will be assessed for any financial implications


NHS risk assessment ‘traffic light’ system incorporated within the performance report


No legal implication/links to legislation have been identified


Meeting performance targets enables patients to access services appropriately.


No impact on staffing / workforce

Outcome of Equality Impact Assessment:

Not applicable

Sub Group/Committee:

NHS CKW individual PCTs Finance and Performance and Quality Groups

Recommendation (s):

• •

NOTE the performance of NHS Calderdale, NHS Kirklees and NHS Wakefield District PCTs’ against key PRINCIPAL outcomes/measures for 2012/13 and key quality and safety metrics; APPROVE the action being taken to address areas of under/over performance; and AGREE additional actions required to address areas of over/under performance.

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CKW Cluster: Quality & Performance Report


Purpose of Report To inform the CKW Cluster Board of NHS Calderdale (NHSC), NHS Kirklees (NHSK) and NHS Wakefield District (NHSWD) PCTs’ performance against the 2012/13 NHS Operating Framework ‘principal’ headline outcomes/measures and key quality and safety metrics.


Background This Quality and Performance report sets out a summary position of Commissioner and Provider performance against the key 2012/13 NHS Operating Framework principal headline outcomes/measures and key quality and safety metrics, details the actual activity against plan, year-to-date position and forecast outturn (end-year position forecast based on year-to-date activity). The main driver for inclusion of the performance indicators is that they are those indicators by which the North of England (NoE) SHA will determine the organisation performance of a PCT Cluster. These indicators are ‘principal’ indicators and are subject to change, a recent addition to the list is NHS Health Checks. The performance team will ensure that amendments are made to the report in line with the view that the NoE SHA take. The quality and safety measures are also identified within the NHS North of England quarterly quality dashboards. The summary incorporates the existing performance risk management “traffic light” system (RAG) to performance monitor/manage progress being made to achieve delivery of the outcomes/measures: Green - target being achieved/no risk to delivery;  Amber - below/above target, situation needs reviewing, remedial action needs Investigation; and  Red - serious deviation from target, corrective action plan required. A point to note is that the ‘data thresholds’ within the Department of Health NHS Performance Assessment Framework were revised in August 2012 and so the data thresholds within the Report have been amended to reflect these changes.

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Quality Issues highlighted 3.1

Healthcare Associated Infections: Meticillin-resistant Staphylococcus Aureus (MRSA) The over-performance highlighted is an issue across the CKW Cluster. The performance matrix shows validated performance to the end of November 2012. However, the following narrative for NHS Wakefield District and MYHT reflects cases reported during December 2012 (data unvalidated). Board members should also note that this report focuses on cases occurring since August. Cases between April and July were reported in the last two Cluster Quality & Performance Reports. 3.1.1 NHS Calderdale Four MRSA bacteraemias have been reported since the beginning of the financial year against an objective of 3. There have been no reported since June 2012. 3.1.2 NHS Kirklees Eleven MRSA bacteraemias have been reported since the beginning of the financial year against an objective of 10. Two pre 48 hour MRSA cases have been reported since the last report: Case – 24.09.2012: patient had a long term urinary catheter, with frequent bypassing and UTIs. Patient had previous history of MRSA colonisation. Patient had a long standing history of leg ulcers- non concordance with dressings; patient refused rehabilitation despite intermediate care involvement. Issues identified social care provider unaware of MRSA status. Antibiotic prescribing by the Nurse Practitioner did not follow the primary care antibiotic formulary. Community nursing failed to refer patient to continence team despite frequent urinary catheter bypassing and frequent catheter changes. The training of the provider of social care on urinary catheter management was sub optimal. Case deemed avoidable. The action plan has been monitored and signed off. Case – 05/11/2012: patient had a history of uncontrolled diabetes and mental health issues. Patient was non compliant with insulin administration. District Nurse had to visit to observe insulin administration not always able to enter household. Patient had CPN involvement but only had contact three times in three months. Patient had previous admissions for hypoglycaemia. MRSA screen on admission in October 2012, result positive. This result was not shared with the ward, patient, GP and Community IPC team. Patient was not commenced on suppression treatment. Case deemed avoidable. 3.1.3 NHS Wakefield District Seven MRSA bacteraemias have been reported since the beginning of the financial year against an objective of 10. However, a further two post-48 hour cases were reported by MYHT in December 2012, therefore the trajectory has been exceeded. The two pre 48 hour MRSA bacteraemia cases attributable to NHS Wakefield since August 2012: Case – 19.08 2012: elderly patient residing in a care home with no underlying medical conditions. No previous admissions to hospital. Patient had antibiotics prescribed by GP for ulcer on toe this was in line with antibiotic prescribing formulary. DDIPC requested typing of MRSA as one other resident in care home known to be colonised, results were different typing therefore no transmission. Learning identified patient not screened when admitted to Pinderfield’s. Case deemed inconclusive. Page 9

