CoG (11/16) Item 9.2 - Northern Lincolnshire and Goole ... · responded to the initial feedback...
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Transcript of CoG (11/16) Item 9.2 - Northern Lincolnshire and Goole ... · responded to the initial feedback...
CoG (11/16) Item 9.2.2
DATE 17 November 2016
REPORT FOR Council of Governors
REPORT FROM Kathryn Helley, Deputy Director of Performance Assurance/Asst Trust Sec
CONTACT OFFICER Kathryn Helley, Deputy Director of Performance Assurance/Asst Trust Sec
SUBJECT
CQC Update
BACKGROUND DOCUMENT (IF ANY)
EXECUTIVE COMMENT (INCLUDING KEY ISSUES OF NOTE OR, WHERE RELEVANT, CONCERN THAT THE COG NEED TO BE MADE AWARE OF)
COUNCIL ACTION REQUIRED
To note the report
CQC Action Plan
Executive Summary October 2016
Progress RAG Rating
RED The action is off plan and cannot be returned to the planned date or it has already missed the planned completion date
AMBER
Current indications are that action is on target OR is off plan but action is being put in place to mitigate the delay and the action is expected to return to the planned completion date
GREEN Action completed
BLUE
Action has been completed and there is now compelling evidence that the action has been embedded in day to day processes so it is unlikely that there will be a recurrence of the issue
1
Our improvement plan & our progress
Background & Introduction
• During October and November 2015 and January 2016, the Trust received announced and unannounced visits by the CQC. The Trust responded to the initial feedback received in respect of the issues identified from these visits including review and follow-up of a backlog of OPD follow-up patients, which the Trust was aware of and already dealing with prior to the CQC inspection, and in respect of the environment in A&E for the management of patients with a mental health problem, and provided assurances to the CQC on the implementation and delivery of plans to address these issues. The final report of the inspection was published on 15 April 2016. An action plan in response to the additional findings and recommendations was submitted to the CQC by the deadline of 6 May 2016. Following feedback received from the CQC, some amendments and additions have been made to the action plan. Support from our Commissioners has also been sought where some actions are outside of our control.
• Whilst this executive summary is intended to provide an overview of the plan progress including risks to delivery and also next steps, the full CQC action plan & associated KPIs are also attached.
• Delivery of the CQC action plan and in turn ensuring ongoing improvement to quality of care is the Trust’s foremost priority.
Oversight & Assurance Arrangements
• Strengthened oversight and assurance arrangements are in place to support the changes required and ensure the early escalation of risks to delivery including monthly 1:1 challenge meetings with Executive leads, weekly monitoring of the action plan and KPIs by the Executive Team (with a monthly CEO challenge meeting) and monthly by the Trust Board (details of the oversight & assurance arrangements are attached).
• The Trust’s CQC action plan has also been strengthened to include a strict BRAG rating. The benefits of the use of a BRAG rating, supported by a robust challenge and escalation process (see details of oversight & assurance arrangements attached), is that it shows both that actions have been completed and that there is clear evidence of embedding in day to day processes.
• In addition to the completion of the immediate actions, the Trust fully understands the need to sustain progress and ensure that the actions are embedded and lead to measureable improvements. To this end and in addition to the above arrangements, Key Performance Indicators (KPIs), each with a clear trajectory and timescale for demonstrating sustained improvements, have also been agreed.
• The Board assurance sub-committees (e.g. Quality & Patient Experience Committee, Trust Governance & Assurance Committee and Mortality Performance Assurance Committee) each has oversight of relevant sections of the CQC action plan and associated KPIs. The sub- committees, in turn, will be required to provide assurance to the Trust Board in respect of delivery and embedding of those elements of the plan and progress against the associated KPIS and / or to escalate any concerns or risks to delivery and the mitigating actions.
• As part of the above arrangements and in order to provide independent assurance in respect of the Trust’s progress with the delivery of its CQC action plan, the Trust has appointed an external ‘Improvement Director’, Eric Morton. It is intended that the Improvement Director will provide the following:
- challenge of the Trust’s delivery of the CQC action plan including through individual challenge meetings with lead Executives;
- independent assurance – internally & externally (including to NHSI and the CQC) as to the progress being made; and / or
- escalation of risks to delivery.
