NHS NOTTINGHAM · PDF fileHampshire CCG 29 5 NHS North Tyneside CCG 17.47 6 NHS Southport and Formby CCG 29 6 NHS Castle Point and Rochford CCG 27.31

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Quality Report

Quarter 3 2015/16

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Section Contents Page

1.0 Executive Summary

3

2.0 Introduction

4

3.0 Patient Safety

4-11

3.1 Health Care Associated Infections

4

3.2 Serious Incidents

8

4.0 Safeguarding

11-14

4.1 Transforming Care

11

4.2 Care Homes

13

4.3 Continuing Health Care Retrospective Reviews

14

5.0 Quality Visits to Providers

15-17

6.0 Patient Experience

18-20

6.1 Patient Advice and Liaison Service

18

6.2 Complaints

18

6.3 Patient Experience Activity

19

6.4 Patient Stories

20

7.0 Primary Care Quality

21

7.1 CQC Inspections

21

7.2 Quality Monitoring

22

8.0 Nursing and Midwifery Council Revalidation

22-23

9.0 Recommendation

24

Appendix 1 Summary of Complaints and MP Letters Quarter 3 2015/16

25-26

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Quality Report

Quarter 3 2015/16 1.0 Executive Summary

This Quality Report provides an update on the activity of the Quality and Patient Safety Team, acting on behalf of Nottingham North and East (NNE), Nottingham West (NW) and Rushcliffe Clinical Commissioning Groups (CCGs), collectively known as the South Nottinghamshire CCGs, during the period Quarter 3 2015/16. The report also identifies any local or national initiatives or developments aimed at improving the quality of services. The following are included in this report: An update on Health Care Associated Infection position against limits up to the end of quarter

3, 2015/16. This shows that Nottingham University Hospitals (NUH) and NHS Rushcliffe CCG are currently over trajectory for Clostridium difficile and NUH has not achieved zero tolerance for Methicillin Resistant Staphylococcus Aureus Blood Stream Infection (MRSA BSI). Additional information has been included in this section to enable comparison of the CCGs and NUH with similar organisations which gives more context to organisational performance against nationally set trajectories.

An update on numbers and categories of Serious Incidents (SIs) reported to the end of quarter

3 2015/16. This shows that the overall number for Q3 is similar to Q1 and Q2 but there has been an increase in pressure ulcers and a reduction in falls, Health Care Acquired Infections (HCAI) and maternity related incidents.

An update on the Transforming Care Programme (the response to the Winterbourne View

investigation) including the requirement for a 10% reduction in inpatient cohort and transfer of a further 10% to a less restrictive setting. The status of the current South Nottinghamshire funded inpatients as at the end of Quarter 3 (0 NNE, 3 NW and 0 Rushcliffe) with learning disabilities and/or autism in locked rehabilitation and Assessment and Treatment Units is also provided.

An update on care homes of note identifying changes since the last report.

A progress report on retrospective Continuing Health Care review completion showing that all

three CCGs are currently meeting or exceeding the revised national trajectories for completion.

Details of Quality Visits undertaken to our providers during the first three quarters of 2015/16 including complaints,

PALS and patient stories. A summary of Quarter 3 complaints and MP letters is included at Appendix 1.

An update on CQC inspections in Primary Care.

An update on National plans to introduce Nursing and Midwifery Council revalidation from April 2016.

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The report is considered in detail at the South Nottinghamshire CCGs Quality and Risk Committee and presented to the Governing Bodies for information and assurance purposes. 2.0 Introduction Commissioning is a tool for ensuring high quality, cost–effective care. Quality is a key thread that underpins the work undertaken by commissioning groups. The mission is to improve the health and wellbeing of people in Nottinghamshire with a specific aim to improve quality by delivering improvements across the three domains of quality:

Patient Safety Patient Experience Clinical Effectiveness

Quality is only achieved when all three domains are met; delivering on one or two is not enough. To achieve a good quality service the values and behaviours of those working in the NHS need to remain focussed on patients first. Our ambition is to commission excellent, safe and cost effective healthcare for Nottinghamshire. The Quality Strategy (2014‐2019) sets out how we will ensure quality is at the heart of commissioning. The Quality Framework sets out our Governance processes for achieving this. These documents set the context for this Quality Report which provides an update on the activity of the Quality and Patient Safety Team, acting on behalf of Nottingham North and East (NNE), Nottingham West (NW) and Rushcliffe Clinical Commissioning Groups (CCGs) during the period Quarter 3 2015/16. The report also identifies any local or national initiatives or developments aimed at improving the quality of services. 3.0 Patient Safety

Patient Safety will be our highest priority (Quality Strategy 2014-2019).

3.1 Healthcare Associated Infections (HCAIs) The table below shows the position against HCAI limits as at end of Quarter 3 2015/16.

Organisation Clostridium difficile MRSA Blood Stream Infection (BSI)

Full Year Limit (Limit to

end Q3 2015/16)

Actual to end of Q3 2015/16

Pre/Post 72 hour

Full Year Limit

Actual to end of Q3 2015/16

NNE CCG 47 (31) 27 21 Pre 6 Post 0 0

NW CCG 21 (15) 13 4 Pre 9 Post 0 0

Rushcliffe CCG 24 (16) 18 10 Pre 8 Post 0 0

NUH 91 (66) 76 N/A 0 6

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Clostridium difficile All cases of Clostridium difficile (C diff) and MRSA Blood Stream Infections (BSI) are subject to a Root Cause Analysis (RCA) or Post Infection Review (PIR). Where lapses in care are identified appropriate action plans are developed to mitigate risk and learning is shared across the health community. CCG targets Targets for CCGs are set nationally and population based. Cases are designated as pre or post 72 hours, using the Public Health England definition, which is:

Pre 72 hour / Community Acquired = diagnosis confirmed by a stool sample taken within 72 hours of admission to hospital or diagnosis from a GP sample.

Post 72 hour / Hospital Acquired = diagnosis confirmed by a stool sample taken 72 hours after admission to hospital.