Case – 06.10.2012: patient with complex medical history. Patient resided in a care home. Patient had been in inpatient area at MYHT where hospital acquisition of MRSA (resistant strain) had occurred. Patient had MRSA resistant colonisation. Patient had recurrent UTIs. Nurse practitioner requested the care home obtain an MSU and prescribed antibiotics. Issues identified. Care home did not obtain the urine sample and prescribing for a UTI did not follow primary care formulary. Case deemed avoidable. 3.1.4 CHFT Three post 48 hour MRSA bacteraemia have been reported since the beginning of the financial year against an objective of 4. 3.1.5 MYHT Five post 48 hour MRSA bacteraemia has been reported since the beginning of the financial year against an objective of 7 by month 8. However, a further three cases were reported in December 2012; therefore the national HCAI objective has been breached. Of these four cases were in Wakefield residents, three in Kirklees and one in a Leeds resident. Case Five (6.11.2012) apportioned to NHS Wakefield District - The patient was on elderly care ward - Pinderfield’s site. This was a new area at the time of the case; the medical staff were; Locum Consultant, Locum Registrar and Locum SHO. The patient developed painful cellulitis from a peripheral cannula site. The RCA investigation highlighted poor recording of VIP scores. There were gaps in the documentation of the removal of cannulae. The case was avoidable as the policy on line management was not followed. MYHT Medical Director and Infection Control Doctor have reiterated to all clinical staff - ensure all lines are reviewed at every ward round and at least twice a day. Remove lines that are not required and always follow aseptic technique when inserting them. Case Six (9.12.2012) apportioned to NHS Kirklees- Patient on gate 20 – haematology at Pinderfield’s. Patient had Hickman line inserted as a day case. Admitted 29.11.2012 for high dose melphan stem cell transplant. Twelve days post operative developed pyrexia. Blood culture taken as policy. Patient had been screened weekly during the admission and all screens negative. Numerous samples taken to ascertain MRSA acquisition. Skin sore noted on head – swab taken and MRSA positive. Case avoidable as hospital acquired acquisition. No previous acquisition on gate 20. Case Seven (18.12.2012) apportioned to NHS Wakefield District - gate 34 Pinderfield’s. Patient had a cystoscopy and biopsy 7 December 2012, uneventful recovery. Patient known to be previously MRSA colonised, nursed in side room. Readmitted with haematuria, no urine sample taken on admission. Patient attended radiology department 18.12.2012 for insertion of nephrostomy tube. Urine sample taken following procedure - positive for MRSA. Following the insertion of the nephrostomy tube the patient developed a temperature reviewed by FY1. Radiology was unaware of patient MRSA status therefore prophylactic antibiotics were not prescribed prior to the procedure. Case deemed avoidable missed opportunities – urine sample on admission and surgical prophylaxis. Case Eight (22.12.2012) apportioned to NHS Wakefield District – Patient admitted 17 December 2012 with chest pain. Cannula inserted by paramedics tissue re-sited by SHO. Patient completed IVs 18 December 2012, cannula remained insitu. Patient transferred from AAU to ward 20. No review of blood results. Patient informed staff of phlebitis, waited ten hours to be seen by SHO. Blood culture taken by ANTT competent healthcare professional. Case deemed avoidable missed opportunity for removing cannula. Page 10

Due to the MRSA position a HCAI Control Group has been set up which meets weekly chaired by Executive Director. Assistant Director of Nursing and Divisional Clinical Chairs must give assurances on action plans. MYHT Director of Infection Prevention and Control has met with matrons and band 7s on the Pinderfield’s site to ensure aware of the communication from Medical Director and Infection Control Doctor on management of lines and competency training on ANTT; and ensure this had been cascaded down their communication channels. Staff raised concerns on levels of sickness, size of the wards, escalation beds without staffing even though funding available to support the escalation beds and the timely review of patients by doctors. A performance notice for the breach has been served to MYHT. . 3.2