The Improvement Director will provide a monthly formal written progress report to the Trust and that report is attached to this summary).
• ‘On the ground’ testing to ensure embedding of the actions taken occurs via a variety of mechanisms including Announced and Unannounced Director Visits, Chief Nurse and Medical Director walk arounds and internal CQC themed visits.
• The Trust will also continue to commission other external support as the need is identified. This will include both audit and verification of actions put in place but also peer review and visits to other Trusts to learn from good practice elsewhere.
2
Our improvement plan & our progress
Progress / current position including any slippage / risks to delivery and mitigating actions
• Whilst good progress continues to be made with delivery of the CQC action plan, arising from the first two cycles of the revised oversight & assurance arrangements
(including review by the relevant Board assurance sub-committees, a number of actions within the plan have been BRAG rated as red (ie. where timescales have slipped
or where risk to delivery has been identified). For these red rated items, the relevant Board assurance committees were asked to consider mitigation actions and revised
timescales (where appropriate). Action
Number
Action Target
Completion Date
Explanation for Red Rating Expected
Completion Date
CQC3b Introduction of Paediatric Nurses to
the ED.
31 July 2016 As part of a review of establishments the Trust considered the introduction of dedicated
paediatric nurses for ED, not least due to the fact that there was the possibility of redeployment
of some of the paediatric nurses from childrens to A&E. If this had occurred, the nurses would
have required additional training to ensure that they were dual trained in order for them to be
able to see the wide range of patients who come through the door in A&E. Following a review
what other Trust have in place in A&Es and in discussions with NHSI, it was identified that it
would be more effective to adopt a pathway approach, as others have, thereby providing
appropriate care to all groups of patients at all times. These ratified pathways are in place and
plans are in place for them to be reviewed by NHSI for completeness. The pathways allow for
paediatric care that is unable to be delivered by A&E nurses, to be delivered via the paediatric
specialist team on site when required. Evidence to demonstrate the effectiveness of this model
is currently being collated and will be available by the end of October 2016.
31 October 2016
CQC14 The Trust must ensure there are
adequate specialist staff, training and
systems in place to care for
vulnerable people specifically those
with dementia.
31 August 2016 2 substantive appointments made – awaiting employment checks – 1 has 1 month notice
period, the other a 3 month notice period.
Member of staff working temporary hours on the bank from 5th September supporting Quality
Matron. Completion of national dementia audit is on track. All other actions are complete.
31 October 2016
CQC15 The Trust must ensure there are
adequate specialist staff, training and
systems in place to care for
vulnerable people specifically those
with learning disabilities.
31 August 2016 In North Lincolnshire, the NL CCG have commissioned RDash (mental health provider) to
recruit an ALD nurse to work between hospital and primary care (3 days hospital-based).
Recruitment to this post is underway. Following creation of a business case for a post at the
North East Lincolnshire end of the patch, a formal request was made to NEL CCG to
fund/commission a post. This request has not been supported. The business case has been
reviewed by NLAG ET against other priorities. Agreement has been reached to fund a full time
band 6 ALD liaison nurse post. Recruitment to this post is currently underway. The Trust
continues to receive positive feedback from a number of sources in relation to delivery of
person-centred care for patients with a learning disability. In addition to the involvement of the
lead Quality Matron, 2 other members of staff with an Adult LD qualification have been offering
advice and support on an ad-hoc basis. The Chief Nurse has written to neighbouring providers
to seek support in relation to an interim position however at this stage no resource has been
identified in support but advice over the phone may be available to the QM lead re: recruitment
as required. Telephone calls are in the diary to discuss further with Care Plus Group and
Navigo. Recruitment process is now underway. One of the new dementia nurse specialists has
experience of working with LD patients and should be in post by late October/early November
so will be a resource to utilise. Additional resource identified in KPMG review of the
safeguarding team re: supporting MCA/DOLS. Issue identified to ET for reserve list
prioritisation. Recruitment to this post will also provide support for staff in caring for patients with
an LD. Meeting held with Head of Community & Therapies and Lead Superintendant
Physiotherapist for the Adult LD team to consider how to strengthen inter-professional
collaboration.
