Dr Cheryl Crocker, Regional Lead Patient Safety Collaborative, EMAHSN. 

Cheryl summarises the recent 'State of Care report', the CQC annual overview of health and adult social care in England which was published on 14 October 2015. Cheryl also talks about how our work at the East Midlands Patient Safety Collaborative is already contributing to improving safety across our region.For the first time, the CQC have been able to draw on the findings of our new ratings system across all of the sectors they regulate. CQC analysis shows that, despite increasingly challenging circumstances, many services have managed to either improve or maintain quality.

Key Headlines

Many services providing good or outstanding care
More than 80 per cent of GP practices and six out of ten of adult social care services inspected so far have been rated as good or outstanding. Of the hospitals rated, 38 per cent were also found to be good or outstanding.

However, alongside these encouraging findings, there remains significant variation in quality and an unacceptable level of poor care. Up to 31 May 2015, 7 per cent of acute, primary medical and adult social care services had been rated as inadequate.


Safety a concern
Safety has proved to be the biggest concern across all of the services the CQC inspected. Over one in 10 hospitals and a similar proportion of adult social care services have been rated as inadequate for safety, alongside 6 per cent of GP practices and out-of-hours services.

A range of factors have been shown to affect the safety of services; failure to investigate incidents properly and learn from them has been highlighted as well as leadership.

Across all sectors, services were most likely to receive an inadequate rating for safety, compared with the other key questions: 10% of adult social care services, 6% of primary medical services and 13% of hospitals. Similarly, a lower proportion of services were rated good or outstanding for safety. This confirms the CQC early finding last year, outlined in the 2013/14 State of Care report, about safety in hospitals and points to similar concerns in the other sectors.

The biggest concerns relate to the safety of services (where 10% were rated inadequate) and to the quality of leadership within services (where 8% of services were rated inadequate for the well-led key question). Ratings show that nursing homes provide a poorer quality of care than other adult social care services. Just under half (46%) of nursing homes rated up to 31 May 2015 were rated good or outstanding and one in 10 (10%) were rated inadequate. However despite around two-thirds of locations rated so far in domiciliary care, residential homes and community social care (which includes Shared Lives schemes) being good or outstanding (68%, 65% and 68% respectively), there is room for improvement across the whole of the adult social care sector.


Review of Serious incident investigations
In the review of the quality of investigations into serious incidents involving patient care in acute hospitals, the CQC conclude that while investigation of serious incidents is often seen as one of the most important elements of the patient safety process, this can be counterproductive if not done well. The implementation and roll-out of root cause analysis investigation techniques across the NHS has had the unwanted side-effect, in some cases, of being under pressure to meet timescales at the expense of the quality of the investigation. This suggests, and is supported by the findings of the review, that the categorisation of serious incidents has become inconsistent with the original purpose, which was to identify significant opportunities for learning to reduce or eliminate the risk of the same thing happening again. Indeed in a third of the investigation reports the CQC reviewed it was not clear from the description of the incident or recommendations of the investigation that the incident met the criteria for a full investigative response. Other approaches to meet the needs of the patient and identify learning may have been more appropriate.


Safe
While 57% of the services we have rated were good or outstanding for safety, there were 33% that required improvement and 10% that were rated inadequate.


What is the EMAHSN PSC doing to support?
Following our comprehensive engagement exercise in 2014 our stakeholders identified key areas they wanted the Patient Safety Collaborative to focus on. These are:

• Safety in Care Homes
• Suicide Prevention in Primary Care
• Delirium
• Transfers of Care
• Culture and Leadership for safety
• Measurement for safety
• Improving capability for safety
• Evidence review

The EMAHSN has developed a number of programmes seeking to address the concerns outlined in the CQC report. These are:

Safety in Care Homes: We have commissioned a standards document to identify what GOOD safety looks like for care homes. Care home staff identified that there were a number of standards available but these were not all related to safety and located in different places. This document brings together all standards together in one place with a focus on safety. This is endorsed by NICE.

We are piloting an international benchmarking tool in the care home setting. The LPZ annual prevalence audit tool, developed in the Netherlands, identifies care problems, such as pressure ulcers, falls, continence, nutrition, hydration, etc. We have begun with pressure ulcers and continence. We will explore the feasibility of introducing this tool in the context of the East Midlands. So far we have delivered training in audit and pressure ulcer recognition to 30 care homes in preparation.

Root Cause Analysis (RCA) Investigation process: We have recognised the limitations of the traditional approach to investigations in the NHS and are exploring some novel approaches. This includes developing a Human Factors Analysis and Classification (HFAC) for mental health settings.

Serious Incident External Peer Review standards: We have developed through co-design, a set of Serious Incident standards for external peer review. These are based on the Patient Association Peer Review of complaints methodology. We are already seeing this approach used for pressure ulcers and other areas of harm where there are multiple cases and traditional methods have failed to produce learning which then leads to prevention.

We have produced a compendium of RCA training across our healthcare providers and stimulated review and assessment/evaluation of this training. This has led organisations to consider if their current approach needs refreshing.

Human Factors: We are working in partnership with Health Education England East Midlands to develop human factors roadshows and supporting through funding, several projects related to harm which utilise a human factors approach.

Leadership: We have invited all providers within the East Midlands to take part in a Board development programme for safety, delivered by AQuA. Adapted from the Institute of Health Improvement (IHI) in Harvard, USA, this programme will equip Boards with essential information to enable them to transform their safety culture. This is supported with a suite of metrics to measure safety culture/climate and support improvements.

Development and dissemination of best practice: We have collated and disseminated a number of best practice case studies across the East Midlands and supported our stakeholders through developing networks and peer reviews. 

A summary of the report can be accessed here: State of Care Report Summary.

The full report PDF can be downloaded here.

There is always more work to be done. If you'd like to talk to us about the East Midlands Patient Safety Collaboraitve, please get in touch.