Annual Organisational Audit (AOA) of directors/Board... · Annual Organisational Audit Annex C (end of year questionnaire) Superseded Docs (if applicable) Contact Details for further

Annual Organisational Audit (AOA) End of year questionnaire 2018-19

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BRP Agenda Item A7(i)

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Please do not use this version of the form to submit your response. 2

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Annual Organisational Audit Annex C (end of year questionnaire)

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Lynda NortonProfessional Standards TeamQuarry House Leeds LS2 7UE 0113 825 1463

Document StatusThis is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of this document are not controlled. As a controlled document, this document should not be saved onto local or network drives but should always be accessed from the intranet

The AOA (Annex C of the Framework for Quality Assurance) is a standardised template for all responsible officers to complete and return to their higher level responsible officer via the Revalidation Management System. AOAs from all designated bodies will be collated to provide an overarching status report of progress across England.

By 00 January 1900

Lynda Norton

Medical Directors, NHS England Regional Directors, GPs

#VALUE!

A Framework for Quality Assurance for Responsible Officers & Revalidation April 2014 Gateway ref 01142

2017/18 AOA cleared with Publications Gateway Reference 07760

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24 March 2019

000182

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OFFICIAL

Annual Organisational Audit (AOA)

End of year questionnaire 2018-19

Version number: 1.0

First published: 4 April 2014

Updated: 24 March 2015, 18 March 2016, 24 March 2017, 23 March 2018,

January 2019

Prepared by: Lynda Norton Project Manager for Quality Assurance, NHS England

Classification: OFFICIAL

Promoting equality and addressing health inequalities are at the heart of NHS England’s values. Throughout the development of the policies and processes cited in this document, we have:

Given due regard to the need to eliminate discrimination, harassment and victimisation, to advance equality of opportunity, and to foster good relations between people who share a relevant protected characteristic (as cited under the Equality Act 2010) and those who do not share it; and

Given regard to the need to reduce inequalities between patients in access to, and outcomes from healthcare services and to ensure services are provided in an integrated way where this might reduce health inequalities.


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Contents

Contents ..................................................................................................................... 4

1 Introduction.......................................................................................................... 5

2 Guidance for submission ..................................................................................... 7

3 Section 1 – The Designated Body and the Responsible Officer .......................... 8

4 Section 2 – Appraisal......................................................................................... 11

5 Section 3 – Annual Board Report and Statement of Compliance...................... 15

6 Section 4 – Comments ...................................................................................... 16

7 Reference.......................................................................................................... 17


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1 Introduction

The Annual Organisational Audit (AOA) is an element of the Framework of Quality Assurance (FQA) and is a standardised template for all responsible officers to complete and return to their higher level responsible officer. AOAs from all designated bodies will be collated to provide an overarching status report of the responsible officer function across England. Where small designated bodies are concerned, or where types of organisation are small, these will be appropriately grouped to ensure that data is not identifiable to the level of the individual.

As the first cycle of medical revalidation is now complete, it is the right time to update the FQA and its underpinning annexes. The update started by reviewing the AOA and taking account of the feedback received at the beginning of this work, we have produced a slimmed down questionnaire for responsible officers to compete for the 2018/19 exercise.

In response to feedback from designated bodies, we have simplified the categories of appraisals in the 2018/19 AOA to:

• Category 1 - a single figure of completed medical appraisals

• Category 1a – fully compliant appraisal figure (optional)

• Category 2 – no change (‘approved missed’ e.g. maternity, sickness)

• Category 3 – no change (‘unapproved missed)


This slimmed down AOA concentrates primarily on the quantitative measures of previous AOAs, the numbers of doctors with a prescribed connection and their appraisal rates. As the systems and processes that support medical revalidation are established, the emphasis has moved to reporting on how these should be developed year on year through the newly revised Board report instead. The Board report is also a component of the FQA. In time, we expect to introduce suitable quantitative measures about the remaining components of the responsible officer function, for example responding to concerns, monitoring of performance and identity checks.

The AOA 2018/19 questionnaire is divided into four sections:

Section 1: The designated body and the responsible officerSection 2: Appraisal Section 3: Annual Board report and Statement of ComplianceSection 4: Additional Comments

The questionnaire is to be completed by the responsible officer on behalf of the designated body for the year ending 31 March 2019. Inputting the information can be appropriately delegated. The completed questionnaire should be submitted before or by the deadline

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The final date for submission will be detailed in an email containing the link to the electronic version of the form, which will be sent after 31 March 2019.Whilst NHS England is a single designated body, for this audit, the national, regional and local offices of NHS England should answer as a ‘designated body’ in their own right..

Following completion of this AOA exercise, designated bodies should:

• Consider using the information gathered to produce a status report and to conduct areview of their organisations’ appraisal developmental needs.

• Complete their Board report and submit it to NHS England by 27 September 2019.The Board report template has also been revised as described above and nowincludes the annual statement of compliance. The new version will enabledesignated bodies to review and develop their systems and processes. It will alsoenable them to provide assurance that they are supporting patient care by fulfillingtheir statutory obligations in respect of the responsible officer function.

For further information, references and resources can be found at page 16 www.england.nhs.uk/revalidation


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2 Guidance for submission

Guidance for submission:

• A small number of questions require a ‘Yes’ or ‘No’ answer. To answer ‘Yes’, youmust be able to answer ‘Yes’ to all the statements listed under ‘to answer ‘Yes’’

• Please do not use this version of the questionnaire to submit your designated body’sresponse.

• You will receive an email with an electronic link to a unique version of this form foryour designated body.

• You should only use the link received from NHS England by email, as it is unique toyour organisation.

• Once the link is opened, you will be presented with two buttons; one to download ablank copy of the AOA for reference, the second button will take you to the electronicform for submission.

• Submissions can only be received electronically via the link. Do not completehardcopies or email copies of the document.

• The form must be completed in its entirety prior to submission; it cannot be part-completed and saved for later submission.

• Once the ‘submit’ button has been pressed, the information will be sent to a centraldatabase collated by NHS England.

• A copy of the completed submission will be automatically sent to the responsibleofficer.

• Please be advised that Questions 1.1-1.3 may have been automatically populatedwith information previously held on record by NHS England. The submitter isresponsible for checking the information is correct and should update the informationif and where required before submitting the form.


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3 Section 1 – The Designated Body and the Responsible Officer

SSection 1 The Designated Body and the Responsible Officer

1.1 Name of designated body: Head Office or Registered Office Address if applicable line 1 Address line 2 Address line 3 Address line 4 City County Postcode

GMC registered last name Phone

Responsible officer: Title GMC registered first name GMC reference number Email


Medical Director: Title GMC registered first name GMC reference number Email


Clinical Appraisal Lead: Title GMC registered first name GMC reference number Email Chief executive (or equivalent): Title First name Last name GMC reference number (if applicable) Phone Email


No Medical Director

No Clinical Appraisal Lead

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1.2 Type/sector of designated body:

(tick one) NHS

Acute hospital/secondary care foundation trust

Acute hospital/secondary care non-foundation trust

Mental health foundation trust

Mental health non-foundation trust

Other NHS foundation trust (care trust, ambulance trust, etc)

Other NHS non-foundation trust (care trust, ambulance trust, etc) Special health authorities – NHS Litigation Authority, now NHS Resolution, NHS Improvement, NHS Blood and Transplant, etc)

NHS England

NHS England (Local office)

NHS England (regional office)

NHS England (national office)

Independent / non-NHS sector

(tick one)

Independent healthcare provider

Locum agency

Faculty/professional body (FPH, FOM, FPM, IDF, etc)

Academic or research organisation

Government department, non-departmental public body or executive agency

Armed Forces

Hospice

Charity/voluntary sector organisation

Other non-NHS (please enter type)


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1.3 The responsible officer’s higher level NHS England North responsible officer is based at: [tick one] NHS England Midlands and East

NHS England London

NHS England South East

NHS England (National)

Department of Health

Faculty of Medical Leadership and Management - for NHS England (national office) only

Other (Is a suitable person)

1.4 A responsible officer has been nominated/appointed in compliance with the regulations.

To answer ‘Yes’: • The responsible officer has been a medical practitioner fully registered under the Medical Act 1983

throughout the previous five years and continues to be fully registered whilst undertaking the role ofresponsible officer.

• The responsible officer has been formally nominated/appointed by the board or executive of theorganisation.

Yes

No


NHS England South West

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Section 2 – Appraisal Section 2 Appraisal

2.1 IMPORTANT: Only doctors with whom the designated body has a prescribed connection at 31 March 2019 should be included. Where the answer is ‘nil’ please enter ‘0’.

1 1a 2 3

Num

ber of Prescribed

Connections

Com

pleted A

ppraisal (1)

(Optional)

Com

pleted A

ppraisal (1a)

Approved

incomplete or

missed appraisal

(2)

Unapproved

incomplete or

missed appraisal

(3)

Total See guidance notes on pages 12-14 for assistance completing this table

2.1.1 Consultants (permanent employed consultant medical staff including honorary contract holders, NHS, hospices, and government /other public body staff. Academics with honorary clinical contracts will usually have their responsible officer in the NHS trust where they perform their clinical work).

2.1.2 Staff grade, associate specialist, specialty doctor (permanent employed staff including hospital practitioners, clinical assistants who do not have a prescribed connection elsewhere, NHS, hospices, and government/other public body staff).

2.1.3 Doctors on Performers Lists (for NHS England and the Armed Forces only; doctors on a medical or ophthalmic performers list. This includes all general practitioners (GPs) including principals, salaried and locum GPs).

2.1.4 Doctors with practising privileges (this is usually for independent healthcare providers, however practising privileges may also rarely be awarded by NHS organisations. All doctors with practising privileges who have a prescribed connection should be included in this section, irrespective of their grade).

2.1.5 Temporary or short-term contract holders (temporary employed staff including locums who are directly employed, trust doctors, locums for service, clinical research fellows, trainees not on national training schemes, doctors with fixed-term employment contracts, etc).

2.1.6 Other doctors with a prescribed connection to this designated body (depending on the type of designated body, this category may include responsible officers, locum doctors, and members of the faculties/professional bodies. It may also include some non-clinical management/leadership roles, research, civil service, doctors in wholly independent practice, other employed or contracted doctors not falling into the above categories, etc).

2.1.7 TOTAL (this cell will sum automatically 2.1.1 – 2.1.6).

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2.1 Column - Number of Prescribed Connections: Number of doctors with whom the designated body has a prescribed connection as at 31 March 2019 The responsible officer should keep an accurate record of all doctors with whom the designated body has a prescribed connection and must be satisfied that the doctors have correctly identified their prescribed connection. Detailed advice on prescribed connections is contained in the responsible officer regulations and guidance and further advice can be obtained from the GMC and the higher level responsible officer. The categories of doctor relate to current roles and job titles rather than qualifications or previous roles. The number of individual doctors in each category should be entered in this column. Where a doctor has more than one role in the same designated body a decision should be made about which category they belong to, based on the amount of work they do in each role. Each doctor should be included in only one category. For a doctor who has recently completed training, if they have attained CCT, then they should be counted as a prescribed connection. If CCT has not yet been awarded, they should be counted as a prescribed connection within the LETB AOA return.

Column - Measure 1 Completed medical appraisal: A completed annual medical appraisal is one where either:

a) All of the following three standards are met:i. the appraisal meeting has taken place in the three months preceding the agreed appraisal due date*,ii. the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28

days of the appraisal meeting,iii. the entire process occurred between 1 April and 31 March.

Or b) the appraisal meeting took place in the appraisal year between 1 April and 31 March, and the outputs of

appraisal have been agreed and signed-off by the appraiser and the doctor, but one or more of the threestandards in a) has been missed. However, the judgement of the responsible officer is that the appraisal hasbeen satisfactorily completed to the standard required to support an effective revalidation recommendation.

For doctors who have recently completed training, it should be noted that their final ACRP equates to an appraisal in this context.

Column - Measure 1a (Optional) Completed medical appraisal: For designated bodies who wish to and can report this figure, this is the number of completed medical appraisals that meet all three standards defined in Measure 1 a) above. This figure is not reported nationally and is intended to inform the internal quality processes of the designated body.

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Column - Measure 2: Approved incomplete or missed appraisal: An approved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of a Category 1 completed annual medical appraisal, but the responsible officer has given approval to the postponement or cancellation of the appraisal. The designated body must be able to produce documentation in support of the decision to approve the postponement or cancellation of the appraisal for it to be counted as an Approved incomplete or missed annual medical appraisal.

Column - Measure 3: Unapproved incomplete or missed appraisal: An Unapproved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of a Category 1 completed annual medical appraisal, and the responsible officer has not given approval to the postponement or cancellation of the appraisal. Where the organisational information systems of the designated body do not retain documentation in support of a decision to approve the postponement or cancellation of an appraisal, the appraisal should be counted as an Unapproved incomplete or missed annual medical appraisal.

Column Total: Total of columns 1+2+3. The total should be equal to that in the first column (Number of Prescribed Connections), the number of doctors with a prescribed connection to the designated body at 31 March 2019.

* Appraisal due date:A doctor should have a set date by which their appraisal should normally take place every year (the ‘appraisal duedate’). The appraisal due date should remain the same each year unless changed by agreement with the doctor’sresponsible officer. Where a doctor does not have a clearly established appraisal due date, the next appraisal shouldtake place by the last day of the twelfth month after the preceding appraisal. This should then by default become theirappraisal due date from that point on. For a designated body which uses an ‘appraisal month’ for appraisal scheduling,a doctor’s appraisal due date is the last day of their appraisal month.For more detail on setting a doctor’s appraisal due date see the Medical Appraisal Logistics Handbook: (NHS England2015).

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2.2 Every doctor with a prescribed connection to the designated body with a missed or incomplete medical appraisal has an explanation recorded

If all appraisals are in Categories 1, please answer N/A.

To answer Yes:

• The responsible officer ensures accurate records are kept of all relevant actions and decisions relating to theresponsible officer role.

• The designated body’s annual report contains an audit of all missed or incomplete appraisals (approved andunapproved) for the appraisal year 2018/19 including the explanations and agreed postponements.

• Recommendations and improvements from the audit are enacted.Additional guidance: A missed or incomplete appraisal, whether approved or unapproved, is an important occurrence which could indicate a problem with the designated body’s appraisal system or non-engagement with appraisal by an individual doctor which will need to be followed up.

Measure 2: Approved incomplete or missed appraisal: An approved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of a Category 1 completed annual medical appraisal, but the responsible officer has given approval to the postponement or cancellation of the appraisal. The designated body must be able to produce documentation in support of the decision to approve the postponement or cancellation of the appraisal for it to be counted as an Approved incomplete or missed annual medical appraisal.

Measure 3: Unapproved incomplete or missed appraisal: An Unapproved incomplete or missed annual medical appraisal is one where the appraisal has not been completed according to the parameters of a Category 1 completed annual medical appraisal, and the responsible officer has not given approval to the postponement or cancellation of the appraisal. Where the organisational information systems of the designated body do not retain documentation in support of a decision to approve the postponement or cancellation of an appraisal, the appraisal should be counted as an Unapproved incomplete or missed annual medical appraisal.

Yes No

N/A

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5 Section 3 – Annual Board Report and Statement of Compliance

Section 3

3.


The last Annual Board Report was signed off on:

The last Statement of Compliance was signed off on:

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6 Section 4 – Comments

Section 4 Comments

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7 Reference Sources used in preparing this document

1. The Medical Profession (Responsible Officers) Regulations 2010 (Her Majesty’s Stationery Office, 2013)

2. The Medical Profession (Responsible Officers) (Amendment) Regulations 2013 (Her Majesty’s Stationery Office, 2013)

3. The Medical Act 1983 (Her Majesty’s Stationery Office, 1983)

4. The National Health Service (Performers Lists) (England) Regulations 2013

5. Revalidation: A Statement of Intent (GMC and others, 2010)

6. Guidance on Colleague and Patient Questionnaires (GMC, 2012)

7. Effective clinical governance for the medical profession: A handbook for organisations employing, contracting or overseeing the practice of doctors (GMC 2018)

8. The GMC protocol for making revalidation recommendations: Guidance for responsible officers and suitable persons (GMC, 2012, updated in 2014)

9. Providing a Professional Appraisal (NHS Revalidation Support Team, 2012)

10. Appraisal in the Independent Health Sector (British Medical Association and Independent Healthcare Advisory Services, 2012)

11. Joint University and NHS Appraisal Scheme for Clinical Academic Staff (Universities and Colleges Employers Association, 2002, updated in 2012)

12. Preparing for the Introduction of Medical Revalidation: a Guide for Independent Sector Leaders in England (GMC and Independent Healthcare Advisory Services, 2011, updated in 2012)

13. Medical Appraisal Logistics Handbook (NHS England, 2015)


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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Healthcare Associated Infections Final Quarter Review & Annual Report

1st April 2018 to 31th March 2019

June 2019

Agenda item A7(i)a BRP

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Contents:

Page Introduction 3 Executive Summary 4 Section 1: Overview of Healthcare Associated Infections (HCAIs) 5 Section 2: Clostridium difficile (C. difficile) Infections 15 Section 3: Methicillin-resistant Staphylococcus Aureus (MRSA) Bacteraemia 20 Section 4: Methicillin-sensitive Staphylococcus Aureus (MSSA) Bacteraemia 21 Section 5: Gram-negative Bloodstream Infections (GNBSI) 24 Section 6: Influenza 26 Section 7: Surgical Site Infections (SSIs) 28 Section 8: Sepsis 30 Section 9: Antimicrobials 31 Section 10: Serious Infection Review Meetings 32 Section 11: Collaborative Initiatives 33 Section 12: Future Goals 36

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Introduction This is the Annual Report for Infection Prevention and Control (IPC) which includes the fourth quarter report in the series for 2018/19 and provides an overall summary of the findings of investigations following Healthcare Associated Infections (HCAI) within the Trust between April 2018 and March 2019. The report reviews rates of Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and Methicillin-sensitive Staphylococcus aureus (MSSA) bacteraemia, as well as cases of Clostridium difficile (C. difficile) and the Gram-negative bloodstream infections (GNBSI): Escherichia coli (E. coli), Klebsiella and Pseudomonas bacteraemias. The nursing and medical teams complete Root Cause Analysis (RCA) forms for all but GNBSI bacteraemias, the findings from which have contributed to this report. From 2018/19, as advised by NHS Improvement (NHSI) visit, there is no longer a separate HCAI Strategic Plan as this is now incorporated into the IPC Operational Plan which is reviewed / monitored for compliance during monthly IPC Operational meetings. This report will be ratified by the Infection Prevention and Control Committee (IPCC) and the Clinical Risk Group (CRG) and once approved will be accessible from the IPC intranet page: http://nuth-intranet/cms/SupportServices/InfectionPreventionandControl.aspx Best practice and lessons learned should be shared widely with all staff.

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Executive Summary This report should be circulated to all clinical staff. The key data from this report are as follows:

Organism Q4 2017/18 2017/18 Total Q4 2018/19 2018/19 Total

MRSA 1 4 0 2

MSSA 34 96 15 91

E. coli 36 173 41 180

Klebsiella 21 75 22 92

Pseudomonas 5 20 7 32

Organism Q4 2017/18 Q4 2018/19

Reported Cases

Cases Counted Against

Contract

Reported Cases

Cases Counted Against Contract

C. difficile 30 25 17 16

Organism 2017/18 Total 2018/19 Total

Reported Cases

Cases Counted Against

Contract

Reported Cases

Cases Counted Against Contract

C. difficile 88 77 77 48

National Trajectory for NuTH

≤77 ≤76

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Section 1: Overview of HCAIs This has been a busy year for the Infection Prevention and Control (IPC) team. Among the many areas that we have been working on, there are some highlights that are worth mentioning: A significant effort has been dedicated to improve the quality and availability of HCAI data for all directorates, which in turn helps identify areas for improvement and of good practice. Areas of good practice and where sustainable HCAI reductions have been met, have been shared widely across the Trust, very much in line with the Trust’s Quality Improvement ethos. The infection Prevention and Control intranet page has been updated, to reflect our refreshed strategies and goals, and our renewed operational plan. We have updated the structure and Framework of our Infection Prevention and Control Strategic and Operational groups, allowing for a refocus on our onward strategy. The team have been involved in a series of initiatives led by NHSI, aiming at achieving the national ambition to reduce Gram negative blood stream infections by 50% by 2025. Notably, our UTI collaborative project with our Clinical Commissioning Group (CCG) (see page 33) demonstrated a significant reduction in UTI related sepsis in Elderly care, and reviewed catheter care plans emerging from this work have been rolled out through the Trust. The Trust has achieved 74% ‘flu vaccination in all front line staff this year, the highest number of vaccinations in our history. Again, this has been the product of the hard work of many, and led by our Occupational Health team (see page 26). So, did our efforts work, what has changed, are we seeing improvements? We have seen a real reduction in the overall number of C. difficile cases in the Trust, but more importantly, we have seen a real improvement in the management of each one of these cases with fewer lapses in care and reliable documentation. This has allowed us to successfully appeal 29 cases to our Commissioners. More information relating to C. difficile infections can be found from page 15. We have had the least MRSA bacteraemias that we have ever had; 2 cases last year (see page 20). Moreover, we have had over 7 months without an MRSA bacteraemia (see page 12). This is something to be proud of. We have had a challenging year with MSSA bacteraemias, with a total of 91 cases. This was fewer cases than last year, although we had hoped to see a greater improvement. However, this has presented an opportunity to learn from some cases which has led to improving practice. Information on sources of infection and directorate positions can be found from page 21. Gram Negative Bloodstream Infections (GNBSI) are the leading cause of sepsis and a very complex group of infections with multiple possible sources. Of these, E. coli are by far the

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most common followed by Klebsiella and Pseudomonas and further information can be found from page 24. We are focusing on the main causes of bacteraemia which are Urinary Tract Infections (UTIs) and Hepatobiliary sepsis. Our UTI work bore fruit and we saw some real reductions in our figures particularly in summer months. There is however some work to be done to achieve sustainable improvements this year. HCAI prevention relies on attention to detail, sometimes in very busy and complex environments and any improvement is testament of the hard work delivered by everyone. This report is both a summary of our performance last year, as well as an opportunity to thank everyone for their ongoing support. Thank you. Dr Lucia Pareja-Cebrian Director of Infection Prevention and Control (DIPC)

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1.1 Overview of Trust Onset HCAIs per 100,000 bed days for 2018/19

11.6 8.8

14.4

18.9

24.2

17.4

25.4

17.0

5.0 6.6

16.6 13.3

0

5

10

15

20

25

30

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

C. difficile Infections per 100,000 bed days

per 100,000 bed days 12mth Average National average

2.4 2.4

0

1

2

3


MRSA Bacteraemias per 100,000 bed days


34.7

21.9

12.0

21.3

14.5

29.9

20.8

7.3

17.5

6.6

14.2 11.1

0

5

10

15

20

25

30

35

40


MSSA Bacteraemias per 100,000 bed days


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46.3 43.8 43.2

37.8

21.8

34.9

23.1

31.5

47.4

29.6 28.4 24.4

0

10

20

30

40

50


E. coli Bacteraemias per 100,000 bed days


13.9 15.3

31.2

18.9

9.7

17.4 20.8

14.6

24.9

11.5

19.0 15.5

0

5

10

15

20

25

30

35


Klebsiella Bacteraemias per 100,000 bed days


13.9

6.6

2.4

9.5

7.3

2.5

6.9

2.4

5.0

3.3

9.5

2.2

0

3

6

9

12

15


Pseudomonas Bacteraemias per 100,000 bed days


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1.2 Comparison against the Shelford Group per 100,000 bed days

40.54

21.65 20.16 19.11 16.55 16.32 15.41 15.08 13.02

6.41

0.005.00

10.0015.0020.0025.0030.0035.0040.0045.00

Shelford Group Rates per 100,000 beds of C. difficile Infections April 2018 - March 2019

1.83 1.68

1.38 1.32

0.91 0.88

0.51 0.42 0.38 0.36

0.000.200.400.600.801.001.201.401.601.802.00

Shelford Group Rates per 100,000 beds of MRSA Bacteramias April 2018 - March 2019

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25.44

19.29

12.48 12.38 11.60 11.00 10.94 10.21 8.86 7.12

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Shelford Group Rates per 100,000 beds of MSSA Bacteraemias April 2018 - March 2019

50.34

39.82 38.15 31.46 30.65

25.96 24.54 23.88 22.63 20.93

0.00

10.00

20.00

30.00

40.00

50.00

60.00

Shelford Group Rates per 100,000 beds of E. coli Bacteraemias April 2018 - March 2019

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25.13 21.73 20.53 19.50

15.58 14.29 14.22 14.19 13.95

9.77

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Shelford Group Rates per 100,000 beds of Klesiella Bacteraemia April 2018 - March 2019

20.49

13.40 12.83 11.92 10.94

7.40 6.78 6.11 5.51 3.67

0.00

5.00

10.00

15.00

20.00

25.00

Shelford Group Rates per 100,000 beds of Pseudomonas Bacteraemias April 2018 - March 2019

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1.3 Overview by Directorate per 100,000 bed days April 2018 – March 2019

Directorate MRSA C. diff MSSA E. coli

No. Rate No. Rate No. Rate No. Rate

Cancer Services 0 0.00 7 35.86 8 40.98 23 117.8

Cardiothoracic Services 0 0.00 4 6.85 20 34.27 11 18.85

Childrens Services 0 0.00 8 17.71 8 17.71 11 24.36

ENT, Plastics, Ophthalmology & Dermatology 0 0.00 1 0.00 0 0.00 0 0

EPOD 1 4.62 1 4.62 4 18.50 0 0

Institute of Transplantation 0 0.00 0 0.00 0 0.00 2 29.31

Internal Medicine 0 0.00 26 18.90 13 9.45 44 31.98

Musculoskeletal Services 0 0.00 2 5.61 5 14.02 7 19.63

Neurosciences 0 0.00 4 16.21 4 16.21 9 36.48

Periop and Crit Care 1 5.53 6 33.20 11 60.87 26 143.9

Surgical Services 0 0.00 13 24.01 10 18.47 31 57.26

Urology and Renal Services 0 0.00 5 18.77 5 18.77 13 48.8

Womens Services 0 0.00 0 0.00 3 7.14 3 7.138

Trust Total 2 0.41 77 15.70 91 18.56 180 36.71

1.4 Overview of Months Free of MRSA Bacteraemia April 2018 – March 2019

1.5 Microbiology Activity The table on page 13 demonstrates Microbiology activity relating to sample processing between April 2018 and March 2019. NuTH introduced a double bottle blood culture system in December 2017 and therefore 2018/19 demonstrates the first full financial year with this system in place. An initial audit showed benefits of this implementation to include reduced length of stay, prevention of ITU

3 4

1

7

0

2

4

6

8


Total Number of Months MRSA Bacteraemia Free April 2018 - March 2019

No of Months MRSA Bacteraemia Free Median

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admission, improved patient outcome and improved antimicrobial stewardship.

Blood cultures Apr to

Jun 2017 Jul to

Sep 2017

Oct to Dec

2017

Jan to Mar 2018

Collected 8716 8899 7806 9201

Positives (all organisms) 836 787 737 841

Potential Contaminants 84

(0.92%) 83

(0.93%) 74

(0.95%) 126

(1.37%)

Blood cultures

Apr-Jun 2018

Jul-Sep 2018

Oct-Dec 2018

Jan-Mar 2019

Collected 8332 8030 8130 8681

Positives (all organisms) 826 809 752 824

Potential Contaminants 124 (1.48%)

110 (1.36%)

129 (1.6%)

161 (1.8%)

Stool samples for C. difficile investigations Apr to

Jun 2017

Jul to Sep

2017

Oct to Dec 2017

Jan to Mar 2018

Collected 1677 2323 1726 1883

Tested 1432 1699 1498 1627

Rejected based on insufficient sample, lack of clinical information or non-diarrhoeal

245 (14.6%)

222 (15%)

228 (13%) 256

(13.5%)

Stool samples for C. difficile investigations Apr-Jun

2018 Jul-Sep 2018

Oct-Dec 2018

Jan-Mar 2019

Collected 1740 1647 1654 1655

Tested 1488 1368 1423 1442

Rejected based on insufficient sample, lack of clinical information or non-diarrhoeal

252 (14.5%)

279 (17%)

231 (14%)

213 (13%)

Nationally it has been suggested that stool sample submission/testing for C. difficile is monitored in line with the positivity rate. Therefore there will be a focus on increasing the number of stools tested overall whilst reducing the number of rejected specimens through streamlining our laboratory processes and education of clinical teams to review all patients with diarrhoea and send stool samples if suspecting infective causes. 1.6 Specimen Transit Time Timely transport of specimens to the Microbiology Laboratory is important to ensure rapid diagnosis and treatment of infection. Delays in transport of specimens were previously identified as an issue in several RCAs and actions have been taken to improve transportation times. This is now monitored on a regular basis by Microbiology and Facilities. The tables on page 14 shows the percentage of samples (C. difficile samples only in order to provide a snapshot of overall transit times) failing to arrive within agreed timelines (symptoms to

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diagnosis should be 18 hours as per PHE guidance).

Exception Reporting Apr to Jun

2017 Jul to Sep

2017 Oct to Dec

2017 Jan to Mar

2018

No. % No. % No. % No. %

Number of samples with a transit time between 24 & 48hrs

102 6.1 99 5.8 133 8 104 5.5

Number of samples with a transit time >48hrs

22 1.3 33 1.9 15 0.9 17 0.9

Exception Reporting Apr to Jun

2018 Jul to Sep

2018 Oct to Dec

2018 Jan to Mar

2019

No. % No. % No. % No. %

Number of samples with a transit time between 24 & 48hrs

93 5.3 71 4.3 58 4 58 3.5

Number of samples with a transit time >48hrs

9 0.5 12 0.72 8 0.5 10 0.6

C. difficile transit times have shown a sustained improvement with an average % of samples received between 24-48 hours of4.2% and 0.6% for >48 hours in 2018/19 compared to 6.3% and 1.3% respectively in 2017/18. Clinical staff continue to be educated about the importance of sample transit times via a number of channels. Options for improving Blood Culture transit times are currently being explored by the Microbiology team and a Laboratory Medicine Specimen Reception Group has been set up to investigate potential issues effecting transit of specimens to all laboratory disciplines.