31 October 2016
CQC25 Resolution of the Ophthalmology
backlog.
31 December
2015
Whilst the December 2015 timescale relates to the earlier work, the RAG rating relates to
current ongoing capacity issues.
Goole - October 2016
Scunthorpe -
November 2016
DPoW - January 2017
CQC26a Resolution of other specialty backlog. 31 December
2015
Whilst the December 2015 timescale relates to the earlier work, the RAG rating relates to
current ongoing capacity issues.
Work being
undertaken to
determine dates as
per ophthalmology
above
CQC50a Estates and Facilities to work with
Community and Therapy Services
Group to ensure all Portable
Appliance Testing (PAT) is
completed.
30 September
2016
There are 2 properties where PAT testing has to be completed. These will be completed by
31st October 16. The 2 outstanding properties are Pilgrim Primary Care Centre and Stirling
Medical Centre. A total of 30 properties have been completed.
31 October 2016
3
Our improvement plan & our progress
• A number of actions have also been BRAG rated as blue during the second round of the cycle (i.e. where the relevant Board sub-
committee was assured that sufficient evidence exists of embedding in to day to day practice).
Action Number
Action Executive Lead
CQC8a Continue to resize available resource and capacity, enact where required on the grounds of safety and look to CCGs for support when issues are 'flushed out' (nursing).
Tara Filby
CQC13 The Trust must stop including newly qualified nurses awaiting professional registration (band 4 nurses) within the numbers for registered nurses on duty.
Tara Filby
CQC17 The Trust must ensure there are always sufficient numbers of radiologists to meet the needs of people using the radiology service.
Karen Dunderdale
CQC44 Processes for ensuring that equipment is included in the Trust replacement plan and on the risk register to be shared again with Associate Chief Operating Officers to ensure compliance.
Karen Dunderdale
CQC52 The Trust must ensure that all substances which could be harmful are stored appropriately, specifically within the Ironstone Centre.
Karen Dunderdale
CQC53 The Trust should ensure that there is a standard operating procedure for the use of the second theatre (anaesthetic room) to maintain patient safety with maternity.
Karen Dunderdale
CQC58 Ensure that staff are aware of the need to ensure that multi-use equipment is cleaned between patients (maternity services).
Karen Dunderdale
CQC60 At DPOW, move to the use of single use monitoring belts (maternity services). Karen Dunderdale
CQC64 Whilst there is a process in place for staff to follow, there are notices displayed and verbal consent is obtained from patients and / or relatives for the use of the cameras / monitors, consent needs to be recorded in patient' notes.
Karen Dunderdale
CQC87 The Trust must review the validation of mixed sex accommodation occurrences, ensure patients are cared for in an appropriate environment and report any breaches. Undertake immediate review.
Karen Dunderdale
CQC94 Update of the Patient Information leaflet – NLAG/Health Watch Karen Dunderdale
CQC114 The Trust must ensure three-monthly safeguarding supervision takes place for health visitors. Karen Dunderdale
CQC132 The Trust should strengthen the support provided to nuclear medicine technologists by the ARSAC (administration of radioactive substances advisory committee) licence holder.
Karen Dunderdale
• These ratings are recommended to the Trust Board for formal ratification. The assurance templates and supporting evidence are
attached to this report to support the Board’s consideration of this recommendation.
• Progress with our overall action plan ‘at a glance’ is shown on pages 6 - 15 of this report. 4
Our improvement plan & our progress
Reporting our progress
• A report on our progress with the delivery and embedding of actions within the CQC action plan will be provided to the Trust Board
monthly.
