Agenda item

The Quality Account priorities of King’s College Hospital are attached.

7.1  Zoe Reed, SLaM Strategic Director, presented the draft quality account and explained that the top priorities were paying attention to physical health and reducing violence. She said that the Quality Accounts will be finalised in May, and that they are narrowing down priorities. A member referred to the information on complaints and noted the high level of the Psychosis CAG complaints and enquired what ‘local resolution’ meant. The Strategic Director said that this CAG has a very high level of activity so the level of complaints may well be proportionate and offered to provide some vignettes on how complaints were resolved locally.

7.2  Debbie Parker, Deputy Chief Nurse and Elizabeth Palmer, Acting Director of Assurance presented the papers from Guy’s and St Thomas’ on the Quality Account, complaints and pressure ulcers. It was noted that the final Quality Account, with data, will be completed in May. A member asked about the 19 pressure ulcers acquired in the community and asked who looks after these patients, and if this would be the CCG. The Deputy Chief Nurse explained that when community acquired sores are picked up the hospital liaises with the organisations and may make a Safeguarding alert.  Dr Zeineldine, Chair of the CCG, agreed that these were looked at to ensure that the CCG have data and non attributable cases are highlighted. He said that the CCG have community teams looking at tissue viability and prevention. The chair requested some follow up action on this by all concerned, particularly focussing on action taken following the identification of a pressure sore and what would lead to a safeguarding alert. 

7.3  The chair noted that one of the complaints was about a fracture that had been missed on an x-ray. He asked how that this would be dealt with if a tumour was missed on a scan.  The Director of Assurance said if  there is reason to think there is a competence issue then this would be followed up, however she explained that  sometimes these are to do with A & E fractures in children, which  can very difficult to observe.  She added that the hospital constantly look for patterns and trends.

7.4  The King’s Medical Director presented the Quality Accounts report for King’s College Hospital. He referred to the report and noted the Trusts achievements last year. He explained that King’s did not achieve a target on diabetes; however action on this has now been mandated as a patient safety issue.

7.5  A member asked the Medical Director to explain ‘ward ware’. He responded that this is part of the national early warning system. The nurse at the bed enters data into an iPod like device, which then gets electronically recorded. In an ideal world any untoward patent data would initiate an alert that would trigger a clinical response that would change the physiology of the patient. He explained that King’s are developing the software. A member asked if the Trust will retain the intellectual software. He said in this case the project is being done with an outside private developer: but with lots of testing inside the hospital. He was then asked if the Trust keep software propriety in the NHS, and he said that this is the general principle, but in this case the software is privately developed.

7.6  A member noted that there is an upward trend in complaints. The Medical Director agreed, and explained this is because King’s are seeing an increase in activity. He explained that several years ago complaints were in the 1000‘s; much higher than now. He added that the Trust do look at hospital complaints data, which inpatients tend to use, and intelligence from PALs , which gets more information from outpatients. He commented that the Trust looks at complaints for trends and problems and noted that the France’s report is focusing our minds on this.

7.1  The chair noted that the recent Southwark Vulnerable Adult Safeguarding report indicated that there had been no Safeguarding alerts from any of the local Trusts and asked why this was so. Hospital Trust representatives commented that this might indicate a lack of a comprehensive link up and promised to look into this.

RESOLVED

SLaM will provide:

• Clarity on if the level of complaints received by the Psychosis CAG is proportionate to the level of activity.

• Some vignettes on how complaints were resolved through ‘local resolution’.

Guys and St Thomas's and Kings College Hospital

Will provide more information on the community acquired pressure sores and explain the follow up action taken; including any referral to Safeguarding, and/or Clinical Commissioning Group and work done to liaise with community providers & organisations.

Guys and St Thomas, Kings College Hospital and SlaM

Hospital Foundation Trusts were asked to comment on why no safeguarding alerts were recorded being made to Southwark’s Vulnerable Adult Safeguarding partnership board report 2011-12