2011 Survey of Adult Inpatients The indicator included in the dashboard shows the composite score for ‘responsiveness to inpatients’ personal needs’ comprising five key questions utilised for the national CQUIN indicator. The 5 questions asked in the National Pt Experience indicator are: 1. Were you involved as much as you wanted to be in decisions about your care and treatment? 2. Did you find someone to talk to about worries and fears? 3. Were you given enough privacy when discussing your care and treatment? 4. Were you told about medication side effects to watch out for when you went home? 5. Were you told who to contact if you were worried about your condition after you left hospital? It shows that both Trusts score below the SHA average for this score, for all ten categories within the survey both CHFT and MYHT scored ‘About the Same’ when compared with other trusts. . The table below shows the response rate plus the number of questions RAG rating for both providers.




Response rate (national 53%)



Green (highest 20% of Trusts)


1 – privacy for examination or treatment

Border – Green/Amber

5 – feel threatened by other patients; posters on hand washing; nurses talking in front of you; nurses washing hands between patients; staff saying different things

Amber (middle 60% of Trusts)



Red (lowest 20% of Trusts)


3 – posters on hand washing and how to complain, information about medicines

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3.2.1 CHFT Overall, when comparing 2011 results with 2010 movement in the quality of care reported were: • 2 questions where there had been a decline in the quality of care received. • 9 questions where improvement had been made. • 51 questions where there was little difference Following discussion at Quality Board the actions and next steps have been agreed and will be overseen by the Calderdale and Greater Huddersfield CCE Quality Groups. The actions include the expected achievements of the local CQUIN to take into account the national survey results, ongoing monitoring of real time patient feedback and other CHFT national surveys via the Quality Board and Quality Group. 3.2.2 MYHT The survey results illustrate an overall improvement in patient experience of care and treatment – for 22 questions the improvement in score from last year is statistically significant. An improvement plan has been agreed, and shared with the Quality Review Group in June 2012, covering waiting times; communication and provision of information on medications; delays in discharge; communication and provision of information on discharge; complaints and views on the quality of care; provision of information on hand washing; and staffing levels. 3.3

2011 National NHS Staff Survey In March 2012 the results from the 2011 national NHS staff survey were published. The results are primarily intended for use by NHS organisations to help them review and improve staff experience so that staff can provide better patient care. The CQC also use the results from the survey to monitor ongoing compliance with essential standards of quality and safety. 3.3.1 MYHT As there is a direct link between staff experience and patient care the results for MYHT available here ware discussed at the Executive Contract Board in May 2012 Their results have deteriorated from the previous year, with more than twenty of the key result areas being worse than 2010. Commissioners highlighted the importance of ensuring the delivery of effective and quality patient care and the need to safeguard the reputation of the Trust, in the light of the results. The next steps identified were to engage staff to determine the root causes and devise appropriate responses, as well as a number of corporate led interventions to improve processes including:• Making it Better Together – a staff engagement initiative; • Monthly RAG reports for appraisal compliance; • Establish of Organisational Wellbeing Strategic Working Committee; • Review of induction programmes; • Introduction of an Employee Assistance Programme; • ‘Energising for Excellence’ nursing conference held in September 2012 showcasing and sharing good practice; and • Review and awareness raising of Trust’s whistle blowing policy.

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Further analysis of results by Clinical Service Group / Division have also been undertaken to allow the identification of key issues and develop more local action plans to address priority areas. There was a further presentation to the Quality Board in December 2012, and an agreement that results of interim local ‘pulse’ surveys and comparative information would be presented to a future meeting. 3.4

Never Events In July 2012 CHFT reported a wrong site surgery Never Event. The patient had a left nephrectomy on 15 March 2012 because the kidney was chronically infected and non-functioning. The following day the patient had to return to theatre because of bleeding. During the second procedure, it transpired that the left kidney remained in situ. An incident report was completed that day, and an internal investigation has been carried out. The investigators have found that during the first operation, the tail of the pancreas was removed instead of the left kidney. The Never Event was reported in line with the Serious Incident policy and procedure. The investigation report and action plan have been received, reviewed and additional information sought for clarification by the Cluster Medical Director. This case is now closed.