• The report will include:
- this executive summary
- the detailed CQC action plan
- progress against the associated KPIs
- the monthly report from the Trust’s Improvement Director
• The report will also be shared with Governors and with relevant external stakeholders including:
- CQC
- NHSI
- CCGs
- HealthWatch
- OSCs
- MPs
• Progress against the plan will also be shared with staff through the existing communication and cascade arrangements in place within the
Trust.
5
Our Progress: ‘At a Glance’
Area Summary of Actions Agreed Timescale for Implementation of
Immediate Actions
Progress
Summary
Staffing Levels Review and where appropriate make changes to staffing levels:
- medical staff in A&E - revised rota (CQC1) 31 August 2016 Completed
- medical staff in critical care - annual leave (CQC2) 31 July 2016 Completed
- medical staff in critical care - introduction of rotas (CQC2) 1 October 2016 Completed
- nursing staff within A&E (CQC3a) 31 August 2016 Completed
- introduction of Paediatric Nurses to A&E (CQC3b) 31 August 2016 Some Slippage
- nursing staff within Medicine - establishment review (CQC4) 31 July 2016 Completed
- nursing staff within Surgery (CQC5) 31 August 2016 Completed
- rreview of midwives (CQC6) 31 August 2016 Completed
Continue to develop innovative solutions in partnership with other providers (CQC7) 31 October 2016 On Target
Continue to resize available resource and capacity & enact where required on the grounds of
safety - process in place - nursing (CQC8a)
31 April 2016 Embedded
Continue to resize available resource and capacity & enact where required on the grounds of
safety - enacting as required - medical (CQC8a)
31 August 2016 Completed
Proactively plan for and monitor any gaps in staffing and act accordingly - process in place
(CQC9a)
30 April 2016 Completed
Proactively plan for and monitor any gaps in staffing and act accordingly - enacting as required
(CQC9a)
31 August 2016 Completed
Review dedicated management time allocated to ward co-ordinators: and managers (CQC10a) 31 August 2016 Completed
Review dedicated management time allocated to ward co-ordinators / shift leaders (CQC10b) 30 September 2016 Completed
Review and ensure adequate out of hours anaesthetic staff (CQC11) 31 October 2016 Completed
Review and ensure adequate consultant cover for AMU - audit) (CQC12a) 31 July 2016 Completed
Recruit additional ACPS to deliver a different model of care / use of locums in interim if no
substantive appointment is made (CQC12b)
30 September 2016 Completed
Cease using newly qualified nurses awaiting professional registration within ward numbers
(CQC13)
30 June 2016: Completed & Ongoing Embedded
Ensure there are adequate specialist staff, training & systems in place to care for vulnerable
patients specifically patients with dementia & learning disabilities (CQC14 & CQC15)
31 August 2016 Some Slippage
Appoint a Practice Development Midwife within Maternity Services (CQC16) 30 April 2016 Embedded
Ensure there are sufficient numbers of Radiologists (CQC17) 31 July 2016 Embedded
6
Our Progress: ‘At a Glance’
Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Out-patient capacity Reinforce Access Policy & SOP regarding cancellation of clinic appointments and
requirement for clinical involvement om the process & decision making (CQC18)
Immediate (16 October
2015)
Completed
Monitor compliance with the above requirement (CQC19) Immediate (16 October
2015)
Completed
Undertake RCA to ensure issues identified at CQC visit in respect of the
cancellation of clinic appointments without clinical input is not systemic (CQC20)
31 October 2015 Embedded
Revise, Re-issue and Reinforce Access Policy (CQC21) 10 November 2015 Completed
Appoint overarching lead for with oversight of the clinical administration systems
and processes (CQC22)
2 November 2015 Embedded
Complete the clinical cancellation workshops and ensure ongoing staff
engagement in respect of the changes to clinical administration systems and
processes arising from the clinical admin review (CQC23)
30 November 2015 Embedded
Implement the recommendations from the Clinical Admin Review. (CQC24) 30 November 2015 Completed
Implement the current Patient Admin Action Plan including feedback from SAT /
operational teams and recommendations from KPMG Audit. (CQC30)
30 November 2016 Completed
Address the OPD backlog and ensure there is robust monitoring of these
arrangements going forward and monitor progress and with KPIs through the Executive Team. NB. Whilst immediate action was taken prior to and at the time
of the CQC visit, there has remained a capacity shortfall which has resulted in a
further backlog of out-patient follow-ups in Ophthalmology and other specialties. .