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Section 2: Clostridium difficile (C. difficile) Infections 2.1 Breakdown by Directorates

2.2 Appeals

The annual trajectory for 2018/19 for C. difficile was not more than 76 cases and the Trust had 77 cases this financial year. Contractual sanctions remain and there will be a financial penalty of £10,000 for each case over 76. The appeals process continued in 2018/19, whilst the total number of cases are reported nationally any successful appeals are locally

5 2 4

19

1 3 3 8

3

2

2

4

2

7

1 1 3

5

2

0

5

10

15

20

25

30

C. difficile Infections by Directorate April 2018 - March 2019

No. of Un-appealed Cases No. of Successful Appeals

75 65 67

57

77

48

11 24

27

17

11

29

0

10

20

30

40

50

60

70

80

90

100

2013/14 2014/15 2015/16 2016/17 2017/18 2018/19

Trust C. difficile infections (2013/14 - 2018/19)

Cases Not Appealed Cases Appealed Successfully

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deducted from the trajectory for the purpose of incurring any financial sanctions. The majority of C. difficile cases which cannot be appealed relate to delayed diagnosis, particularly in relation to the timing of the stool sample being sent to the laboratory. Thorough documentation is essential in helping to identify when a stool sample should be sent. In the fourth quarter of this financial year 4 cases out of 17 Hospital Onset reported cases have been successfully appealed. Cases are appealed when the Trust can demonstrate that best practice had been followed. For contractual purposes, successfully appealed cases will be deducted from the overall Trust reported rate. Given the high standard of delivered care 29 cases have now been successfully appeal in 2018/19 resulting in 48 cases being counted against the Trust’s trajectory.

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2.3 C. difficile learning from RCAs April 2018 – March 2019 Of the 77 C. difficile cases attributed to the Trust in 2018/19, 75 RCAs were requested and 73 were received fully completed. The following dashboard provides an indication of whether best practice was followed.

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2.4 Lapses in Care from C. difficile Cases In cases where best practice has not been followed, this is classed as a ‘lapse in care’. Work to review every case of C. difficile is ongoing throughout the year and the pie chart below demonstrates the cases between April 2018 and March 2019 that were shown as having a lapse in care and those where best practice was followed. As illustrated below, the main reasons why cases could not be taken to appeal were the delay in sending samples to the laboratory, incomplete documentation, antibiotics, delays in isolating the and delays in isolation.

22%

17%

15%

12%

8%

7%

6%

3% 3%

3% 2% 1% 1%

Learning points from C. difficile cases Best practice followed

Delay in sending sample

Documentation

Other

Antibiotics

Delay in isolation

Communication

RCA Outstanding

Hand hygiene

Documentation

Laxatives

Delay in diagnosis

Unknown

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2.5 Audits Following each case of C. difficile that is identified post-72 hours of admission, an audit which includes observation of practice and assessment of knowledge, is performed by the IPC Nurses (IPCNs). The audit questions have been reviewed and the frequency reduced to one audit post result. If any aspects of non-compliance are identified, they will be included in the discussion at the RCA meeting with consideration given for any necessary actions in the ward learning. 2.6 2019/20 Objectives In the next financial year (2019/2020), NHSI has published changes from DH in the reporting algorithm for C. difficile infections, reducing the time for any sample submitted ≥3 days from admission will be attributed to the Trust. Additionally, previous healthcare exposure will be taken into account, therefore if a patient has had an inpatient stay in the previous 4 weeks the case will also now be attributed to the Trust. This will be defined as Community Onset Hospital Acquired (COHA), the number of previous cases this relates to is displayed in the box below. Number of Hospital

onset CDI Community onset

hospital Acquired CDI (COHA cases)

Appeals Objective

2017/18 88 39 11 ≤77

2018/19 77 25 29 ≤76

2019/20 ≤113

Although it is not anticipated to increase in the total number of C. difficile cases the Trust reports, the above change in attribution has been reflected in NuTH’s objective for 2019/20 which is no more than 113 cases, equating to no more than 24.9 cases per 100,000 beds. Financial sanctions will continue in 2019/20 although there will be an increase focus on learning and improving patient safety. For 2019/20, the contractual sanction that can be applied to each C. difficile case in excess of an acute organisation’s objective will remain at £10,000. However, trusts will still be able to appeal C. difficile cases where it can be shown that the infection was unavoidable due to the care being provided in line with policy, therefore NuTH will continue to hold appeal meetings with the Clinical Commissioning Group (CCG) throughout 2019/20.

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Section 3: Methicillin-resistant Staphylococcus Aureus (MRSA) Bacteraemia 3.1 Cases There have been 2 patients who had confirmed Trust assigned MRSA bacteraemia in this financial year. A summary of the cases are as follows:

ePOD case: o The patient was transferred with a history of MRSA colonisation and eradication

therapy was prescribed and administered in-line with Trust policy. Good practice was identified for appropriate screening and antibiotic prescribing.

o Due to the changes in reporting guidance for 2018 from NHSI this case cannot be considered for assignment to third party.

Peri-operative & Critical Care case: o The patient acquired MRSA colonisation whilst under Peri-op & CC care and

eradication therapy was prescribed and administered in-line with Trust policy. The patient subsequently developed MRSA bacteraemia. Subsequent typing of the strain revealed that this was identical to the first case of MRSA bacteraemia in June 2018 and that there had been cross-infection between patients. Environmental challenges in this clinical area were identified therefore deep cleaning has taken place and refurbishment of the cubicles is underway.

3.2 Actions Listed below are the key points and actions from all cases above.

ePOD case: o Advised of MRSA status by transferring hospital and best practice followed as

patient was isolated immediately. o Burns Ward and ICU cubicles refurbished to resolve environmental concerns

identified following case review. o Chlorhexidine wound irrigation to be prescribed on eRecord by medical staff and

signed as administered. To be audited for effectiveness and compliance. o To be shared at regional and national Burn Network Audits, Directorate Plastic

Surgical Audit, weekly MDTM Audit and minuted for discussion at ward communication meeting

Peri-operative & Critical Care case: o Hand hygiene; transmission in critical care led to original MRSA Acquisition.

Clinical team is focusing on hand hygiene compliance. o Consideration could have been given to earlier repeat blood cultures as pyrexia

continued. This has been communicated to staff and learning cascaded through departmental meetings and through the Sepsis Steering Group.

o Due to patient’s complex condition and MRSA status, bacteraemia may have been unavoidable.

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Section 4: Methicillin-sensitive Staphylococcus Aureus (MSSA) Bacteraemia 4.1 Comparison by Directorates

At the end of the financial year there has been a decrease in MSSA rate by 5 cases, bringing the end of year total to 91 in comparison to 96 in 2017/18. There has been a slight decrease in most Directorates, with the greatest decrease in MSSA bacteraemia within Surgical Services with a total of reduction of 6 cases, followed by Children’s Services with a reduction by 4 cases and Neurosciences with a reduction of 3. Medicine, Peri-operative & Critical Care and Urology & Renal Services have seen increases to their rates. MSU and Women's Services have remained on a par with the previous year. Cardiothoracic Services had increased rates at the beginning of the financial year associated with Surgical Site Infections (SSIs), however this reduced during the year resulting in their final rate also being on par with the previous year. Throughout the Trust, the main sources of MSSA bacteraemia remain device related and skin/soft tissue. As a result the IV Nurse Specialist post is now substantive and continues to work and support clinical areas for effective device management. The learning from RCAs continues to be shared during Directorate Serious Infection Review Meetings (SIRMs) to re-enforce good practice. Consistency in clinical care is essential and the care bundles are now in place and becoming embedded in clinical practice. Peripheral IV and urinary catheter audit tools have now been provided to the Matrons to enable directorates to monitor practice have ownership of actions and learning which are then reported into Directorate SIRM action plans where required. The standardisation of skin prep in theatres has been fully embedded and included in the SSI prevention care bundle with the aim of reducing SSI. 4.2 Octenisan Washes Octenisan body wash continues to be promoted for the use of all in-patients to reduce the microbial load on the patient’s skin and the prescription is auto-generated by eRecord. Prescribing times have been altered which has resulted in some improvement in compliance of administration, with support and education to the clinical teams from the Matrons and IPC Nurses. Audits of Octenisan administration compliance are performed monthly by the Pharmacy Department; the results of which are then sent to Ward Managers, Matrons, IPCNs for review / action if required. This information is also monitored at Directorate SIRM.

9 20

12 5 1

9 5 7 5 16

4 3

8

20

8

4

13

5 4 11

10

5 3 0

10

20

30

40

Nu

mb

er

of

MSS

A B

acte

rae

mia

s

Directorate 12 month Comparison

Apr - Mar 2018/19

Apr - Mar 2017/18

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4.3 MSSA learning from RCAs April 2019 – March 2019 Of the 91 MSSA bacteraemia attributed to the Trust in 2018/19, 87 RCAs were requested and 85 were received. This is an improvement on last year’s completion rate and demonstrates the effectiveness of the process for reviewing cases of MSSA bacteraemia and crucially, increased engagement from clinical colleagues towards the HCAI agenda.

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4.4 Mandatory Training Compliance with ANTT practice remains the focus for infection reduction. Trust Education Group (TEG) have agreed that ANTT training will be mandatory for all medical staff as it has been proven that the best performing hospitals have a high percentage of ANTT competencies. All aspects of peripheral cannula care, from insertion to removal, are an important part of this. RCA had identified that half of the Trust’s MRSA and MSSA bacteraemia are line-related. There is already a robust process for ANTT competence in nursing, midwifery and AHP staff. This quarter’s figures for ANTT mandatory compliance for Medical and Dental staff are as follows:

Aseptic Non Touch Technique training (%) Jan Feb Mar

ANTT (M&D staff only) 60% 64% 68%

2018/19’s figure

Aseptic Non Touch Technique training (%) Average for 2018/19

ANTT (M&D staff only) 44%

This quarter’s figures for IPC mandatory compliance for all staff are as follows:

Infection Control Mandatory Training (%) Jan Feb Mar

Infection Control 88% 90% 91%

2018/19’s figure

Infection Control Mandatory Training (%) Average for 2018/19

Infection Control 87%

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Section 5: Gram-negative Bloodstream Infections (GNBSI) HCAI and Sepsis are related. It is estimated that there are 123,000 sepsis episodes per year in the UK and it could lead to around 37,000 preventable deaths per year in the UK. Sepsis in the UK is responsible for more deaths every year than bowel, breast and prostate cancer put together. Proportionally, Gram Negative Organisms such as E. coli, Pseudomonas and Klebsiella are the most common organisms involved in sepsis and these are the same organisms involved in HCAIs. Nationally, bloodstream infections (BSI) caused by E. coli are responsible for more deaths than Staph aureus (both MRSA and MSSA) and C. difficile combined and as such there is a national ambition to reduce GNBSI by 25% by 2021/22 with the full 50% reduction by 2023/24. The most common source of E. coli bacteraemia continues to be urinary tract infections (UTIs) and of these, catheter associated infections are the most frequent. A project focusing on wards with high rates of catheterised patients as part of a national initiative led by NHS Improvement is covered in Section 10. Hepatobiliary surgery is another important source of bacteraemia and in addition to this all Directorates have identified GNBSI as an area of work in their specific SIRM action plans. 5.1 Trust 2018/19 Figures for Gram Negative Bacteraemias by Directorate

23

11 11

2

44

7 9

26 31

13

3

21

7 2

2 2

20

1 2

11

18

4

2

10

4

2

2 3

4

2

2

3

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

E. coli Klebsiella Pseudomonas

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5.2 Post 48 hours E. coli Bacteraemia Infection Source 2018/19

There are ongoing time constraints for completion of E. coli risk factor forms and therefore 25% of all E. coli bacteraemia do not have completed paperwork to identify the primary source. The Microbiology department continues to work towards improving completion rates. The lead GP for infection control in the Newcastle/Gateshead CCG is now provided with the number of pre 48 hours E. coli, Klebsiella and P. aeruginosa cases per GP surgery on a monthly basis in an attempt to identify any ‘hot spots’ where actions may be required in order to reduce cases of GNBSI in the community.

4%

15%

13%

3%

1%

25% 1%

2%

1%

12%

23%

Post 48 hours E. coli Bacteraemia Infection Source 2018.19

DUEL SOURCE

GASTROINTESTINAL

HEPATOBILIARY

INDWELLING INTRAVASCULARDEVICENO UNDERLYING FOCUS OFINFECTIONNot complete

OTHER

RESPIRATORY TRACT

SKIN AND SOFT TISSUE

UNKNOWN

URINARY TRACT

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Section 6: Influenza 6.1 ‘Flu Vaccination Campaign 2018/19 The 2018/19 ‘flu campaign was very successful within the Trust as there was an increase in the total number of staff vaccinated. The final total was 74% of frontline staff being vaccinated by February 2019 compared to 65% in 2017/18. Therefore this meant the Trust had achieved 75% of the total payment threshold for CQUIN. In order to achieve 100% CQUIN target an additional 273 clinical staff needed to be vaccinated by the end of the campaign. Additionally a key accomplishment was achieving over 75% vaccinations for staff working in high risk departments (see table below), by keeping very careful oversight and risk assessment management of these areas which ensured skilled staff for specialist areas were not redeployed, which has a direct positive impact on patient care.

Directorate Department No of Staff

No of Staff vaccinated

30/01/2019 Percentage

317 Cancer Services/ Clinical Haematology Directorate

317 Ward 33 Clinical Haematology - FH 26 22 84.62%

317 Ward 34 NCCC - FH 27 23 85.19%

317 Ward 35 NCCC - FH 29 27 93.10%

317 Ward 36 NCCC - FH 31 25 88.57%

317 Cardiothoracic Directorate

317 Ward 21 Cardiothoracic ITU FH 129 104 80.62%

317 Ward 23 Paediatric Cardiology - FH (53) + 317 Paediatric Cardiology Specialty - FH (27)

80 61 76.25%

317 Paediatric ICU - FH 109 96 88.07%

317 Ward 25 Thoracic Surgery - FH 25 22 88.00%

317 Ward 29 Chest Medicine - FH 28 25 89.29%

317 Ward 30 Cardiothoracic Surgery - FH 34 28 82.35%

317 Children's Services Directorate

317 Ward 1a Paediatric Medicine - RVI 37 36 97.30%

317 Ward 2 Paediatric Medicine - RVI 27 22 81.48%

317 Ward 3 Bone Marrow Transplant - RVI (9) + 317 Paediatric SCIDS - RVI (35)

71 66 92.96%

317 Ward 4 Paeds Oncology - RVI (48) + 317 Paediatric Oncology Spec - RVI (24)

71 60 83.33%

317 Ward 14 Paediatric Oncology Day Unit - RVI 16 12 75.00%

317 Ward 12/ PICU - RVI (93) + 317 Paediatric ICU Specialty - RVI (6)

99 89 89.90%

317 Peri-operative & Critical Care - FH Directorate

317 Ward 37 ICCU - FH 113 94 83.19%

317 ITU Medical Staff - FH 17 15 88.24%

317 Peri-operative & Critical Care - RVI Directorate

317 ITU (Medical Staff) - RVI 33 30 90.91%

317 Ward 18 ITU - RVI 112 88 78.57%

317 Ward 38 ITU Leazes Wing - RVI 115 105 91.30%

317 Urology/ Renal Services Directorate

317 Ward 38 IOT FH 41 39 92.68%

317 Women's Services Directorate

317 Ward 35 Special Care Baby Unit - RVI 110 95 86.36%

Total Staff

Total Vaccinated

Total % for high risk areas

1358 1184 87%

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The CQUIN for 2019/20 ‘flu campaign is aiming for 80% uptake based on current staff numbers. This will require 9,585 staff vaccinated which is an increase of 763 staff.

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Section 7: Surgical Site Infections (SSIs) The Trust has received October – December 2018 surveillance reports from PHE. The quarterly SSI rate for both hip and knee replacements was 0%. The Trust annual SSI rate at the end of quarter 4 for hip replacements is 0.2% which remains below the national 5 year average of 0.6%. The annual SSI rate for hip replacements at the end of quarter 4 is 0.4% which is also below the national average of 0.5%. Spinal surgery has demonstrated stability in the number of infections, as it replicates the number of infections declared within the previous quarter. By doing so the quarterly SSI rate is 1.1% which is below the national 5 year average of 1.3%; however the annual position has ended slightly above the national SSI average at 1.5%. 6.1 Combined Spinal SSI rate (NuTH and National)

6.2 Hip replacements SSI rates (NuTH and National)

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

Jan -March2017

April -June2017

July -Sept2017

Oct -Dec

2017

Jan -March2018

April -June2018

July -Sept2018

Oct -Dec

2018

Jan -March2019

Combined SSI Rate

Nuthcombinedquarterly rates

Trust Annualrate

National rates

0%

0%

0%

1%

1%

1%

Jan -March2017

April -June 2017

July - Sept2017

Oct - Dec2017

Jan -March2018

April -June 2018

July - Sept2018

Oct-Dec2018

Hip SSI Rate

QuarterlyTrustInfectionRate -HipsNational 5YearAverageRate -HipsTrustAnnualAverage

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6.3 Knee replacements SSI rates (NuTH and National)

0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

0.80%

0.90%

Jan -March2017

April -June2017

July -Sept2017

Oct -Dec

2017

Jan -March2018

April -June2018

July -Sept2018

Oct-Dec2018

Jan -March2019

Knee SSI Rate

Quarterly TrustInfection Rate -Knees

Average forTrust - Knees

NationalAverage Rate -Knees

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Section 8: Sepsis A Baseline Audit has been completed within the Emergency Department into the management of patients recognised as having sepsis and the compliance with the Sepsis 6 Care Bundle. The teaching guidance for the Practice Development Group has been updated to reflect the Trust’s Sepsis Message in line with national guidelines. The CQUIN target has continually been met for recognition and treatment of sepsis with more than 90% of patients with sepsis receiving antibiotics within 60 minutes and will now be included within the NHS National Contract. The SHMI and VLAD outcomes for sepsis have improved over the last 12 months and Newcastle Hospitals has the lowest mortality rate for Suspicion of Sepsis regionally. The Sepsis Steering Group has written a Sepsis Policy which has been ratified at Clinical Policy Group and which defines the identification and treatment of sepsis within the Trust. The policy is closely aligned to NICE guidelines and national recommendations from the Sepsis Trust. This policy will be updated in Quarter 1 of 2019/20. Within the Trust we continue to perform well against other trusts in the region and nationally in terms of outcomes from suspected Sepsis. Work with the Shelford group continues and we are leading an education workstream as part of this group. The next challenge will be to integrate Sepsis into electronic observation systems.

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Section 9: Antimicrobials 9.1 CQUIN CQUIN targets and final results (up to an including end of March 2019) for 2018/19 can now be summarised in table below:

CQUIN 2018/19

Target Final results

4% reduction in overall antibiotic use Achieved 0.08% reduction (so failed target by 3.92%)

4% reduction of Carbapenems Achieved a 8.1% reduction (exceeded target by 4.1%)

3% increase of Access antibiotics to 51.52%

Achieved a 0.7% increase to 49.22% (so failed target by 2.3%)

CQUIN objectives 2019/20 AMR have been updated to: 1a Improving the management of lower Urinary Tract Infection in older people, namely

appropriately diagnoses and treatment as per NICE. 1b Improving appropriate antibiotic surgical prophylaxis in elective colorectal surgery,

namely one dose prophylaxis per procedure as per guidelines. Work is underway working with a Medicine Multidisciplinary Team (MDT) and a Colorectal MDT on how to best achieve this objective. The monetary value for each of the CQUINs is still to be confirmed. 9.2 Antimicrobial Stewardship (AMS) The agreed priorities for AMS for the Trust are:

Adherence to antibiotic guidelines

Timely review of antibiotics To agreed framework to deliver these objectives is the DH ‘Start Smart then Focus’, which includes education and changes to prescribing behaviours. A study that explores the effectiveness of an electronic tool in changing prescribing practice called ARK (Antibiotic Review Kit) will be piloted in the Directorate of Medicine. Directorate Antibiotic usage reports are now being shared with Directorates. The reports have proven informative and useful for discussion on Trust targets, antibiotic prescribing patterns and types of antibiotics being prescribed. Peer review antimicrobial usage “Take 5” audits are also included in the Directorate reports.

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Section 10: Serious Infection Review Meetings These meetings are multidisciplinary and include the Clinical Director, Matron, Sister/Charge Nurse, Consultant and Directorate Manager during which the cases and actions are reviewed by the DIPC, a member of the Senior Nursing Team (including IPC Matron) and Site IPC Doctor. This enables discussion and learning to be shared across the Trust.

To support Directorates to create, own and put into practice their agreed Action Plans, based on local priorities reflecting Trust guidelines. (The Action Plan must be updated and sent to the Information and Data Manager at least 7 days prior to the scheduled meeting.)

To capture and share good practice across the Trust and within Clinical Teams from strong Directorate leadership.

To minimise the number of Healthcare Associated Infections (HCAIs) within the Trust.

To ensure Directorate involvement and ownership.

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Section 11: Collaborative Initiatives 11.1 NHS Improvement (NHSI) Visit NSHI were invited to the Trust due to the Trust’s HCAI position and visited in August 2018. The feedback was overall positive and there was a focus upon decontamination, some of the points highlighted were:

Clinical areas do not have designated space for clean/dirty commodes – plan to review for standardised cleaning area where possible which is to be undertaken as future estates work is performed in the clinical area.

Designated storage areas for clean equipment; recommended to have standardised signage, this was reviewed however there are no designated storage areas in corridors which have been agreed due to fire regulations.

Washing machines to be located in clean area rather than dirty area, alternative accommodation continued to be explored due to space restrictions.

Recommended short, easy to read policies for quick reference guide, this is being implemented as IPC policies are reviewed/renewed.

NHSI was complimentary about each area visited and of the commitment within the Trust. 11.2 NHSI National UTI Collaborative The Trust was approached from NHSI to showcase the collaborative work which was undertaken in partnership with the Newcastle / Gateshead CCG during the National UTI collaborative. A national review meeting is being organised by NHSI with a suggestion of a meeting in March 2019, sharing examples of some exemplary work from the UTI collaborative cohorts, as well as from a wider gram negative bloodstream infection (GNBSI) perspective. A local working group has been formed to maintain a focused approach to UTI reduction as part of the national GNBSI reduction initiative. The aim is to continue with the project and to replicate the initiative in other clinical areas. The work undertaken for the UTI collaborative has now been recognised nationally at the British Journal of Nursing Awards and was awarded second place. This will also be presented at a regional NHSI event in April to share learning. The project is being rolled out in stages across the Trust and is currently being cascaded via the Nurse Consultant – Continence Care, clinical educators and IPCNS to RVAS and RVI30/31. 11.3 High Level Isolation Unit (HLIU) The HLIU on RV19 continues to maintain a state of readiness to manage patients with High Consequence Infectious Diseases (HCIDs), through on-going education and training of staff; however training additional staff from paediatrics remains a challenge. There has however been a significant increase in the number of ICCU staff booking onto training following an awareness campaign by one of the ICCU Sisters.

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The Trust has also recently become a designated centre in England for the management of respiratory HCIDs. Preparations for this are progressing and include development of protocols and a suitable environment on RV18 for safe management. Following the Senior Nurse (Practice Development IPC) Winston Churchill Memorial Trust Project; an international scoping of HLIUs, staff from the Trust are involved in a national study to develop one standard PPE ensemble for the management of confirmed cases. 11.4 Preventing E. coli Sepsis A group of Microbiologists, Surgeons and Infection Control Doctors are developing focused work on preventing E. coli sepsis secondary to HPB, by addressing antibiotic prescribing, surgery pathways and postoperative care. 11.5 National NHSI Gram Negative Reduction Day In March the Trust had representation at the national NHSI gram negative reduction day for cancer services. This event confirmed the four commonest causes for E. coli BSI are related to UTI, hepatobiliary, gastrointestinal tract and febrile neutropenia, suggesting the organisations concentrate on these factors to be successful in reducing E.coli BSI. The Trust has current work streams focused upon these sources to reduce associated infections which include the ongoing work for catheter assessment and early removal, and drain care for hepatobiliary patients. 11.6 IPC Game Launched Members of the IPC Nursing team have developed a game to education staff on the correct management of diarrhoea which with the assistance of the Innovation Team and charitable funds, has now been produced commercially. The Poopology Game is a unique approach to staff training, designed for health and social care staff working in hospital, nursing/residential and domiciliary care settings. It was launched by Focus Games on 1st April 2019 with social media communications and articles in national nursing journals. Further information on the game can be found at www.poopologygame.co.uk 11.7 Improvement Carbapenemase-producing Enterobacteriaceae (CPE) Detection

Process A more rapid test for CPE was successfully introduced on 4th March 2019 on admission screens for patients at risk of being colonised with the organism. This new Polymerase Chain Reaction (PCR) test has already demonstrated improved patient flow through wards and

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theatres and reduction in the number of terminal cleans required to be undertaken by the rapid response team. In the long term it is hoped that the initiative will be cost neutral and possibly a cost improvement, but will certainly improve the patient experience by reducing the time patients require isolation pending screening results.

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Section 12: Future Goals Excellent infection prevention and control (IPC) practices and antibiotic stewardship are fundamental to safe, effective and high quality care. We all have a responsibility to ensure we achieve IPC standards and we should all strive to do the right thing, at the right time, every time. There is an IPC Operational Plan which supports the governance framework and improvement initiatives to help prevent HCAI in the Trust. This is overseen by the Director of Infection Prevention and Control (DIPC), Matron for IPC and other members of the multi-disciplinary IPC Operational Group. In the table on page 37 are the agreed goals for 2019/20:

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12.1 IPC Strategic Goals Aim: Define key priorities for IPC strategic goals and a communication plan to the organisation Area of Work Main Message What We Want People To Remember

Antibiotic stewardship

Start smart then focus Start smart – if you suspect bacterial infection, take appropriate cultures and start patient on broad spectrum antibiotics

Then focus – o Clinical review at 48 hours o Check microbiology sensitivities o Decide:

Stop

IV to oral switch

Change antibiotic

Continue

OHPAT (is patient suitable for OHPAT service?)

Monthly antibiotic audits should be undertaken by junior doctors

Devices Safe lines save lives Lines

Right device, right time

Use standard Aseptic Non-Touch Technique (ANTT) for cannula insertion o Wash your hands before starting of the procedure o Wear gloves o Disinfect the skin with 2% chlorhexidine in 70% alcohol for 30 seconds, and leave to dry o Avoid contaminating the cleaned skin or device (do not touch the key site or key parts, i.e. the

part of the cannula that will be inserted) o Whoever inserted the cannula should document the insertion on the PIVC Record

Review devices twice daily and act if there are signs of infection

Remove devices that are no longer required Catheters

Assess need/reason for urethral catheter at least daily

Clean catheter insertion site at least daily

Think Trial With Out Catheter (TWOC) as soon as clinically indicated

Undertake Bladder Scanning to assess for urine residual volume

Consider alternatives to urinary catheters i.e. assessment and treatment programmes for bladder health care, intermittent catheterisation (IC)?

Dipstick testing is not an effective method for detecting urinary tract infections in catheterised adults

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Area of Work Main Message What We Want People To Remember

Diagnosis of C. difficile infection

Send a stool sample to Microbiology on the second episode of diarrhoea (Type 5-7 suspected infectious stool) and request a test for C. difficile

Isolate patients with suspected infectious diarrhoea

Review laxatives and antibiotics for patients with Type 5-7 stool

Document all stools for patients who have diarrhoea (Type 5-7 stool) on the C. difficile pathway

C. difficile testing requires sufficient sample, at least 1/5th of the container.

C. difficile treatment should be prescribed and administered as soon as possible.

Diagnosis of CPE infection

CPE risk – anyone admitted to a hospital overseas or outside the North East of England in the last 12 months

Ask all patients admitted to the Trust if they have been in hospital overseas or outside the North East of England in the last 12 months and act if ‘yes’

Isolate patients until they are confirmed as CPE negative

Screen at-risk patients within 24 hours of admission (then on day 3 and 5 if negative)

Take a rectal swab from the patient (and swabs from any wounds) using a RED Copan swab and send to Microbiology for CPE testing

Ensure there is faeces on the swab

Surgical site infection

Reduce surgical site infection (SSI)

All patients washed with Octenisan prior to surgery.

When antibiotic prophylaxis required, administration should be given 30-60 mins prior to Knife to Skin.

Standardised use of skin prep intra-operatively with 2% Chlorhexidine in 70% alcohol (ChloraPrep) or Betadine.

Patients should remain normothermic intra-operatively.

SSI Care Bundle to be promoted and audited.

Estates Know how to escalate your Estates issues

To be defined

Author: Dr Lucia Pareja-Cebrian, DIPC (on behalf of IPCC)

June 2019

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Agenda Item A7(i)b BRP

TRUST BOARD

Date of meeting 27 June 2019

Title Consultant Appointments

Report of Andy Welch, Medical Director

Prepared by Claudia Sweeney, HR Officer (Medical & Dental)

Status of Report Public Private Internal

☒ ☐ ☐

Purpose of Report For Decision For Assurance For Information

☐ ☐ ☒

Summary The content of this report outlines recent Consultant Appointments.

Recommendations The Board of Directors is asked to review the decisions of the Appointments Committee.

Links to Corporate Objectives

Putting patients first; maintaining financial viability/stability

Links to Strategy and Clinical Risks

Continue to recruit and retain the very best staff

Impact

Tick yes or no as appropriate Yes No

Quality and Safety x

Legal x

Financial x

Human Resources x

Equality and Diversity x

Engagement and communication x

Sustainability x

If yes, please give additional information: N/A

Reports previously considered by

Consultant Appointments are submitted for information in the month following the Appointments Panel.

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Agenda item A7(i)b

____________________________________________________________________________________________________ Consultant Appointments Trust Board – 27

th June 2019

CONSULTANT APPOINTMENTS

1. APPOINTMENTS COMMMITTEE – CONSULTANT APPOINTMENTS

1.1 An Appointments Committee was held on 30 April 2019 and interviewed 4 candidates for 2 Consultant Endovascular Surgeon posts.