Regardless of pre or post 72 hour designation all cases are assigned to the CCG relevant to the GP that the patient is registered with. Analysis of the 13 community acquired cases in quarter three has identified that 5 cases were pre 72 hour admission samples and 8 were from GP samples. 11 of the cases had received recent antibiotics which were in line with current prescribing guidelines and 1 of those not receiving antibiotics was a relapse case whose initial disease was prompted by antibiotic treatment. Antibiotics are a known risk factor for developing C diff infection. No management issues were found, 1 patient was found to be self- medicating with loperamide highlighting the importance of gaining a full history from the patient as this may have masked the severity of their disease. Learning from the case reviews this quarter included advice to a GP on taking a wound swab when treating a patient with antibiotics to ensure that the patient received the appropriate treatment. There is no evidence of cross infection in any of the cases reviewed. Work continues to gain a greater understanding into the cases presenting locally, it is recognised that many of these cases have multiple co-morbidities and that this is a complex disease. One RCA investigation completed on behalf of Nottingham West CCG was led by Health Partnerships as the community nurses were managing this patient’s longstanding leg ulcers. It was apparent that the patient received multiple doses of antibiotics for frequent leg ulcer infections and the key learning was that had the patient commenced compression bandaging earlier following tissue viability assessment, this would have reduced the risk of subsequent C diff infection. There was also poor communication between secondary and primary care and a joint action plan has been developed across organisations and specialist areas to address the issues and ensure learning. Comparison with other similar organisations is helpful to gain contextual detail on trajectories against performance targets and this is supplied in the tables below for the 3 South Nottinghamshire CCGs. Whilst Rushcliffe CCG is the only CCG to be outside of its performance target, when compared with comparative CCGs it has the lowest incidence of C diff amongst its peers. The peer groups shown below reflect those used within RightCare and are based on number of factors including deprivation scores, age distribution, population density and ethnicity. Categorisation of CCGs by RightCare has been linked to the Office of National Statistics (ONS) clusters. NNE and NW are within the same peer group named manufacturing towns. Rushcliffe is located within the Prospering Smaller Towns group.

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Comparative data for Rushcliffe CCG for C diff:

Rating Peer Comparison to NHS Rushcliffe CCG

Clostridium difficile cases

Rating Peer Comparison to NHS Rushcliffe CCG

Clostridium difficile rates

per 100,000 mid-year population

1 NHS Rushcliffe CCG 18 1 NHS Rushcliffe CCG 10.43

2 NHS South West Lincolnshire CCG

26 2 NHS High Weald Lewes Havens CCG

20.89

2 NHS Guildford and Waverly CCG

27 3 NHS Horsham and Mid Sussex CCG

20.9

4 NHS High Weald Lewes Havens CCG

31 4 NHS East Leicestershire and Rutland CCG

21.94

5 NHS East Surrey CCG 42 5 NHS Guildford and Waverly CCG 22.67

6 NHS West Suffolk CCG 47 6 NHS East Surrey CCG 33.09

6 NHS Stafford and Surrounds CCG

50 7 NHS West Suffolk CCG 38.06 (End of Nov)

8 NHS Horsham and Mid Sussex CCG

51 8 NHS South West Lincolnshire CCG

38.34

9 NHS East Leicestershire and Rutland CCG

56 9 NHS Stafford and Surrounds CCG

40.10 (End of Nov)

Comparative data for Nottingham North and East and Nottingham West CCGs for C diff:

Rating Peer Comparison to NHS NNE and NW CCGs


Rating Peer Comparison to NHS NNE and NW CCGs

Clostridium difficile rates

per 100,000 mid-year population

1 NHS Nottingham West CCG 13 1 NHS South Eastern Hampshire CCG

5.61

2 NHS Wyre Forest CCG 15 2 NHS Southport and Formby CCG 10.30

3 NHS Fareham and Gosport CCG

25 NHS Wyre Forest CCG 11.96 (End of Nov)

4 NHS Erewash CCG 26 3 NHS Fareham and Gosport CCG 12.34

5 NHS Nottingham North and East CCG

27 4 NHS South East Staffs and Seisdon Peninsular CCG

15.74

6 NHS South Eastern Hampshire CCG

29 5 NHS North Tyneside CCG 17.47

6 NHS Southport and Formby CCG

29 6 NHS Castle Point and Rochford CCG

27.31

7 NHS North Tyneside CCG 33 7 NHS Nottingham West CCG 31.75

8 NHS South East Staffs and Seisdon Peninsular CCG

37 8 NHS Nottingham North and East CCG

31.9

9 NHS Castle Point and Rochford CCG

39 9 NHS Solihull CCG 39.46

10 NHS Solihull CCG 57 10 NHS Erewash CCG 49.61

Nottingham University Hospitals (NUH) C diff toxin positive assessments have identified lapses in the quality of care in 11 cases. These include:-

Cross-infection

Inappropriate antimicrobials

Delayed diagnosis

Four infection prevention and control related quality visits have taken place at the Queens Medical centre campus between June – December 2015 by the CCG and the Trust Development Authority (TDA) as part of the ongoing TDA development offer.

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The Trust had implemented a significant amount of proactive initiatives to address the previous concerns relating to cleanliness and basic infection control measures. Four clinical areas were visited; a mixture of announced and un-announced locations. The visiting group was assured that:

Strategic leadership of infection control was strong and that the Board were fully engaged.

Infection prevention and control is owned at all levels.

The environment was clean. The challenge going forward is to sustain this improvement and the CCG will continue to work closely with the Trust. Comparative data for NUH is given in the table below for C diff:

Rating Peer Comparison to Nottingham University

Hospitals NHS Trust


Rating Peer Comparison to Nottingham University

Hospitals NHS Trust

Clostridium difficile rates per 100,000 overnight

occupied bed days

1 St George HealthCare NHS Trust

39 1 St George HealthCare NHS Trust

3.85

1 Guys and Thomas’ NHS Foundation Trust

39 2 Guys and Thomas’ NHS Foundation Trust

7.28

2 University Hospitals of Leicester NHS Trust

40 3 Oxford University Hospitals NHS Trust

10.75

3 Oxford University Hospitals NHS Trust

48 4 Nottingham University Hospitals NHS Trust

13.25

4 University Hospitals of Birmingham NHS Trust

50 5 University Hospitals of Leicester NHS Trust

13.66

5 Sheffield Teaching Hospitals NHS Trust

53 6 University Hospitals of Birmingham NHS Trust

19.06

6 The Newcastle upon Tyne NHS Foundation Trust

65 7 The Newcastle upon Tyne NHS Foundation Trust

19.45

7 Nottingham University Hospitals NHS Trust

76 8 Sheffield Teaching Hospitals NHS Trust

22.09

8 Leeds Teaching Hospitals NHS Trust

109 9 Leeds Teaching Hospitals NHS Trust

33.63

MRSA Blood Stream Infections (BSI) Nottingham University Hospital NHS Trust (NUH) The NUH MRSA Objective (2015-16) is zero tolerance. There have been five cases assigned to the Trust and one case provisionally assigned (diagnosed in December 2015). The Trust has evidenced consistent high levels of compliance with MRSA screening since 2011 and their policy is more comprehensive than national guidance. A healthcare associated infection (HCAI) reduction plan is in place across the organisation and MRSA reduction remains a priority for the Trust and the Nottinghamshire health economy. Actions are focused on:-