Hospital Standard Mortality Rate (HSMR) Although the HSMR for MYHT shows 104.3, the annual rebasing exercise for 2011/12 showed MYHT as a significant negative outlier with an HSMR of 108.2. In June 2012 commissioners were alerted that the 2011/12 rebasing of HSMR nationally was likely to flag MYHT as a significant negative outlier. This is now a standing agenda item at the Quality Board. A paper and action plan was presented to the group in July 2012, which showed that:• •

Non-elective activity is the greatest contributor, mortality is higher at Dewsbury, and across the Trust higher at weekends. An additional outlying diagnostic group pneumonia – has been identified; The following actions are being taken to review:– Palliative care coding; – Patient level data for respiratory medicine; – Adequacy of weekend and out-of-hour cover arrangements; – Consultant teams flagged as outliers; – Escalation of sick patients out of hours.

The Trust then established a Task & Finish Group to review and address the issues identified. Clinical commissioners from both North Kirklees and Wakefield CCG are involved in this Group and working on both remedial actions and sustainability of HSMR figures in the longer term MYHT have strengthened the following governance processes around mortality including:• Continuous monitoring of the HSMR and SHMI; • Use of the Dr Foster Real-Time Monitoring tool to identify any HRG groups, procedures, specialties or consultants with mortality above expected levels; • Use of a ‘Cause of Death’ form for completion by a doctor for every death in hospital. Each case has to be discussed with the responsible consultant to ensure accuracy of the Death Certificate; Page 13

• • • •

Weekly ‘Patient Safety Panel’ which reviews death rates by week, moderate and severe incidents, cardiac arrests and other relevant data and takes action to ensure improvements to care processes are made where necessary; Mortality reviews by all relevant specialties to ensure any avoidable issues are identified and acted upon; Introduction of Global Trigger Tool; A ‘Mortality Steering Group’ will be introduced to monitor key data relevant to mortality, including relevant coding statistics, and to ensure appropriate actions are taken.

Due to the actions being taken data shows that the HSMR has reduced to 93 (Apr-Sept 2012) against a target of a pre-rebased goal for 2012/13 of <90. 3.6

Patient Reported Outcome Measures (PROMs) The latest quarterly PROMs report from the Yorkshire and Humber Quality Observatory was published in August 2012 reflecting 2011/12 information and is available at here. PROMs are discussed quarterly at the respective Quality Boards and the outcomes are fed into the relevant elective/planned care commissioning work streams. 3.6.1 CHFT Since April 2009 NHS Calderdale have worked with CHFT to focus on the response rates for the pre-operative questionnaires (participation rate) driving for an 80% rate. The Trust remains above the 80% target for participation rates overall, and for all procedures except varicose veins. This is an improvement on 2010/11. Work is continuing on both the participation rates and the response rates to the post-operative questionnaire. The Trust remains as a positive outlier for outcomes for both knee replacement and hip replacement. 3.6.2 MYHT The report shows that MYHT continues to have low participation rates – significantly lower than regional and national averages. Participation rates have also fallen between 2010/11 and 2011/12 for all procedures. The report gives provisional data for health gain for 2011-12 and identifies MYHT as a negative outlier following Hip Replacement (using Oxford Score) and Knee Replacement (using EQ5D). The Yorkshire & Humber Quality Observatory recommends that organisations should work to get participation rates as high as possible to increase the usefulness of the outcomes data. The contract with MYHT states that the provider should administer pre-operative PROMs questionnaires to patients ensuring that the collected data is as representative of their patient populations as possible. PROMs are routinely monitored through Quality Board arrangements. MYHT are developing a remedial action plan which will be discussed at their Clinical Quality and Governance Committee and brought to the MYHT Quality Review Group in January 2013.

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CQUINs The overview of the development of local CQUIN schemes including implementation, trajectories setting, improvement plans and recommending these to the relevant Contract Management Boards continues to be managed through the Clinical Quality Board arrangements. All providers submitted Quarter 2 returns by the specified deadline (31 October 2012). For Quarter 2, our main providers achieved the following performance:



Q4 comments



MYHT – Acute


MYHT – Community




Did not achieve access to crisis, routine and psychological therapies indicators.