By unanimous resolution, the Committee was in favour of appointing both Dr Anne Burdess and Mr Matthew Thomas. Dr Burdess holds MB ChB, (University of Edinburgh) 2000, MRCS (Edinburgh) 2004, CCBST (Edinburgh) 2005, PhD (University of Edinburgh) 2013, and FRCS (Edinburgh) 2017. Dr Burdess is currently employed by the Trust as a Locum Consultant Vascular Surgeon. Mr Thomas holds MB ChB (University of Leeds) 2004, MRCS (Edinburgh) 2008, MCE (University of Newcastle) 2013, ChM (Vascular and Endovascular Surgery [University of Edinburgh]) 2017 and FRCS (Edinburgh) 2018. Mr Thomas is currently employed as a Specialty Trainee in Vascular Surgery based at The Freeman Hospital. Dr Burdess is expected to take up the post of Consultant Endovascular Surgeon as soon as possible. Mr Thomas is expected to take up the post of Consultant Endovascular Surgeon in 2020.

1.2 An Appointments Committee was held on 1 May 2019 and interviewed 2 candidates for the post of Consultant Neuroradiologist.

By unanimous resolution, the Committee was in favour of appointing Dr Joanna Perthen. Dr Perthen holds PhD (MRI Physics [University of Newcastle]) 2003, MBBS (University of Newcastle) 2012, PGCert Clinical Research (University of Newcastle) 2015, and FRCS (UK). Dr Perthen is currently employed as a Specialty Trainee in Clinical Radiology based at the Royal Victoria Infirmary. Dr Perthen is expected to take up the post of Consultant Neuroradiologist in September 2019.

1.3 An Appointments Committee was held on 10 May 2019 and interviewed 2 candidates for the post of Consultant Paediatric Cardiologist.

By unanimous resolution, the Committee was in favour of appointing Dr Abbas

Khushnood. Dr Khushnood holds MBBS (University of Baroda [India]) 1997, MBA (Cardiff) 2004, and MRCPCH (UK) 2010. Dr Khushnood is currently employed by the Trust as a Locum Consultant Paediatric Cardiologist.

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Agenda item A7(i)b

____________________________________________________________________________________________________ Consultant Appointments Trust Board – 27

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Dr Khushnood is expected to take up the post of Consultant Paediatric Cardiologist as soon as possible.

1.4 An Appointments Committee was held on 17 May 2019 and interviewed 5 candidates for 2 Consultant Otolaryngologist posts.

By unanimous resolution, the Committee was in favour of appointing both Miss Isma

Iqbal and Miss Lakhbinder Pabla. Miss Iqbal holds MBBS (University of Newcastle) 2005, MRCS (England) 2008, DOHNS

(England) 2009, FRCS (England) 2015, and PGCert MEd (University of Newcastle) 2016. Miss Iqbal is currently employed as an Associate Specialist in Rhinology and Skull Base at Frankston Hospital, Australia.

Miss Pabla holds BM BCh (University of Oxford) 2007, DOHNS (England) 2010, MA

(University of Oxford) 2011, FRCS (England) 2017, and PGDip MEd (University of Newcastle) 2018. Miss Pabla is currently employed as a Locum Paediatric Otolaryngologist at Alder Hey Children’s Hospital.

Miss Iqbal is expected to take up the post of Consultant Otolaryngologist in August 2019. Miss Pabla is expected to take up the post in 2020.

2. RECOMMENDATION

1.1 – 1.4 – For the Board to receive the above report.

Report of Andy Welch Medical Director 19 June 2019

58

THIS PAGE IS INTENTIONALLY

BLANK

59

Agenda item A7(i)b BRP

TRUST BOARD

Date of meeting 27th June 2019

Title Honorary Consultant Appointments

Report of Andy Welch, Medical Director

Prepared by Andy Welch, Medical Director


☒ ☐ ☐


☐ ☐ ☒

Summary The content of this report outlines recent requests for Honorary Consultant Contracts

Recommendations The Board of Directors is asked to note the award of/ extension to the Honorary Consultant Contracts


Continue to recruit and retain the very best staff


Putting patients first and providing care of the highest standard focusing on safety and quality. Enhancing our reputation as one of the country’s top, first class teaching hospitals, promoting a culture of excellence in all that we do.

Impact


Quality and Safety

Legal

Financial

Human Resources

Equality and Diversity

Engagement and communication

Award of Honorary Consultant Contracts


Honorary Consultant Appointment requests are submitted as and when requests are received

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____________________________________________________________________________________________________Honorary Consultant Appointments Trust Board – 27

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HONORARY CONSULTANT APPOINTMENTS

1. HONORARY CONSULTANT APPOINTMENT REQUESTS 1.1 Dr Joanne Fletcher Dr Joanne Fletcher MBChB Edinburgh 1996, MRCP London 1999, FRCR London 2003, is currently employed by County NHS Foundation Trust as a Consultant Radiologist. An Honorary Contract for Dr Fletcher is requested to allow her to support training in PET/CT and safeguard delivery of vulnerable services with the North East of England. There will be no financial implication to the Trust.

1.2 Dr Alison Verner Dr Alison Verner, MB BCh BAO Belfast 1996, MRCPCH Belfast 1999, MPhil Belfast 2009, is currently employed by Belfast Health & Social Care Trust as a Consultant Neonatologist and Clinical Lead for Neonatology. An Honorary Contract has been requested to allow her to provide independent external input into local mortality review in the neonatal service. This will involve the external reviewers having the opportunity to review case summaries via secure NHS email prior to the review with sight of notes when at the Royal Victoria Infirmary followed by the formal MDT review. The contract is for one day every 4 months. There will be no financial implication to the Trust.

1.3 Dr David Millar Dr David Millar, MB BCh BAO Belfast 1994, MRCP 1998, MRCPCH (elected) 1998, FRCPCH (elected) 1998, is currently employed by Belfast Health & Social Care Trust as a Consultant Neonatologist. An Honorary Contract has been requested to allow him to provide independent external input into local mortality review in the neonatal service. This will involve the external reviewers having the opportunity to review case summaries via secure NHS email prior to the review with sight of notes when at the Royal Victoria Infirmary followed by the formal MDT review. The contract is for one day every 4 months. There will be no financial implication to the Trust.

1.4 Dr Simon Bomken Dr Simon Bomken, BMedSci (Hons) Newcastle 1999, MBBS (Hons) Newcastle 2002, PhD Newcastle 2013 is currently holds an Honorary Contract as Consultant/ Clinical Fellow in Paediatric Oncology.

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An extension to his Honorary Contract has been requested by Newcastle University until 30 August 2019. There will be no financial implication to the Trust.

1.5 Dr Sithara Ramdas Dr Sithara Ramdas, MBBS India 2001, DCH (RCPCH, UK) 2005, MRCPCH 2006, FRCPCH 2017 is currently employed by Oxford University Hospitals NHS Foundation Trust as a Consultant Paediatric Neurologist. An Honorary Contract has been requested as Dr Ramdas is part of a team who run a highly specialised clinic in congenital myasthenic syndrome in Oxford. 6 clinics will run per year and colleagues will join them for approximately two per year. This will also facilitate MDT discussion on complex patients and avoid patients travelling to Oxford. It is anticipated that this arrangement will initially be for 3 years There will be no financial implication to the Trust.

1.6 Dr Jacqueline Palace Dr Jacqueline Palace, BM (Honours) Southampton 1983, MRCP (UK) 1986, DM Southampton 1992, FRCP (UK) 2000, is currently employed by Oxford University Hospitals NHS Foundation Trust as a Consultant Neurologist. An Honorary Contract has been requested as Dr Palace is part of a team who run a highly specialised clinic in congenital myasthenic syndrome in Oxford. 6 clinics will run per year and colleagues will join them for approximately two per year. This will also facilitate MDT discussion on complex patients and avoid patients travelling to Oxford. It is anticipated that this arrangement will initially be for 3 years There will be no financial implication to the Trust.

1.7 Dr Shabana Anwar Dr Shabana Anwar, BSc (Hons) Pharmacology Wales 2000, MBBCh (with Honours) Wales 2002, MRCP 2005, FRCA 2009, MA Manchester 2014, FFICM 2014, CCT (Dual) 2014, is currently employed by the Ministry of Defence. An Honorary Contract has been requested by the Clinical Director for Cardiothoracic Services, Dr Kevin Brennan, as she requires a base hospital to maintain her clinical skills, and contribute to NHS work. As a recent former Consultant in Cardiothoracic Anaesthesia and Intensive Care, she would be ideally placed to return to the department as her base unit. There will be no financial implication to the Trust.

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2. RECOMMENDATIONS The Board is asked to note:

1.1 Dr Joanne Fletcher will receive an Honorary Contract as a Consultant Radiologist. 1.2 Dr Alison Verner will receive an Honorary Contract as a Consultant Neonatologist. 1.3 Dr David Millar will receive an Honorary Contract as a Consultant Neonatologist. 1.4 Dr Simon Bomken will receive an extension to his Honorary Contract as a Consultant

Paediatric Oncologist until 30 August 2019. 1.5 Dr Sithara Ramdas will receive an Honorary Contract as a Consultant Paediatric

Neurologist. 1.6 Dr Jacqueline Palace will receive an Honorary Contract as a Consultant Neurologist. 1.7 Dr Shabana Anwar will receive an Honorary Contract as a Consultant Anaesthetist.

Report of Andy Welch Medical Director 17th June 2019

63


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Agenda item A7(ii) BRP

TRUST BOARD

Date of meeting

27th June 2019

Title 2019 Midwifery Staffing Review Report

Report of Maurya Cushlow, Executive Chief Nurse

Prepared by Elaine Blair, Associate Director of Midwifery

Status of Report

Public Private Internal

☒ ☐ ☐

Purpose of Report

For Decision For Assurance For Information

☐ ☒ ☐

Summary

This report provides the 6 month Midwifery Staffing Review report following the introduction and use of BirthRatePlus (BR+). It adheres to the recommendations set out by NHS Improvement Developing Workforce Safeguards guidance October 2018, the guidance set by the National Quality Board (NQB 2016) and compliance with the NHS Resolution Clinical Negligence Scheme for Trusts (CNST) Maternity Incentive scheme. It updates the Board in relation to the following: • Early data collection from the new Birth Rate Plus(BR+) Acuity tool for

intrapartum and in-patient care

Evidence of supernumerary status for the midwifery delivery suite coordinator

Compliance with women receiving one to one care in established labour

Red flags reporting related to staffing

Planned and actual staffing fill rates • Vacancy and turnover for Midwifery • The current midwife:birth ratios


• To put patients and carers at the centre of all we do and to provide care of the highest standard in terms of both safety and quality.

• To continue to be recognised as a first-class teaching hospital, counted amongst the top 10 in the country, which promotes a culture of excellence, in all that we do.

• To ensure compliance with National requirements.


Compliance with NICE, NQB Guidance and NHS Resolution CNST Maternity Incentive scheme


Putting patients first and providing care of the highest standard focusing on safety and quality.

Working in partnership to deliver fully integrated care and promoting health lifestyles to the people of Newcastle and beyond

Enhancing our reputation as one of the country’s top first class teaching hospitals, promoting a culture of excellence in all that we do.

Impact Tick yes or no as appropriate Yes No

Quality and Safety √

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____________________________________________________________________________________________________ Executive Chief Nurse Report Trust Board – 27

th June 2019

Legal √

Financial √

Human Resources √

Equality and Diversity √

Engagement and communication √

Sustainability √

If yes, please give additional information: • Failure to assure safe staffing levels may lead to patient harm, litigation claims

against the Trust and loss of reputation. • Assurance of Safe Staffing based on Midwifery Staffing Review

process highlights the need to ensure alignment between base line establishment requirements and financial budget setting to meet safety and quality standards and comply with national guidance.


The Board has previously received annual Nursing and Midwifery Staffing Review reports and a six monthly Safe Staffing assurance report. This is the first Midwifery Staffing Report informed by new BR+ methodology.

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MIDWIFERY STAFFING REVIEW REPORT USING THE BIRTH RATE PLUS ACUITY TOOL

2019/2020 FINANCIAL YEAR

1. INTRODUCTION The purpose of this report is to provide the Board with an overview of midwifery staffing and provide assurance that this Trust is compliant with national guidance in relation to safe staffing. NHS Resolution Clinical Negligence Scheme for Trusts (CNST) Maternity Incentive scheme requires a bi-annual report that covers staffing and safety issues. The National Quality Board (2016) clearly articulates the requirement to undertake an in depth nursing and midwifery staffing review annually with an update on actions highlighted to the Board on a six monthly basis. Future reports will harmonise with the wider six monthly safe staffing report. This report provides the data review from January – April 2019 and has been enabled by the recent acquisition of the nationally recommended maternity workforce acuity tool Birth Rate Plus. It will provide the results of early data collection and narrative in relation to this. Whilst we can provide assurance to the Trust board of current safe staffing, further data collection is considered essential to accurately inform the Trust Board regarding any possible changes to establishment. A further six monthly update will be provided in October 2019 along with the wider Trust six monthly Nursing and Midwifery staffing review report. 2. NATIONAL AND LOCAL POSITION • There is a clear imperative for ensuring safe staffing levels in the NHS. This imperative is

driven through the patient safety agenda by legislation, compliance with the Care Quality Commission (CQC) and the NHS Constitution. Underpinning this is an increasing body of evidence that staffing levels make a difference to patient outcomes, quality of care delivery, efficiency of care and patient experience.

• The climate within maternity services has changed over the last 10 years with a rise in

acuity for many women. The professionals choosing to work within maternity services are reducing; the numbers of specialist medical trainees have reduced year on year and correspondingly so are midwifery numbers. This results in a workforce that is weighted towards those nearing retirement with a deficit at the other end of the workforce in newly qualified midwives. This is reported across the country and whilst it has not yet presented a significant issue in the North East of England, it is a growing concern.

• The Women’s directorate recognise that maternity services must modernise to meet

the truly women centred approach that is required whilst still delivering efficiencies. They must consider new ways of working to support midwives, obstetricians, anaesthetists, and neonatologists and ensure staffing numbers are adequate and

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appropriate and the workforce trained to a high standard through multidisciplinary training to enable safety and quality.

• The vision for maternity services across England is “to become safer, more personalised,

kinder, professional and more family friendly; where every woman has access to information to enable her to make decisions about her care; and where she and her baby can access support that is centred around their individual needs and circumstances” (Better Births 2016). Staff need to be supported to deliver woman centred care working in highly efficient teams in well led organisations that are open transparent, innovative and constantly learning to improve services.

• Maternity staffing is central to delivering the triple aim of health and wellbeing, care

and quality, funding and efficiency as described in the NHS England documents; Five Year Forward View (2014) and Leading change, adding value nursing framework (part,3 2016). It is increasingly apparent that personalised care leads to safer care and better outcomes. It is also well recognised that when staff work in well led positive environments and are supported to take pride in their work, outcomes for babies and women will improve.

3. NURSING AND MIDWIFERY STAFFING REVIEW REPORT 3.1 Methodology A new BR+ App has been purchased which provides a live maternity acuity tool for use in intrapartum care and both antenatal and postnatal in patient areas. Data was collected from January – April 2019. Further data collection is considered essential to inform accurate and robust data. There are no tools available to help calculate community midwifery or for outpatient areas and these areas are undergoing a separate review. The key focus of BR+ data is for midwives delivering direct clinical care in the aforementioned areas. The wider establishment review commenced last year is also in progress for maternity services. The aim of this paper is to present the challenges of staffing the maternity service, highlight the national standards with regards to midwifery staffing and provide assurance regarding the standard of staffing levels and the monitoring supporting it. The BR+ data has been used as a benchmark to underpin this report, alongside the use of national guidance and professional judgment. The current local pressures and forthcoming demands on maternity services have been discussed. New staffing paradigms have also been explored. This has endeavoured to provide a measured approach to staffing requirements for the future. Benchmarking with similar regional Trusts is of limited value due to the differences in case mix and operational service delivery. 3.2 Background: Calculating the Midwifery Staffing Requirement

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In 2014 a full and detailed midwifery workforce planning exercise was undertaken by an external workforce analysis company Birthrate Plus Consultancy (BR+). The report demonstrated the birth to midwife ratio of 1:35. The Royal College of Midwives recommendation is 1:28 for hospital births and this was clearly suboptimal at that time. At that time BR+ indicated an additional 43 wte midwives were required. A further review by the Directorate concluded that with revised models of service delivery, which included increasing the number of Nursery Nurses, developing the role of Maternity Support Workers, and a modest investment in more Band 2 Health Care Assistants there were safe staffing alternatives to the original requirements of the BR+ headline figure. To support the safe, smooth and effective running of the maternity services, the Directorate formally requested an increase in the funded midwifery establishment of 20 wte (Band 6). These above changes were considered sufficient to ensure a service change that did not affect the quality or safety of care. Following due consideration of the report and proposed new paradigms in care, further investment in both midwifery and support staff was provided and funded by the Trust Board over a two year phased approach.

*237.81 are wte midwives available to deliver direct in patient care 3.2.1 Midwife to Birth Ratios In 2015 initial funding enabled all support staff posts to be recruited and 10wte midwives. There are some roles within the pathways of pregnancy and childbirth, which cannot be delegated within the legal role of the midwife defined in statute. In addition the Directorate also continued to fund, an additional 20 wte midwives from within existing budget. This is necessary to maintain safe staffing levels and the midwife: birth ratio 1:27 for hospital births. Without these additional midwives, the birth to midwife ratio would increase to 1:30; this would be inadequate and unsafe for a regional and tertiary obstetric and maternity service. 3.2.2 Staffing ratios A staffing ratio of 1:1 for women in established labour is recommended in NICE Guidance as the minimum standard for women in established labour. BR+ acknowledges that higher risk women will require higher ratios. The Committee did not recommend staffing ratios for other areas of midwifery care. This was because of the differences in how maternity services

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are configured and a variation in midwifery staffing requirements. Birthrate Plus® recognises the value in expanding skill mix to ensure the efficient use of staff and suggests 10-15% of ‘midwifery’ time can be delegated to appropriately trained and graded support staff. Within maternity services at Newcastle Hospitals, this has been achieved through the use of band 3 Maternity Support Workers (MSWs) and Nursery Nurses within the postnatal wards. Ongoing review has been regularly undertaken, balanced with professional judgment and local benchmarking. It is anticipated that the utilisation of BR+ will provide the service with robust data regarding safe to inform future staffing reports. 3.2.3 Care delivery and national drivers In 2014 when the last BR+ review was undertaken there were approximately 7500 births annually at Royal Victoria Infirmary and whilst numbers have plateaued in the last 3 years, at 6500, the acuity and complexitity of the women and their care has increased. Since this formal staffing review in 2014 a number of significant changes have occurred and there is a need to continue the work to implement the National Maternity Review (Better Births). NHS Planning Guidance for 19/20 sets out key priority areas and key deliverables for 19/20 for eg the target of 35% of women to be booked on a continuity pathway by March 2020. The implementation of Saving Babies lives Care Bundle, version 2 continues and is due for completion March 2020. Realising a national ambition of a 20% reduction in the rates of still birth, neonatal death and brain injury by the end of 2020/21 and a further reduction of 50% by 2025

The NHS Long Term plan reaffirmed the work to improve quality outcomes for maternity care as a national priority. Maternity claims in England account for the highest value, and the second highest number of claims (NHSLA 2012). It is therefore essential that the Trust continues to deliver the highest possible standard of care including safe staffing levels. Work is ongoing to demonstrate full compliance with the CNST Maternity Standards and the maternity unit is currently in Wave 3 of the national Maternity and Neonatal Safety Collaborative.

3.2.4 Workload Challenges In recent years there has been recognition of significant workload changes which were not supported by additional staff resources. Examples of this include:

Ongoing midwifery input in developing a Maternity module for CERNER

Increase in antenatal surveillance requiring increase in midwifery sonography

Increase in complex safeguarding management and referals

New specialist roles for Diabetes, Mental Health, Smoking cessation- depleting clinical expertise to more specialist roles

Increase in practice support midwives Meeting the national ambition of Continuity of Carer for women is a challenge and to fully implement will require major organisational and workforce change. There is an obligationto

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balance this maintain current provision and balance current outstanding CQC-rated maternity unit with user feedback reporting ‘better than expected’ results. 3.2.5 Vacancy rates The unit has experienced low vacancy rates this past year and has been successful in recruiting to all vacancies with an annual turnover rate of 10.6%. 3.2.6 Sickness rates There is an acute awareness that directorate sickness rates have been well above the Trust’s target of 3%. Specific work to investigate the reason for the high sickness identified stress as the main factor. Concluding that the environment in the maternity unit can be a very stressful environment here has been some specific work developed to help try to better understand and address this. The directorate are addressing this in collaboration with HR, Occupational Health and Health Psychology. The management of sickness at recent performance, reviews an improvement in sickness rates. A programme of restorative clinical supervision is provided to midwives, delivered by the Professional Midwifery Advocates with the aim of building resilience in accordance with A-EQUIP supervision clinical model and is welcomed by midwives. 3.2.7 Maternity Leave The unit has experienced sustained high levels of maternity leave. This is currently sitting at 6% and temporary underspend has been used to over recruit to manage the gaps created by maternity leave. The challenge is that the staff recruited to cover the gaps in workforce are require a significant amount of training and support to develop the skills of the staff they are replacing. However, this provides a pipeline of midwives to work in the service. 3.2.8 Preceptorship Newly registered Band 5 Midwives are recruited at Band 5 and transition to Band 6 over approximately 18 months to two years. The introduction of a new band 5 induction package has been successful, adjusted the period of supernumerary status to 26 weeks, and reduced the attrition rate soon after appointment. The directorate has invested further strengthening the practice support midwives on delivery suite within budget, to support the development and maintenance of the clinical skills required. Band 5 midwives currently represent approximately 33% of the rotational midwifery work force. Supporting them through a detailed preceptorship programme enabling the transition to Band 6 requires high investment from more senior staff. An estimate of the impact on the midwife to birth ratio for the Newly Qualified Midwives (NQM’s) and the aforementioned 20 wte over recruits would further increase this to 1:31. A further uplift to account for this professional transition would assist maintaining this programme. 3.2.9 Annual Leave

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Capped at 14%. 3.2.10 Maternity specific mandatory training Midwives require skills drills training due to the high risk element of the role and in accordance with CNST standards. They also require a range of public health training, which includes safeguarding, smoking cessation, infant feeding, perinatal mental health and diabetes to ensure that they can fulfill the educational requirements of the role. Infant feeding training provision has increased for all staff and has reaped rewards in the recent attainment of UNICEF Baby Friendly Initiative Stage 3 accreditation. The directorate has also demonstrated a significant reduction in pregnant women smoking which helps to reduce high risk in this cohort of women. A team of Professional Midwifery Advocates provide all midwives with group clinical supervision. Current mandatory and in-house training currently demonstrates 98% compliance. 3.3 Staffing Establishments Summary findings from 1st Phase Birthrate Plus

BR+ Required WTE Completion Rate LTS Sickness/Maternity Leave

Newcastle Birthing Centre

80% 0%

Delivery Suite

10.7 – 8.7 90% 0%

Post-Natal 6.7 – 4.8 75% 7%

Ante-Natal (Ward 34/MAU)

3.65 – 1.43 65% 0%

Community 21.8%

Rotational 14.7%

Total + 21.05 – 14.93

3.3.1 Intrapartum Care - Newcastle Birthing Centre (NBC) Staffing The midwifery establishment for Newcastle Birthing Centre is based on 5 midwives per shift, 24 hours a day 7 days a week, to provide responsive and safe antenatal triage and assessment, intrapartum care and postnatal care to low risk mothers and babies. Optimal staffing based on this establishment calculation is as follows:

Establishment total 27.5

Core Team Midwives 11.0

Rotational Band 5 5.5

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The first 4 months of 2019 suggests that the Newcastle Birthing Centre was between 1.77% and 0.06% under established. Planned establishment comparisons using BR+ The completion of the acuity tool is good, with an 80% completion rate. Whilst the planned establishment for the NBC is 5 midwives reflected through the number of actual midwives rostered for duty, the acuity tool shows that fewer midwives are on duty than planned. Data clearly demonstrates that this is because midwives were frequently redeployed internally to other areas to manage activity as a result of the acuity in the NBC. Red Flags There was only 1 red flag in January; this was a delay between presentation and triage. Despite 5 midwives on duty there were 3 other women in labour plus postnatal patients. This is an unusual occurrence. There were no occasions when we were unable to provide one to one care in labour on the NBC from January to April 2019. 3.3.2 Intrapartum Care - Delivery Suite Midwifery Staffing The midwifery establishment for the Delivery Suite is based on 13/ 14 midwives per day shift depending on elective caesarean section lists and, 11 midwives per night shift and weekend day shifts. The Delivery Suite Co-ordinator on every shift is supernumerary and excluded from these numbers. This information is currently evidenced using the daily activity records and in future will be captured as an independent red flag on BR+. The directorate is assured of 100% compliance in this regard. The midwives provide responsive and safe labour induction, intrapartum care and postnatal care to high risk mothers and babies. There are currently 21 caesarean section slots per week and 12 induction of labour slots daily. The Practice Support team will also provide clinical care if necessary, eg to maintain one to one care in labour. This can have implications for supporting the NQM although the Band 7 co-ordinator if the practice support midwife is providing care, fulfils this role. Optimal staffing based on this establishment calculation is as follows:


Core Team Midwives Band 7 9.4




The first 4 months of 2019 suggests that the Delivery was under established by between 10.72 WTE and 8.79 WTE. Planned establishment comparisons using BR+ The completion of the acuity tool is very good with an average 90% completion rate.

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Although the planned establishment for the DS is between 11-14 midwives (excluding the co-ordinator) the acuity tool demonstrates the actual establishment was fewer than the planned number as a result of high levels of sickness and maternity leave as well as a midwives working in a supernumerary capacity during their preceptorship period. The staffing factors influencing the number of midwives on duty are monitored by the senior midwifery team and appropriate actions taken to accommodate shortfalls. Red Flags After instigating management actions to increase staffing levels and clinical actions to reduce clinical activity there were 32 red flag events. However, 24 were a decision to delay induction of labour at the point of admission and of the remaining red flags;

1 delay in suturing within 60 minutes

5 delay in pain relief

Despite the pressures on all staff groups there were only 2 occasions over a 4-month period were one to one care in labour was unachievable.

The directorate will use this data to identify what actions can be taken to mitigate against some of these staffing challenges in the future.

3.3.3 Postnatal Midwifery Staffing The midwifery establishment for the postnatal inpatient areas is based on 8 midwives per day shift, and 5 midwives per night shift. These numbers include a Co-ordinator on each of the two wards. The midwives provide responsive and safe postnatal care to high-risk mothers and babies over two wards including those babies receiving transitional care. In other trusts, these vulnerable babies would be cared for on the SCBU separated from their mothers. The care of these transitional babies is supported by a team of transitional care nurses and nursery nurses who are included in the data submitted to BR+. Optimal staffing based on this establishment calculation is as follows:




The first 4 months of 2019 demonstrates that the postnatal areas was under established by between 6.7 WTE and 4.81 WTE.

Planned establishment comparisons using BR+ The completion of the acuity tool over both wards is on average 75%. The rate is anticipated to improve as rotational midwives have now been provided with training and passwords to access the acuity tool; initially this was the responsibility of the small core teams in each area. The planned establishment for the postnatal area is for 8 midwives (including the co-ordinator). However, the acuity tool demonstrates that this is often not the case and that the actual staff available was less than the planned establishment due to high levels of

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maternity leave and sickness. The acuity tool demonstrated that the postnatal areas were understaffed between 23.6 % and 59.1% of the time between January and April. Red Flags The directorate are currently revising the red flags for non-intrapartum areas as it is perceived that the current NICE recommended red flags provide less valuable data on the postnatal wards. For that reason, the evaluation of the red flags for these areas are incomplete. Despite a deficit between the planned and actual establishment safety was not compromised. However based on the number of informal complaints via PALS, quality of experience has not been consistently maintained. Staffing on the postnatal wards has been reduced due to a combination of staffing factors, as previously stated (maternity leave, sickness levels and NQM) and providing support to intrapartum areas to maintain one to one care during labour as demonstrated by the management and clinical actions captured using BR+. 3.3.4 Antenatal Ward Staffing The planned establishment for Ward 34 is 3 midwives per day shift and 2 per night shift


Core Team Midwives 2.7

Rotational Band 5/6 9.7

The first 4 months of 2019 demonstrates that Ward 34 was under established by between 3.65 WTE and 1.43 WTE. Planned establishment comparisons using BR+ The completion of the acuity tool was on average of 65%. The rate is anticipated to improve as rotational midwives have now been provided with training and passwords to access the acuity tool whereas initially this was the responsibility of the small core teams in each area. Therefore, caution must be used when interpreting the data. Red Flags There was only 1 red flag - delay in pain relief. The bank shift fill rate for the antenatal services was 43%. This is unsurprising as the midwifery workforce with bank contracts are predominantly staff with existing substantive contracts. 3.3.5 Community Midwifery Staffing The planned establishment for community midwifery is based on the provision of a 7 day service with an on call service for homebirth. There are four community teams across the city: West, Central, East and North.

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There is no acuity tool for community midwifery; however, BR+ recommends a caseload midwife to woman ratio of 1:98. The table below demonstrates high caseloads and as with all other aspects of maternity care, the complex care women require is increasing. To achieve this ratio it would require an additional 8.26 WTE midwives.