In respect of Ophthalmology, the Trust has agreed a clear improvement plan and
trajectory which has been discussed with CCGs and includes additional further
capacity, consideration of external capacity, validation and discussions with CCGs
in relation to further referral avoidance measures. Improvement plans and
trajectories have and are being agreed for all other specialties (CQC25)
31 December 2016 BRAG Rated as RED Due to
Current OPD Follow-up
Backlog
Improve OPD appointment cancellation rates and DNAs (CQC62) 31 October 2016 Completed
Agree the arrangements for out of hospital cardiology and respiratory services with
Commissioners (CQC31)
31 October 2016 Completed
Support & Guidance for GPs pre-referral to be agreed with Commissioners
(CQC32)
31 October 2016 On Target
MSK pathway to be progressed with commissioners (CQC33) 31 October 2016 Embedded
Assurance visits to OPD to be agreed with commissioners as part of wider
programme of assurance visits (CQC34)
31 October 2016 Completed
7
Our Progress: ‘At a Glance’ Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Environment & Equipment Make changes to the environment within A&E at SGH:
- to provide a dedicated room for the management of patients with a mental
health condition; (CQC35)
11 March 2016 Embedded
- to ensure treatment rooms are suitable for patients on trolleys; (CQC42) 11 March 2016 Embedded
- To create a separate waiting & treatment area for children that is safe and
secure; (CQC54)
30 September 2016
(commencement)
31 December 2016
(completion)
On Target
- To create separate entrances for patients self-presenting with minor injuries or
illnesses and those conveyed by ambulance with serious injuries (CQC55)
30 September 2016
(commencement)
31 December 2016
(completion)
On Target
Strengthen the risk assessment tool for patients with a mental health condition
(CQC39)
30 November 2015 Completed
Review the current CAMHS Team support to ensure children presenting in the
A&E Department with mental distress receive timely specialist assessment of their
needs including the review of pathways (CQC85b)
29 February 2016 Completed
Provide MHA training for staff within A&E (CQC40) 30 September 2016 (revised
date)
Completed
Install an alarm in both A&E triage areas (CQC41) 29 February 2016 Embedded
Ensure there is sufficient space and seating for patients and their supporters in
OPD (CQC56)
31 October 2016 On Target
Ensure the premises and location of the Ophthalmology Department is ‘fit for
purpose’ (CQC57)
31 October 2016 Completed
Ensure that equipment (specifically maternity, resuscitation and critical care
equipment) is checked, is in date and is ‘fit for purpose’ (CQC45)
31 July 2016 Completed
Processes for ensuring that equipment is included in the equipment replacement
plan and on the risk register to be shared with Groups and reinforced (CQC44)
30 June 2016 Embedded
Strengthen Equipment Group Terms of Reference & associated actions (CQC43) 30 September 2016 Completed
Increase staff awareness in relation to the need for checking equipment (CQC46) 31 July 2016 Completed
8
Our Progress: ‘At a Glance’
Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Environment & Equipment Include equipment checks in existing monitoring arrangements & assurance visits
e.g. internal CQC themed visits (CQC47)
31 May 2016 Completed
Ensure that community equipment and environments are cleaned in accordance
with agreed cleaning schedules (CQC48 & CQC49)
31 July 2016 Completed
Ensure that community equipment is serviced and tested for electrical safety -
PAT testing (CQC50a)
30 September 2016
(Revised date 31/10/16)
Some Slippage
Ensure the safe storage of intravenous fluids - maternity at SGH (CQC51) 6 May 2016 Embedded
Ensure the safe storage of substances which could be harmful - Ironstone Centre
(CQC52)
30 June 2016 Embedded
Develop a standard operating procedure for the use of the second maternity
theatre (CQC53)
30 June 2016 Embedded
Ensure that within maternity services multiple use equipment and devices are
cleaned or decontaminated between use and records of cleaning are maintained