At the end of quarter 2, further trajectory setting was considered and is now complete. These trajectories had not been set sooner as had been dependant on the validation of new data collection system; this had applied to 10 of the 54 indicators.

Spire Elland Hospital


BMI Huddersfield


Spire Methley Park





Did not achieve COPD discharge care bundle indicator

Dementia training figures indicator is rated as Amber

CQC Reviews of Compliance 3.8.1 MYHT The CQC made an unannounced inspection to the Day Surgical Unit at PGH on 5 September 2012. A condition of registration was issued by the CQC on Thursday 13 September 2012 that the Trust should not admit any patients for a period exceeding 23 hours to the unit. During the visit, CQC judged that the provider was non-compliant with 3 of the 4 outcomes assessed. These were; Outcome 1 - people’s privacy and dignity were not being maintained due to the environment in which they were staying. Outcome 8 - there were not effective systems in place to reduce the risk and spread of infection. Page 15

Outcome 9 – people who use the service, staff and visitors were not adequately protected against the risks of unsafe or unsuitable premises. In response, the Trust has now improved the Unit to bring it up to the standard required for short stay inpatients including: • Installation of bedside lights; • Improvement of the catering service so that patients now have the same choice and standard of food as any other ward in the hospital; • Installation of lockers at every bed space; • Improvements to signage and the introduction of swipe card access for the theatre area; • There will also be improvements to the washing facilities with the installation of two shower units in the coming week. An action plan was presented to the Quality Board in November 2012. This included actions to provide assurance that:• No inappropriate personnel are able to access the theatre complex; • Essential information is cascaded down to staff on the unit; • Ensure that appropriate patients are allocated to the unit. Further inspections were made to all three hospital sites on 12 and 13 November 2012 to check the actions taken to meet essential standards following previous CQC inspections in July and September 2012 at Pinderfields and Dewsbury. The inspection at Pontefract was a routine inspection as part of scheduled visits. At Pontefract and Dewsbury the CQC judged that the provider was compliant with all 7 outcomes assessed. At Pinderfields there was a minor concern about the care and treatment patients were receiving, particularly during the admission and discharge experience of patients stay in hospital and patients receiving outpatient treatment (Outcome 4). In order to assure the CQC of the provider’s continued effectiveness of quality assurance and risk management systems a monthly report on the Trust’s approach to staff engagement and communication; and the Risk Management Committee’s responses to Serious Incidents and complaint handling has been requested. The action plan and monthly report will be presented to the Quality Board from February 2013. The CQC also concluded that the actions taken to improve the complaints process, the environment on Gate 40 (Day Surgical Unit), and the staffing, dignity and respect for elderly medicine wards at DDH had ensured compliance with the essential standards. 3.8.2 White Rose Surgery PMS Plus Ltd The CQC carried out an unannounced inspection in August 2012. During the visit, CQC judged that the provider was non-compliant with 3 of the 5 outcomes assessed. These were; Outcome 4 - WRS PMS Plus Ltd did not have effective arrangements in place to audit and review the resuscitation equipment in place should a patient emergency arise. Outcome 12 - Appropriate checks were not being undertaken before staff began work for the WRS PMS Plus Ltd. Page 16