Community Team Caseload

Midwife WTE

Caseload Ratio Women : WTE midwife

West 709 6.7 106

North 1118 7.9 141

Central 999 8.5 118

East 900 6.64 135

The ratios above suggest that the community midwifery staffing appears suboptimal. To mitigate against this, there has been investment in maternity support workers and their input should be considered (in line with BR+) resulting in a ratio of 1:110. MSWs provide essential support to the non-midwifery elements of care. Further work is ongoing but is considered safe. 3.3.6 Maternity Assessment Unit (MAU) There is no acuity tool for MAU; this is a high-risk area and the midwifery establishment for MAU is based on 4 midwives per day shift and 2 midwives per night shift (7 days per week). These numbers include the MAU Co-ordinator. The midwives provide responsive and safe antenatal and on occasion postnatal care to high risk women. Women attend the MAU for planned appointments and emergency care. Emergency admission comparisons between 2015 to date show numbers have doubled. Accordingly a review of current planned establishment has been identified as insufficient and an additional midwife is sourced daily from the staff bank to cover as an interim measure to maintain safe staffing. Further detailed work is ongoing in relation to this aspect of maternity care. 3.3.7 Ultrasound The directorate is currently scanning to capacity and struggling to offer scans in a timely manner to all women who require them in accordance with national guidance. There is a national shortage of midwife sonographers and the directorate continually supports midwives to undertake the Post Graduate training. This takes 18 months before staff are competent to work independently and once qualified require payment at Band 7. 3.3.8 Specialist Midwives There is a diverse team of specialist midwives who provide both clinical and educational expertise. They represent 10wte and help ensure care is in accordance with national

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standards. They are part of the unit’s escalation policy to provide additional clinical resource at times of service need. 4. RISK AND MITIGATION This report highlights that a detailed midwifery staffing review process has been undertaken in line with national mandate and guidance. The analysis demonstrates that overall the funded establishments are fit for purpose but high levels of, maternity leave and sickness, and, increasing demands for education and training within maternity services are placing pressures on day to day deployment of midwives. This is managed dynamically by the senior midwifery team in response to changing need. The use of staff bank is helping address shortfalls in rotas and strong leadership facilitates the safe distribution of staff in response to constantly changing service demands. The valuable contribution support staff add to the quality and safe staffing of the unit is recognised and the blended models provide more collaborative delivery of care to women and babies. When combined with midwives in staffing ratios can alter the midwife to birth ratio to more realistic levels. Intrapartum care will always take priority but reallocating staff to provide this care impact other aspects of care delivery. This is unlikely to change in periods of unpredictable increased activity. Whilst this risk cannot be fully mitigated, robust professional leadership is in place to actively support the senior midwifery team in assuring safety. Work is ongoing to explore new paradigms in care including the possible use of Associate Practitioners in obstetric theatres. 5. SUMMARY The new BR+ App is beginning to provide acuity data which will help inform further midwifery staffing reports. Data from January – April 2019 shows Delivery suite and NBC data input compliance is good and now providing robust data. The ward areas compliance is steadily improving and will further ensure future data is reliable. The BR+ Apps will help inform all staffing reports in the future and help demonstrate compliance with national standards and assurance around safe staffing in maternity. Red flags, 1:1 care delivery and the supernumerary status of the coordinator will be captured and reportable in all future reports. The data reports will feature on all relevant Directorate governance assurance forums as a standing agenda item for discussion. It is evident the ward staffing regularly support demands of providing 1:1 care to women in labour. This is suboptimal and t on occasion may affect the quality of care experienced by women, such as delays in care and routine discharges but it is not considered to affect safety. Ensuring ongoing visibility will highlight any risks emerging in relation to patient

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safety. Staff are both skilled and practiced in ensuring ongoing staffing is risk assessed and via enhanced in-house education and training midwives can work across the unit, flexibly, responsive to the needs of the service. Support staff contribute greatly to maintain high quality care and enhanced patient experience. High levels of sickness and maternity leave are currently providing challenges. Proactive attempts are being made to mitigate against this. Further pressures to providing a safe service are the high levels of maternity-specific education and training required. An adjusted uplift to help accommodate this could help provide a solution to this ongoing issue. Within this Trust, the uplift is currently included in establishment and funded as 22.5% for maternity. There is Trust wide work ongoing to refine this, which may provide an opportunity to help accommodate the existing pressures. BR+ will help inform any further staffing paper and further detailed work is ongoing to explore innovative ways to maximise use of staff and maintain the high standards of care within the maternity unit. 6. RECOMMENDATION The Trust Board is asked to:

i) Receive and review the Maternity Staffing Review report from January – April 2019 assisted by new BR+ acuity tool

ii) Consider the approach taken in line with national guidance iii) Acknowledge and comment accordingly on actions outlined within

Maurya Cushlow Executive Chief Nurse 19th June 2019

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PATIENT EXPERIENCE –QUARTER 4

1. COMPLAINTS MANAGEMENT

The Trust has received 538 complaints within the last financial year in comparison to 610 in

the previous year which is 72 fewer complaints overall. Taking into consideration the level

of patient activity, the highest percentages of patients complaining are within Surgical

Services (0.06%), Urology & Renal, Childrens, Neurosciences, Cardiothoracic and MSU (all

with 0.04%). The Trust average remains at 0.03% this quarter (0.01% equates to 1 per

10,000).

Although Patient Relations have seen a general decrease in formal complaints received, it is

felt the overall complexity of the complaints has increased. More Multi-Directorate, cross

Organisation complaints are received and joint investigations requested.

A total of 150 complaints have been received in quarter 4 which is a slight increase from the

previous quarter (139). There has been a decline in complaints being responded to within

the original agreed dates; however there has been an increase in responses being closed

within the combined original and renegotiated time scales. This is due to a number of

contributing factors which include; complexity of the complaints; multi directorate

involvement; seasonal holidays and multi trust responses. The Head of Patient Experience is

monitoring this closely and this information is shared weekly at the Trust ‘stand up’ wall for

further discussions and scrutiny.

Q4 Q3 Q2 Q1

New complaints opened 150 139 118 131

Complaints closed 129 127 140 143

Complaints closed within original timescales 42% 53% 52% 45%

Compliant closed within original and reneg timescales 73% 71% 75% 86%

Acknowledged within 3 days 93% 95% 96% 97%

Directorates Complaints ActivityPatient %

Complaints Ratio (YTD)

17-18 Ratio (

Full Year)

Cardiothoracic Services 41 113,560.00 0.036% 1:2770 1:2274

Children's Services 34 94,436.00 0.036% 1:2778 1:2012

Community 18 63,093.00 0.029% 1:3505 1:3508

Dental Services 13 122,099.00 0.011% 1:9392 1:6024

Directorate of Medicine 56 167,776.00 0.033% 1:2996 1:2271

Directorate of Medicine (ED) 39 159,533.00 0.024% 1:4091 1:3163

ePOD 49 431,145.00 0.011% 1:8799 1:6490

Musculoskeletal Services 43 122,525.00 0.035% 1:2849 1:2255

NCCC & Specialist Haematology 24 173,628.00 0.014% 1:7235 1:7806

Neurosciences 45 114,442.00 0.039% 1:2543 1:2411

Patient Services 20 68,300.00 0.029% 1:3415 1:5284

Peri-operative and Critical Care 12 36,958.00 0.032% 1:3080 1:3467

Surgical Services 45 72,307.00 0.062% 1:1607 1:1186

Urology and Renal Services 28 74,712.00 0.037% 1:2668 1:2458

Women's Services 46 152,119.00 0.030% 1:3307 1:3866

Trust (with activity) 513 1,966,633.00 0.026% 1:3834 1:3249

2018-19

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The Directorate of Medicine (including ED) has received the highest number of complaints

this quarter (24) which is a similar trend to previous quarters. ‘All aspects of clinical

treatment’ remains the highest theme from the primary subject areas

There have been 12 outstanding concerns raised following receipt of final complaint

responses from a range of directorates. This has provided the Trust with some assurance

that complainants are satisfied with the quality of investigations.

From the 128 resolved complaints in Quarter 4, 22 complaints were upheld, 24 complaints

were partially upheld and 82 were not upheld.

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The Trust received four new referrals from the PHSO during quarter 4. In one case the Ombudsman has now confirmed that an investigation has been refused and the remaining three remain under investigation. Six final reports were received from the Ombudsman in the period relating to complaints that had been previously submitted; three were not upheld and three complaints were partially upheld. Lessons are shared with directorates and changes made as a result of PHSO reviews. In one case Trust staff were criticised for poor pain management and information was provided to the complainant regarding the improvement in the Palliative Care service since the time of treatment in 2016. The outcome of another PHSO investigation identified communication shortcomings in the Cardiothoracic Directorate and as a result a standard template will be used for referrals to the surgical team which provides information regarding the patient’s clinical condition, past medical history and contact details of the referrer/referring hospital. This will facilitate communication and correspondence provided at the time of discharge. A generic line will be added to the discharge letter requesting that the referrer ensures all relevant parties are informed of the admission and treatment received at the Freeman by the Thoracic Surgical Team.

The number of referrals made to the Ombudsman has fallen slightly with 22 received in 2018/2019 compared to 27 in the previous financial year.

Patient Relations Department (PRD) and PALS are continuing to work closely to ensure patients are supported when raising concerns and complaints. There has been a decrease over the last 6 months in PALS referrals to patient relations department and a steady flow from PRD to PALS. PALS continue to see an increase of direct patient contacts with 834 in comparison to 712 in the previous quarter, representing compliments, comments, enquiries, complaints and concerns. The main themes identified through PALS are with regards to Communication (188), Care and Treatment (145) and Appointments (138).

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2. PATIENT EXPERIENCE SURVEYS 2.1 National Urgent and Emergency Care Survey 2018

The following summary shows an overall positive experience for patients attending the Emergency Department /Minor Injuries(Type 1) and the Walk in Centres (Type 3). Type 1 Results

- 28% response rate (250 responses) compared to 26% in 2016. - 98% of patients said they were treated with respect and dignity - 96% said the doctors and nurses listened to them - 82% rated their care as 7 or more out of 10

Compared to the 2016 survey, the Trust scored:

- Significantly better on 1 question – the patient understood why tests were needed (96% compared to 91% in 2016)

- Significantly worse on 1 question – the patient understood the results of tests (94% compared to 99%

- No significant difference in 26 questions Type 3 results

- 27% response rate (112 responses). No comparison available as not covered in the 2016 survey.

This national survey runs every two years and asks patients who attend Type 1 and Type 3 centres questions about their attendance, care and treatment. The Trust contracted the Picker Institute to undertake the survey on our behalf. The initial results have been received although the Care Quality Commission (CQC) will not publish the national benchmark results until August 2019.

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- 98% of patients said they were treated with respect and dignity - 99% said the health professional listened to them - 91% rated their care as 7 or more out of 10

Compared to the 31 other organisations who used Picker for this survey, the Trust scored significantly better on one question (100% of patients has confidence and trust in the health professional) and significantly worse in none. No significant difference compared to average for 31 questions.

2.2 National Inpatient Survey 2019

2.3 Liver Transplant Patient The Freeman Hospital is participating in a pilot study which the British Liver Transplant Group have commissioned with the Picker Institute. This pilot is a survey regarding patients’ experience of liver transplants and the Freeman Hospital is one of seven centres taking part in the research. The clinical leads for this project at the Freeman Hospital are Derek Manas and Mark Hudson. 2.4 Coaching Project – Patient Evaluation

We recognised the importance of capturing the patient experience as part of the evaluation process of the coaching and learning in clinical practice (CLIP) project. The team were keen to examine if the presence of more students on the ward affected the patient experience in terms of privacy, safety and overall experience. A short semi-structured questionnaire was developed and members of the Patient Experience Team visited three wards, once per week over a three week period. The survey was carried out with both patients where students were present in the bays and where they were not, in order that any differences in the experience could be identified.

Overall my experience was good things at the

time did look busy and I was treated well I think

you are all stars and a very big thank you.

Each and every time I have been admitted to

A&E, I've been treat from the ambulance

through to the consultant to the transport home,

with care, dignity and kindness. Thank you.

The annual adult inpatient survey is due to take place in

Autumn 2019. The Trust has been approached by Ipsos

Mori who is working with the CQC to conduct a pilot to test

a mixed method approach to the Inpatient survey. The

Trust will therefore be involved in this pilot which will run

alongside the usual survey methodology.

The CQC results of the 2018 Adult Inpatient Survey are due

to be published in June 2019.

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The results show that most aspects of the patient experience rated more highly when students were present (apart from privacy on the ward). This was a welcome result especially around noise during the day and privacy at the bed space given that there would be more people in the bays at times. The increase in staffing has shown to lead to an improved feeling of safety on the ward and improved responses to the call bell. 2.5 Maternity Voices Partnership

A Maternity Voices Partnership (MVP) is a team of women and their families, commissioners and providers (midwives and doctors) working together to review and contribute to the development of local maternity care. In this Trust, Olivia Hicklenton, Maternity System Project Midwife has established connections and attended a number of groups in the community to ensure that the views of women and partners from all areas are heard. This includes teenagers, the Romanian community, BAME community and Jewish community with the support of local involvement forums such as Healthwatch, the Health and Race Equality Forum (HAREF), Barnardo’s and the Angelou Centre. In addition, a Facebook group has been set up and has over 400 members which is used to share information and ask for views and ideas which is then shared with the directorate to consider ideas for improvement. Changes as a result of the engagement with the MVP include:

- The purchase of five reclining chairs to improve the comfort of partners staying overnight on the postnatal wards.

- The improved facility for women with babies on Special Care Baby Unit (SCBU) to get hot meals form the Birth Centre at any time and work with Tiny Lives and the neonatal unit to improve care for these women.

- Changes in the visits made to the postnatal ward by Bounty.

- Training for staff on supporting migrant women during pregnancy - Advice made available (provided by UNICEF) regarding artificial formula so mums can

have the information they need.

All staff have been very nice. Student

nurses help as an extra pair of hands

2 student nurses were exceptional

when I was feeling unwell. Above and

beyond

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3. APEX – ADVISING ON THE PATIENT EXPERIENCE

The APEX Group has now been running since October 2018 and has an increased membership of around 20 people. In Quarter 4, staff who have attended the group have asked for patient views on:

- Falls prevention exercise referral - Complaints response process - Low molecular breast imaging research.

‘Interesting discussions and input’ (member)

‘There were a lot of opinions, everyone was engaged, and a general consensus arrived at on what probably should happen’ (member)

‘This meeting made it clear that we should involve patients and the public at a much higher level, in the planning of the project itself, rather than just components such as reviewing patient-facing documentation.’ (presenter) 4. NHS FAMILY AND FRIENDS TEST

The Trust continues to perform well in terms of the percentage of patients who would recommend the Trust to their family or friends if they needed similar care or treatment. There has been an increase in the recommendation rate for the emergency department and community services, however response rates overall have declined.

Inpatients Emergency Outpatients

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

Response rate % 12.70% 12.30% 11.90% 12.70% 1.60% 1.70% 1.40% 1.10% 2681* 748* 1930 1671

Recommendation rate % 97% 97% 97% 97% 93% 94% 91% 94% 96% 95% 96% 96%

Maternity Community

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Response rate % 29% 23% 25.30% 22.70% 71* 85* 47* 82*

Recommendation rate % 99% 98% 99% 99% 95% 96% 92% 95%

*based on actual average number of responses not response rate

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NHS England has been carrying out a project to improve some areas of the way the Friends and Family Test works across the country, with a view to publishing refreshed FFT Guidance by the end of April 2019. To date this has not been received. Informal feedback is that the FFT question will change and trusts will get six months to implement the changes. The Patient Experience Steering Group has agreed to delay order of new stock until the revised guidance is published. This may lead to a decline in the number of responses as areas run out of stock; patients will still have the option to complete the survey online or using the kiosks in the Trust. Once any changes are made, the opportunity will be used to re-launch the Friends and Family Test with staff and patients to try to increase participation and response rates

5. NHS CHOICES AND TAKE 2 MINUTES

Site Star rating

RVI 4.5 stars based on 177 ratings

Freeman 5 stars based on 118 ratings

GNCH 4 stars based on 7 ratings

Newcastle Dental Hospital 4.5 stars based on 53 ratings

6. SMALL CLAIMS

The Trust has received a total of 60 small claims with 14 of those being received in Q4. The

majority of claims are in relation to lost glasses, dentures and personal belongings.

Q1 18/19 Q2 18/19 Q3 18/19 Q4 18/19

Number of claims received 16 17 13 14

Number upheld 12 9 8 9

Amount paid £834 £1533 £2532.48 £2509.37

Ms Maurya Cushlow Executive Chief Nurse 19th June 2019

The Trust maintains a 4.5 star plus star rating across the

Freeman, RVI and Dental Hospital. In Quarter 4 the main theme

from positive feedback was that patients felt emotionally

supported and felt care was co-ordinated. Subjects for negative feedback focus

primarily on access to care with issues such as waiting times and appointments.

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Safeguarding Annual Report

2018 / 2019

June 2019

Agenda Item A7 (ii) BRP

89

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=2ahUKEwjmlsurorriAhUq0uAKHcEpD_gQjRx6BAgBEAU&url=https://jantrust.org/project/against-fgm/&psig=AOvVaw06axnymjeWnHcpiDuCeSpF&ust=1558996804264499

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=2ahUKEwiT8NTm-LniAhVk6uAKHYJcBfwQjRx6BAgBEAU&url=https://www.counselcareconnection.org/how-to-help-abused-grandchildren/&psig=AOvVaw2HB03cJPKuNebW1Tm_T6v4&ust=1558985786723845

2 | P a g e

The Key Facts

9554

Safeguarding Cause for Concerns Raised

820

Maternity Cause for Concerns responded to

2164

Safeguarding Children Cause for Concerns responded to

1019

Safeguarding Strategy Discussions in the MASH1

2624

Safeguarding Adults Cause for Concerns responded to

1814

Learning Disability Referrals responded to

713

Deprivation of Liberty Safeguards applications made

59

Referrals to MARAC2

154

Child Protection Medicals completed

187 Acute Paediatric Forensic Assessments completed

1 Multi-Agency Safeguarding Hub

2 Multi-Agency Risk Assessment Conference - for high risk victims of domestic abuse

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Contents:

INTRODUCTION FROM THE EXECUTIVE CHIEF NURSE 4

FOREWORD FROM THE CHAIR OF THE SAFEGUARDING COMMITTEE 5

IN FOCUS 6

SAFEGUARDING STRATEGY 2018-2021 7

PARTNERSHIP WORKING 11 MATERNITY & WOMENS SERVICES 12

SAFEGUARDING CHILDREN 15

SAFEGUARDING ADULTS 18

LEARNING DISABILITY XX 21

MENTAL CAPACITY ACT / DEPRIVATION OF LIBERTY SAFEGUARDS 23

SAFEGUARDING TRAINING 25

GOVERNANCE & ASSURANCE 28

APPENDICES:

One - Trust Safeguarding Mandatory Training Matrix 2019

29

Two - Trust Safeguarding Management Arrangements 2017-2018 31

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Introduction from the Executive Chief Nurse

I am proud to present the Trust’s Annual Safeguarding Report for

2018/2019. Safeguarding is firmly embedded within the Trust’s

core values and we pride ourselves in providing care of the

highest quality whilst being assured that this is underpinned by

quality and safety. Safeguarding continues to change in response

to the context of societal risks and this is particularly evident in

Newcastle where we have contributed to a number of large scale

reviews and statutory developments.

Fundamentally, it remains the responsibility of every NHS-

funded organisation, and each individual healthcare professional

working in the NHS, to ensure that the principles and duties of

safeguarding children and adults are holistically, consistently and conscientiously applied:

the well-being of those children and adults is at the heart of what we do.

As an NHS health care provider it is our responsibility to ensure that we are able to fulfil our

statutory duties and to be assured they are working effectively. Safeguarding children,

young people and adults at risk is fundamental to the services that the Trust provides and is

something that we regularly review through our internal and external governance

arrangements. The principles of safeguarding and managing risk have some inherent

similarities that strengthen the interface between the Trust’s teams; however, we also

recognise there are distinct differences and to that end we have separate teams to provide

specialist approaches to children’s safeguarding and adult safeguarding and to safeguard

the unborn child.

Partnership working is vital to the success of safeguarding individuals at risk and the Trust’s

safeguarding teams are committed to multi-agency partnership working and supporting the

work of the Newcastle Safeguarding Children’s Board, Newcastle Safeguarding Adults Board

and the Safe Newcastle partnership.

Maurya Cushlow

Executive Chief Nurse

12 June 2019

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Foreword by the Chair of the Safeguarding Committee

It gives me great pleasure to be able to present this

Safeguarding Annual Report during my third year as Chair of

the Safeguarding Committee. I warmly invite you to share the

achievements and challenges that the safeguarding teams

have experienced over the past year; the previous

Safeguarding Annual Report was presented to the Trust Board

in June 2018.

The accountability for safeguarding nationally is firmly

protected in legislation for both children and adults. This has

been transformed in recent years with the introduction of

new legislation and responsibilities which need to be

incorporated into the widening scope of NHS safeguarding practice and provide the

framework that the Trust’s safeguarding teams work towards and deliver upon.

It is evident from the report that a significant amount of work has been undertaken by the

teams to safeguard children, young people, adults and unborn babies at risk of harm. This

includes the development of tools to assist in the recognition of sexual exploitation;

promoting awareness of FGM and revising pathways for referral; increasing awareness of

radicalisation and other complex issues such as neglect and domestic abuse.

It is clear from this report that domestic abuse remains a key priority within the Trust and

for the safeguarding teams as the scale of this problem both locally and nationally equates

to a public health issue. This is evidenced through the work the safeguarding teams do and

the Schwartz Round in January 2019 that focused on domestic abuse and received excellent

feedback from staff who attended.

The new training matrix has been a major achievement and is designed to reflect guidance

from the intercollegiate documents for children’s safeguarding and adult safeguarding. This

has been a tremendous piece of work that has been completed over the past year and

responds to the guidance whilst being pragmatic for a Trust of our size and complexity.

Another challenge has been meeting the national requirements for Prevent training.

I would like to express my thanks to the Trust’s safeguarding teams for all of their hard work

and dedication to protect children, young people and adults at risk.

Prof Kath McCourt CBE FRCN

Non-Executive Director

12 June 2019

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IN FOCUS: The Trust’s Safeguarding Professionals

The Newcastle upon Tyne Hospitals NHS Foundation Trust strives to be the very best

healthcare provider by putting patients at the heart of everything we do. Safeguarding

children and adults at risk of abuse or neglect is a collective responsibility. The safeguarding

teams are fundamental to this philosophy and provide person centred and compassionate

care in a highly demanding and fluid environment. This is achieved by delivering care with

measurable outcomes focused upon safeguarding patients, carers and staff. Our

commitment to people of all ages from all ethnic origins and backgrounds takes into

account the diverse needs of our local communities and the wider patient populations

served by the Trust.

Head of Safeguarding

Women’s Services Safeguarding 1.0 wte Named Midwife

Children’s Safeguarding

1.0 wte

0.3 wte

5.5 wte

1.8 wte

Named Nurse Safeguarding Children

Named Doctor

Safeguarding Children Nurse Advisors

Administrators

Adult Safeguarding

1.0 wte

0.05 wte

2.1 wte

1.0 wte

1.5 wte

Named Nurse Safeguarding Adults

Named Doctor

Safeguarding Adults Specialist Nurses

Mental Capacity/DoLS Lead

Administrators

Learning Disability 1.8 wte

0.5 wte

Learning Disability Specialist Nurses

Administrator

Safeguarding Education 1.0 wte Safeguarding Trainer

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SAFEGUARDING STRATEGY 2018 - 2021

The Newcastle upon Tyne Hospitals NHS Foundation Trust is one of the most successful

teaching Trusts in the country offering the second highest number of specialist services than

any other group of hospitals in the UK. Our hospitals have over 1,800 beds and we manage

over 1.72 million patient ‘contacts’ every year. We provide innovative, high standard

healthcare, including community services and primary care and the Trust is totally

committed to safeguarding despite our size and complexity.

Safeguarding within the Trust starts with safe recruitment to ensure suitably qualified and

skilled staff are selected. Safeguarding is central to providing excellent services and is not an

alternative for safe or high quality care. The Trust is committed to ensuring staff

demonstrate an understanding of their safeguarding responsibilities by early recognition

and prompt response to safeguarding concerns.

Although safe care is a high priority for the NHS, learning from national and local reviews for

both adults and children tells us this is not always evident for everyone all of the time. All

Trust staff are required to complete mandatory safeguarding training for safeguarding

children and adults at risk; the level and frequency of training is determined by job role. The

framework for safeguarding children’s training is aligned to the intercollegiate document

(2019); there is currently no equivalent for safeguarding adults. All 13 500 staff have access

to Trust policies and procedures which reflect best practice and current guidance.

The Trust’s Strategic Goals and Core Values

Putting patients first and providing care of the highest standard focusing on safety and

quality.

Working in partnership to provide fully integrated care and promoting healthy lifestyles

to the people of Newcastle.

Maintaining the ongoing development and success of our organisation.

Taking pride in what we do and maintaining a high level of professionalism at all times.

The safeguarding teams have further defined the safeguarding strategic goals and core

values that provide the foundation for the work we do on behalf of the Trust. These are

aligned to the “6 C’s” which are the six fundamental values defined in “Compassion in

Practice”3 that put the person being cared for at the heart of the care they are given.

3 Department of Health “Compassion in Practice: Nursing, Midwifery & Care Staff: Our vision and Strategy

(2012)

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Safeguarding Strategic Goals and Core Values – ‘compassion in practice’

CARE Promote a culture of prevention and early detection to keep children, young people and

adults at risk safe from harm.

Respect and value individuals irrespective of age, race, religion, gender or beliefs.

Provide access to safeguarding advice and support for Trust staff by means of a duty nurse.

Protect individuals who may be deprived of their liberty to receive appropriate health care.

Safeguard individuals of all ages who have a learning disability and ensure safe access to Trust services.

COMPASSION Promote an open culture that allows staff to raise concerns about abuse of children, young people and adults at risk.

Put the person at the centre of everything we do; listen to children and their families, adults and their carers and respond to their needs.

Make safeguarding personal and involve individuals in decisions about their care.

COMPETENCE Deliver safeguarding supervision to keep children, young people and adults safe.

Deliver high quality training based on national standards and best practice guidance.

Ensure safeguarding policies and procedures are fit for purpose.

Maintain contemporaneous documentation to meet the Trust’s Governance standards.

Monitor the quality of safeguarding practice through audit and case file reviews.

Develop a dataset of information to monitor outcomes and standards of care.

COMMUNICATION Provide patient information to help them understand what safeguarding means to them.

Deliver ‘Learning from Practice’ events to share learning from serious case reviews, appreciative inquiries and domestic homicide reviews to enhance professional knowledge and improve outcomes for all individuals.

Lead on the health safeguarding agenda in multi-agency forums especially in Local Safeguarding Children Boards and Local Safeguarding Adults Boards.

COMMITMENT Be tenacious in a quest to deliver a highly responsive safeguarding service that is dynamic and responds to contemporary issues in safeguarding.

Ensure we meet the organisational, legal, and strategic responsibility under the Children’s Acts and Working Together (2015) and the Care Act (2014).

Demonstrate commitment to multi-agency working, liaising where appropriate and offering professional challenge in order to keep children, young people and adults safe.

COURAGE Be an advocate for safeguarding individuals and do not be afraid to challenge other

professionals or agencies to deliver their professional responsibilities.

Improve practice by learning from mistakes in a culture without blame.

Be solution focused and innovative to advance practice and improve outcomes.

Promote equality and diversity and challenge anti-discriminatory practice.

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Workforce development

The Trust is committed to the continuing development of a highly

skilled workforce that is confident in facing the challenges that

arise from safeguarding. This will continue to be developed

through strong leadership, training and experienced safeguarding

teams. The strategic safeguarding aims related to the Trust’s

workforce are to:

Deliver high quality education to build the knowledge and skills of

staff to recognise and respond effectively to safeguarding

concerns including:

o PREVENT

o Neglect & self-neglect

o Domestic abuse including routine enquiry

o Sexual exploitation of children, young people and adults

o Female Genital Mutilation (FGM), modern day slavery and trafficking

o The Mental Capacity Act and Deprivation of Liberty Safeguards

Actively listen to what children and adults tell us so they remain central to decision making

about their care and treatment.

Systematically review Trust policies and procedures in response to local and national

learning from serious case reviews.

Support staff to make reasonable adjustments for patients with a learning disability to

ensure their needs are met.

Enhance the personal journey for individuals making the transition from children’s to adult

services.

Policies and procedures provide a framework for safeguarding practice and support staff to

recognise and respond effectively to a safeguarding concern. There is a need to streamline

these to ensure processes are clear and detailed enough for staff to do the right thing.

However, learning from serious case reviews tells us that having policies and procedures in

place is not in itself robust, it is how they are accessed and implemented that is

fundamental to good practice.

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Measuring the impact to safeguard children, young people and adults at risk using the

Care Quality Commission’s five themes

Domain Outcome measurements

SAFE

Safeguarding supervision available for all Trust staff

Core work of health visiting and school nursing

Access to timely and effective emergency/minor injury treatment

EFFECTIVE

Share learning from serious case reviews, learning reviews and internal

reviews to improve clinical practice.

Internal audit and policy development / review

CARING

Effectiveness to respond to and reduce further harm

Reduction in pressure area damage, infections, VTE

Reduction in medication incidents

RESPONSIVE

Learning from Serious Case Reviews / Domestic Homicide Reviews

Learning from Serious incidents

Learning from complaints

Implementation of national guidance and statutory legislation

WELL LED

Executive leadership to promote the safeguarding agenda throughout the

Trust.

Expert safeguarding advice to support all staff across the Trust to safeguard

children and adults.

The Trust has been selected as a Global Digital Exemplar (GDE) which will deliver

exceptional care through the use of world-class digital technology and information. This will

for clinicians and support service change to help improve health for all.

There has been a tremendous amount of work completed in the Trust over the past 12

months to deliver GDE and the safeguarding teams have actively contributed to this work.

This work is ongoing and has captured existing documentation to provide a future work flow

that will be easily accessible and secure in different formats. For the safeguarding teams,

this will mean they have more timely access to accurate clinical information for patients in

any area of the Trust by supporting the transition to electronic documentation. This will

improve systems and processes to facilitate more effective information sharing, retrieval

and data management.

Additional work has been progressed to develop a safeguarding module in SystmOne which

will enhance information sharing and documentation for patients in the community.

Although it remains uncertain how long this will take to develop, this has been warmly

embraced by the teams who will be able to use SystmOne functionality to provide more

seamless communication with community services in the Trust.