Enhancing compliance with effective antimicrobial stewardship

Strengthening and sustaining compliance with screening and decolonisation, hand hygiene, equipment and environmental cleanliness and decontamination

Improving infection control communication and information sharing across the health economy

The CCG is currently working with NUH to further develop the local Clostridium difficile toxin positive assessment process to ensure the opportunity for learning is maximised. There is also an intention to expand the scope of responsibility of the currently commissioned MRSA coordinator

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post to include other healthcare associated infections to enhance health community collaborative working. It is difficult to predict when performance is expected to meet standard. Outcomes from post infection reviews showed that two cases were clinically unavoidable, one case was avoidable and two cases were not true bacteraemia cases (contaminated sample and colonised line). One investigation is still on-going. A contractual sanction of £10,000 was imposed following the one avoidable case. The Trust has evidenced consistent high levels of compliance with MRSA screening since 2011 and their policy is more comprehensive than national guidance. The CCG is assured that NUH is prioritising MRSA reduction and are also working with colleagues across the health economy to ensure best practice and relevant measures are in place. NHS Nottingham North and East CCG No cases assigned. NHS Nottingham West CCG No cases assigned. NHS Rushcliffe CCG No cases assigned. 3.2 Serious Incidents (SIs) and Never Events (NEs) The table below identifies the number of SIs reported by providers where the 3 South Nottinghamshire CCGs are Co-ordinating Commissioners. These providers consist of Nottingham University Hospitals Trust (NUH), Health Partnerships (HP), Circle, Nottingham (CN), Nottingham Woodthorpe Hospital (NWH) and BMI The Park. A section has been added to include Primary Care (PC) SIs due to delegated responsibility from NHS England to the CCGs for oversight and monitoring from 1 April 2015. The figures are up to the end of quarter 3 2015/16. The revised SI framework (March 2015) moved away from grading incidents based on severity (0-2) instead focusing on the level of investigation required, which makes the data for last year and 2015/16 incomparable.

Serious Incidents – 2015/16

Organisation Concise1 Comprehensive2 Independent Investigation3

Total YTD Total

Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3 Q1 Q2 Q3

NUH 26 15 10 8 7 6 0 0 0 34 22 16 72

HP 17 26 29 0 0 0 0 0 0 17 26 29 72

Circle 0 0 0 0 1 1 0 0 0 0 1 1 2

NWH 0 0 0 0 0 0 0 0 0 0 0 0 0

The Park 0 0 0 0 0 0 0 0 0 0 0 0 0

South CCGs 0 0 0 0 0 0 0 0 0 0 0 0 0

NNE PC 1 0 2 0 0 0 0 0 0 1 0 2 3

NW PC 1 0 0 0 0 0 0 0 0 1 0 0 1

Rushcliffe PC 1 0 0 0 0 0 0 0 0 1 0 0 1

Total 46 41 41 8 8 7 0 0 0 54 49 48 151 1Concise internal investigation - Suited to less complex incidents which can be managed by individuals or a small

group at a local level 2Comprehensive internal investigation - Suited to complex issues which should be managed by a multidisciplinary

team involving experts and/or specialist investigators where applicable

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3Independent investigation - Required where the integrity of the investigation is likely to be challenged or where it

will be difficult for an organisation to conduct an objective investigation internally due to the size of organisation or the capacity/ capability of the available individuals and/or number of organisations involved

The tables below show comparative data by theme. Pressure Ulcers

Pressure Ulcers - 2015/16

Organisation Q1 Average no. per month

Q2 Average no. per month



NUH 8 2.66 9 3 4 1.33

HP 16 5.33 24 8 28 9.33

Circle 0 0 0 0 0 0

NWH 0 0 0 0 0 0

The Park 0 0 0 0 0 0

CCGs 0 0 0 0 0 0

NNE Primary Care

0 0 0 0 1 0.33

NW Primary Care 1 0.33 0 0 0 0

Rushcliffe Primary Care

1 0.33 0 0 0 0

The updated SI framework (March 2015) has been interpreted to exclude unavoidable stage 3 and 4 PUs as SIs. HP have opted to continue their current practice and undertake a full Root Cause Analysis (RCA) investigation for all stage 3 and 4 PUs to continue to optimise learning from key themes. NUH have adopted a streamlined review of PUs initially to enable them to focus a more comprehensive review for avoidable PU damage. Primary Care PU damage is also only entered as an SI if it is deemed avoidable, following discussion between the GP practice and the Quality Team. The rise in PUs in HP has resulted in the organisation undertaking a deep dive into 6 months’ worth of data (Jan 2015-June 2015) which has meant reviewing patient profiles of those who developed PU damage. This has provided evidence to support anecdotal advice from staff that increasing frailty, age and complexity are contributory factors to PU damage, which is compounded by increasing numbers of patients being in the community due to earlier hospital discharge and processes to avoid inappropriate hospital admission. HP has also identified that their staff profile is an area for additional action which includes staffing skill mix, roles of registered and non-registered staff, training and clinical support as well as dependency and capacity modelling. A final area which HP is focusing on is human factors around safety, quality improvement projects and culture. The report is expected at the next Quality Scrutiny Panel (QSP), following discussion at Board level. Falls

Falls - 2015/16





NUH 10 3.33 5 1.66 1 0.33

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NUH have committed to continue their previous CQUIN work into falls prevention by expanding the falls prevention team, aligning the falls prevention care bundle with e-observations and expanding the RCA process to learn from repeat fallers, which is their main challenge. Healthcare Associated Infection

Communicable diseases (C Diff/outbreaks) - 2015/16





NUH 5 1.66 5 1.66 5 1.66

CHP 1 0.33 1 0.33 0 0

Q3 NUH HCAI SIs 1. MRSA – 2015/32853 - October 2. MRSA – 2015/34478 - November 3. MRSA – 2015/34538 - November 4. Norovirus – 2015/35412 - November 5. MRSA – 2015/39134 - December

Q3 HP HCAI SI 1. None Never Events Three Never Events reported in Q3 at NUH. These consisted of a medication error (wrong route administration), wrong implant/prosthesis and a retained foreign object post-procedure. There is no common link in terms of clinicians and areas involved.

