PUBLIC
Report to the Meeting of the
Oxford Health NHS Foundation Trust
Board of Directors
May 2014
Quality and Safety Report
including Q4 Learning and Development Report
For Information
The following report outlines current areas of concern or priorities across our trust in relation to quality and patient safety for quarter 4 (2013/14). It draws on reports on incidents that have been submitted to the Integrated Governance Committee and the Safety Committee where these reports were reviewed in detail. The areas covered are:
1. Patterns of reported incidents (including pressure ulcer prevention and AWOLs)
2. Restraint and Seclusion reporting
3. Serious incidents requiring investigation
4. Physical and Mental Health Safety Thermometers
5. Safer Care Programme
6. Infection Prevention and Control
7. Care Quality Commission Standards and Regulations
8. Clinical and Professional Development
9. Patient and Personal Safety training (PPST)
10. Complaints, Compliments and PALS Annual Report 2013/14
Recommendation
The Board is asked to note the report.
Author and Title:
Tehmeena Ajmal, Head of Quality and Safety; Rebecca Kelly, Learning from Incidents Lead; Gavin Garman, Head of Nursing, Specialised Services; Helen Bosley, Infection Prevention Control Matron; Jill Bailey, Consultant Nurse and Safer Care Lead, and David Slingo, Head of Learning and Development; Jane Kershaw, CQC Manager
Lead Executive Director: Ros Alstead, Director of Nursing and Clinical Standards
1. A risk assessment has been undertaken around the legal issues that this paper presents and there are no issues that need to be referred to the Trust Solicitors.
2. This paper provides assurance and evidence against the Care Quality Commission Outcome: 4, 5, 7, 8 and 16.
Quality and Safety Report May 2014
Page 1
Executive summary
Incidents
Overall, the level of incident reporting has increased quarter on quarter to a peak in Q2, and while there was a drop in Q4 the levels each quarter have remained consistently higher than the previous year. Numbers of reported green and yellow incidents (low/minor injury or property damage) continue to be the largest numbers of incidents reported. Community physical health services and mental health services continue to remain the two highest reporters. Violence and aggression health and falls are the three highest category of incident reported. The number of incidents in “web holding” (awaiting assessment and risk rating) has increased slightly from 337 in last quarter to 455 in Q4 in line with the National Patient Safety Guidance. We regard a high level of incident reports as indicative of a good safety culture.
Restraint and seclusion
There were 351 reported incidents of physical restraint in quarter four. Totals for the previous four quarters were 338, 293, 406 and 370. The mean number per month for the last eighteen months is 137. Violence and aggression (60% of all incidents) followed by self harm (25%) were the main reasons for restraint.Of the reported incidents 99% were graded as yellow or green (moderate or low risk) or were not yet graded. Only two forms were graded orange this quarter. Two further incidents resulted in serious harm. The number of forms recording the use of ‘pain compliance’ is 4.8% having been 10-24% in the last six quarters. This is therefore a fall in its use and represents just 17 incidents in total over the quarter.
The percentage of restraints recorded as prone has fallen from 25% in quarter 2 to 22% (the figures in the previous quarters were 40%, 32% and 32%). Supine and kneeling restraints have also decreased in frequency. In Q4, the recorded duration of restraint ranged from 1 minute to 9 hours with 9% of restraints (31 incidents) lasting over 1 hour (compared to 2.9% -13% in previous reports).
The total number of reported seclusions in Q4 was 77, compared to 44, 66 and 59 in the previous three quarters. The mean per month for the year of 2013/14 was 20.5, for the calendar year of 2013 it was 19. The main cause for seclusion was violence and aggression.
A review of our training and practice around the use of physical intervention in inpatient mental health wards of patients is progressing well. The providers of alternative physical interventions training and packages aimed at reducing violence and aggression (such as Respect, Maybo and Safewards) have all been visited or have visited our trust to demonstrate their programmes. A project to film patients and staff talking about their experience of restraint to be used in future training is underway. Details of what restraints have been reported, where they occurred, whether anyone was injured and whether prone restraint or pain was utilised is now reported in to the clinical governance team’s weekly review meeting.