Outcome 16 – WRS PMS Plus Ltd does not have an effective system in place to regularly assess and monitor the quality of service that people receive, as there are no functioning governance structures in place. The provider submitted their response and action plan to the CQC. Actions include; • Review of resuscitation protocol; • Risk assessments and monthly inspection of emergency equipment; • Review of staff records to ensure compliance with hr procedures and employment checks; • Completion of clinical risk assessments; • Analysis of patient surveys and reporting to the provider executive management group; and • Development of audit programme. 3.8.3 Spectrum The CQC carried out unannounced inspections to two locations where services are provided by Spectrum during October 2012. During the visit to Central Clinic the CQC judged that the provider was non-compliant with 1 of the 5 outcomes assessed - Cleanliness & infection control. Spectrum was not following appropriate guidance regarding infection control. It was not clear whether cleaning schedules were being followed, the cleaning storage room was cluttered and there was insufficient segregation of clean and dirty equipment. This has been discussed with Spectrum at the Contract Management Board on 30 October 2012 and a number of actions have already been undertaken to ensure future compliance. 3.8.4 CHFT The CQC carried out an unannounced inspection in November 2012. During the visit, CQC judged that the provider was non-compliant with 1 of the 5 outcomes assessed. Outcome 21 - People were not protected from the risks of unsafe or inappropriate care and treatment – one document reviewed was incomplete and illegible, the patient and their carers had not been consulted for a DNAR decision, and instructions for one patient were found in another patient’s records - which had a moderate impact on people using the service. The Trust has developed a detailed action plan regarding DNACPR, which was presented to the Quality Board on 18 December 2012. It was established that all the staff on the ward were aware that the patient was for was resuscitation but the form had not been removed from the patient’s record. Record keeping is being looked at alongside the review of nursing documentation. 3.8.5 BMI Huddersfield The CQC carried out an unannounced inspection in November 2012. During the visit, CQC judged that the provider was non-compliant with 1 of the 5 outcomes assessed. Outcome 4 – Evidence was not available to ensure that the emergency arrangements for the urgent provision of blood and blood products including out of hours had been tested and timed. The CQC judged this could have a moderate impact on people using the service. A request has been made to the provider to share the report and action plan in response to the inspection. This will be followed up at the March 2013 Contract and Quality Meeting with BMI. Page 17

NHS Calderdale have agreed a process with all independent sector providers have a robust process in place that ensures commissioners are informed of inspections prior to the inspection reports being published. 3.9

Quality Handover Document On the 18th of December 2012, on behalf of the CKW Cluster Board the Cluster Governance Committee received Quality Handover Document in its second draft status. The Quality Handover Document been mandated by the National Quality Board and created to capture and record the quality information held by the three primary care trusts within the CKW cluster namely; Calderdale, Kirklees and Wakefield. These are the SENDER organisations who are preparing to transfer quality intelligence and information to RECIEVER organisations, such as Clinical Commissioning Groups or the National Commissioning Board, Public Health England etc. The implementation of the Health and Social Care Act 2012 will affect almost every part of the NHS, and whilst legislation seeks to improve the quality of care for patients, it is known that any period of structural change can put quality and safety at risk. The National Quality Board (NCB) set expectations that the discipline and rigour that occurs in financial handover should be applied to matters of quality. The NCB describes a form of ‘clinical due diligence’ and set out formal handover arrangements for PCTs and SHAs (the sending organisations) to ensure that organisational memory on quality issues was captured and communicated to the receiving organisations (CCGs, local Authority, NHSCB). For CKW Cluster a Quality & Safety Summary has been produced on a quarterly basis since June 2011, as a legacy document. This is shared with the SHA, the CCE Quality Group and available on the intranet at The National Quality Board published its ‘HOW TO GUIDE: Maintaining quality during transition: preparing for handover in May 2012, which required Primary Care Trusts to articulate its plans to transfer quality intelligence to its most appropriate destination. The initial plan was developed by the Heads of Quality & Safety from local CCGs and presented to and approved by the Cluster Governance Committee on 20 June 2012, and the first draft presented to the CKW cluster committee on behalf of the CKW board in October 2012. The national document states that CEOs of receiving organisations should nominate a named transition lead, responsible for the receipt of functions. The Medical and Nursing Directors, or equivalent, should share responsibility for receiving the quality handover document, and taking any necessary steps to ensure risk continues to be managed. The plan states that the handover document should be taken to the final board meeting of the sending organisation in March 2013 and receiving organisation should receive the document formally at its first public board meeting in April 2013. The process of transferring quality information will not be complete until March 2013 in line with the timeline for PCT closedown. Because all documents are working documents and contain confidential information they are currently exempt from FOI requests. Three of the four National Commissioning Boards areas have already received requests for the Quality Handover documents to be released however the are currently exempt. Page 18