Never Events

Organisation 2014/15 Full Year

Average no. per month 2014/15

2015/16 Q1

2015/16 Q2

2015/16 Q3

2015/16 Q4

Average no. per month 2015/16

NUH 3 0.25 0 1 3 0.44

HP 0 0 0 0 0 0

Circle 2 0.16 0 0 0 0

NWH n/a n/a 0 0 0 0

BMI The Park n/a n/a 0 0 0 0

South CCGs 0 0 0 0 0 0

NNE Primary Care

n/a n/a 0 0 0 0

NW Primary Care

n/a n/a 0 0 0 0


n/a n/a 0 0 0 0

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Maternity incidents (NUH only)

NUH Maternity SIs - 2015/16

Category





Unexpected admission to NICU

2 0.66 0 0 0 0

Unexpected neonatal death

1 0.33 0 0 0 0

Intrauterine death 1 0.33 0 0 0 0

Unplanned admission to ITU

1 0.33 0 0 0 0

Maternity Obstetric: baby only (foetus, neonate and infant

4 1.33 0 0 0 0

Maternity Obstetric: mother and baby (foetus, neonate and infant)

0 0 0 0 0 0

Maternity Obstetric: mother only

0 0 1 0.33 0 0

From 20 May 2015, STEIS SI categories changed. There are now only 3 maternity categories (baby only; mother and baby; mother only) The unexpected admission to NICU, unexpected neonatal death, intrauterine and unplanned admission to ITU categories were in use on STEIS from 1 April – mid May 2015 and are therefore included in this report; however they are no longer in use. There have not been any maternity incidents reported since July 2015. The CCG are currently validating this with the Trust. 4.0 Safeguarding 4.1 Transforming Care Following the abuse uncovered at Winterbourne View Hospital the Department of Health published ‘Transforming care: A national response to Winterbourne View Hospital’ (DH, 2012) which sets out a programme of action to transform services so that people no longer live inappropriately in hospitals but are cared for in line with best practice, based on their individual needs, and that their wishes and those of their families are listened to and are at the heart of planning and delivering their care. On 18 August 2015 NHS England issued a letter to Clinical Commissioning Group Accountable Officers setting out key actions and immediate steps that commissioners need to take to support delivery of the Transforming Care Programme to achieve system wide transformation for patients with Learning Disabilities and/or Autism and challenging behaviour or a mental health condition. The aim is to reduce the inpatient cohort by a further 10% by the end of March 2016 (a reduction of 50% was required by the end of March 2015) and transfer of a further 10% to less restrictive settings. Nottinghamshire has been identified as a ‘fast track’ area and therefore there is also an

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expectation that a reduction in inpatient beds will also be achieved. A Nottinghamshire wide Transforming Care Implementation Programme Board has been established to oversee the work required to achieve this. The focus will be on provision of community based alternatives. In addition to the above, there are a number of priority actions. The current position for the three South Nottingham County CCGs is as follows:

1. Patient risk register – An up to date register of patients ‘at risk of admission’ to be kept to facilitate identification and mitigation of risk of admission. Nottinghamshire has a risk register which is used to plan pre-admission Care and Treatment Reviews (CTRs) and ‘blue light’ meetings if there is not enough time to arrange a full CTR.

2. Pre admission Care and Treatment Reviews (CTRs) - to be implemented from

September 2015 to facilitate admission to less restrictive settings where appropriate. In Nottinghamshire pre-admission CTRs are undertaken where possible. If due to time constraints/ urgency of the situation this is not possible a ‘blue-light’ meeting is held to assess the most appropriate placement/ care for the patient.

3. Redesigning services –CCGs are required to provide evidence by 21 September 2015 of credible plans and timescales to redesign services to provide optimal local capacity through community pathway redesign. A response for all six Nottinghamshire CCGs was submitted by the deadline.

4. Monitor and manage bed capacity and length of stay – and seek to expedite discharge and address any barriers. Regular reviews of bed capacity and length of stay are undertaken and barriers identified and addressed.

5. Reduction trajectories- 10% reduction trajectories for inpatient cohort and 10% transfer to less restrictive setting to be submitted to NHS England by 21 September 2015. A response for all 6 Nottinghamshire CCGs was submitted by the deadline. The table below shows the trajectories for the 3 South Nottinghamshire CCGs.

CCG Trajectory by end March

2016

Current Position as at

end Q3

Predicted Discharges by end Mar

2016

Predicted Variance from

Trajectory

NNE 1 0 0 -1

NW 2 3 1 0

Rushcliffe 2 0 0 0

These numbers represent a reduction that is greater than 10% as the starting numbers are so small and therefore when rounded up can result in up to a 50% reduction. NHS England has agreed that although the trajectories are set at individual CCG level the performance across the whole of Nottinghamshire would be considered.

As at the end of September 2015 there were three South Nottinghamshire funded inpatients (0 NNE, 3 NW and 0 Rushcliffe) with learning disabilities and/or autism in locked rehab and Assessment and Treatment Units (ATU) placements.

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The table below shows the current status of the five South Nottinghamshire CCG patients.

CCG NNE NW Rushcliffe

Total number of patients 0 3 0

CTR completed or planned within agreed timescale (within 3 months of admission and six monthly thereafter)

3

Ready for discharge immediately

Ready for discharge within 3 months 1

Ready for discharge in 3-6 months

Ready for discharge in 6-9 months

Not ready for discharge 2

4.2 Care Homes The Quality and Patient Safety Team continue to undertake joint quality monitoring visits to care homes with the local authority wherever possible. The table below shows the main changes since the last report. Quality monitoring processes are being revised and to be shared across Mid-Notts CCGs to ensure consistency across the county.

Legend: History of concerns that are resolving but require some monitoring to ensure progress maintained On-going concerns around quality of care delivery / lack of compliance with CQC standards – home requires regular monitoring of standards of care and action plans by CQC/LA/CCG

Serious concerns raised / contract suspensions in place / non-compliance with CQC standards – home requires frequent monitoring of standards of care and action plans by CQC/LA/CCG Care homes noted to have low level concerns / CQC compliance issues but not requiring CCG input

Nottingham North and East CCG

Name of Home Current RAG

Previous RAG

Summary

Hallcroft ↔ Improvement notice in place and extended to February 2016. Ongoing quality monitoring to ensure improvements maintained.