Serious incidents requiring investigation
This quarter has seen a further decrease in the number of SIRIs compared with Q3. There has been a 75% reduction in reported SIRIs compared with Q4 in 2012-13. The reduction in suspected suicides and avoidable pressure ulcers has accounted most significantly for this reduction. Over the last two years the overall number of reported SIRIs has reduced by one third. Suspected suicides are the main cause of SIRIs reported in Quarter 4 followed by unexpected death. An analysis by quarter indicates that there is no increasing or decreasing trend although the Q4 data in the last three years has seen a spike in numbers reported. There is no obvious explanation for this. The national picture (Confidentail Inquiry) over the last few years is that suicide rates in the general populaton have started to increase. This rise in not reflected in the figures for our trust. Currently out of date actions total 116 (30% of all actions).
A table top review of seven complaints and five serious incidents in crisis services was undertaken in March 2014 by corporate and divisional senior leads. There was no pattern of factors across the incidents; the key outcome of the review was the need for increased awareness of the risk of suicide in the over 50s with affective disorder and that the teams should be better aware of the rise of suicide in this patient group.
Since 1/4/2012 and 31/3/2014 there have been 3 deaths that would meet the criteria for an inpatient death. None of these deaths occurred in an OHFT inpatient area. All were patients who had been inpatients. One was AWOL and in the criminal justice system in Poland and one was an informal patient not returning from leave. The third death was of a man who was an inpatient at the OUH at the time of their death. All three died by suspected suicide. The days between deaths are 192, 153 and 75.
Safety thermometer
Over the past twelve months the percentage of harm free care has ranged between 86.92 and 90.53% of the 1000-1200 patients assessed each month. This compares with national figures (all participating trusts in England) ranging between 92.2 and 93.62% of the 196,000-210,000 patients assessed each month.
Safer care
Work is continuing on reducing unauthorised absence, reducing medication omissions and improving medication reconciliation, reducing self harm and reducing the use of restraint.
Infection prevention and control
There have been 2 confirmed cases of Clostridium difficile in Q4 taking the total to fourteen (of which twelve have been deemed unavoidable. The care for all fourteen patients was appropriate. There was one case of MRSA (a patient known to be MRSA positive) and no MSSA cases. There were four cases of E-Coli bactaraemia. The increase is consistent with an increase in the general population and the reason for this is being investigated by the Health Protection Agency and Infection Control teams in Oxfordshire. There has been good compliance with hand hygiene and bare below the elbows and decontamination. Enabling staff to attend training has been challenging.
General Quality Update
Learning and Development
A range of development programmes have been available this quarter for all bands of staff including clinical practice, safe working and leadership and development. Learning beyond registration ‘flexible funding’ has enabled 910 staff in bands 5 – 9 to access training and education. Eight staff will start the new Frontline Programme in April 2014 which supports the national drive to improve clinical leadership.
At the start of FY13/14 our performance for all levels of PPST was 81%. This excludes staff not available for training for example due to long term sickness, maternity leave or secondments. At the end of FY13/14 the overall PPST performance was 88%.
Against a target of 100% for performance & development reviews the position of 90% held for all of Qtr 4, showing six percentage points improvement for the full year.
Complaints and PALS Annual Report (2013/14)
This report will be published on our website.
MAIN REPORT
1. Incident reporting
1.1 Total number of incidents by quarter
Overall, the level of incident reporting has increased quarter on quarter to a peak in Q2, and while there was a drop in Q4 the levels each quarter have remained consistently higher than the previous year. This continues to reflect the work undertaken in the Trust to encourage reporting of any and every safety incident. A higher level of reporting demonstrates an improved safety culture where staff see the value and importance of reporting and where improvements are implemented as a result.