The format of the Quality Handover Document includes: Section 1: Executive Summary Section 2: NHS Calderdale, Kirklees and Wakefield Healthcare System Section 3: Key Contacts Section 4: Quality Profile Section 5: Information Sources and Access Section 6: Record of Handover Meetings (Face to face - Assembly) Section 7: Risk Register (at handover) Section 8: Approvals Process (Sign Off Governance) Section 4 contains a quality profile for each existing PCT area and these are attached as NHS Calderdale (Appendix Two) NHS Kirklees (Appendix Three) and NHS Wakefield (Appendix Four). The Quality Handover Documentation were submitted to the Strategic Health Authority (SHA) on the 7th of December 2012 prior to the SHA presenting them to the NHS North of England (NoE) Transition Board. The NHS NoE Transition Board will receive the plans on behalf of the National Quality Board. After the Transition board a letter will be sent to all PCT CEOs and cluster Directors of Nursing. The letter will include specific feedback from each cluster areas submissions describing the next steps and also confirmation of submission dates for FINAL, 3rd version documents. At this stage the final dates is likely to be the 15th March 2013. However the Cluster Governance Committee have requested that they receive the document in its final draft status in February 2013 so it can be prepared for final publication with the premise of publishing as much of the information it as possible. The Quality Handover Documents will taken to the final board meeting of the sending organisation in March 2013 and receiving organisation should receive the document formally at its first public board meeting in April 2013.

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Performance Issues Highlighted 4.1

Issues highlighted within the performance report:Outcome/Measure Cancer: 62 day urgent GP referral to treatment

Calderdale RAG*

Kirklees RAG*

Wakefield RAG*

Clostridium Difficile Mixed Sex Accommodation Ambulance Response Times Cat A 8min NHS Health Checks Health Visitors * *RAG status based on NHS Performance Assessment Framework thresholds, where published, if not known, then actual versus plan is applied.


Cancer: 62 Day urgent GP referral to treatment The under-performance highlighted is with NHS Wakefield District with issues predominantly at MYHT. 4.2.1


Key issues: • MYHT is achieving the national cancer waiting times performance target of 85% with a YTD position of 88.1% April-October 2012; •

The performance of 82.7% against a target of 85% for NHS Wakefield CCG patients with a YTD position of 84.59%. The underachievement is due to 13 out of 75 patients treated breaching the 62 day pathway in October;

Of these 13 patients, 5 cases were solely MYHT breaches while the other 8 were shared breaches between MYHT and Leeds. The breach dates ranged from 64 days to 153 days; and

Some of the breaches reason given were due to patient choice (holidays), some were due to being complex cases thus needing longer/further investigations e.g. lung, urology haematological and some were due to delays in surgery at Leeds possibly due to late handover from MYHT.

Key Actions: • Commissioners will request further detailed breach analysis to be undertaken by the Trust and will review outcomes with the MY Cancer Team.

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Healthcare Associated Infections: Clostridium Difficile (C.Diff) The over-performance highlighted is the FOT based on YTD activity with NHS Calderdale and NHS Kirklees. NHS Calderdale There have been 53 clostridium difficile infection (CDI) cases attributed to NHS Calderdale against an objective of 44. The objective was breached in October, however there has been an improving picture since the breach was confirmed with 3 cases reported in November and 2 cases reported in December (December data not validated). Of the 53 cases, 11 were diagnosed in the community (GP samples), 21 were diagnosed on admission to hospital and the remainder were diagnosed during hospital admission in the local acute Trust, Leeds or Bradford hospitals. A review of the cases to date has been completed with a number of risks associated with CDI noted more frequently than others. The most common risk factor highlighted in the review was recent hospital inpatient episode. This was followed closely by antibiotic use, a third of which were cephalosporins. Proton pump inhibitor (PPI) use has also been noted in approximately 50% of cases. A previous history of CDI had been reported rarely in previous years but has been seen more this year. Lessons learned from investigations have also been identified. These include communication and documentation issues, urinary catheter management issues, prescribing issues and other care issues. Actions to address both the risks and the lessons learned are part of the CDI improvement plan for the health economy. NHS Kirklees NHS Kirklees is over planned trajectory to date with 83 cases reported to1 April â&#x20AC;&#x201C; 30 November 2012. Of these 51 were community samples of which 14 resided in care homes. Weekly data continues to be reviewed and submitted to NHS North of England HCAI lead with monthly mapping of all cases to identify trends. The CDI alert cards are sent by the infection prevention and control team to patients following a positive sample, and the information copied to their GP. Enhanced surveillance by the infection prevention and control team continues and work is progressing with medicines management to evaluate links between CDI â&#x20AC;&#x201C; antibiotic prescribing and PPI prescribing.