Stoke House ↔ CQC inspection rated as inadequate and in special measures. Contract suspensions in place by both health and local authority. Regular quality monitoring and meetings with the provider continue.

Braywood Gardens N/A Planning application made by the provider to extend the care home thus increasing bed capacity.

Coppice Lodge N/A CQC inspection of the service, 26/27.11.15. Warning notices issued regarding Regulation 18 - staffing

Nottingham West CCG


Previous RAG

Summary

Silverwood ↔ Through recent quality monitoring; concerns have been identified in relation to staffing and care documentation. Follow up quality monitoring to be scheduled.

Low

Moderate

Noted

High

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Rushcliffe CCG


Previous RAG

Summary

Eton Park ↔ The home remains in administration and consequently

will continue to receive quality monitoring visits.

Church Farm at Skylarks

↓ Number of concerns raised by visiting healthcare professionals. Concerns relate to application of MCA and DOLS, medication management, infection prevention and control, care documentation and quality assurance. Guidance given from both LA and CCG. A meeting with the provider have been held and a voluntary suspension on admissions was agreed. LA and CCG have scheduled further quality monitoring activity to monitor progress against an action plan.

4.3 Continuing Health Care Retrospective Reviews. On 15 March 2012, The DH published a Dear Colleague letter from Sir David Nicholson explaining the introduction of a close down of Continuing Healthcare (CHC) retrospective assessments from the period 2004–2012, which have not previously been assessed for eligibility. This means that people will no longer be able to come forward and request a retrospective assessment for CHC beyond the cut off dates published, unless there are exceptional circumstances.

Time Period of Care Deadline (for people to request retrospective assessment)

1st April 2004 – 30th September 2007 30th September 2012

1st October 2007 – 31st March 2011 30th September 2012

1st April 2011 – 31st March 2012 31st March 2013

CHC is now high on the national agenda with a potential systematic investigation by the Parliamentary Health Service Ombudsman across the NHS with regards to mishandling of Previously Unassessed Periods of Care (PUPoC) and increasing Parliamentary and Ministerial interest and concern. The national deadline for completing outstanding retrospective reviews is March 2017. We are working closely with the retrospective CHC team (commissioned from Arden Greater East Midlands Commissioning Support Unit (Arden GEM CSU)) to ensure that the deadline for completion of retrospective reviews will be met. We had set trajectories for each of the CCGs to achieve completion by 31 March 2016 however in December we were invited to resubmit revised trajectories which achieve completion by end June 2016, it is still hoped that we will be able to achieve completion ahead of this new deadline and we have set an internal ‘stretch’ target to encourage this. The trajectories have been set using analysis of the outstanding cases by stage in process recognising that the early parts of the process are most time intensive. As a result the trajectories are more heavily weighted so show completion of cases in the latter months. The following chart shows the achievement against the trajectory and stretch target for Nottinghamshire as at the end of December 2015. January data will be available on 17 February 2016. Monthly updates are provided by Arden GEM CSU. The table shows numbers of reviews outstanding for each of the three South Nottinghamshire CCGs.

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CCG No of requests received by deadline

National Trajectory (planned number outstanding as at end Dec 2015)

Stretch Target (aspirational number outstanding as at end Dec 2015)

Actual number outstanding as at end Dec 2015

Comments

NNE 198 21 20 17 Both national and local trajectories exceeded

NW 141 21 19 17 Both national and local trajectories exceeded

Rushcliffe 178 16 12 11 Both national and local trajectories exceeded

5.0 Quality Visits to Providers.

The Quality Team co‐ordinates quality visits to providers for which their CCGs are co-ordinating commissioners, in line with contractual agreements. The provider organisations which receive scheduled, responsive and unannounced visits by the Quality team are Nottingham, University Hospitals (NUH), County Health Partnerships (CHP), Circle, Ramsay Nottingham Woodthorpe Hospital and BMI The Park Hospital (visits to the latter two providers commenced from Quarter 2 onwards). The aims of the visits are to:

gain a contextual understanding of the services which are commissioned develop effective working relationships between staff in provider and commissioner

organisations facilitate triangulation and exploration of indicators of service delivery and enhance

intelligent interpretation and analysis identify awareness and action of provider in relation to key areas of concern and enable

staff and service users to share their perspective on these Lay members from the CCGs take part in the quality visits to providers (once their code of conduct is signed and the ‘Disclosure and Barring’ approval is received). CCG Governing Body members and CCG officers are encouraged to take part in these visits and can contact Liz Owen ([email protected]) to arrange attendance. The details of all quality visits undertaken year to date are shown below. Visits undertaken during the last quarter are shown in bold along with dates of scheduled visits for the remainder of the year (in italics).

CIRCLE, NOTTINGHAM

Date Area Reason for Visit Outcome

12.05.15 Gateway D - Orthopaedics

Routine visit to gain an understanding of the service, develop working relationships and provide assurance.

Assurance of good clinical leadership and compassionate, thoughtful service delivery for patients at this visit. Awareness of methotrexate Never Events required for learning.

mailto:[email protected]

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09.09.15 Termination of pregnancy

Concerns had been raised regarding a part of this pathway not under CNs control. Gain understanding of whole service and seek assurance.

Understanding of whole service achieved and assurance gained that CN are collaborating with the other providers involved in this service in order to address the concerns raised and to align the patient pathway and working practices.

19.11.15 Dermatology In light of recent issues across the East Midlands with Dermatology Services

Assured by the staff’s commitment to develop the tele-dermatology service and overcome the recent issues that the service had experienced.

26.01.16 Short Stay Unit

15.03.16 TBC

HEALTH PARTNERSHIPS


18.05.15 JAKS federation

Assure on action being taken to address workforce and capacity issues which had led to avoidable pressure damage on 6 occasions.

Now enhanced clinical and managerial leadership in the locality since March 2015. Clinicians being developed to undertake DN role with support, supervision and guidance. Developing highlight summaries/dashboards to identify any areas of concern which may impact on quality and safety

03.07.15 NNE team Seek assurance on action being taken on staffing issues/PUs

NNE Senior management team reviewing PU management by staff and senior nurses, which includes allocation of visits, caseload management, lack of senior staff to provide leadership. Action plan devised to address issues and follow up visit undertaken to meet with clinical staff.