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PARTNERSHIP WORKING

Newcastle Hospitals is a key partner agency in safeguarding within the city and across the

region. The Trust supports the strategic and operational work of Newcastle Safeguarding

Children’s Board, Newcastle Safeguarding Adults Board and the Learning Disability Clinical

Network. This is achieved through:

Membership of NSAB / NSCB and on the sub-groups of both

Boards.

Multi-agency audit and multi-agency training with NSAB &

NSCB.

Active contribution to:

o Serious Case Reviews (adults & children)

o Appreciative Inquiries (adults and children)

o Domestic Homicide Reviews with Safe Newcastle

Partnership

o Complex abuse meetings

Contribution to Multi Agency Risk Assessment Conferences (MARAC)

The safeguarding adults team also lead on the PREVENT agenda and represent the Trust

at the CHANNEL Panel which is co-ordinated by Safe Newcastle

The safeguarding advisors from the children’s team rotate weekly to provide full-time

specialist health input into the Multi Agency Safeguarding Hub (MASH).

A safeguarding children’s advisor was seconded into a police led multi-agency

safeguarding hub tackling city-wide sexual exploitation of children and adults.

The teams all work across boundaries with organisations and local authorities outside of

Newcastle due to the high volume of service users from other areas.

The named midwife attends the Child Death Overview Panels (CDOP’s) that reviews all

deaths of children up to the age of 18 years, excluding stillbirths. CDOP’s are made up

professionals with expertise from a range of organisations. The North of Tyne CDOP

undertakes reviews locally for all children normally resident in Northumberland, North

Tyneside and Newcastle.

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MATERNITY & WOMEN’S SERVICES SAFEGUARDING

Maternity services provided care for 6508 women during the period April 2018 - March

2019. Of this 3111 (47.8%) were Newcastle residents with the remaining 3397 (52.2%)

attending from neighbouring Trusts, predominantly Northumberland, North Tyneside and

Gateshead. This shows comparable numbers to 2017/2018 figures. As the RVI continues to

operate as a Regional centre for specialist Obstetric and Neonatal care, multi-agency

safeguarding remains a key priority within the maternity services to promote the health and

wellbeing of women and their babies.

KEY ACHIEVEMENTS 2018 – 2019

During 2018/2019 the maternity services have continued to review safeguarding processes

to continually promote robust and effective systems to ensure women and their babies are

safe. As such there have been a number of developments and new initiatives implemented.

CP-IS and FGM-IS

The Child Protection – Information Sharing (CP-IS) and the Female Genital Mutilation –

Information Sharing (FGM-IS) are both national systems that were implemented in

2017/2018 and are now well embedded in the Directorate. They provide additional

reassurance that information is shared appropriately to ensure babies and children are kept

safe.

Babies subject of Child protection Plan (CPP) needing an immediate place of safety after

delivery

For all unborn babies subject of a CPP the ‘core group’ complete a birth plan antenatally and

send a copy to the RVI to ensure staff understand what the plans are for mum and baby

after delivery until discharge. This includes when the discharge plan is for baby to go into

SAFEGUARDING MATERNITY & WOMEN’S SERVICES – THE FACTS

March 2017 March 2018 March 2019

Number of cause for concerns received from

staff 908 879 820

Number of FGM cases reported 56 28 44

Babies born on child protection plans 260 108 77

Babies discharged into foster care 52 52 37

Number of safeguarding supervision sessions

delivered 45 59 72

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foster care and whether it is considered safe for the mum to care for the baby on the

postnatal ward. In cases where the risks are considered too high e.g. previous history of

non-accidental injury (NAI) / flight risk, babies have historically been transferred to SCBU

until the Interim Care Order (ICO) has been granted by the court and baby can be discharged

to foster care. Recently the appropriateness of this in terms of cost and the increasing

pressures for SCBU cots has been questioned. Following discussions with CSC and police a

new process was agreed whereby these babies are placed under police protection

immediately after delivery and placed in foster care until the ICO is granted. This new

process was ratified at the safeguarding committee April 2019 and implemented in the May.

Named Midwife Role Development

In response to feedback from senior midwives, a process was introduced in January 2019

whereby the Named Midwife makes daily contact with the postnatal and antenatal wards

for an update of all safeguarding cases and proposed plans of action. This has resulted in

midwives continuing to take the lead for their own safeguarding cases as well as promoting

joint working between the Named Midwife and midwives with particularly complex and

challenging cases.

Complex / challenging cases

During 2018/2019 there have been a number of complex and challenging cases, which

appear to be on the increase. Safeguarding concerns have related to concealed pregnancy,

presenting for termination of pregnancy at an advanced gestation, disengagement with

services and whereabouts unknown, sexual exploitation / child sexual exploitation and

suspected modern day slavery (MDS) / trafficking. These complex cases require a multi-

agency approach to promote effective inter-agency working.

Development of Mental Health (MH) pathway to separate from SG (red / yellow file)

Psychiatric disorder during pregnancy and following delivery is common; both as new

episodes and recurrences of pre-existing conditions. All mental disorders in the antenatal

and postnatal period may have a significant impact on the mother-infant relationship. In

addition, the mother-father/partner and family relationship may be affected. As such early

identification and appropriate referral pathways are essential to promote a woman’s mental

health status.

Recognising that midwives varied in their level of confidence and competence in this area a

MH Task & Finish group was established in 2018. To date there are a number of

developments that have been achieved:

Yellow plastic wallets introduced into patient records to hold ‘Mental Health

letters and care plans’

Public Health Education and Training session revamped to meet midwives needs

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Development of a flowchart to advise staff which team to contact for different

mental health needs

Development of a maternity specific Liaison Psychiatry Referral form

Attendance of a CPN at the speciality mental health ANC

A review of the current guideline to reflect the developments of the group

(ongoing)

Case reviews as a regular learning resource

Audits

During 2018/2019 two specific audits were undertaken in relation to FGM

and Child Protection Plans / Child In Need plans / Birth plans. Both of these

were presented at the April 2018 safeguarding committee and will

contribute to the safeguarding teams cyclical annual audit calendar.

Case Study - Women’s Services

‘Chloe’ was referred to Children’s Social Care (CSC) in early pregnancy by the community

midwife due to issues of drug and alcohol misuse and domestic abuse. Two older children

had been removed under police protection following a domestic incident where Chloe was

found to be intoxicated and the children had physical injuries. The children live with

maternal grandparents under a special guardianship order. The referral progressed to a

strategy and section 47 enquiry and following an Initial child protection Conference the

unborn was made subject of a CPP.

Although there was initial disengagement with services and agencies Chloe articulated that

she recognised the concerns, ended the abusive relationship and started to engage with

professionals. By the time the birth plan was written professionals were feeling more

optimistic about Chloe’s progress and her ability to care for the baby. As such the plan was

for Chloe to care for the baby on the post-natal ward after delivery and to be discharged

with the baby to supported accommodation.

During the early few days there were no concerns identified, however following this staff

became increasingly concerned regarding her ability to safely care for the baby after

discharge. These concerns were escalated to CSC resulting in CSC seeking legal advice. CSC

applied to the court for an ICO, which was granted and the baby discharged to foster care.

This case demonstrates the fluidity of safeguarding cases and the importance of remaining

vigilant at every stage of the safeguarding process. The midwives were vigilant and

professional in their approach to challenge a previously agreed plan to ensure a baby’s

wellbeing and safety remained the top priority.

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SAFEGUARDING CHILDREN

The Trust’s safeguarding children team deliver a high quality service that promotes the

safety and well-being of children and young people at risk of abuse. The team are extremely

responsive to staff, providing advice and support to meet the demands of a motivated and

vigilant workforce which has resulted in 2164 cause for concern forms being raised in

2018/19 and a further 1019 cases reviewed in the Multi-Agency Safeguarding Hub (MASH).

There has been a notable increase in the numbers of children with perplexing symptoms

that are potentially indicative of Fabricated and/or Induced Illnesses; this is in part due to

the specialty areas within The Great North Children’s Hospital. These cases are invariably

complex and need significant time to manage and respond appropriately.

A children’s safeguarding nurse advisor supports the MASH to provide health information

and contribute to multi-agency decision making with police and children’s social care; this

serves to improve outcomes for children and young people.

Staff in the 0-19 service continue to receive quarterly safeguarding supervision from the

children’s team. Safeguarding supervision is well established in the Emergency Departments

and New Croft Sexual Health Services; it is available to all Trust staff on request.

The safeguarding trainer and children’s team continue to support multi-agency training

provided by the Newcastle Safeguarding Children’s Boards (NSCB).

The Child Protection Information Sharing (CP-IS) programme has been extended within the

Trust to include Eye Casualty and is also being implemented in the Dental Hospital for

unscheduled appointments.

SAFEGUARDING CHILDREN – THE FACTS


Total number of cause for concerns received from

staff 2872 2446 2164

Information sharing 1252 1171 866

Overdose/ alcohol misuse or substance misuse by

young person 313 326 309

Referrals made to children’s Social Care by Trust staff 204 224 251

Child protections medicals were completed 148 130 154

Total number of cases reviewed in the MASH 1284 816 1019

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Key Achievements 2018 – 2019

Implementation of a pilot to include dental assessments for all children

attending for a child protection medical assessment both in and out of

hours.

Collaborative working with NSCB to develop shared multi-agency pathways

for the approach to children with obesity and self-harm.

The four trigger questions tool (to identify risk of sexual exploitation in the Emergency

Departments) has been improved to trigger an electronic alert to the Children’s

Safeguarding Team in the event of a positive response to any of the 4 questions.

Exploration of safeguarding modules for SystmOne to improve record keeping systems.

The Safeguarding Children Supervision Policy has been updated to include feedback

from an audit and series of focus groups with the 0-19 service.

Review of practice within the Emergency Department’s for children/young people who

leave before being seen. This has negated the need to send a ‘cause for concern’ to the

safeguarding team where no concern has been identified. This does not include children

or young people who leave against medical advice.

The Named Doctor and Nurses have re-established participation in the National Tertiary

Named Professionals Network, coordinated by Great Ormond Street Hospital involving

networking, peer review and shared learning amongst named safeguarding professionals

working in tertiary hospitals across the country.

Participation in the Northern Hospitals Peer Review Meetings on Abusive Head Trauma,

involving multidisciplinary discussion of cases, sharing learning and peer review.

Local multi-disciplinary peer review meeting for cases of Abusive Head Trauma.

Inclusion of HEADSSS assessments in our revised Child Protection Medical Assessment

Proforma to assist in capturing the voice of the chid.

The access of medical photography images has been upgraded to be available

electronically within our Powerchart IT system.

Collaboration with Radiology colleagues to implement updated guidelines and complete a

quality improvement project to demonstrate compliance with skeletal survey follow-up.

Thanks to the hard work of the Radiology team, we achieved 100% compliance with

skeletal survey follow-up imaging across a year’s period

Development of a Safeguarding Handbook for Junior Doctors rotating through the Great

North Children’s Hospital.

Delivery of Safeguarding update sessions focussing on current ‘Hot Topics’ such as

County Lines, Modern Slavery, Human Trafficking and Child Sexual Exploitation.

Challenges & Priorities 2019 – 2020

Working collaboratively through the upcoming changes to safeguarding structures and

arrangements in the Newcastle area, moving from the NSCB to a Safeguarding Partners

arrangement.

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Implement and embed the multi-agency obesity and self-harm pathways.

Implement the newly updated ‘Was Not Brought’ policy for approach to children not

being brought for outpatient appointments.

Re-establishing North East Regional Safeguarding Peer Review Network.

Establish ‘Court Skills Training’ course for staff that are called to give evidence in court,

focusing on what to expect in court, and how to prepare beforehand.

Implementing a radiology pager system in Emergency Department (ED) so that children

may be called for x-ray whilst waiting in the paediatric department, instead of waiting in

the adult department.

Moving to Paperlite electronic records and how this will be implemented with regards to

Safeguarding, Child Protection Medical and Forensic Assessments.

New guidance is expected on Fabricated or Induced Illness and will need to be reviewed

and implemented locally.

Updating the regional safeguarding training for the Paediatric Specialty Training

Programme within Health Education England North East (HEENE).

It remains of utmost importance in the work we do to capture the voice of the child, and

understand their lived experience.

What difference has the team made to the protection of vulnerable

children and young people?

In collaboration with our colleagues in the Dental Hospital, we have

launched a pilot project, to include routine dental assessments for all

children attending for child protection medical assessments.

We started this collaborative approach in January 2019 and whilst the data is still being

collected to look at the effectiveness of the project and the impact for our local children, it

has been very well received by staff and families alike. Our child protection medical

assessments now have a ‘one stop shop’ approach, where children are seen for the medical

assessment, any investigations needed following that assessment, and will then also see one

of our dental colleagues. The dental team not only assess the child’s current dental status,

but provide important dental hygiene and health promotion advice, a toothbrush and

toothpaste pack to take home with them, and where necessary, organise follow-up with

either the Dental Hospital or signpost to the local general dental practitioner. The dental

assessment undoubtedly contributes important information to the overall safeguarding

assessment, especially where there may be other features of neglect, but is also a key

opportunity to capture a population of child with unmet dental health needs and make an

important contribution to their overall health and wellbeing.

We are all extremely proud of this project and are looking forward to sharing the

outcomes of this approach with you in due course.

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SAFEGUARDING ADULTS

Safeguarding Adults continues to grow and is becoming more

complex, with greater evidence of emerging themes and trends in relation to cuckooing and

county lines, where adults at risk are targeted and exploited by others. Since the

introduction of the Care Act 2014, agencies continue to have statutory requirements to

respond to concerns of harm, abuse or neglect and the inclusion of self-neglect remains a

significant aspect of work. Safeguarding Adults remains a multi-faceted world, where

individuals and families are faced with the constant need for resilience and tenacity for the

teams providing care. The team remains committed to multi-agency partnership, and

collaboration. Referrals to the team have increased and highlight the importance of

recognising and responding to harm, abuse and neglect, and the team continues to support

and advise staff from a range of services within the Trust.

As a team we continue to work to demystify safeguarding and to ensure that safeguarding is

a focus of support for individuals and families. During the year, we have supported qualified

staff and students to spend time with the team which it is hoped will encourage referrals

and highlight the positive outcomes that can result from the safeguarding process. The team

has also continued to develop practice through case review, legal literacy sessions and a

successful Schwartz round that touched on the impact of domestic abuse for staff

throughout the Trust.

SAFEGUARDING ADULTS – THE FACTS


Total cause for concerns received from staff 2094 2237 2624

Case discussion 168 343 415

Domestic abuse 317 311 429

Financial abuse 93 94 124

Exploitation 14 n/a 0

MARAC 48 55 59

Modern Slavery 7 34 9

Neglect 141 367 498

Physical abuse 63 89 139

Psychological / emotional abuse 48 55 101

Radicalisation 5 7 13

Self-neglect 314 438 537

Sexual abuse 71 95 109

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During 2018 / 2019 the team have supported the care and treatment for 2624 adults who

are at high risk of harm through self-neglect. The team also contributed to over 193 multi-

agency adult safeguarding meetings. Contributing to multi-agency safeguarding meetings

calls for the team to consider relevant information that may enhance understanding and

reduce risk. 429 queries were raised in relation to domestic abuse which also includes

support to Trust staff affected by domestic abuse. The team has facilitated 59 referrals for

victims at risk of homicide or significant harm to MARAC within the region. There have been

498 concerns in relation to neglect and 34 concerns were raised in respect of modern day

slavery.

Key Achievements 2018 - 2019

High level contribution to multi-agency working and case management.

The development and publication of an adult safeguarding supervision policy.

Response to high risk domestic abuse through referrals and contribution to MARAC.

Responding to self-neglect which is a high level concern within adult safeguarding as

defined by the Care Act (2014) regardless of age or disability and working with legal and

multi-agency partners to reduce risk.

Collaboration with Human Resources to support Trust staff affected by domestic abuse.

Evidence of increasing referrals to the team which highlights the complex and growing

nature of adult safeguarding.

Developed a framework to identify case outcomes and promote safe practice.

Contribution to the Trust’s “paperlite” project to support a more integrated electronic

safeguarding record.

In January 2019 a well evaluated Schwartz round explored the impact of responding to

domestic abuse and underlined the positive contribution of the safeguarding team. In

early April 2019 a further Schwartz round considered the impact of domestic abuse on

members of staff and how they can be supported within the Trust.

Challenges & Priorities 2019 – 2020

To broaden the implementation of evidence based safeguarding supervision across a

wide range of Trust services

Audit and assurance frameworks will be strengthened further.

Continue to respond to a high number of increasingly complex referrals and to consider

how this continued increase in workload can be managed.

Contribution to the development of the Newcastle Multi-Agency Safeguarding Hub

Embed practice development for the safeguarding nurse specialists through learning

from local and national case reviews, legal literacy sessions and reflective practice.

Rekindle work in relation to non-accidental injury

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What difference have safeguarding adults made to patient care?

The safeguarding adult’s team support staff to recognise and respond to categories of harm

and abuse including; modern slavery, self-neglect and sexual abuse. Working to reduce risk

and promote safety is the primary goal of the safeguarding team and embeds the principles

of prevention, proportionality, protection, partnership working, empowerment and

accountability. The team embrace the “Think Family” approach to identify others who may

be at risk and have a strong working relationship with children’s’ safeguarding.

Case study - adult safeguarding

A patient attended an outpatient appointment with evidence of bruising to her hands and

around her ears, with a disclosure by a paid carer of suspected physical abuse towards the

patient with a diagnosed learning disability by a family member. The team were unable to

get a view from the individual herself how this had occurred. On initial review it was felt the

patient lacked capacity around safety.

There was immediate discussion with medical staff and that contact should be made with

social services and an adult safeguarding referral was made. Further discussion within the

team later considered if there should have been police contact or admission to hospital to

ensure immediate safety. At the time of the initial referral, information had not indicated

the full picture and it was on reviewing the case within the coming days that it became

apparent, that there was a historical concern of neglect including the involvement of the

Court of Protection.

On reflection, this case emphasised the difficulties in adult safeguarding linked to non-

accidental injury where an adult does not have capacity around keeping themselves safe.

Understanding their view, exploring what has happened and understanding the wider

picture, was not possible in this case. The case also reiterated the principles of adult

safeguarding with the fundamental ones in this case being proportionality and protection.

In this case, the team asked for an urgent strategy meeting, however this did not happen for

a number of weeks. A further review was requested and GP involvement. It was apparent

from a previous admission the patient found hospital settings distressing and as the injuries

could have been indicative of self-injurious behaviour, possibly due to pain – on balance the

decision not to admit the patient was believed to be the best at the time.

The case also highlighted that there can be difference in opinion, It is important to reflect

and reconsider options without criticism or blame. An appreciative approach is a valued and

person centred application essential for safeguarding to promote safe practice.

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Learning Disability

The Trust’s two Learning Disability (LD) Specialist Nurses and administrative support are

based in the adult safeguarding team. The nurses work across all areas of the Trust in both

hospital and community providing support to children, young people and adults with a clear

diagnosis of a learning disability to ensure equity of healthcare by the provision of

reasonable adjustments. It is a major achievement that such a small team have managed to

deliver such high quality services within the context of an ever increasing workload.

LEARNING DISABILITY – THE FACTS


Total number of electronic alerts present in patient

records 2116 2298 2757

Adults 1850 1984 2398

Young people 266 314 359

Referrals received for advice and support 2055 1708 1814

Inpatient episodes for people identified with a

learning disability 719 816 982

Day case attendances by people identified as having

a learning disability 540 513 429

Outpatient attendances by people identified as

having a learning disability 4961 5339 5850

Emergency Department attendances involved a

person with learning disabilities. 786 974 904

People with learning disabilities who died whilst

receiving Trust care 16 10 15


Continued awareness raising in the Children’s Directorate to enable clinical teams to

identify children with a learning disability.

Supporting the roll out of the hospital passport for children and young people with

additional needs. This is enabling clinical teams to ensure pathways of care support

reasonable adjustment to meet individual needs.

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Proactive contribution to the mortality reviews (LeDeR) for patients with learning

disabilities who died within the Trust and participation in multi-agency LeDeR reviews

co-ordinated by Newcastle and Gateshead Clinical Commissioning Group.

Learning from the deaths of patients with a clear diagnosis of a learning disability has

been shared with the Learning Disability Steering Group, the Trust’s Mortality

Surveillance Group, Safeguarding Committee and a Safeguarding Communication Forum.

Expert advice and support to patients, people and professionals to ensure even the most

complex people with learning disabilities have good access to high quality healthcare

and reasonable adjustments to meet their individual needs.

Support Trust services to seamlessly manage the transition from children’s services to

adults for all young people with a learning disability.

Contribution to the NHSI National Benchmarking Audit for learning disability.

The LD nurses have continued to support Trust-wide practice developments alongside

very complex individualised facilitation and advice to clinical teams.

The ‘recruitment’ of a number of consultants who want to support the learning disability

nurses and champion learning disability across the Trust.

The change in leadership across the Trust has identified an Associate Director of Nursing

to provide professional leadership for the learning disability work across the Trust.

Challenges and Priorities 2019 - 2020

Continuing to raise awareness so that healthcare professionals recognise their

responsibilities to provide the same level of care to people with learning disabilities as to

others, and not to make assumptions about quality of life or the appropriateness of

medical interventions.

Continuing to support the LeDeR process to review all deaths of patients with a

diagnosis of learning disability that die within the Trust.

Supporting the National Cancer Audit for individuals with a learning disability.

Supporting STOMP-STAMP (Stopping over medication of people with a learning

disability; Supporting Treatment and Appropriate Medication in Paediatrics).

Supporting implementation of the NHSI Improvement Framework.

Supporting GDE and PaperLite to implement electronic patient records that support the

care and treatment of patients with a learning disability who access any Trust service.

What difference have we made?

The two nurses have made a difference to the journey of individual patients through the

hospital Trust and enabled patients with very complex and challenging learning disabilities

to have fair access to health care. By supporting staff to recognise people with learning

disabilities they are in a stronger position to understand the needs of patients with learning

disabilities and make reasonable adjustments to support their hospital journey. The team

have liaised closely with Trust services and partner agencies to coordinate the care of those

with complex health conditions, aided by the use of a hospital passport.

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MENTAL CAPACITY ACT / DEPRIVATION OF LIBERTY SAFEGUARDS

The Mental Capacity Act

2005 (MCA) aims to

empower people to make

decisions for themselves

as much as possible, and

to protect people who

may not be able to take

some decisions. The Act

applies to anyone aged 16

or over in England and

Wales and is relevant for both care and treatment decisions. As a legal duty, NHS England

expects all service providers funded by the NHS to meet the requirements of the Act.

Additionally, commissioners are required to ensure that the services they commission are

complying with the MCA. Amendments to the Mental Capacity Act will come into effect

during 2019 for implementation in 2020; this will change how a person may be deprived of

their liberty where he/she does not have the capacity to consent.

MENTAL CAPACITY & DEPRIVATION OF LIBERTY SAFEGUARDS – THE FACTS


Total number of Deprivation of Liberty Applications made

by the Trust 581 400 713

RVI 331 202 384

Freeman 192 142 308

CAV 58 56 21


The Trust Board has received monthly updates through the Integrated Quality Report

provided by CGARD.

There has been a 78% increase in the number of DoLS applications across the Trust as a

result of a comprehensive DoLS action plan that was successfully implemented in

response to a reduction in DoLS applications across the Trust in 2017/18.

There is evidence that some wards are showing earlier recognition of patients who may

be deprived of their liberty whilst in Trust care.

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Bespoke training packages for MCA & DoLS have been developed and delivered and the

application of the MCA and DoLS has been promoted on an individual ward basis.

There is evidence of a greater proportion of Trust staff that has completed face-to-face

MCA & DoLS training.

There has been a continuous audit cycle to promote DoLS awareness and confidence

within ward staff.

Regional links with external MCA / DoLS Leads across the region have been maintained.

We have ensured the delivery of high quality compassionate and safe care to patients

who lack capacity to consent to care or treatment.

Challenges and Priorities 2019 - 2020:

The major priority will be responding to the changes in legislation regarding deprivation

of liberty and supporting the transition from the current DoLS process to Liberty

Protection Standards (LPS).

Preparing staff for the introduction of Liberty Protection Safeguards & developing

training packages to support the implementation.

It will be a challenging priority to maintaining the number of DoLS applications across

the Trust until the LPS framework is in place.

Improve the quality of DoLS applications as they can vary depending upon the

experience of staff.

Education and training to ensure the understanding of how the application of the MCA is

absolutely central to all practice with patients from 16+ years that may have difficulties

with giving consent.

It is an absolute priority for the Trust to ensure that any patient who is unable to

consent to being in hospital for care or treatment is protected by the Deprivation of

Liberty Safeguards.

Embedding accountability for DoLS and the application of the Mental Capacity Act across

the Trust in all relevant settings.

What difference have we made?

We have protected patients by ensuring that they are lawfully deprived of their liberty

within the legislative framework provided by the Deprivation of Liberty Safeguards.

We have supported staff in developing their confidence and knowledge in applying the

principles of the Mental Capacity Act and recognising when an individual is deprived of

their liberty. This will be continued throughout 2019/20.

Staff are recognising deprivations of liberty earlier and the quality of DoLS applications

has improved; although further work is still needed in some areas.

We are dispelling the misconception that a DoLS application is only necessary when the

patient objects; and similarly that a DoLS can authorise treatment. This lies with the

MCA.

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Safeguarding Education and Training

Improving skills and knowledge of safeguarding enhances staff confidence to identify and

respond to safeguarding concerns. This is a high priority for the safeguarding teams.

Safeguarding Training Compliance

Course Compliance

March 2017 %

Compliance

March 2018 %

Compliance March 2019 %

Safeguarding Adults Level 1 95.71% 97.59% 93.90%

Safeguarding Children Level 1 95.71% 97.56% 93.49%

Safeguarding Adults Level 2 76.96% 83.15% 88.89%

Safeguarding Children Level 2 77.29% 81.93% 89.95

Safeguarding Children Level 3 71.23% 73.18% 81.09%

Prevent 15.29% 40.21% 78.03%

A major achievement in 2018 – 2019 has been the revision to the Training Needs Analysis

(TNA) for safeguarding mandatory training that was previously completed in 2015. This has

been updated to reflect national changes and alignment with the Core Skills Training

Framework, providing a national benchmark for statutory / mandatory training. This also

enables the Trust to recognise training completed by staff joining us from other

organisations and prevents duplication as the competency is portable and transfers with the

member of staff. The revised TNA was develop over the past 12 months and after

consultation and agreement across the Trust, was implemented in April 2019. This has been

an incredibly challenging task and reflects:

Prevent is mandatory for all Trust staff and requires a refresher training every 3 years.

The publication of the Intercollegiate Documents for Safeguarding Adult4s published in

August 2018 and the revised Intercollegiate Guidance for Safeguarding Children5

published in January 2019.

The introduction of safeguarding adult’s level 3 which has been allocated to staff across

the Trust working in mainly adult areas. Examples of staff who have been allocated Level

3 for adult safeguarding include senior sisters / charge nurses, matrons and district

nursing staff, staff in 0-19 service, maternity services, Sexual Health and the Emergency

Department. 4 Intercollegiate Document: Adult Safeguarding: Roles and Competencies for Health Care Staff (1

st Edition

published August 2018) 5 Intercollegiate Document: Safeguarding Children and Young People: Roles and Competencies for Healthcare

Staff (4th

Edition published January 2019).

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Some staff will need to complete level 3 adult safeguarding and level 3 children’s

safeguarding on an annual basis. This has resource implications in terms of time to

release staff to complete the training and for the safeguarding trainer to develop and

deliver face to face training.

The TNA aims to streamline training requirements and to make the ‘flowchart’ clearer and

easier to understand. It is important to understand that the training matrix is based on

levels 1 – 3 for safeguarding and Prevent.

The training matrix defines the basic level of training that a member of staff will need to

complete to achieve key skills and compliance. It is advocated that staff still need to

complete additional training specific to their individual job role and this should be captured

in a training passport or revalidation documentation for nurses and midwives. Safeguarding

skills and competencies should be reviewed annually at appraisal.

It is recommended nationally that no more than 50% of any training should be eLearning;

although face to face training will remain the preferred method for level 3, there is an

eLearning option available that has been validated by the Core Skills Training Framework.

This option is available to staff and should help to promote compliance in some areas that

have struggled to release staff to attend training.

Both Intercollegiate Documents recognise that there are contextual safeguarding issues that

are equally relevant to both children’s and adults safeguarding. Level 3 safeguarding training

in the future will offer an extended training package that will combine the essential skills

and competencies required for safeguarding adults, safeguarding children and Prevent.

The safeguarding trainer will also develop some practice guidelines in 2019/20 to support

the implementation of the revised training matrix.

Additional Key achievements 2018 - 2019

Compliance has increased Level 2 Adult’s and Children’s safeguarding and for

Safeguarding Children Level 3.

11013 staff have been trained in PREVENT up to the end of March 2019.

The safeguarding trainer has supported NSAB multi-agency training for safeguarding

adults and safeguarding children training with NSCB.

The nurse advisors from the safeguarding children’s team have continued to support

safeguarding children’s multi-agency training co-ordinated by the NSCB.

The safeguarding trainer has provided additional weekly sessions for safeguarding

children Level 3 to increase compliance rates across the Trust

A RAG rating system has been introduced to help improved compliance

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Safeguarding Communication Forums provide a platform to raise awareness on topical

issues and have been attended by over 300 Trust staff in the past year. Topics during

2018/2019 have included:

Sexual Exploitation” so what does that actually mean?”

Domestic abuse – the impact, on families, individuals, services and wider social picture

Modern Day Slavery by Chris Reeves (NE Partnership & Network Co-ordinator)

Presentations by the Safeguarding Team

o Learning Disabilities Mortality Review (LeDeR)

o “Was Not Brought”

o The future for Safeguarding Mandatory Training

Introduction to Sexual Violence & Trauma Training for Health Staff by Dawn Bowman,

Volunteer Coordinator & Training Lead for Rape Crisis Tyneside and Northumberland

Schwartz Rounds to promote awareness of domestic abuse were positively received in

January 2019 and early April 2019. 115 people attended the January round and 84% rated is

as either excellent or exceptional. Below are some comments from staff:

Powerful presentations highlighting frustrations met when dealing with cases.