Eliminating Mixed Sex Accommodation No in-month over-performance highlighted for November 2012, the last reported breach was in June 2012, however, year-to-date over-performance is highlighted across the CKW Cluster with issues at Calderdale and Huddersfield Foundation Trust and Mid Yorkshire Hospital Trust. Previous over-performance, reasons and actions being taken, were provided in the last CKW Cluster Quality & Performance Reports.

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Ambulance Response Times The under-performance highlighted is with NHS Wakefield District. NHS Wakefield District Yorkshire Ambulance Service (YAS) are currently failing to meet the Red 1 emergency ambulance target threshold of 75%. The Yorkshire Ambulance Service is continuing to develop action plans, and staff rota’s to address the issue of underperformance on the red 1 category calls. It should be noted however that for 12/13 Ambulance services are monitored against the combined Red category performance (Red 1 & Red 2 calls) of 75% and YAS are forecasting achievement of this target. NHS Bradford as ‘Host’ Commissioner for the Yorkshire Ambulance Service Contract are continuing to work with the Provider to ensure the activity profile for the year has been calculated correctly and to establish pathways to help reduce demand going forward. The Yorkshire Ambulance Service are in the process of pulling together their Integrated Business Plan which indicates an anticipated growth in Emergency Ambulance Activity by 3% each year for the next 5 years. It is expected that the commencement of the 111 service could have a further impact on activity growth.


NHS Health Checks The under-performance highlighted is with NHS Kirklees. A Local Enhanced Service to deliver Health Checks started in June 2012. A total of 66/74 practices are signed up to deliver the LES and those not signed up are being followed up by the relevant CCG. The CCG’s are in the process of developing an inter-practice referral system to pick up the eligible population of those practices who continue to opt out of the LES. A number of practices who signed up to the LES were not ready in time to submit data for Q2 because of set up, implementation and staff issues. While we are confident we will meet performance requirements for Q3 and Q4 but the fact that there are no performance figures for Q1 because the LES didn’t start until Q2 means that our ability to meet the end of year performance expectations could be affected.


Health Visitors The under-performance highlighted is with NHS Wakefield District with issues predominantly at Mid Yorkshire Hospital Trust. As at the end of October the number of health visitors in post at Mid Yorkshire is 65.66 WTE with a further 4.6 WTE in post but not on the statutory return which is below target of 73.5%. The trust is also carrying 1.66 WTE vacancy and is funded for a further 8 WTE health visitors. Actions being taken to address the underperformance are :Page 27

• • • • • • • 4.8

Currently there are 18 nurses currently undertaking full or part time health visiting student placements; Continued development of professional networks/meetings are ongoing; Leadership development for band 7 team leaders continues; Participation in SHA workstreams for Preceptorship, supervision, education and training; Staff newsletter developed and sent out on monthly basis to inform of real time progress of implementation plan as part of the communication and engagement strategy development; Road shows are planned and now being rolled out; and Exit interviews for all leavers were held.

Flu In line with the Chief Medical Officer’s letter on Seasonal Flu Vaccination (, NHS North of England is aiming for the increased rate of 70% uptake by Health Care Workers in 2012/13. This has been shown to be achievable in trusts which implement best practice, and it is regarded as a necessary part of the planning for winter pressures. Currently (w/e 28/12/12) both Calderdale and Huddersfield Foundation Trust (CHFT) and Mid Yorkshire Hospitals Trust (MYHT) are not meeting this standard. This is being addressed through the Quality Boards or Contract Boards with CHFT and MYHT where action plans to improve these numbers will be requested.

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Recommendations The CKW Cluster Board is asked to: -

NOTE NHS Calderdale, NHS Kirklees and NHS Wakefield District, PCTsâ&#x20AC;&#x2122; performance against the principal headline outcomes/measures; APPROVE the action being taken to address areas of under/over performance; and AGREE additional actions required to address areas of over/under performance.

Report Owners:

Peter Flynn; Director of Performance & Commissioning Intelligence; and Sue Cannon, Executive Director of Quality & Governance

Report Author:

Natalie Ackroyd: Business Reporting and Planning Manager (NHS Kirklees) Laura Elliot: Head of Quality (NHS Wakefield District)

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