01.09.15 West Bridgford R14 team


Assurance gained due to good clinical leadership and effective working within team.

7.12.15 Leg Ulcer Clinic, Oak Tree Lane Surgery

To gain a greater understanding of the service and seek assurance on action being taken in response to the leg ulcer clinic scoping exercise undertaken in 2014

Positive visit providing good assurance regarding actions taken in response to the findings of the scoping review. Very motivated staff and good levels of patient satisfaction noted.

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26.02.16 NNE Locality Team

10.03.16 TBC

NOTTINGHAM UNIVERSITY HOSPITALS


10.08.15 Frail elderly pathway – Focus on discharge process

Look at unsafe transfer of care process, have a healthcare system wide approach and strengthen processes.

Visit attended by HP and NUH senior staff and agreement on working together to produce joint unsafe transfers of care report for QSP in future. Agreed that joint working will raise awareness of issues relating to unsafe transfers in and out of acute care/community.

12.10.15 Sterile Services

Visit to new unit to gain an understanding of the service, develop working relationships and provide assurance.

Good leadership and knowledge of service evident. Good grip on safety and quality offered by the managerial team, including the quality lead.

15.12.15 Elective Orthopaedics


Good leadership and knowledge of service evident. Awareness demonstrated of IPC and safety processes

4.2.16 Emergency Department

Joint visit between CCG Quality team and Trust Development Authority to review safety and quality for emergency pathway

9.2.16 Ropewalk House


Ramsay Nottingham Woodthorpe Hospital


13.10.15 General Focus on Infection Control Positive visit providing good assurance of infection prevention and control. Strong evidence of staff engagement, satisfaction and patient focus.

Feb 16 TBC

BMI The Park Hospital


25 Feb 16 All areas Routine visit to gain an understanding of the service, develop working relationships and provide assurance.

Mar 16 TBC

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6.0 Patient Experience.

We will commission patient‐centred services that meet patient expectations (Quality Strategy

2014‐2019). 6.1 Patient Advice and Liaison Service The following table shows the contacts with the PALS service during the last twelve months up to the end of Quarter 3 2015/16.

CCG Jan

15

Feb

15

Mar

15

Apr

15

May

15

Jun

15

Jul

15

Aug

15

Sep

15

Oct

15

Nov

15

Dec

15

Total

Anonymous /

Out of Area /

City

10 5 3 12 13 *30 18 20 13 19 9 14 166

NNE 17 29 15 15 10 10 13 18 12 12 8 8 167

NW 8 1 6 5 2 4 3 4 5 *14 3 5 60

Rushcliffe 9 3 7 9 6 10 7 9 8 9 12 3 92

Totals: 44 38 31 41 31 54 41 51 38 54 32 30 485

* There is no particular identified theme or trend indicating the reason for higher numbers of calls for Nottingham West in October; each enquiry was dealt with on an individual basis. Numbers of complaints regarding GP practices rose across Quarter 3. Patient’s concerns ranged from how to make a complaint, to estates issues and break down in communications between practices and patients. Each concern was dealt with individually and signposted to the appropriate team to investigate. 6.2 Complaints The following table shows the complaints received during the last twelve months. Please note that from 1 April 2015 CCGs have been provided with details of primary care complaints that are received, investigated and responded to by the Central Customer Contact Centre hosted by the Area Team.

CCG Jan 15

Feb 15

Mar 15

Apr 15

May 15

Jun 15

Jul 15

Aug 15

Sep 15

Oct 15

Nov 15

Dec 15

Total

Rushcliffe 0 0 1 3 3 1 1 0 2 1 2 2 16


0 3 0 0 1 0 2 1 1 8

NW 0 0 1 3 0 0 0 0 0 2 1 0 7

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NW Primary Care

2 3 2 1 2 0 0 0 0 10

NNE 1 0 2 2 4 3 0 1 3 1 2 0 19 NNE Primary Care

1 4 2 1 2 2 1 0 0 13

Other 0 0 2 0 0 1 1 1 0 0 1 0 6 TOTAL 1 0 6 11 17 9 4 7 7 7 7 3 79

In total the Complaints team received 12 complaints during Quarter 3 2015/16 these were forwarded to the appropriate provider to investigate as necessary. During this same period 5 complaints were received by the Customer Contact Centre in relation to primary care. Details of complaints and MP Letters / General Sundry correspondence received by the CCG during Quarter 3 2015/16 including outcome data are provided in Appendix 1. Discussions with Nottingham University Hospitals in relation to the implementation of a Service Improvement Log remain slower than we would have liked due to on-going staff changes within their Complaints Department, no timeframe has been provided for this. The Patient Experience Team will endeavour to re start conversations once staff members are in substantive posts. The Patient Experience Team has developed a service improvement log to monitor learning from CCG led complaints and patient stories. You Said, We Did The Patient Experience Team are currently finalising the July – December 2015 ‘You Said, We Did’ Report. Once completed the report will be published on the CCG websites and shared as widely as possible via a range of engagement mechanisms. This evidences that the patient voice has been listened to and service improvements made where appropriate. 6.3 Patient Experience Activity The following paragraphs provide a brief update on patient experience activity undertaken during Quarter 3 2015/16. British Sign Language (BSL) Charter The South Nottinghamshire CCGs action plan is currently undergoing final amendments with a view to this being reviewed by the Deaf Community in the near future to ensure that the plan is robust and fit for purpose. Gluten Free Consultation The Gluten Free Consultation ended on 30 October 2015. All paper responses were inputted on to Survey Monkey by the Patient Experience Team to allow prompt and accurate analysis. Analysis of the responses has been undertaken by the Data Analyst at NWCCG and a draft final report has been developed for submission to each of the CCG Governing Bodies for approval. Once the outcome of the consultation has been determined the Patient Experience Team will respond to all patients who requested details of the outcome. The Patient Experience Team will also support the delivery of the outcome to the wider population.

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Patient Experience Questions The Patient Experience Team is now using the developed questions to capture patient experience. The forms have been distributed to our Patient Engagement colleagues for wider utilisation, which includes the Greater Notts Health and Care partners and HealthWatch Nottinghamshire. It is hoped in the near future that we will work with the Teenage and Student representatives on Rushcliffe CCG Patient Cabinet in order to develop appropriate questions to capture younger patient’s views. Engagement Events – The Patient Experience Team have worked collaboratively with all of the South Nottinghamshire CCGs, Patient Engagement Leads over the past quarter to aid the capture of Patient Experience. These events have included:

NNE Winter Warm Event

Coffee and Chat Event in collaboration with HealthWatch

Meeting with British Gypsum to progress Employer Engagement 6.4 Patient Stories Patient stories continue to be presented to the governing bodies of the south CCGs ensuring the patient remains at the heart of commissioning processes. The table below provides an example of a story that has been received in Quarter 3. A number of patient stories are currently in development.