Inspiring and empowering women, their bravery and determination was encouraging

and will help me get in touch with standing up for our patients and our values.

Thank you for your honesty, especially poignant to hear about self-doubt and taking

brave decisions with support from colleagues.

Really nice to meet the safeguarding team. Hadn't really thought about what happens

beyond referral process. Fantastic work being carried out by some very brave people.

Safeguarding Training Strategic Goals 2019 – 2020

Achieve 95% compliance for all levels of safeguarding training including Prevent by

March 2020.

Develop a portfolio of bespoke Level 3 training packages in response to priority issues

such as trafficking and modern slavery, female genital mutilation, difficult conversations

& unconscious bias, neglect, self-neglect and domestic abuse.

Develop and deliver a safeguarding adults Level 3 training package.

Enhance the current process for safeguarding supervision and develop this further

across the Trust, particularly for adult safeguarding.

In response to serious case reviews, domestic homicide reviews and appreciative

inquiries, continue to develop ‘Learning from Practice’ events.

Promote the use of the Training Passport, for staff to provide evidence of additional

safeguarding training to support Continuing Professional Development and revalidation

for Nurses and Midwives with the NMC.

Continue to support the multi-agency training provided by the NSCB and NSAB.

Actively participate in the learning and development sub-groups of NSCB and NSAB.

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Safeguarding Governance

The Trust has a robust structure in place to ensure policies, procedures, information and

concerns are recorded, discussed and assessed as risks. The Safeguarding Governance

Structure is the ultimate responsibility of the Trust Board.

The Trust’s Safeguarding Committee provides strategic oversight for safeguarding work and

reports to the Trust Board. It provides assurance that safeguarding children and adults at

risk is embedded in our core functions and ensures:

There is a consistent approach to safeguarding across the Trust

That Trust policies are up to date and effective and reflect national guidance.

That Trust staff are adhering to policies and best practice guidance.

That Trust systems and procedures support effective safeguarding practice as a statutory

requirement.

The Safeguarding Committee is chaired by Professor Kath McCourt who, as a non-executive

Director of the Trust, brings challenge and scrutiny from the Trust Board into the work of

the Safeguarding Committee.

Data Protection

In performing our functions and roles around safeguarding, we comply with the

requirements of our Data Protection and Information Management policies. We share

information and intelligence promptly and appropriately, taking into account our Code of

Practice on Confidential Personal Information.

Assurance

The Safeguarding Committee is underpinned by the Trust Safeguarding Operational

Management Group which meets eight times a year and brings together the Trust’s senior

safeguarding managers and named professionals. Internal Trust assurance is led by the

Safeguarding Operational Management Group and has a number of reviewing and reporting

mechanisms including:

Quarterly reports to the Trust Board

Quarterly CCG assurance templates

NSAB and NSCB self-assessment and strategic challenge

Monitoring of service developments / case reviews / policies and audits

Monitoring risks and mitigation

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Level Staff Groups Safeguarding Requirement

Method & Frequency

Prevent Requirement

Method & Frequency

1

All non-clinical staff (e.g. board level execs and non-execs, admin staff, caterers, domestics, counter staff, senior managers/strategic professionals with no patient contact) All clinical staff who have NO patient contact (e.g. laboratory staff, technicians, healthcare scientists etc) Clinical staff Bands 1, 2, 3 & 4 with patient contact (e.g. housekeepers, theatre orderlies, health care assistants, dental nurses, nursery nurses, associate practitioners). Volunteers (all roles)

Adults Level 1

eLearning – every 3 years

000 Preventing Radicalisation - Basic Prevent Awareness


Children Level 1


2

Clinical staff Bands 5 + with any patient contact (adults and/or children) (e.g. radiographer/radiologist, allied health professionals, chaplains, registered nurses, medical staff & dental staff including consultants).

Adults Level 2 eLearning – every 3 years

000 Preventing Radicalisation - Awareness of Prevent (Level 3)


Children Level 2 eLearning – every 3 years

3A

Clinical staff Bands 5 + with primarily adult patient contact who would assess and evaluate the needs of adults where there are safeguarding concerns. (e.g., District nurses, Community Staff Nurses, Mental Health Practitioners working with adults, registered nurses, AHP’s or medical staff with a lead role in adult protection as appropriate to their role).

Adults Level 3

Face to face or eLearning – annually



Children Level 2


MANDATORY SAFEGUARDING ADULTS & CHILDREN AND PREVENT TRAINING REQUIREMENTS

APPENDIX 1

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3B

Clinical staff Bands 5 + who work primarily with children who would assess and evaluate the needs of children / young people where there are safeguarding or child protection concerns (E.g. paed staff nurses, paed surgeons/ paed anaesthetists & intensivists/ dentists/ community children’s’ nurses, looked after children nurses, forensic nurses, mental health Practitioners/psychologists working with children, paed allied health professionals, paed specialist nurses, nursery managers etc). Consultant Paediatric staff will receive training from the Named / Designated Doctor delivered by a series of lectures throughout the year.

Adults Level 2




Children Level 3


3C

Clinical staff Bands 5 + who frequently work with children on a Child Protection Plan or CIN basis (e.g. health visitors, school nurses, midwives, safeguarding nurses, learning disability nurses, lead professionals for safeguarding and child protection, sexual health staff, substance misuse services, ED staff and Walk-in Centre staff etc)

Adults Level 3




Children Level 3


+ additional non mandatory learning e.g. FGM / Domestic Abuse / Sexual Exploitation / Neglect / Self-neglect etc.

All staff are encouraged to attend multi-agency / multi-professional training relevant to their role in addition to the Trust’s core mandatory training as described above.

Apprentices complete mandatory training relevant to their role and grade

Additional training hours / learning to be documented in Training Passport as Continuing Professional Development to be evidenced at appraisal and as part of NMC revalidation

Please contact the Safeguarding Team should you have any queries, or believe you have been allocated the incorrect level of training

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Jo Gamble

Admin Team Lead

Mary Bartram

Deputy Director of Nursing & Patient

Services (Freeman)

Frances Blackburn

Named Nurse Safeguarding Adults

Lesley Sinclair

Safeguarding Trainer

Jill Donnelly

Named Nurse Safeguarding Children

Eileen Wardhaugh / Gill Clare

MCA & DoLS Lead

Matthew Rowley

Specialist Nurses

Learning Disability

Alison Forsyth

Heather Jarvis

Specialist Nurses Safeguarding

Children

Jenny Aitken / Sarah Hutchinson

Gill Hutchison/Deborah King

Sharron Horsman/Debbie Clennell

Liz Wray

Admin Team

Gillian Innes

Trish Urwin

Denise Watson

Nicola Lambert

Named Midwife

Sue Simpson

Head of Midwifery

Elaine Blair

Professional

Accountability

Specialist Nurses

Safeguarding Adults

Helen Dove

Val Murray

Rachel Burn

Executive Trust Lead

EXECUTIVE CHIEF NURSE

Maurya Cushlow

Non-executive Director

Professor Kath McCourt

Named Doctor Safeguarding

Adults

Dr Ahmed Jaafar

Designated / Named Doctor

Safeguarding Children

Dr Caroline Grayson / Dr Andrew Villis

Named Doctor Child Death

Dr Anna Thorley / Dr Stephen Owens

Safeguarding Management Structure

2018 / 2019

APPENDIX 2

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__________________________________________________________________________________________Executive Chief Nurse Report Trust Board 27

th June 2019

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

SAFEGUARDING COMMITTEE QUARTER 4 UPDATE 2018/2019

1. INTRODUCTION

The Trust Board was updated on progress with regard to safeguarding at the January 2019

Trust Board meeting. They also received the Trust’s Safeguarding Annual Report in June

2018. This paper now provides a Quarter 4 update from the Safeguarding Committee to

inform the Board of Directors of implications emerging from new statutory national

guidance, emerging issues, and local practice developments.

Safeguarding activity for Quarter 4 in 2018/2019 evidences 1341 “Cause for Concerns” (CFC)

/ referrals across the safeguarding teams; 130 case discussions in the MASH by the

Children’s Nurse Advisor’s; 288 deprivation of liberty safeguards (DoLS) applications and 464

contacts with the LD team for advice and support.

Safeguarding training is a priority and continues to be delivered weekly at Trust Induction

for all new staff. This is due to change in April 2019 when safeguarding and Prevent will be

delivered by eLearning. Supplementary training is mandatory and is provided in line with

national requirements with additional bespoke safeguarding training on request.

Safeguarding supervision is provided to a range of staff across acute and community

services. The teams continue to review policies and complete audits to provide assurance

regarding safeguarding processes; they also contribute to a number of serious case reviews

with our local authority colleagues and support the work of both local Safeguarding Boards.

Almost 50% of the work across the teams relates to out of area service users.

The Trust’s safeguarding teams continue to deliver a high quality service that serves to

promote the safety and well-being of adults at risk and vulnerable children. They are

extremely responsive to staff, providing advice and support to meet the demands of a

motivated and vigilant workforce. The teams respond to national guidance to improve

practice developments, undertake significant work to review processes to provide assurance

processes are robust and identify areas for development. The work of the safeguarding

teams continues to increase in relation to case numbers, complexity, training expectations

and the need to provide assurance; there are a number of risks they are working to

mitigate. This paper will summarise these issues for the Safeguarding Committee.

Safeguarding Committee 16 April 2019

Agenda item 3.1

Agenda Item A7 (ii) BRP

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2. NATIONAL REPORTS AND REGULATORY UPDATE

Mental Capacity (Amendment) Bill update The Mental Capacity (Amendment) Bill returned

to the Lords on 26 February. The majority of the amendments introduced by the

Government in the Commons were accepted however, the Government’s proposed

statutory definition of deprivation of liberty was not accepted, and the Lords instead voted

for the following definition advanced by Baroness Tyler.

A person is deprived of liberty if they are:

subject to confinement in a particular place for more than a negligible period of time;

o are prevented from removing themselves permanently from the place in which they are

required to reside, in order to live where and with whom they choose; and

o are subject to continuous supervision and control.” and

have not given valid consent to their confinement; and

the arrangements are due to an action of a person or body responsible to the state.

The Lords also voted for responsible bodies to keep a record of the decision and justification

if an authorisation record is not given to the person (and others) within 72 hours, and a

review thereafter. An important clarification of the extent of ‘portability’ of authorisations

was made under the LPS, confirming that the Government’s intention is that:

An authorisation can apply to different settings so that it can travel with a person but cannot be

varied to apply to completely new settings once it has been made, as this would undermine

Article 5.

The Bill now returns to the Commons for consideration of the amendments proposed by the

Lords.

3. PRACTICE DEVELOPMENTS

There are a number of areas of safeguarding practice being developed, either to enhance

patients’ experience and ensure patient safety or to develop best practice especially in

relation to multi-agency working. Examples are outlined below.

i) Adult MASH (Multi Agency Safeguarding Hub)

Further work has progressed towards the development of an adult MASH in Newcastle.

Currently adult social care and the police are co-located at Westgate College with plans to

accommodate staff from other agencies if they are able to re-locate. The Trust’s

Safeguarding Adults Team is keen to be part of the MASH but the small number of staff

means that this will be a hybrid model. Essentially the team will work from the MASH in

Westgate College when they are attending meetings but will continue to work in a ‘virtual’

MASH at other times.

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ii) Review of arrangements to use Special Care Baby Unit as a Place of Safety

Work has been completed to construct a flow chart that defines the process for managing

the care of newborn babies who require to be cared for in a place of safety. This is attached

as Appendix 1. Previously Special Care Baby Unit (SCBU) has provided this support but that

has, on occasions, meant that there are no SCBU beds available for babies who need them.

This results in poorly babies being transferred to other hospitals to receive the care they

need. If the Safeguarding Committee approves the proposed revision to the current

progress the guidance will be circulated to staff and training delivered to ensure the process

is embedded.

v) Electronic Record Keeping (GDE) - Paperlite / SystmOne

The Safeguarding Teams continue to contribute to the work within the Trust to move

towards an improved and more comprehensive form of electronic record keeping. This will

improve systems and processes for the Safeguarding Teams and will enable them to write

directly into patient hospital records.

The Community IT Strategy Group has recently approved safeguarding to have a SystmOne

unit developed and this will progress over the coming months. There are plans to visit

another Trust(s) that use SystmOne to prevent duplication of templates etc. This will also

enhance the sharing of communication with community services in Newcastle and across

the UK that will promote the safety and well-being of children, young people and adults at

risk.

vii) Safeguarding Communication Forums

The arrangements for Safeguarding Communication Forums were revised at the start of the

year and increased to 6 forums per year on alternate months. The same presentation will be

held on both RVI and Freeman sites within the same week enabling 12 sessions per year to

be delivered. This commenced in February with a guest speaker from Dawn Bowman

(Training Lead for Rape Crisis) who presented ‘An Introduction to Sexual Violence and

Trauma’. This was extremely well received. Andy Hackett (Community Safety Specialist)

from Newcastle Local Authority presented a session on ‘Substance Misuse and Alcohol

Misuse’ last week and focused on the impact for individuals within the Newcastle area.

Again, this was very well attended with almost 100 staff attending across the two sessions.

The Trust Communications Team has since been contacted by a number of staff to request

further dates.

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vi) Safeguarding Schwarz Rounds

The Safeguarding Teams presented a Schwarz Round in January 2019 that was really well

attended and received superb feedback. Another Schwarz Round is planned for April 2019

and this will focus on Domestic Abuse from a staff perspective.

4. INTERNAL ASSURANCE / POLICY COMPLIANCE

The Trust Safeguarding Committee has met quarterly as planned to ensure appropriate

scrutiny, challenge and assurance is in place.

Policies in Q4 2018/2019:

Was not Brought (at Hospital Out Patients appointments for Children) – V3.0 remains

under review

An extension has been requested and approved for the Domestic Abuse Policy

Audits completed to date in Q4 2018/2019 and presented to the Safeguarding Committee in

April 2019:

Female Genital Mutilation (FGM) Audit

Maternity Child Protection and Birth Plan Audit

Sexual Health Audit – Under 18 Pro-forma

Audit of Skeletal Survey follow up appointments 2018 (completed by Radiology)

Audits are reported to the Trust’s Safeguarding Committee and provide assurance that

policies and processes are being monitored and reviewed regularly.

2. TRAINING

Training figures for the end of Q4 have been requested; however, the interface from

Allocate that updates ESR with absence data isn’t scheduled to run until 10/04/2019

overnight. There will then be a large number of manual corrections updated on the

11/04/2019 before a full report on the absence data can be completed on 12/04/2019. The

ESR Central team also need to upload about 12,000 competencies before the final year-end

reports can be produced and an exact date for when that will be completed cannot be

provided.

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Safeguarding Mandatory Training Compliance 2018/2019

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4*

Safeguarding Adults Level 1 95.7% 97.6% 87.1% 87.38% 87.30% 93.58%

Safeguarding Children Level 1 95.7% 97.6% 87.1% 86.72% 86.65% 93.22%

Safeguarding Adults Level 2 77.0% 83.2% 80.6% 82.56% 82.13% 88.61%



TOTAL Prevent : 15.3% 40.2% 55.4% 64.85% 69.75% 77.26%*1

BPAT n/a n/a 57.2% 66.00% 70.30%

WRAP n/a n/a 53.4% 63.60% 69.10%

The Trust is compliant with NHS England

national requirement for the submission of

PREVENT assurance data. Quarter 4 data was

submitted on the 04 April 2019.

Prevent training compliance has been reported as 77.26% at the end of March 2019 which

is a significant improvement from 40% at the end of March 2018. The training data has been

provided by the 03 April 2019 to comply with end of year requirements for reporting

purposes. However, this does not enable ESR to update regarding staff that are on long term

sickness absence or maternity leave. This is a challenge when data is dependent on

information from multiple systems. It is anticipated that when a more refined report is

available and extracts LTS, the overall Prevent compliance may increase.

Despite this, the Trust’s compliance rate is still short of the 85% target defined by NHS

England. The Trust is 1 of 12 in the Northern region that is being classed as an outlier

regarding the low Prevent compliance and is under intense scrutiny from NHS England via

the CCG. Up to 1100 more staff need to complete Prevent training to meet the target. This

can be done via eLearning or face to face training. Additional dates have been arranged and

distributed for quarter 1 on both Freeman and RVI sites.

Safeguarding

Staff roles have been aligned to the Training Needs Analysis (TNA) for has been completed

and distributed to all Directorates for comments and approval. Examples of staff groups

aligned to the different levels are detailed below.

1 This is a provisional figure that will change when long term sickness absence is updated on 10 April 2019

Target Red Amber Green

end of Q1 40% 0-29% 30-39% 40%+

end of Q2 80% 0-69% 70-79% 80% +

end of Q3 90% 0-79% 80-90% 90% +

end of Q4 95% 0-84% 85-95% 95% +

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Level 1

All non-clinical staff

All clinical staff Bands 5+ with NO patient contact

All clinical staff Bands 1 to Band 4

Level 2

All clinical staff Band 5 and above with any patient contact (children or adults) but work primarily with

adults.

Level 3A (adults)

Band 7 Senior Sisters / Charge Nurses & Matrons working in adult areas + District Nursing Sisters etc.

Some additional roles will be added into this level later.

Level 3B (both)

Health Visitors & School Nurses /

Unscheduled Care Staff (ED & Walk in Centres) / Sexual Health Staff /Safeguarding Team / LD

Level 3C (children)

All clinical staff Band 5+ working primarily in paediatric areas e.g. Paediatric Staff, Maternity Staff etc

Consultant Paediatric staff will receive training from the Named / Designated Doctor delivered by a series

of lectures throughout the year.

This has been a very complicated process given the range of mandatory safeguarding

training and the publication of the Adult Safeguarding Roles and Competencies for Health

Care Staff (2018). This proposed TNA was distributed across the Trust to Directorate

Managers, Clinical Directors, Matrons, Clinical Educators and a range of other staff; it was

well received with some very positive feedback in terms of how easy the document is to

follow.

The allocation of job roles to the appropriate level of safeguarding and Prevent training has

just been completed and sent to Workforce Development for them to update ESR. This

means that every member of Trust staff will be able to clearly identify the level of training

they require. For some staff, this may mean the level of training will change, but it will

prevent duplication and save time as staff that currently have to complete level 1 or level 2

training will have the requirement to complete level 1 removed. This has been warmly

received and supports the recommendations within the Intercollegiate documents for both

children and adults.

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3. SAFEGUARDING ACTIVITY

Key points for the Safeguarding Committee to note in relation to activity up to the end of

Quarter 4 2018/19:

Women’s Services Safeguarding (Maternity)

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total number of cause for

concerns received 908 879 231 182 218 187

Number of FGM cases reported 56 28 9 13 10 12

Babies born on child protection

plans 260 108 19 25 22 7*

Babies discharged into foster care 52 52 7 15 6 6*

Number of safeguarding

supervision sessions delivered 45 59 9 16 20 37

Safeguarding Children

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total number of cause for

concerns received 2872 2446 643 714 496 430

Information sharing 1252 1171 284 292 185 150

Overdose/ alcohol or

substance misuse by young

person

313 326 106 95 55 58

Referrals to children’s Social

Care by Trust staff 204 224 67 92 71 56

Child protections medicals

were completed 148 130 47 30 36 41

Forensic medicals completed 196 213 38 53 46 50

MASH case discussions 1284 816 328 323 238 130*

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Safeguarding Supervision for the 0-19 Service

Staff Group No. of Staff Requiring

Supervision

Total Receiving Supervision in

Quarter 4

% Uptake

Green = 80% +; Amber = 60 - 80%, Red = ↓60%

Reasons for non-compliance

Health Visitors

69 58 84% 5 staff long term sick; 1 on maternity leave; 6 members of staff booked for April and 5 members of staff overdue.

Public Health School Nurses

20 17 85% 2 staff on sick leave; 1 member of staff booked for April. 2 members of staff overdue.

Safeguarding Adults

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total cause for concerns

received from staff 2094 2081 524 629 626 724

Case discussion 168 343 110 105 92 107

Discriminatory 1 4 0 1 1 2

DoLS Enquiry 192 87 11 24 29 33

Domestic abuse 317 311 76 107 113 120

Exploitation 14 * * * * *

Financial abuse 93 94 24 25 35 34

Institutional 248 17 4 1 0 0

MARAC 48 55 8 15 18 11

MCA Enquiry 83 85 22 21 10 20

Modern Slavery 7 34 2 1 3 2

Neglect 141 367 112 105 123 136

Physical abuse 63 89 20 40 39 33

Psychological/

emotional 48 55 11 17 11 54

Radicalisation 5 7 1 4 3 3

Self-neglect 314 438 102 132 125 150

Sexual abuse 72 95 21 31 24 19

MAPPA Notifications 153 84 26 24 30 15

Violent Patient Notifications 59 72 11 25 27 16

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The safeguarding adults’ team continue to be the single point of contact (SPoC) for Multi

Agency Risk Assessment Conference (MARAC) and MAPPA (multi-agency public protection

arrangements), PREVENT and violent patients on behalf of the Trust.

The team also attend safeguarding adult meetings and support the work of the Newcastle

Safeguarding Adults Board and sub-groups.

Learning Disability

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total number of electronic alerts

present in patient records 2116 2298 * * 2624 *

Adults 1850 1984 * * * *

Transition * * * *

Young people 266 314 * * * *

Referrals received for advice and

support

Adults

Transition

Young people

2055 1708

534

333

23

178

489

288

30

171

479

325

33

121

464

275

36

153

Inpatient episodes for people identified

with a learning disability 719 816 243 236 254 249

Day case attendances by people

identified as having an LD

540 513 120 118 93 98

Outpatient attendances by people

identified as having an LD 4961 5339 1508 1435 1454 1453

Emergency Department attendances

involved a person with an LD. 786 974 251 209 225 219

People with LD who died whilst

receiving Trust care 16 10 7 4 0 4

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Deprivation of Liberty Safeguards (DoLS) 2018/2019 - Trust applications

March

2017

March

2018

2018/19

Q1

2018/19

Q2

2018/19

Q3

2018/19

Q4

Total number of DoLS applications

made by the Trust 581 400 124 132 169 288

RVI 331 202 66 67 83 168

Freeman 192 142 39 62 83 124

CAV 58 56 16 5 N/A N/A

The total number of Deprivation of Liberty Safeguards (DoLS) applications is 713 which

evidences the impact of the efforts made by the MCA/DoLS Lead and Safeguarding Team to

increase staff confidence in completing DoLS applications and awareness of the statutory

requirement for doing so. This is a 78% increase on the DoLS applications for 2018/19 and is

the highest number of applications made in a single year by the Trust.

The increase in applications started in Quarter 3 and continued to rise in Quarter 4.

Although the number of DoLS applications is expected to plateau, a decline in total numbers

is not anticipated. The number of applications for 18/19 has averaged approx. 60 per month

and this will be the target that the team will strive to maintain / improve on during

2019/2020. This has resulted in a demonstrable increase in workload for the MCA/DoLS

Lead, safeguarding Adults Team and the Safeguarding Admin Team. The documentation is

completed by ward staff but the processing and monitoring of the DoLS is managed within

the safeguarding teams. Every single application is administratively intensive and also

requires a CQC notification when the outcome of the application is known. The DoLS

flowchart remains under review. Training sessions for MCA / DoLS will continue to be

provided as will ward based support from the MCA/DoLS Lead to ensure momentum is not

lost. This will continue to be monitored monthly in the Safeguarding Teams and by the

Trust’s MCA Steering Group / Safeguarding Committee.

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7. RISKS AND RISK MITIGATION

There are a number of identified risks:

i) Safeguarding Mandatory Training including Prevent has been added to the Patient

Services Risk Register. The Trust did not meet the national target of 85% for staff

requiring WRAP (PREVENT) training by the end of March 2019; this remains a key

challenge.

ii) Deprivation of Liberty Safeguard applications was added to the Patient Services Risk

Register in response to the reduction in deprivation of liberty applications across the

Trust and increased the risk the potential for unlawful detention of patients. This is

being scrutinised and ongoing audit and education is being progressed.

iii) Electronic record keeping and data management within the safeguarding teams is

reliant on storing documents and excel spreadsheets securely on shared drives. The

safeguarding teams need access to electronic record keeping systems to facilitate

improved documentation and data management.

iv) The Safeguarding Teams are working to improve progress with audits for 2019/20 to

ensure robust review of practice and a continuous cycle of improvement is maintained

within the teams.

v) It is important that safeguarding is continuously embedded as “Everyone’s Business”

through training, education and sharing lessons learnt from case feedback to prevent

vulnerable children or adults at risk from being missed.

vi) The accumulative impact of these risks increases pressure on the Trust’s Safeguarding

Team to meet key performance requirements including audit, review of policies and

professional practice.

Work is ongoing to address these risks as detailed above.

8. SUMMARY

The safeguarding teams are wholly committed and strive to ensure Trust staff are fully

supported to fulfil their safeguarding responsibilities to promote the safety and well-being

of all patients who access Trust services. This update provides assurance that the Trust’s

Safeguarding Teams are pro-actively leading and contributing to work in response to a range

of complex and challenging issues.

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4. RECOMMENDATION

To (i) note the content of this report (ii) support the on-going work of safeguarding teams

within the Trust to protect children and vulnerable adults (iii) note risks and risk mitigation.

Jo Gamble


10 April 2019

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APPENDIX 1

Flowchart for managing CPP well babies who need to go to ‘Place of Safety’ following delivery prior to obtaining ICO

Complete birth plan at first core group after 24/40 gestation following ICPC

Within birth plan document baby to go to place of safety after deliver by obtaining either S20 (CSC) or ‘taken into police protection’

Police safeguarding department Mon- Sun 08.00-17.00 0191 2219603 / 2219602 (OOH 101)

Continue to explore option of S20 throughout the pregnancy / labour Update birth plan as necessary at each core group

Following completion of birth plan social worker to email to Newcastle MASH mailbox

[email protected]

Police to place a MARKER on mother on their IS system that plan is for baby removal at birth

For patients requiring IOL or elective C/S aim to book in Monday – Thursday

In active labour CSC, police (2219602 / 2219603) and security to be informed

After delivery inform CSC, Police and security

Prioritise obtaining the S20 / taken into police protection’ within normal working hours In emergency OOH ring 101 and advise ‘police protection’ required

Aim for police and CSC to attend together with foster carer NB If CSC not in attendance at time of police attendance at RVI they will only remain if

immediate concerns for baby’s safety

Support patient / family / CSC / police with removal of the baby after delivery

KEEP THE PATIENT AND ANY BIRTH PARTNERS FULLY INFORMED THROUGHOUT

SCBU WILL ALWAYS REMAIN AS AN OPTION TO BE USED AS A LAST RESORT AND ONLY IN

EXCEPTIONAL CIRCUMSTANCES

132

mailto:[email protected]

Agenda item A7(iii) BRP

Term Baby to SCBU meetings 2019

Action plan

The following action plan has been developed following the identification of emerging themes at the multidisciplinary Avoiding Term

Admissions into Neonatal units (ATAIN) meetings. The multidisciplinary group agree actions as part of the weekly review of cases as identified

in the TOR.

Date Theme identified Action Leads responsible Date reviewed/completed

Jan 2019

Women who are diabetic do not receive antenatal steroids for fetal lung maturity prior to elective CS pre 39 weeks gestation. All other patient groups delivered electively by caesarean section pre 39 weeks complete a course of steroids prior to delivery.

Neonates, Obstetric Lead and Lead Obstetric Consultant for diabetes to meet and discuss management of antenatal steroids in diabetic women. Explore costs/benefits of administering steroids to women who are GDM and not insulin dependent. 06.05.2019 Multidisciplinary review of criteria for steroids in diabetic patients completed, NICE compliant, all term admissions of infants of diabetics the care was within guidelines. Plan - audit of all diabetic patients care and gestation at delivery to explore modifiable factors such as gestational age and use of steroids and confirm admission rate to SCBU in this group of high risk patients.

Malcolm MacDougall and Trez Hannon/Jenna Wall/Richard Hearn

Audit to be completed by 28.07.2019

133


21.05.2019 ATAIN data presented at Women’s Service Audit day by Dr Parnell. 22.05.2019 Audit of diabetic women following IOL/El CS commenced for all delivered between 01.01.2019-30.04.2019 to assess admission rate and modifiable factors.

Feb 2019

Women who are required to have a general anaesthetic for their caesarean section for psychological or physical reasons after 39 weeks do not receive antenatal steroids.

22.02.2019 Neonatal and Obstetric Intrapartum leads to meet to explore if there is any value in administering steroids when delivering women electively by caesarean section under general anaesthetic. Review literature/risks/information given to women in relation to admission to NICU following delivery under GA. 22.05.2019 For further discussion at Intrapartum Obstetric Group on 4th June as agenda item. JW to action Update literature/risks/information given to women in relation to admission to NICU following delivery under GA. CG to action

Trez Hannon/Jenna Wall/ Rob Tierney

Review at Obs Group 04.06.2019

Literature to be

updated by 26.07.2019

8th March

Baby admitted to SCBU for 2 hourly oral feeds as this is

08.03.2019 Consider as part of the ward reconfiguration what the criteria for transitional care

Michelle Watson/Janet

Review by 07.06.2019 at DMT

134


2019 currently not supported on transitional care on Ward 33.

will be, to potentially include more regular 2 hourly feeds if indicated. 22.05.2019 Requires discussion with DMT to ascertain plan for ward reconfiguration and likelihood of establishing a ward with correct transitional care staffing for this group of vulnerable neonates. JW to action

Berrington

Following a decision being made, plans/revised guidance communication to be cascaded to staff. Continue to monitor via ATAIN meetings

Aim to audit compliance after 3 months and present findings at audit and Q&S

135

PMRT - Perinatal Mortality Reviews Summary ReportThis report has been generated following mortality reviews which were carried out using

the national Perinatal Mortality Review ToolThe Newcastle upon Tyne Hospitals NHSFT

Report of perinatal mortality reviews completed for deaths which occurred in the period:

1/1/2019 to 31/3/2019

Summary of perinatal deaths*Total perinatal* deaths reported to the MBRRACE-UK perinatal mortality surveillance in this period: 11

Summary of reviews**

Stillbirths and late fetal losses

Number of stillbirths and late fetallosses reported

Reviewsin

progress

Reviewscompleted

***

Grading of care: number of stillbirths and late fetallosses with issues with care likely to have made a

difference to the outcome for the baby

9 4 5 0

Neonatal and post-neonatal deaths

Number of neonatal and post-neonatal deaths reported

Reviewsin

progress

Reviewscompleted

***

Grading of care: number of neonatal and post-neonatal deaths with issues with care likely to have

made a difference to the outcome for the baby

8 5 5 0

*Late fetal losses, stillbirths and neonatal deaths (does not include post-neonatal deaths which are not eligible for MBRRACE-UK surveillance) – these are the total deaths reported and may not be all deaths which occurred in the reporting period ifnotification to MBRRACE-UK is delayed. Deaths following termination of pregnancy are excluded.