Total Number of Incidents by Quarter
Q3 2012/13 / Q4 2012/13 / Q1 2013/14 / Q2 2013/14 / Q3 2013/14 / Q4 2013-42498 / 2615 / 2792 / 2977 / 2954 / 2718
1.2 Incidents by risk rating for the last four quarters
Numbers of reported green and yellow incidents (low/minor injury or property damage) continue, as expected, to be the largest numbers of incidents reported. Since the increase in Q3 in orange incidents the numbers in Q4 have dropped again. The number of incidents in “web holding” (awaiting assessment and risk rating) has increased slightly from 337 in last quarter to 455 in Q4 which may reflect the structural changes which were implemented during this period. The health and safety team continues to remind managers to sign off these incidents. In addition the numbers of incidents in web holding are reported fortnightly to senior managers and divisional directors.
1.3 Incidents by directorate
Community physical health services and mental health services continue to remain the two highest reporters of incidents[1].
1.4 Top six incident categories reported (by month)
The chart below shows the main categories of reported incidents over the last twelve months.
1.5 Violence and aggression
1.5.1 Ashurst PICU is the highest reporter in Q4 with 96 incidents compared with 80 in Q3. Two of these incidents resulted in moderate harm and were both patient on patient assaults. Only twenty incidents resulted in any injury (which was minor).
1.5.2 Sandford ward reported a 50% reduction in incidents in Q4. Of the 40 incidents reported in Q4, only thirteen resulted in any injury or property damage (which was minor). Three quarters of all incidents involved two patients.
1.5.3 Kestrel ward remained in the top three this quarter with a slight reduction in the number of incidents reported from the previous quarter. Of 45 incidents only six resulted in injury (which was minor).
1.6 Health
This is the first time it has featured as one of the top six incidents. This cause group is used primarily for reporting pressure ulcers (avoidable and unavoidable). Abingdon and Wantage District Nursing teams were the two highest reporters respectively. The majority of these were reported as moderate harm which would normally indicate a pressure ulcer category of 2 or lower. Linfoot ward also reported a large number of pressure ulcers this quarter although the majority of these appear to have been patients who were admitted already experiencing pressure damage. None of these reported pressure ulcers were attributable to care provided within OHFT (i.e. avoidable).
16.1 Highfield Oxford was the third highest reporter with Linfoot ward (Witney). Almost all of the incidents in this context were related to patients resisting treatment and none resulted in any injury. One patient was involved in half of the incidents reported.
1.7 Self Harm
Portland ward and Marlborough House Wiltshire continue to be the highest reporters and both have seen an increase in self harm incidents in Q4 compared to Q3. On Portland ward there were 47 ligatures incidents reported with the majority of these involving three patients. All of these resulted in either minor or no injury. One patient was involved in almost half of the overall numbers of self harm incidents on Portland. In Marlborough House Wiltshire, there was one incident resulting in moderate harm, fourteen minor injuries and in the remainder no harm was reported.
1.8 Falls
Linfoot ward, Harding ward and Didcot hospital reporting the highest number of incidents respectively. On Linfoot one patient accounted for at least 25% of reported incidents and 27 of the 28 reported incidents resulted in either minor or no injury. On Harding Older Adult ward of the 37 fall related incidents reported, 35 resulted in minor or no injury and four of the patients were involved in most of the incidents with four or more falls reported each. In Didcot hospital all of the incidents reported resulted in either low or no injury with no clear pattern noted.
1.9 Medication related incidents
Linfoot, Wenrisc and Portland were the three highest reporters of medication incidents in Q4, most commonly relating to omitted doses. On the two community hospital wards, 37 or the 38 incidents resulted in no reported harm. On Portland ward there were only nine reported incidents and six of these were related to patients refusing to take medication and requiring PMVA restraint.
1.10 Communication/confidentiality
The highest three reporters were Single Point of Access, Reception area and Urgent Care. None of the reported incidents resulted in more than minor or no harm. There are no clear themes as numbers are small. The only issue of note was that the majority of incidents reported by Reception relate to difficulties accessing a range of on call staff.
2. Restraint and Seclusion Reporting
2.1 Particular attention is drawn to
· a decline in the use of prone restraint and the use of pain