Origin Story Action Patient feedback

Carer’s perspective of services available to patients with Working Age Dementia

It is acknowledged that services offering support and advice to patients and their carers need to be more flexible and coordinated in their approach. The following recommendations are made:

Support the implementation of carer services now being established across South Nottinghamshire.

The CCG Patient Experience Team should monitor and collate information provided by carer’s and patients in relation to services provided by the NHS to ensure that carers are able to access information and support in a seamless way.

CCG to strengthen carers section on websites to ensure information is easily accessible.

The Patient Experience team to ensure information is shared via the “You Said, We Did” report which is distributed widely to raise awareness of services and support available.

Work with carers to establish if current service provision is sufficient, is it what’s required?

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7.0 Primary Care Quality 7.1 CQC Inspections The tables below show the CQC inspections planned or undertaken to date. Outcomes are included where available. It should be noted that some delay in receipt of formal reports has been experienced due to the CQC internal quality assurance processes that must take place prior to publication of formal reports.

Nottingham North and East

Practice Name Date of Visit Outcome

Willows Medical Centre 06/01/2015 Good

Calverton Practice 07/01/2015 Outstanding

Park House Medical Centre 13/01/2015 Good

Om Surgery 14/01/2015 Good

Newthorpe Medical Centre 14/01/2015 Good

Plains View Surgery 11/03/2015 Good

Trentside Medical Group 03/11/2015 Not Yet Available

Daybrook Medical Practice 18/11/2015 Not Yet Available

Torkard Hill Medical Centre 02/12/2015 Not Yet Available

Apple Tree Medical Practice 02/12/2015 Not Yet Available

Nottingham West


West End Surgery 25/03/2015 Requires Improvement (action plan in place)

The Linden Medical Group 27/03/2015 Requires Improvement (action plan in place)

Church Walk Surgery 25/08/2015 Outstanding

Valley Surgery 03/11/2015 Not Yet Available

Saxon Cross Surgery 18/11/2015 Good

Oaks Medical Centre 02/12/2015 Not Yet Available

Hama Medical Centre 02/12/2015 Not Yet Available

West End Surgery has re-registered since the previous inspection the CQC will therefore undertake a further full inspection under the new registration. This is due to take place in January 2016.

Rushcliffe


East Leake Medical Group 04/02/2015 Outstanding

Ruddington Medical Centre 09/02/2015 Good

Belvoir Health Group 12/02/2015 Good

St Georges 10/02/2015 Outstanding

Castle Healthcare Practice 08/09/2015 Not Yet Available

East Bridgford Medical Centre 25/08/2015 Requires Improvement (action plan in place)

West Bridgford Medical Centre 15/09/2015 Good

Musters Medical Practice 08/09/2015 Good

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7.1 Quality Monitoring In preparation for April 2016 when the CCGs takes on the quality monitoring responsibility of primary care, the Quality Team has continued to work with the CCGs’ primary care leads and primary care quality representatives from the Nottinghamshire and Derbyshire CCGs and the NHS England Area Team to develop a Primary Care Quality Assurance and Support Framework incorporating a quality dashboard, risk matrix and escalation process. The framework and dashboard have been amended to reflect the comments received from the Primary Care Commissioning Committee and have undergone further development in view of feedback received from primary care colleagues. Establishment of the three Primary Care Quality Sub-Groups (one for each of the South Nottinghamshire CCGs) is underway and all are expected to be meeting from February 2016. The primary care quality dashboard and risk matrix and other information will be used to identify potential or actual risks to quality within primary care and to determine a Red / Amber / Green (RAG) rating for each member practice. The group will agree a response to ensure that individual practices are supported where necessary and will escalate any concerns about quality and risks to the Primary Care Commissioning Committee. 8.0 Nursing and Midwifery Council Revalidation.

Revalidation will be the process by which registered nurses and midwives will demonstrate to the NMC that they continue to remain fit to practise. Revalidation will take place every three years at the point of renewal of registration. The new process will commence for registrants requiring revalidation in April 2016.

Nurses and midwives will have ownership of, and will be held accountable for, their own revalidation process. Every three years at the point of renewal of registration, nurses and midwives will need to demonstrate to the NMC that they continue to remain fit to practise in order to remain on the register.

Nurses and midwives will need to be able to evidence the following requirements for the three years prior to revalidation:

450 hours practice- since the last report it has been confirmed that this does not necessarily have to be direct patient care but can be activity related to nursing e.g. management, education and commissioning. Any activity related to a post that requires NMC registration in the person specification would be applicable. (There are additional requirements for midwives who also undergo statutory supervision) This is unchanged from previous requirements.

35 hours of continuing professional development (CPD) - at least 20 hours of which must be participative learning. 40 hours was originally proposed which would have been an increased requirement, but in the final guidance 35 hours which was the previous requirement has been retained. The stipulation in relation to participative learning is however new.

Evidence of 5 pieces of practise related feedback- this can be from patients, relatives, carers, colleagues, students and could be used to demonstrate how the registrant meets the code of conduct and/or how they have reflected, learned and altered their practise as a result of feedback. This is a new requirement.

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Reflection- it is proposed that a minimum of 5 pieces of reflection (which can be on the code, practise related feedback or CPD) be completed. This is a new requirement.

Professional development discussion- a professional development discussion must be held with another NMC registrant using the above reflections/ feedback. This is a new requirement.

Professional indemnity- registrants who do not automatically by virtue of their employment have vicarious professional indemnity arrangements will need to be able to demonstrate that they have appropriate cover for the scope of clinical work that they undertake. This is unchanged from previous requirements.

Self- declaration- registrants will need to declare that they have met the above requirements and also provide a self-declaration in relation to their health and character. This is unchanged from previous requirements.

Third party confirmation- this will usually be completed by the line manager and simply confirms that the registrant has met the revalidation requirements. If the line manager is an NMC registrant they can also undertake the professional development discussion. If they are not this should be completed by an appropriate NMC registrant prior to seeking third party confirmation from the line manager. It is important to note that this is not confirmation that the registrant is fit for practice that is the role of the NMC. This is a new requirement.