** Post-neonatal deaths can also be reviewed using the PMRT

*** Reviews completed and have report published

Report Generated by: Heather RaeDate report generated: 10/06/2019 15:04

136

waterfalla

Typewritten Text

Agenda item BRP A7(iii)

Table 1: Summary information for the babies who died in this period and for whom areview of care has been completed – number of babies (N = 10)

Perinatal deaths reviewedGestational age at birth

Ukn 22-23 24-27 28-31 32-36 37+ Total

Late Fetal Losses (<24 weeks) 0 0 -- -- -- -- 0

Stillbirths total (24+ weeks) 0 0 2 0 1 2 5

Antepartum stillbirths 0 0 2 0 1 2 5

Intrapartum stillbirths 0 0 0 0 0 0 0

Timing of stillbirth unknown 0 0 0 0 0 0 0

Early neonatal deaths (1-7 days)* 0 0 0 0 3 0 3

Late neonatal deaths (8-28 days)* 0 0 0 1 0 0 1

Post-neonatal deaths (29 days +)* 0 0 1 0 0 0 1

Total deaths reviewed 0 0 3 1 4 2 10

Small for gestational age at birth:

IUGR identified prenatally and management wasappropriate

0 0 0 1 2 0 3

IUGR identified prenatally but not managed appropriately 0 0 0 0 0 0 0

IUGR not identified prenatally 0 0 0 0 0 0 0

Not Applicable 0 0 3 0 2 2 7

Mother gave birth in a setting appropriate to her and/or her baby’s clinical needs:

Yes 0 0 3 1 4 2 10

No 0 0 0 0 0 0 0

Missing 0 0 0 0 0 0 0

Parental perspective of care sought and considered in the review process:

Yes 0 0 3 1 4 2 10

No 0 0 0 0 0 0 0

Missing 0 0 0 0 0 0 0

Booked for care in-house 0 0 1 1 3 0 5

Mother transferred before birth 0 0 0 0 0 0 0

Baby transferred after birth 0 0 0 0 0 0 0

Neonatal palliative care planned prenatally 0 0 0 0 0 0 0

Neonatal care re-orientated 0 0 0 1 2 0 3*Neonatal deaths are defined as the death within the first 28 days of birth of a baby born alive at any gestational age; earlyneonatal deaths are those where death occurs when the baby is 1-7 days old and late neonatal death are those where thebaby dies on days 8-28 after birth. Post-neonatal deaths are those deaths occurring from 28 days up to one year after birth

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Table 2: Placental histology and post-mortems conducted for the babies who died in thisperiod and for whom a review of care has been completed – number of babies (N = 10)


Ukn 22-23 24-27 28-31 32-36 37+ Total

Late fetal losses and stillbirths

Placental histology carried out

Yes 0 0 2 0 1 2 5

No 0 0 0 0 0 0 0

Hospital post-mortem offered 0 0 2 0 1 2 5

Hospital post-mortem declined 0 0 1 0 1 2 4

Hospital post-mortem carried out:

Full post-mortem 0 0 1 0 0 0 1

Limited and targeted post-mortem 0 0 0 0 0 0 0

Minimally invasive post-mortem 0 0 0 0 0 0 0

External review 0 0 0 0 0 0 0

Virtual post-mortem using CT/MR 0 0 0 0 0 0 0

Neonatal and post-neonatal deaths:

Placental histology carried out

Yes 0 0 1 0 2 0 3

No 0 0 0 1 1 0 2

Death discussed with the coroner/procurator fiscal 0 0 1 1 3 0 5

Coroner/procurator fiscal PM performed 0 0 0 0 0 0 0

Hospital post-mortem offered 0 0 1 1 3 0 5

Hospital post-mortem declined 0 0 1 1 3 0 5

Hospital post-mortem carried out:

Full post-mortem 0 0 0 0 0 0 0

Limited and targeted post-mortem 0 0 0 0 0 0 0

Minimally invasive PMpost-mortem 0 0 0 0 0 0 0

External review 0 0 0 0 0 0 0

Virtual post-mortem using CT/MR 0 0 0 0 0 0 0

All deaths:

Post-mortem performed by paediatric/perinatal pathologist*

Yes 0 0 1 0 0 0 1

No 0 0 0 0 0 0 0

Placental histology carried out by paediatric/perinatal pathologist*:

Yes 0 0 2 0 1 2 5

No 0 0 0 0 0 0 0*Includes coronial/procurator fiscal post-mortems

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Table 3: Number of participants involved in the reviews of late fetal losses and stillbirthswithout resuscitation

Role Total Review sessions Reviews with at least one

Chair 2 22% (2)

Vice Chair 0 0%

Admin/Clerical 21 100% (9)

Bereavement Team 0 0%

External 0 0%

Management Team 2 22% (2)

Midwife 19 55% (5)

Neonatal Nurse 32 55% (5)

Neonatologist 78 55% (5)

Obstetrician 13 77% (7)

Other 33 55% (5)

Risk Manager or Governance Team 10 44% (4)

Safety Champion 0 0%

Table 4: Number of participants involved in the reviews of stillbirths with resuscitation andneonatal deaths

Role Total Review sessions Reviews with at least one

Chair 0 0%

Vice Chair 0 0%

Admin/Clerical 0 0%

Bereavement Team 0 0%

External 0 0%

Management Team 0 0%

Midwife 3 100% (1)

Neonatal Nurse 0 0%

Neonatologist 0 0%

Obstetrician 2 100% (1)

Other 0 0%

Risk Manager or Governance Team 2 100% (1)

Safety Champion 0 0%

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Table 5: Grading of care relating to the babies who died in this period and for whom areview of care has been completed – number of babies (N = 10)


Ukn 22-23 24-27 28-31 32-36 37+ TotalSTILLBIRTHS & LATE FETAL LOSSESGrading of care of the mother and baby up to the point that the baby was confirmed as having died:A - The review group concluded that there were no issues with care identifiedup the point that the baby was confirmed as having died 0 0 2 0 1 2 5

B - The review group identified care issues which they considered would havemade no difference to the outcome for the baby 0 0 0 0 0 0 0

C - The review group identified care issues which they considered may havemade a difference to the outcome for the baby 0 0 0 0 0 0 0

D - The review group identified care issues which they considered were likely tohave made a difference to the outcome for the baby 0 0 0 0 0 0 0

Not graded 0 0 0 0 0 0 0

Grading of care of the mother following confirmation of the death of her baby:A - The review group concluded that there were no issues with care identifiedfor the mother following confirmation of the death of her baby 0 0 2 0 1 2 5

B - The review group identified care issues which they considered would havemade no difference to the outcome for the mother 0 0 0 0 0 0 0

C - The review group identified care issues which they considered may havemade a difference to the outcome for the mother 0 0 0 0 0 0 0

D - The review group identified care issues which they considered were likely tohave made a difference to the outcome for the mother 0 0 0 0 0 0 0

Not graded 0 0 0 0 0 0 0

NEONATAL AND POST-NEONATAL DEATHSGrading of care of the mother and baby up to the point of birth of the baby:A - The review group concluded that there were no issues with care identifiedup the point that the baby was born 0 0 1 1 3 0 5




Not graded 0 0 0 0 0 0 0

Grading of care of the baby from birth up to the death of the baby:A - The review group concluded that there were no issues with care identifiedfrom birth up the point that the baby died 0 0 1 1 3 0 5




Not graded 0 0 0 0 0 0 0

Grading of care of the mother following the death of her baby:A - The review group concluded that there were no issues with care identifiedfor the mother following the death of her baby 0 0 1 1 3 0 5

B - The review group identified care issues which they considered would havemade no difference to the outcome for the mother 0 0 0 0 0 0 0

C - The review group identified care issues which they considered may havemade a difference to the outcome for the mother 0 0 0 0 0 0 0

D - The review group identified care issues which they considered were likely tohave made a difference to the outcome for the mother 0 0 0 0 0 0 0

Not graded 0 0 0 0 0 0 0

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Table 6: Cause of death of the babies who died in this period and for whom a review ofcare has been completed – number of babies (N = 10)

Timing of death Cause of death

Late fetal losses 0 causes of death out of 0 reviews

Stillbirths 5 causes of death out of 5 reviews

hypoxia due to placental abruption

Known anecephalic

hypoxia ? due to cord entanglement and excessive fibrin in the cord

Fetocide for Cystic Fibrosis

severe uteroplacental insufficiency

Neonatal deaths 4 causes of death out of 4 reviews

1a Sepsis due Serratia Marcesans 1b Prematurity

Severe Pulmonary Hypoplasia Fetal Akinesia syndrome

severe pulmonary hypoplasia Fetal Akinesia Syndrome

Pulmonary Hypoplasia Autosomal Recessive Polycystic kidney disease

Post-neonatal deaths 1 causes of death out of 1 reviews

Disseminated HSV2 infection Extreme Prematurity

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Table 7:Issues raised by the reviews identified as relevant to the deaths reviewed, by thenumber of deaths affected by each issue* and the actions planned

Issues raised which were identified as relevantto the deaths

Numberof

deaths

Actions planned

Modifiable factor – Parental Consanguinity. Thoughthe exact genetic mutation could not be found itwas felt the most likely reason for recurrence ofthis condition in two pregnancies was anautosomal recessive mutation associated withparental consanguinity.

2 No action entered

No action entered

Delivery of inotropes and antibiotics appears tohave been within the timescales recommendedfrom the time the decision was made.

1 No action entered

Despite not having the results of a post-mortemthe review team are confident about the cause ofthe baby's death

1 No action entered

It was discussed that resistant Herpes is extremelyrare and it is very unlikely that earlier knowledgeand treatment with Foscarnet would have beenmore successful. There is no experience of the useof this medication in preterm infants but it is knownto be highly nephrotoxic and it was felt likely by thereviewing team that it would have had potential toadd to the severity of illness.

1 No action entered

It was felt that it was good practice to have theinput of the Microbiology team at an early stagewhen a pathogen had been identified. – Goodpractice

1 No action entered

It was noted the UVC was changed to a long lineearly on life. The documentation was notcompletely clear as to the reason for this but therewas no evidence of infection. The reviewing teamfelt the UVC position was satisfactory but didcomment that doing a combined chest andabdominal film can project the tip of the UVC in away that leads to concern about position. It wasnoted that we have a much narrower tolerance forUVC positioning after previous low UVCextravasations

1 No action entered

Maternal BMI was elevated at booking. This is arisk factor for pregnancy complications andpreterm birth.

1 No action entered

The baby was cold on arrival in the neonatal unit 1 No action entered

The reviewers noted a discrepancy in e-prescribingbetween the time of administration and therecorded time on the electronic system as itrecords the time of admin. as the time of signingand means retrospective signing (eg in emergencysituations) results in inaccuracies in the timeline ofdrug administration. This did not impact on thecare of this infant.

1 No action entered

The reviewing team considered whether there 1 No action entered

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142

should have been more in depth investigation ofthe early anaemia requiring transfusion. It wasdiscussed that this could have included bothkleihauer and cranial ultrasound. It wasacknowledged that at this stage it would have beenunlikely to have changed management.

*Note - depending upon the circumstances in individual cases the same issue can be raised as relevant to the deathsreviewed and also not relevant to the deaths reviewed.

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Table 8: Issues raised by the reviews which are of concern but not directly relevant to thedeaths reviewed, by the number of deaths in which this issue was identified* and the

actions planned

Issues raised which were identified as relevantto the deaths

Numberof

deaths

Actions planned

Despite not having the results of a post-mortemthe review team are confident about the cause ofthe baby's death

2 No action entered

No action entered

It is not possible to assess from the notes whetherfollowing the resuscitation of the baby a rapidsafety focused resus de-brief with the staffinvolved was carried out

2 No action entered

No action entered

It was noted that both twins airways were initiallymanaged by either an ANNP or senior traineepromptly before being handed on for consultantmanagement. The reviewing team felt that wherethere is expectation that the airway will be difficultto manage it should be the most skilled clinicianpresent who leads with the airway, in this caseeach infant had a consultant leading. Thereviewing team did feel there was no impact onthe outcome from the short delay in establishing adefinitive airway in each infant and that there wasno association between airway management andcause of death.

2 No action entered

As part of the department briefing in a minute we willdisseminate the information that in cases where there isexpected airway difficulty it should be the seniormostmember of the team managing the airway at least initially.

During resuscitation the baby required intubationbut there were difficulties with the intubation

1 No action entered

From information identified earlier in the tool thismother met met the national guideline criteria forscreening for gestational diabetes but this doesnot appear to have been identified and she wasnot offered screening

1 No action entered

Fundal height measurements had not been plottedon a chart

1 No action entered

It is not possible to assess from the notes whetherthe thermal management during resuscitation ofthe baby was appropriate

1 No action entered

It was difficult to get dad out of prison to visit whenFinley was dying

1 We will ask the CDOP to write to the Prisons authority to askthat in circumstances where children of prisoners are dyingthere is some thought about how to facilitate rapid movementof the prisoner to allow visiting where appropriate

It was noted that on an occasion where there hadbeen pyrexia there was no documented thoughtprocess around the potential for infection.

1 This will be raised via Briefing in a minute process

It was raised that the removal of the long line atthe start of the deterioration with sepsis made

1 Where there has been a delay in performing a plannedactivity it should be recorded (without disclosing clinical

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management with inotropes more challenging butconversely that removal of the long line in a septicinfant was appropriate. On review of the timelinethere was appropriate decision making to reinserta long line which was only delayed by the need forclinical staff to attend another acute event. It wasfelt by the reviewing team that this delay due toother activity could have been recorded better inthe notes.

details of another patient) why. Raise via Briefing in a minute

*Note - depending upon the circumstances in individual cases the same issue can be raised as relevant to the deathsreviewed and also not relevant to the deaths reviewed.

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Table 9: Top 5 contributory factors related to issues identified as relevant to the deathsreviewed, by the frequency of the contributory factor and the issues to which the

contributory factors related

Issue Factor Numberof

deaths

Issues raised for which these were the contributoryfactors

No contributory factor entered 1 The baby was cold on arrival in the neonatal unit

The reviewing team considered whether there should havebeen more in depth investigation of the early anaemiarequiring transfusion. It was discussed that this could haveincluded both kleihauer and cranial ultrasound. It wasacknowledged that at this stage it would have been unlikely tohave changed management.

The reviewing team felt it was a very good pickup (by arelatively junior member of the team) that the rash couldpotentially be herpes. This resulted in earlier treatment thanyou may have normally expected. – Good practice

There was discussion by the reviewing team as to whether thedose of acyclovir given was appropriate. Reviewing theavailable formularies it would appear Arevah was given theappropriate dose. The reviewing team acknowledged there isvery little in the way of robust evidence around the adviseddoses in the formulary.

It was discussed that resistant Herpes is extremely rare and itis very unlikely that earlier knowledge and treatment withFoscarnet would have been more successful. There is noexperience of the use of this medication in preterm infants butit is known to be highly nephrotoxic and it was felt likely by thereviewing team that it would have had potential to add to theseverity of illness.

The reviewing team felt there was good attention paid to thepotential distress Arevah may have had from the skin lesionsthat developed in the final days and advice was sought fromclinical teams with appropriate experience (Oncology for oralmucositis) to try and improve the symptoms.

There was discussion about the use of Nitric in this case. Thereviewing team discussed that there is very limited evidencefor use but acknowledged it is commonplace in currentpractice. It was felt it was neither right or wrong to considerthe use of this in these circumstances.

The reviewing team felt there was good documentation of thethought process around the actions taken in the care ofArevah.

The reviewing team felt the management of the Herpesinfection was appropriate. Early resistance testing would havebeen unlikely to have changed the outcome given the clinicalcircumstances but could be considered in future cases. In thiscase it was found, retrospectively, that the initial sampleswere sensitive to acyclovir and that there had been a mixtureof resistant and wild type HSV2 in the 2nd and subsequentsamples.

There was discussion around the role of steroids in treatmentwhere there is Herpes. The review team did not feel this wasa factor in either disease severity or the development of

11 of 12


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resistance.

No contributory factor entered 1 There was early involvement of the surgeons at the point ofdeterioration.

It was noted the UVC was changed to a long line early on life.The documentation was not completely clear as to the reasonfor this but there was no evidence of infection. The reviewingteam felt the UVC position was satisfactory but did commentthat doing a combined chest and abdominal film can projectthe tip of the UVC in a way that leads to concern aboutposition. It was noted that we have a much narrower tolerancefor UVC positioning after previous low UVC extravasations

The reviewing team discussed the rationale and decisionmaking around taking Jessie to theatre. It was felt that thedecision to take to theatre was appropriate given the clinical,biochemical and radiological signs. It was acknowledged thatnot all teams would make the same decisions given the samepicture. The Belfast team felt it was a positive point that therewas ready and rapid access to theatre in the out of hoursperiod.

The reviewing team discussed the role and choices of fluidsand inotropes in the resuscitation of unwell infants. It wasacknowledged that there is a variety of practice between unitsand clinicians and a lack of evidence for individual agents. Itwas however raised that in acute surgical cases and in gramnegative septicaemia there can be a need for rapid andaggressive fluid resuscitation and that though there may beoptions available in what fluid to give there is a lack ofevidence behind any single choice and often a need to givesomething that is rapidly accessible. The reviewing team feltthe fluid resuscitation and inotrope management wasacceptable for current practice.

No contributory factor entered 1 There were no specific contraindications to organ donation butthis was not discussed with the parents as part of end of lifecare for their baby

Modifiable factor – Parental Consanguinity. Though the exactgenetic mutation could not be found it was felt the most likelyreason for recurrence of this condition in two pregnancies wasan autosomal recessive mutation associated with parentalconsanguinity.

No contributory factor entered 1 Modifiable factor – Parental Consanguinity. Though the exactgenetic mutation could not be found it was felt the most likelyreason for recurrence of this condition in two pregnancies wasan autosomal recessive mutation associated with parentalconsanguinity.

There was discussion about whether the coroner should havebeen told a cause of death could not have been given as wedid not have an exact diagnosis but the reviewing team feltthat it was clear that this was a lethal congenital anomaly andparticularly in light of the post-mortem in the older siblingwhich did not provide any answers it would have beenunhelpful to the parents to have pushed for the coroner totake this as the certified cause of death is as accurate andcomplete as we can expect at this point.

Patient Factors - Physical Factors 1 Maternal BMI was elevated at booking. This is a risk factor forpregnancy complications and preterm birth.

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Newcastle upon Tyne Hospitals NHS Foundation Trust

Saving Babies Lives – June 2019 update

Element 1: Reducing Smoking in pregnancy

Element Description Intervention Process Indicators Outcome Indicators Evidence

Reducing smoking in pregnancy by carrying out Carbon Monoxide (CO) test at antenatal booking appointment to identify smokers (or those exposed to tobacco smoke) and referring to stop smoking service/specialist as appropriate

Carbon monoxide (CO) testing of all pregnant women at antenatal booking appointment and referral, as appropriate, to a stop smoking service/specialist, based on an opt out system. Referral pathway must include feedback and follow up processes.

1. Recording of smoking status of each pregnant woman

1. Number/rates of women smoking at booking

A booking proforma (See Appendix 1) is well-established and local data obtained from Euroking is shown in Appendix 2.

2. Recording of CO reading for each pregnant woman

2. Number/rates of women smoking at time of delivery (SATOD)

3. If this identifies exposure to smoke or a high CO reading, referral to stop smoking service or other action

From 1/4/18-31/3/19 –a total of 184 women were referred at booking , 494 women in total were referred to Stop Smoking Services by NuTH staff (other referrals came from sonographers, EPU, Centre for life or the wards). 32 women declined any input once contacted, 202 initially agreed to take part but did not follow it up, 260 women started a program of quitting. Source: NuTH referral data.

Element 2: Risk Assessment and Surveillance of Pregnancies for Fetal Growth Restriction

Element Description

Intervention Process Indicators Outcome Indicators Evidence

148


isk Assessment and Surveillance of Pregnancies for Fetal Growth Restriction

1. Use supplied algorithm to aid decision making on classification of risk, and corresponding surveillance of all pregnancies. (Some providers may wish instead to use the RCOG algorithm*)

Risk stratification algorithm (either care bundle or RCOG) incorporated in unit protocol

All relevant staff trained in use of algorithm

The Trust Guideline for ‘Detection and management of the Small for Gestational Age Baby’, with associated flowchart, is based on RCOG guidance and used for risk stratification and implementing a plan for monitoring (see Appendix 3).

All midwife sonographers and obstetric staff are trained in the use of this guideline and flowchart, so that appropriate monitoring organised according to risk and additional monitoring is undertaken if a SGA baby is detected. Flowcharts are present in all scan rooms and in the Trust antenatal clinic setting

Proportion of pregnancies appropriately screened and monitored according to risk

The process of screening is well established with risk assessment beginning at booking by the community midwife and on-going referral for consultant care and appropriate monitoring arranged, if a woman is deemed at increased risk of an SGA baby. This also applies if the risk status changes at point during pregnancy,

Customised growth charts are generated for each individual mother at their dating scan and kept in the handheld notes. Symphysis fundal height is plotted on this chart for low risk women. For those women at increased risk of SGA/fetal growth restriction serial ultrasound is arranged and estimated fetal weight (EFW) is also plotted on this chart

Additional checks to ensure all women at risk of an SGA baby have serial growth scans include:

- At the dating scan previous birth weights are plotted on a woman’s customised growth chart so that if a woman has had a baby in the past that was SGA, then serial growth scans are organised if not already.

149


- There is an additional check for women who smoke at their anomaly scan that serial growth scans have been organised.

- Guidance for high-risk categories are visible in the Trust AN clinic and individual rooms.

Formal audit is to be undertaken in June 2019 to determine compliance.

2. For women at high risk of fetal growth restriction, fetal growth to be assessed using serial ultrasound scans as per algorithm (Appendix B). Estimated fetal weight derived from ultrasound measurements recorded on a chart**

a. Use of estimated fetal weight charts implemented

Estimated fetal weight derived from ultrasound biometry and used to plot every growth scan

For those women at increased risk of SGA/fetal growth restriction, serial ultrasound is arranged and estimated fetal weight (EFW) devised from ultrasound biometry), is plotted on the woman’s personal customised growth chart which is kept in the handheld notes

b. Training programme on use of charts in place

All staff competent in use of estimated fetal weight charts, and audited within Trusts e.g. through midwifery supervision/trust based training and competence records

Perinatal Institute training is in place to enable staff to develop staffs’ competency in the use of the charts.

100% of community midwives have had education and skills training which includes use of customised growth charts.

Community midwives additionally given access to Perinatal Institute e-training as best practice which includes guidance as to when to refer in.

High Risk women receive regular fetal growth scans – multiple indicators for this.

Training records of staff attending available.

3. For low risk women, fetal growth to be assessed using antenatal symphysis fundal

a. Use of symphysis fundal height charts implemented

Symphysis fundal height charts used in each pregnancy

Perinatal Institute training is in place to enable staff to develop staffs’ competency in the use of the charts.

All fundal height measurements plotted on chart

An audit will be undertaken week commencing 3rd June 2019 to include compliance with fundal height measurement chart plotting.

150


height charts** by clinicians trained in their use. All staff must be competent in measuring fundal height with a tape measure, plotting measurements on charts, interpreting appropriately and referring when indicated.

b. Training programme in place on use of fundal height charts, interpretation and referral

Audit of representative sample of maternity to identify that:

charts are being used

charts are plotted correctly staff in need of further training are identified

evidence of completion of re-training available.

All staff are trained in the use of fundal height charts.

Birth weights of babies once born, are now input onto the Mother’s customised growth chart using the GROW software package. This is then an accurate way of determining whether a baby was small for gestational age (< 10th centile).

An audit will be undertaken on all deliveries in June 2019 to determine whether babies were screened appropriately according to risk as per NUTH Small for gestational Age Guideline.

4. Ongoing audit, reporting and publishing (on local dashboard or similar) of Small for Gestational Age (SGA) birth rate, antenatal detection rate, false positive rate and false negative rate.

Completion of SGA detection audit cycle

Increase/decrease of antenatal detection rate of SGA babies at birth, including false positive and false negative rate

Audit to be undertaken in June and to be included as part of Quality Assurance Framework. There is evidence of in-depth case review of babies admitted to SCBU at term with severe growth restriction, picked up through weekly ATAIN meetings

The Trust submits all data of stillbirths to MBRRACE. Birthweights of stillbirths is input into the Saving Babies Lives database and provides detection weights

Rate of stillbirths with SGA with and without antenatal detection

5. Ongoing case-note audit of

Appropriate process established

Action plans based on missed case audit

Term babies admitted to SCBU are reviewed on a case by case basis to identify learning opportunities. Snap

151


selected cases not detected antenatally, to identify learning and improve future detection

for review of e.g. 10 or more cases each 6 months

are implemented to drive improvement

shot audit is to be undertaken week commencing 3rd June 2019 to determine compliance.

All babies over 37 weeks are reviewed by the Term Admissions Review Group (Terms of reference attached see Appendix 4). A Datix of any term babies who are unexpectedly small or unexpectedly admitted to SCBU is completed and case reviewed.

Element 3: Raising awareness of Reduced Fetal Movement

Element Description

Intervention Process Indicators Outcome Indicators

Evidence

Raising awareness amongst pregnant women of the importance of detecting and reporting reduced fetal movement (RFM), and ensuring providers have protocols in place, based on best available evidence, to manage care for women who report RFM.

1. Information and advice leaflet* on reduced fetal movement (RFM), based on current evidence, best practice and clinical guidelines, to be provided to all pregnant women by, at the latest, the 24th week of pregnancy and RFM discussed at every subsequent contact.

a. Leaflet* given to and discussed with all pregnant women by 24th week of pregnancy

Percentage of women reporting RFM who have received the leaflet*

Patient Information Leaflet and pregnancy booklet given to every booking for maternity care in Newcastle Hospitals http://www.newcastle-hospitals.org.uk/downloads/Womens Services/Pregnancy_Book_2015.pdf .

b. Feedback obtained from sample of women to gauge whether messages have been assimilated as intended

Percentage of women reporting RFM who understood the message

An audit is to be undertaken in MAU week commencing 3rd June 2019. The audit will be undertaken by a Medical Student and the results of the audit disseminated to Maternity Audit meeting.

2. Use provided checklist to manage care of pregnant women who report reduced fetal movement, in line with RCOG Green-

a. Protocol in place that follows checklist for care for pregnant women who

Stillbirth rate (decrease/increase)

Antenatal Flowchart policy includes “Reduced Fetal Movement” flowchart (See Appendix 5). Table demonstrating MBRRACE Stillbirth

152

http://www.newcastle-hospitals.org.uk/downloads/Womens%20Services/Pregnancy_Book_2015.pdf




top Guideline 5716 report RFM data (See Appendix 6). All pregnant women reporting reduced fetal movement are monitored. Babies who are determined as being small are induced accordingly. Induction rates are monitored on a monthly basis and the yearly rate was 40.81% for 2018/19. This represents a similar rate as for 2017/18 (39.35%).

b. Care for all pregnant women who report RFM managed

ii. Induction rate (increase/decrease)

iii. Percentage of women reporting RFM who have 1. further action

Element 4: Effective Fetal Monitoring During Labour

Element Description

Intervention Process Indicators Outcome Indicators Evidence

Effective fetal monitoring during labour

All staff who care for women in labour are required to undertake an annual training and competency assessment on cardiotocograph (CTG) interpretation and use

a. Number of staff who have received training on CTG interpretation and auscultation (use this as numerator and express as a %)

Intrapartum stillbirth decreases/increases

Training is mandatory and provided on an annual basis. The expectation is that all staff will have undertaken this training and annual compliance will be available by the end of JULY 2019.

153


of auscultation. No member of staff should care for women in a birth setting without evidence of training and competence within the last year.

b. Number of staff who are deemed competent in CTG interpretation and auscultation (use this as numerator and express as a %)

All cases are reported to NHS Resolution.

c. Number of staff who have successfully completed mandatory annual updates on CTG interpretation and auscultation (use this as numerator and express as a %)

(Denominator for each indicator: total number of labour ward staff at trust whose role includes the care of women in labour.)

Number of cases of severe brain injury decreases/ increases*

Buddy system in place for review of cardiotocograph (CTG) interpretation, with protocol for escalation if concerns are raised. All staff to be trained in review system and escalation protocol.

a. Buddy system used in all intrapartum CTG interpretation according to local protocol

Intrapartum stillbirth decreases/increases

The Trust has an Intrapartum guideline which identifies “fresh eyes” approach (buddy system). See Appendix 7.

b. Sticker system used according to guideline for all women in labour undergoing CTG monitoring

Number of cases of severe brain injury* decreases/ increases

Sticker system is in use (see Appendix 8) for all women in labour undergoing CTG monitoring.

154


c. Escalation protocol in place and used appropriately

(documentary evidence required for each indicator)

Neonatal death within first seven days involving severe brain injury* decreases/ increases

All cases are reported nationally to Royal College of Obstetricians & Gynaecologists RCOG ‘Each Baby Counts’ via on-line data collection portal. Escalation Protocol for reacting to abnormal CTG tracing is in place and is in line with NICE guidelines 2017 for CTG interpretation and classification.