A North Midlands Sub Regional Revalidation Steering Group has been established to share the learning from the pilot sites, assess organisational readiness and support implementation of revalidation. The Director of Nursing and Quality represents the three South Nottinghamshire CCGs on the Board.

A scoping exercise has been completed to understand the numbers of staff employed within the CCGs who are registered with the NMC and to establish if this is a requirement of their post or personal choice. This has identified seven staff across the CCGs who are registered with the NMC, six of which require this as part of their role. The dates that each of these nurses is due for revalidation has also been established. A recent Area Team return has been completed for the three South Nottinghamshire CCGs which provides good assurance regarding their state of readiness. A number of template documents and a newsletter have been issued by the Area Team and these have been provided to all CCG nurses and also cascaded to practice nurses. This has been followed up by a letter outlining the new requirements and a self-assessment tool which is aimed at helping practices identify what practices they need to do to prepare for revalidation. The Quality Team has offered to attend existing meetings/ events to provide an update on revalidation and answer any questions. The Quality Team has delivered a number of revalidation presentations and question and answer sessions to practice nurses, practice managers, GPs and care home staff in September and October 2015 and is currently establishing if further sessions are required or if staff are attending sessions run by Health Education East Midlands locally. The feedback following the sessions was positive with attendees identifying that it had been worthwhile and informative. The Director of Nursing and Quality has also sent letters to GP practices and care homes within the three South Nottinghamshire CCG boundaries in November 2015 signposting to national and local resources and training events. Providers have submitted evidence to the relevant Quality Scrutiny Panel or quality monitoring meeting of the actions they are taking to ensure readiness by the April 2016 deadline.

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9.0 Recommendation The report is considered in detail at the South Nottinghamshire CCGs’ Quality and Risk Committee and presented to the Governing Bodies for information and assurance purposes.

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Appendix 1 Summary of Closed Complaints/ MP Letters including Outcomes Quarter 3 2015/16

Month 2015

CCG Location

Complaint Provider Action taken

October Rushcliffe Concerned about the care/treatment provided and the delays encountered

Walk in Centre

Apologised that the level of care provided was below the expected standard and that the patient encountered delays in obtaining the required care/treatment. All staff to be reminded of the importance of providing patients with pain relief and first aid care on arrival.

October NWC Concerned about a breach of confidentiality by the antenatal clinic at QMC

NUH The staff member did breach the patient’s confidentiality and this was raised as an incident immediately. RCA undertaken and learning identified to eliminate future occurrences. Sincere apologies provided to the patient. The staff member recognised that her actions were wrong and has done everything in her power to learn from the mistake. Staff member to undertake additional Information Governance training in December 2015.

October NNE Requesting CCG position on Hucknall and NCN building

CCG Advised there are currently no plans for the town’s existing GP practices to unite under one roof as a ‘Super Surgery’. However, there are ongoing discussions between Hucknall residents, the CCG, NHS England and the Hucknall practices about the future growth of the town and the impact that may have on the demands on local healthcare provision. As a result of these discussions, which have been patient-led, all the practices are examining how they can work together to ensure that high quality, accessible healthcare is available to every Hucknall resident. They are looking at how they can collaborate on projects to enable greater working flexibility and to extend services. In the long-term, we want to see more services provided in Hucknall that meet the needs of the population, including more urgent care provision.

November NNE Concerned patient refused access to second eye cataract surgery

CCG Apologised for the lack of communication about the CCG commissioning policy which had resulted in an expectation being given that surgery on the second eye would be automatic, which is not the case. All provider colleagues to be re-informed of the policy. Provided information for patient on next steps should they feel there eye sight deteriorates and therefore could qualify for surgery.

November Other Concerned that daughter has been denied OT support due to having accessed the service previously

CHP Complaint forwarded to City CCG upon receipt of GP information for investigation and response.

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MP Letters / General Sundry correspondence received between Quarter 3 2015/16 including outcome data from closed cases.

Month 2015

CCG Location

Concern Provider Outcome

October Rushcliffe Concerns about the cleanliness of toilets at NUH

NUH Apologised for poor levels of cleanliness. Provided details of surveys and Family Friendly Tests which would inform Carillion's action plan on cleaning. Staff to be reminded of the importance of soap dispensers being functional.

October Rushcliffe Requesting CCG position on a new Health Centre in East Leake

CCG Advised that CCG are to produce a local estates strategy in response to the challenges of the NHS Five Year Forward View. CCG to take in to account the significant housing growth planned in Rushcliffe and undertake some work on the impact of this for all of the member practices. In addition, as a Multi-speciality Community Provider vanguard site estate plans will need to reflect new models of care and not simply re-provide existing facilities.

October NNE Requesting the CCG reconsider its position regarding not completing a retrospective CHC review

CHC Advised the CCG would not change its stance and review the period identified due to it being out of the timescale set by the Department of Health.

November Rushcliffe Requesting information on how to access CHC checklists and when these should occur

CHC Advised hospital can request a CHC checklist be completed prior to a patient’s discharge should they feel it is appropriate/necessary. Provided information on the completion of a CHC checklist and who should undertake this.

November Rushcliffe Requesting details on how to obtain a breast MRI and genetic testing due to family history

CCG Advised GP can refer her to secondary care for an MRI, particularly if the GP suspects cancer. However, the GP would have to refer to a Consultant who would make the decision as to whether an MRI was deemed necessary. Patient to go back to GP for further discussions.

November NWC Concerned that Power of Attorney not informed of CHC review meeting

CHC A letter was sent out to the care home providing the date of the review. As reviews only take place annually the CHC team rely on the care homes to cascade the information. This has been highlighted as an issue and CHC are currently looking at processes to address this, to ensure all relevant parties are fully informed. Assurance provided that the Nurse Assessor would not have relied on the patient to provide accurate responses to the questions. Overview of the assessment provided and apologised for any distress or confusion caused.

December Rushcliffe Disputing the calculation of the interest element of a restitution payment

CCG Liaised with CCG Finance team who confirmed that there was an error with the interest calculation. Revised figure sent to enquirer for approval prior to payment.

Documents

NHS NOTTINGHAM · PDF fileHampshire CCG 29 5 NHS North Tyneside CCG 17.47 6 NHS Southport and Formby CCG 29 6 NHS Castle Point and Rochford CCG 27.31