*Diagnosed in the first seven days of life, when the baby:

Was diagnosed with grade III hypoxic ischaemic encephalopathy (HIE)

Was therapeutically cooled (active or passive) Had decreased central tone AND was comatose AND has seizures of any kind.

155

Appendix i

May 2019

Healthcare-Associated Infections Report

156

Healthcare-Associated Infection Report May 2019

0

10

20

30

40

50

60

70

2007/08 2009/10 2011/12 2013/14 2015/16 2017/18

MRSA Yearly Trend

0

1

2

3

4

5

6

7

8

9

10

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

MRSA Bacteraemia - Cumulative PerformanceApril 2019 to March 2020

Cumulative Actual

0

10

20

30

40

50

60

70

80

90

100

110

120


C. difficile - Cumulative PerformanceApril 2019 to March 2020

Cumulative Local Objective Cumulative Actual Cumulative Contract

Objective: ≤113

0

100

200

300

400

500

600

2007/082008/092009/102010/112011/122012/132013/142014/152015/162016/172017/182018/19

C. difficile Yearly Trend

0.00

5.00

10.00

15.00

20.00

25.00

30.00


C.difficile Monthly Incidence Rates Per 100,000 Bed DaysMay 2019

HA C.diff per 100,000 Bed Days National Average/Trust Target

0

5

10

15

20


Gram Negative BacteraemiaMonth on Month Performance May 2019

E. coli Klebsiella Pseudomonas

0

10

20

30

40

50

60

70

80

90

100


MSSA Bacteraemia - Cumulative Performance Against TrajectoryMay 2019

2018/19 Cumulative 2019/20 Cumulative Local Target

0

5

10

15

20

25

30


C. difficile - MedicineMay 2019

Medicine 2018/19 Medicine 2019/20

0

5

10

15

20

25


MSSA Bacteraemia - CardiothoracicMay 2019

Cardiothoracic 2018/19 Cardiothoracic 2019/20

Objective: zero tolerance

Page (2)

157

IPC indicators (reported to DH)

MRSA Bacteraemia - non-Trust 0 0 0

MRSA Bacteraemia - Trust-assigned (objective 0) 0 n 0 0 n

MRSA HA acquisitions 2 3 5

MSSA Bacteraemia - post-48 Hours Admission 12 n 9 n 21 n

E coli Bacteraemia - post-48 Hours Admission 17 10 27

Klebsiella Bacteraemia - post-48 Hours Admission 7 5 12

Pseudomonas Bacteraemia - post-48 Hours Admission 0 3 3

C.diff - Hospital Acquired (objective 76 or fewer) 4 n 10 n 14 n

C.diff - cases appealed - - 0

C.diff - appeals successful - - 0

C.diff related death certificates - 1 1

Part 1 - 1 1

Part 2 - - 0

Periods of Increased Incidence (PIIs)

MRSA Periods of Increased Incidence (PIIs) - - 0

Patients affected - - 0

C.diff Periods of Increased Incidence (PIIs) - 1 1

Patients affected - 2 2

Outbreaks

Norovirus Outbreaks 2 - 2

Patients affected (total) 19 - 19

Staff affected (total) 12 - 12

Bed days losts (total) 66 - 66

Other Outbreaks 2 - 2

Patients affected (total) 11 - 11

Staff affected (total) 3 - 3

Bed days losts (total) 61 - 61

C.diff Transit and Testing Times Target <18hrs

Trust Specimen Transit Time 10:57 10:42 10:49

Laboratory Turnaround Time 03:08 02:41 02:54

Total to Result Availability 14:05 n 13:23 n 13:44 n

Hygiene Indicators/Audits (%)

CAT Trust Total N/A 95.99% n 95.99% n

Hand Hygiene Opportunity N/A 98.38% n 98.38% n

Hand Hygiene Technique N/A 97.92% n 97.92% n

Environmental Cleanliness N/A 96.86% n 96.86% n

Infection Control Mandatory Training (%)

Infection Control 91% n 88% n 90% n

Aseptic Non Touch Technique Training (%)

ANTT (M&D staff only) 69% n 69% n 69% n

July MarJan

Dec

Dec

July

Nov

Oct

Aug

Aug

July Aug JanDec MarNovSept

Aug

Aug

DecSept

DecOct

Oct

Sept

Cumulative

Cumulative

Average

Jan

Nov

Nov

JanNov

Feb MarJan

Feb

Feb

Mar

Mar

DecAug Sept Oct Nov

Oct

Sept Oct

Sept

July

JulyApril May

April May

July

June

June

MayApril

April

Healthcare-Associated Infection Report May 2019

June

June

April May June

May

May

June

April

April May June July Aug Sept Oct Nov Dec Jan

Jan Feb Mar Cumulative

Feb Mar Average

Average

Feb

Feb

Cumulative

Page (3)

158

Agenda item A7(vi)

____________________________________________________________________________________________________ Trust Board Assurance Framework for 7 Day Hospital Services Trust Board – 27

th June 2019

Trust Board Assurance Framework for 7 Day Hospital Services Priority 7DS Clinical Standards

Clinical Standard Self-Assessment of Performance Weekday Weekend Overall

Score

Clinical Standard 2:

All emergency admissions must

be seen and have a thorough

clinical assessment by a

suitable consultant as soon as

possible but at the latest within

14 hours from the time of

admission to hospital

Data from May 2019 audit showed 68% compliance with documented evidence of

consultant reviews. However we are confident that compliance is 90% as the majority of

Directorates have consultant rotas/job plans to ensure patients have access to consultant

reviews on a 24/7 basis. In addition, the intensive care units and the emergency

assessment suite have twice daily consultant ward rounds. The Directorates with some

gaps in compliance with job plans include Children's Services cover at weekends and

Vascular. The percentage of cover continues to grow but is not yet adequate to ensure

this standard is always covered. An approved plan to increase consultant numbers in

Vascular in 2019 will allow provision of consultant compliance in Vascular Services.

Yes, the

standard is

met for over

90% of

patients

admitted as

an

emergency

Yes, the

standard is

met for over

90% of

patients

admitted as

an

emergency

Standard

Met

Clinical Standard Self-Assessment of Performance Weekday Weekend Overall Score


Hospital inpatients must have

scheduled seven-day access to

diagnostic services, typically

ultrasound, computerised

tomography, magnetic

resonance imaging,

Q. Are the following diagnostic

tests and reporting always or

usually available on site or off

site by formal network

arrangements for patients

admitted as an emergency with

critical and urgent clinical needs,

Microbiology Yes available on-site Yes available on-site

Standard Met

Computerised tomography Yes available on-site Yes available on-site

Ultrasound Yes available on-site Yes available on-site

Echocardiography Yes available on-site Yes available on-site

Magnetic resonance Imaging Yes available on-site Yes available on-site

159

Agenda item A7(vi)


th June 2019

Clinical Standard Self-Assessment of Performance Weekday Weekend Overall Score

echocardiography, endoscopy

and microbiology. Consultant-

directed diagnostic tests and

completed reporting will be

available seven days per

week:

Within 1 hour for critical patients

Within 12 hours for urgent patients

Within 24 hours for non-urgent patients

in the appropriate timescales?

The Trust continues to be

compliant with this standard.

Upper GI endoscopy Yes available on-site Yes available on-site


Score


Hospital inpatients must have timely 24

hour access, seven days per week, to key

consultant-directed interventions that

meet the relevant specialty guidelines,

either on-site or through formally agreed

networked arrangements with clear

written protocols

Q. Do inpatients have a 24-

hour access to the following

consultant-directed

interventions 7 days per week,

either on-site or via formal

network arrangements?

Critical Care Yes available on-site Yes available on-site

Standard

Met

Interventional Radiology Yes available on-site Yes available on-site

Interventional Endoscopy Yes available on-site Yes available on-site

Emergency Surgery Yes available on-site Yes available on-site

Emergency Renal

Replacement Therapy

Yes available on-site Yes available on-site

Urgent radiotherapy Yes available on-site Yes available on-site

160

Agenda item A7(vi)


th June 2019


Score

The Trust continues to be

compliant with this standard.

Stroke thrombolysis Yes available on-site Yes available on-site

Percutaneous Coronary

Intervention

Yes available on-site Yes available on-site

Cardiac Pacing Yes available on-site Yes available on-site


Score


All patients with high dependency needs

should be seen and reviewed by a

consultant TWICE DAILY (including all

acutely ill patients directly transferred

and others who deteriorate). Once a

clear pathway of care has been

established, patients should be reviewed

by a consultant at least ONCE EVERY 24

HOURS, seven days a week, unless it has

been determined that this would not

affect the patient’s care pathway.

Case note reviews have confirmed compliance is above 90% for

daily and twice daily reviews. The majority of Directorates have

board round systems in place and a clear process for

identifying patients who do not require a daily ward round. The

exception is there is no single-consultant-led multidisciplinary

board round system in Neurosurgery although there is a

multidisciplinary board round attended by the ward registrar.

Registrar discusses new and changing patients with a

consultant. In addition, on weekends there is partial

compliance in neurosurgery in respect of having a clear process

for deciding patients who do not require a daily consultant

review.

Once daily: Yes the

standard is met for

over 90% of patients

admitted as an

emergency

Once daily: Yes the

standard is met for


admitted as an

emergency

Standard

Met Twice daily: Yes the

standard is met for


admitted as an

emergency

Twice daily: Yes the

standard is met for


admitted as an

emergency

161

Agenda item A7(vi)


th June 2019

7DS Clinical Standards for Continuous Improvement

Self-Assessment of Performance against Clinical Standards 1, 3, 4, 7, 9 and 10.

A brief summary is provided for performance against 3 of these standards.

Standard 7- Mental Health. This standard largely relates to Emergency Departments. The Trust is compliant with appropriate referral and responses to liaison Mental

Health Service, assessments required together with development of urgent and emergency health care plans in place as required.

Standard 9 - Transfer to Community, primary and social care. The Trust is compliant for weekdays but partly compliant on a weekend. The standard requires access to

appropriate senior clinical expertise e.g. via telephone call / an integrated care record where available to mitigate risk of emergency admission. Directorates indicated that

there can be issues in relation to Occupational Therapy, Social Services and Equipment provision and to a lesser extent transport services.

Standard 10 - Quality Improvement. The Trust is compliant with active engagement of all staff involved in the delivery of acute care participating in the review of patient

outcomes to drive care quality improvement. All specialties throughout the Trust, as part of their governance arrangements, adopt the overarching principles of routine

and systematic mortality reviews, which include reviewing all level 2 deaths at specialty M&M meetings. Directorates have clinical audit priority programmes and provide

an annual report on the outcomes of the priority audits together with additional clinical audit activity undertaken. Monthly Patient Safety Briefings are held across the

Trust to share lessons learnt / good practice with a representative from every ward and department invited to attend with a view to cascading to colleagues. The Trust has

a GREATIX system to recognise when staff have gone above and beyond what is expected of them as a Trust professional. The Trust also stages major events e.g. Nursing

and Midwifery Conference and Medical Education Day. The Trust prides itself on being at the very forefront of leading edge initiatives being recognised both nationally and

internationally as having a strong research culture.

162

Agenda item A7(vi)


th June 2019

7DS and urgent Network Clinical Services

Hyperacute Stroke Paediatric intensive

CARE

STEMI Heart Attack Major Trauma Centres Emergency Vascular

Services

Clinical Standard 2 Yes, the standard is met

for over 90% of patients

admitted in an emergency

Yes, the standard is met









No the standard is not

met for over 90% of

patients admitted in an

emergency











































No the standard is not

met for over 90% of

patients admitted in an

emergency

Assessment of Urgent Network Clinical services 7DS Performance (Optional)

Two new vascular consultants were appointed in April 2019 who will take up post in October 2019 and October 2020. As of 1 May, the Trust has taken over the vascular service for Gateshead and as part of that has implemented a consultant of the week (COTW) system on an 8 week cycle. COTW is now in place 6 weeks out of 8 going to full implementation as the new colleagues take up post. It is therefore anticipated that in those weeks when there is COTW, the vast majority of emergency admissions will be seen within 14 hours. A red rating remains until this is embedded into practice.

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164

Agenda item A9 BRP

TRUST BOARD

Date of meeting 27 June 2019

Title Interim NHS People Plan Summary

Report of Dee Fawcett, Director of HR

Prepared by Dee Fawcett, Director of HR


☒ ☐ ☐


☐ ☐ ☒

Summary

NHS England/Improvement published the Interim People Plan for the NHS on 3 June 2019 setting out that national strategic framework for the workforce over the next five years. The content of this report outlines the key proposals which reiterate that to deliver the NHS Long Term Plan, more people will be required working across different roles and professions in all care settings. The way of working will be more collaborative, more agile and flexible and more multidisciplinary and underpinned by culture change throughout the NHS. STPs will be asked to develop detailed people plans over the summer.

Recommendations The Board of Directors is asked to note the contents of this report.


Enhancing our reputation as one of the country’s top, first class teaching hospitals promoting a culture of excellence in all that we do.


Linked to Corporate Strategy

Impact


Quality and Safety X

Legal x

Financial X

Human Resources X

Equality and Diversity X

Engagement and communication X

Sustainability X

If yes, please give additional information: Links to all at a strategic level.


First consideration at Board.

165

Agenda item A9 BRP

____________________________________________________________________________________________________ Interim NHS People Plan Board Summary Trust Board – 27

th June 2019

INTERIM NHS PEOPLE PLAN – A NATIONAL WORKFORCE STRATEGY

1. BACKGROUND On 3rd June 2019, NHS Improvement, NHS England and HEE published the interim NHS People Plan (the plan) outlining the national strategic framework for the workforce over the next five years. A final people plan will be published following the 2019 spending review. The plan was developed following engagement with key stakeholders and to ensure wide input from across the sector. It has been structured around themes, each one with a number of immediate actions which need to be taken by NHS organisations to enable the people who work in the NHS to deliver the Long Term Plan.

2. MAKE THE NHS THE BEST PLACE TO WORK

Develop a ‘new offer’ for people working in the NHS. Consultation and engagement will take place during this summer to inform this, and to ensure that healthcare careers remain an attractive option.

Pay attention to why staff leave the NHS, ensure action to retain current staff, and attract more people to join.

Address and improve the flexible working arrangements, including career breaks and non-linear careers to ensure the NHS is a flexible and modern employer.

Prioritise the people agenda at Board to ensure the staff experience is improved and the NHS is an employer of excellence.

New of revised commitments in the NHS Constitution, forming the basis of a ‘balanced scorecard’ which will inform future CQC well led assessments.

The offer will set out explicitly the commitments particularly relating to: o A healthy, inclusive and compassionate culture, focused on equality and

inclusion, bullying and harassment. o Enabling development and fulfilling careers, focussing on CPD, credentialing of

expertise and line management o Ensure everyone feels they have a voice, control and influence by improving

physical and mental health and wellbeing, reducing sickness absence, work life balance, whistleblowing and freedom to speak up.

Independent review of HR/OD ‘best practice’ in 2019.

3. IMPROVING OUR LEADERSHIP CULTURE

Build leadership and improvement capacity; ‘Developing People Improving Care, framework will focus on helping NHS and social care staff to develop four capabilities: o Systems leadership – working with partners and joining up health and care

services in local communities. o Established quality improvement methods – using knowledge and experience to

improve service quality and efficiency. A new National Director of Improvement has been appointed.

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o Inclusive and compassionate leadership – staff are listened to, and leaders at every level reflect the talents and diversity of people working in health and care services.

o Talent management – to support NHS funded services fill senior posts and develop leadership pipelines with diverse and appropriately experienced people.

Ambition to engage on a ‘new NHS leadership compact’ which sets out the ‘gives and gets’ to shape recruitment, development and appraisal of NHS leaders. The plan calls for: o Development of agreed competencies, values and behaviour frameworks for all

senior leadership roles. This will include consideration of recommendations by the Kerr and Kark Reports.

o The review of regulatory and oversight frameworks to ensure greater focus on leadership, culture, improvement and people management.

o Roll out of talent boards to every region and an expansion of the NHS Graduate Management Training Scheme.

o Development of a central database of directors holding information about qualifications and employment history; engage on the recommendations from the Kark Report about mandatory references and ‘assuring leadership’ in the NHS.

4 ADDRESSING URGENT WORKFORCE SHORTAGES IN NURSING

Significant shortages in many workforce groups. However, nursing shortages are the single biggest and most urgent – partly because of current nurse vacancies – around 40,000 in substantive posts.

Focus on: o Rapid expansion programme to increase undergraduate supply and clinical

capacity by 5,000 for September 2019 nursing undergraduate intakes. o Working directly with Nursing directors to assess organisational readiness,

support required and resources to develop infrastructure to increase placement capacity.

o Increase the undergraduate acceptance rate from 55% (2018) to 70% o Consolidation of recruitment campaigns to reflect a single campaign reflective of

the realities of a modern career in nursing. o Further work with DHSC to raise awareness of financial support programmes for

trainee nurse via the Learning Support Fund (LSF). o 2020: The Year of the Nurse and Midwife – expand ‘ambassador network’, target

15 – 17 year olds, leverage work experience, emerging cadet schemes and volunteering strategy to raise the profile.

International recruitment: short term increase in supply. Plan commits to building global partnerships and exchanges; STP’ICS’s will implement ‘lead recruiter’ arrangements; NHSE will develop new procurement framework of approved international recruitment agencies; best practice toolkit development to highlight good practice and improve experience and retention of international nurses.

Retention and return to practice: Expansion of national retention programme focusing on early years retention and provision of support. Boosting ‘return to practice working

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with ‘Mumsnet’ to launch marketing campaign; further work to convert return to practice courses into employment opportunities.

Continuing professional development (CPD)and flexible entry: o Acknowledgement that the budget for CPD and workforce development has

reduced by almost 50% since 2013/14. o Review how to increase national and local investment to restore over the next 5

years to previous funding levels for CPD. o Explore potential of blended nursing degree programme with online theoretical

component. o Development of clear model explaining different routes into nursing; expand

nursing associate programme for those who wish to continue studying to registered nurse level.

o Consideration of a guaranteed job approach at system level.

5 DELIVERING 21ST CENTURY CARE

Transformational, coordinated care required growth in overall workforce.

Require varied and richer skill mix, new types of roles, different ways of work, working in a more joined-up, multidisciplinary way. o Technology provides potential to automate some tasks and release capacity for

health professionals to focus on high value activities. o Underpinned by culture of mutual trust, respect and understanding across health

and social care settings.

Accelerate efforts to create more flexible and adaptive workforce; obtain most value from critical new roles, e.g. Physician and Nursing Associates, and wider workforce of volunteers.

Scale up development of new roles and models of advanced clinical practice – which will require further investment in development of these roles.

Develop multiprofessional credentials to enable people to widen their knowledge and skills.

Use of the Apprenticeship Levy to effectively provide more routes into healthcare careers.

Harness potential of scientific and technological developments – creating data rich and digitally supported health and care services.

More systematic approach to planning and coordinating workforce transition.

Workforce expansion plans need to account for future levels of investment in education, training and workforce development. o Open 5 new medical schools across England; STP/ICS plans to determine future

expansion in undergraduate medical places. o Increase doctors who can provide generalist care across a range of healthcare

settings. o Develop new nursing associate role o Develop pipeline of AHP’s o Expand use of clinical pharmacists as part of multidisciplinary teams in primary

care.

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o Establish healthcare science workforce programme introducing more flexible entry routes and career pathways.

o Increase Physician Associates; commit to regulate the role and launch consultation on introducing prescribing rights within 24 months of regulation.

Volunteers and carers: Double the number of volunteers within next three years; early focus on Helpforce programme.

Establish ‘Releasing Time To Care’ programme to spread good practice and support continuous improvement.

Support clinical teams to take increasing ownership of how they plan and develop the workforce to ensure right staff available to patients. o Includes consistent and effective implementation of e-rostering and e-job

planning systems; all clinical staff to access to e-rostering systems and able to agree rotas at least six weeks in advance.

Promote and enable wider changes to ways of working; increase use of digital outpatient appointments, use of new technology to track utilisation of hospital beds and equipment; teleconsultations; use of speech recognition; use of digital technology, e.g. automated image interpretation.

Expand community multidisciplinary teams making greater use of training hubs to develop more effective working.

Encourage more diverse and flexible opportunities and careers – encouraging; second and third careers within the NHS. o Increase flexible working – combination of technology and change in people

practice; greater choice in working patterns; enable home working o Remove practical barriers to movement of staff across organisations –

streamlining induction and onboarding. o Tech enabled in house staff banks.

Widening routes into NHS careers: o Apprenticeships and increasing clinical degree level apprenticeships. o STP/ICS collaborative system level arrangements to optimise use of levy. o Volunteering – more attractive option to contributing to healthcare services and

potentially gain employment in the NHS.

Embedding scientific and technological developments – including robotic, AI and genomics to influence how care is delivered. o Attract the best technologists, informaticians and data scientists. o Service transformation skills to implement digital change

6 A NEW OPERATING MODEL FOR WORKFORCE

Dynamic to respond to changing capacity, capability and need

ICS’s should be the main organising unit for local health service; support all local health systems in becoming ICS’s by 2021.

Provide opportunities for local providers to pool capacity and expertise and more rapidly spread good practice in recruitment, retention, developing and deploying the local workforce.

ICS’s taking greater responsibility for some workforce and people functions.

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o Some aspects of workforce policy, eg. Professional regulation, credentialing, prescribing rights – standardised at national level.

o NHS Pension Scheme – taxpayer funded continue to be responsibility of Government.

o Medical trainees, providing right educational opportunities and support to be overseen at a more regional level optimally.

NHSE/I and HEE regional teams to work with ICSs to help equip them with tools and resources for place based workforce planning and transformation. o Workforce roles and responsibilities to evolve. o Changes to be developed in resourcing and accountability to enable ICS’s to take

on greater responsibilities for these activities.

The following principles to underpin decisions about which workforce activities should be carried out at which level: o National workforce activity where:

Necessary to meet statutory responsibilities To benefit from economies of scale Planning is needed over a longer timeframe, e.g.15 years Clear benefits from national role in standardisation or

coordination/implementation National teams have specific and scarce skills/knowledge that its not possible

or desirable to duplication subnationally. o Regional workforce activity where:

Need for assurance role in delivering national priorities, e.g. international recruitment.

Planning needed for medium term time frame e.g. five years Demand for improvement support on a large scale Need for help to foster capacity and capability in local health systems Decisions need to be made across a regional labour market.

o ICS workforce activity where: Regional footprint is too large to affect change Strong local partnerships are required Planning is needed over a short to medium term time frame – e.g. one to

three years. Decisions need to be made about a local labour market.

o Local workforce activity to : Develop and sustain clear vision for the organisations aligned to the overall

ambition of the ICS Develop and embed local values, derived from the NHS Constitution Build an inclusive, compassionate and improvement focused culture Ensure all people are able to do their best work Recruiting and retaining people for a local organisation Account for the wellbeing of employees and advance equality of opportunity Develop and implement organisational people plans and contribute to ICS

people plans.

Nationally to adopt a single joined-up approach to people planning ensuring full alignment of HEE mandate.

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New National NHS People Board, chaired by Chief People Officer, to convene organisations nationally, to develop the full People Plan to be published when the Spending Review has concluded and to assure individual and collective progress against the interim and full People Plan. It will also convene a People Plan Advisory Group. o It will work closely with the Social Partnership Forum o Further engagement events to listen to the wider audience of NHS colleagues and

reflect their views in the development of the plan. o NHS colleagues can join the online conversation about the plan at #OurNHS

People.

Regionally establish much closer working; HEE Regional Directors work alongside NHSE/I Directors of Workforce and OD. This will be as ‘light touch’ as possible.

ICS – to be the ‘default level at which accountability for system wide workforce decision making is based’. o NHS Leaders clear that meaningful workforce functions to ICS relied on them

having the necessary resources (people and funding). o A coproduced ICS maturity framework to benchmark workforce activities at

system level to inform the support that systems can expect from HEE and NHSi and their regional teams and influence decisions at pact and scale.

Local organisations provide an employee’s primary experience of work.

7. RECOMMENDATIONS This interim plan seeks to ensure that the NHS will work together behind a single approach with a ‘unity of purpose’ which has been lacking. Some of the proposed solutions to the workforce challenges will take time and remain dependent on the publication of the final document, the 2019 Government Spending Review, and on a sustainable approach to recruitment and retention of the social care workforce. Several consultations are referenced to inform the final strategy – on leadership behaviours, HR/OD practice and systems maturity are particularly important. Arriving at a sector-wide consensus on future workforce design, and the levels of funding essential for education and training is critical, and priorities include the need to increase funding for CPD, financial support for international recruitment, and revising the currently unworkable apprenticeship levy arrangements. Whilst the proposal to bring forward consultation on new pension flexibility is welcome for senior clinicians, this should be available to support the retention of all members of the workforce. An interim Equality and Health Inequalities Impact Assessment will be published in due course.

Dee Fawcett Director of HR

21 June 2019

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North Regional Talent Board Paper for NHS Organisations

May 2019

PURPOSE

This briefing note is designed to appraise the Boards and Governing Bodies of NHS organisations in

the North of the work on the North Region Talent Board.

BACKGROUND

Talent Management and development is a key part of the NHS Long Term Plan and the new Interim

People Plan which is currently being developed. Aspire Together took its lead from Developing

People: Improving Care, the agreed framework for developing improvement and leadership

capability in the NHS. This set out five conditions for success. One of these is to equip leaders to

develop high quality health and care systems in partnership, collaborating with partners across

boundaries to achieve system goals. Another is to ensure compassionate, inclusive and effective

leaders at all levels. The conditions outlined in Developing People Improving Care are further

supported by the Interim People Plan for the NHS which also talks about Making the NHS the best

place to work, Improving the Leadership Culture, Tackling the Nursing Challenge and Delivering 21st

Century Care.

The North Regional Talent Board aims to bring all of these conditions to life and has been developing

Aspire Together’s programme of work in collaboration with key organisation’s across the North.

VISION FOR TALENT MANAGEMENT IN THE NORTH

Our vision is that all health and care staff, employed in the North of England, can operate to their

full potential for the benefit of health and care services.

The ambition for the Northern Regional Talent Board is to enable a high quality, sustainable

approach to identify, develop, support and deploy leaders, at all levels, to produce a compassionate,

inclusive leadership culture with patients and local communities at its heart.

This will be achieved through embedding good practice, inclusive cultures and talent management

interventions in all organisations.

Talent management will be owned and valued by the whole system and coordinated by the

Regional Talent Board. Organisations will embrace a collaborative approach, share real-time data on

vacancies and demand and support regional talent pipelines.

There are 10 objectives for the Regional Talent Board which are included in the strategy document

available here: https://www.leadershipacademy.nhs.uk/aspiretogether/

THE BOARD’S GOVERNANCE AND WORKSTREAMS

The North Regional Board first met formally in June 2018 and is the second Regional Talent Board to

be established across the country. The Board has a number of key workstreams as shown below.

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Workstream Focus

Regional Talent

Management

Establishment regional talent pools comprising aspirant and current Executive

Directors

Programme management coordination with interdependent workstreams

Collaboration and interdependency with NHS IMAS and the North Executive Talent

(NET) Scheme

STP/ICS Level

Talent

Management

STP/ICS level research, planning and scoping

Specific focus on scoping social care and broader care sector potential

Development of plans and recommendations on developing whole integrated health

and care system approaches

Data Board and Governing Body level vacancy data collection informing talent pool supply

and demand

Future Board or equivalent level data collection in new systems of care

Primary Care Engaging the primary care system with TM agenda

Lead discovery work for all RTBs on primary care

Communication

and

Engagement

Enabling workstream to communicate and engage the region with the NRTB

programme of work

Stakeholder management, system mapping and positioning of the NRTB programme

of work

Diversity and

Inclusion

Development of NRTB and NRTB WG D&I capability

Development of D&I strategy and metrics

Establishment of positive D&I action

National Talent

Management

Creation of National Talent Board and CEO/AO talent approach

Collaboration across regional RTBs and deployment beyond regional boundaries

National strategy and policy

High Potential Scheme – Lancashire and South Cumbria pilot STP

Organisational

Talent

Management

Promote the newly developed organisational TM resources

Link to organisational level support that is developed through the national single

programme of work to develop good TM practice supported by your Local Leadership

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Academy

The Board is chaired by Angela Schofield, Chair at Harrogate & District NHS Foundation Trust. The

Board is supported by a Working Group chaired by Deborah Davies, Managing Director for the

North-West Leadership Academy and a HR Directors Reference Group chaired by Kevin Moynes,

Joint Strategic Director of HR and Organisational Development, East Lancashire Hospital Trust and

Blackpool Foundation Trust. The RTB has a PID in place which pulls together the workplans for each

of the workstreams with key milestones. This is presented to the Board on a regular basis and is

supported by a Communication and Engagement Strategy as well as an Inclusion Strategy which is

currently being developed.

A copy of these documents as well as the governance structure are available on request.

TIMELINE

Below are the key milestones for the next few months. This is by no means the only work being

forward by the RTB but further detail will be added as the work develops. We are continually

looking at how we keep key stakeholders up to date with the work being undertaken which may

include regular updates at key meetings, social media updates and newsletters.

NEXT STEPS

The North Regional Talent Board held its launch event on 5th June 2019 to launch the Aspire

Together’s programme of work which is targeted at NHS organisations in the North. Baroness Dido

Harding spoke at the event on the importance of Talent Management, we used the opportunity to

share with organisations, examples of good talent management practices for others to learn from

and giving opportunity for stakeholders to engage with each of the workstreams.

The nominations for the first talent pools will start in June 19. Further details about the nomination

process are available on the website but every candidate whether self-nominated or by their

organisation will require organisation sign off.

The assessment centres will start in October 2019 and we will be looking for support from key

individuals in the North to come forward to support these in terms of lead and technical assessors.

Further details about this role, the training required and full details about the assessment centres

will also follow in due course.

Further information on the work of the North Regional Talent Board can be found here:

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RECCOMMENDATIONS

The Board is asked to:

1. note the contents of this briefing;

2. publicise the Regional Talent Board within their organisations to aspirant staff and existing

directors; and

3. look to support the Assessment Centre process when further details are circulated by

nominating relevant individuals and providing assessors.

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