- instructions to staff and monitoring (CQC58)
31 May 2016 Embedded
Ensure that within maternity services multiple use equipment and devices are
cleaned or decontaminated between use and records of cleaning are maintained
- E&F Teams to evidence cleaning regimes (CQC59)
31 May 2016 Embedded
Implement single use monitoring belts (CQC60) 31 May 2016 Embedded
Consent Strengthen he arrangements for obtaining and recording consent from patients
and / or their families where CCTV and other monitoring systems may be in use
(CQC64)
16 November 2015 Embedded
Amend the CCTV Policy to capture the above arrangements (CQC65) 18 January 2016 Embedded
9
Our Progress: ‘At a Glance’
Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Medicines Management Ensure the safe storage and administration of medicines; specifically that drug fridge
temperatures are checked daily and minimum and maximum temperatures are recorded
and that staff are aware of the actions to take if the recordings are outside this range:
- Decommission fridge on Ward 23 (CQC66)
1 November 2016 Embedded
Reinforce Trust Policy & Procedure for monitoring of drug fridges (CQC67) 31 March 2016 Embedded
Ensure ongoing monitoring and testing of the above arrangements (CQC68) 30 June 2016 Completed & Ongoing
Implement an electronic system that remotely monitors fridge temperatures (CQC69) 31 October 2016 CQC requirement not
reliance on this action
Ensure the safe storage of oxygen cylinders on ITU at DPOWH (and elsewhere)
- assessment
- remedial works (CQC70)
30 June 2016
31 July 2016
Completed
Ensure the safe storage of oxygen cylinders on ITU at DPOWH (and elsewhere)
- staff awareness (CQC70)
31 August 2016 Completed
Ensure the Discharge Lounge at DPOWH has a facility and process for the safe storage
of medicines and that there is a programme of education for staff (education) (CQC72)
31 May 2016 Embedded
Ensure the Discharge Lounge at DPOWH has a facility and process for the safe storage
of medicines and that there is a programme of education for staff (review) (CQC71)
30 June 2016 Embedded
Ensure that the procedures for the management of controlled drugs in patients’ homes is
standardised and all relevant staff are aware of and follow these procedures (review of
medicine codes) (CQC73)
31 May 2016 Embedded
Ensure that the procedures for the management of controlled drugs in patients’ homes is
standardised and all relevant staff are aware of and follow these procedures (staff
awareness) (CQC74)
30 June 2016 Completed
Ensure that the Patient Group Directions (PGDs) in the A&E Departments are reviewed
and in date (CQC75)
30 June 2016 Embedded
Mortality Address the mortality outliers and improve patient outcomes in these areas. (CQC76) 16 August 2016 Embedded
Introduce critical care specific morbidity and mortality meetings. (CQC77) 31 July 2016 Embedded
Pressure Ulcers Review the use of pressure relieving equipment and prevention blood clot equipment
within theatres. (CQC78)
31 July 2016 Completed
10
Our Progress: ‘At a Glance’
Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Evidence Based Practice
and Monitoring and
Clinical Education
Ensure that the reasons for Do Not Attempt Cardio-Pulmonary Resuscitation
(DNAR) are recorded and implemented in line with best practice. (CQC79)
31 July 2016 Completed
Ensure that the Five Steps for Surgery & WHO Checklist are consistently applied
and practice audited. (CQC80)
31 August 2016 Completed
Continue to work towards delivering care and treatment in line with national
guidance and core standards for Intensive Care. (CQC81)
31 March 2018 On Target
Ensure that policies and guidelines in use in clinical areas are compliant with NICE
or other similar requirements and ensure staff are aware of these policies &
guidelines, specifically within maternity, A&E and surgery. (CQC82)
Ongoing On Target
Ensure that all maternity policies are up to date and reflect current guidance and
that staff are aware of these policies. (CQC83)
30 April 2016 Embedded
Develop a standard operating procedures to ensure consistency of the health
visitor role when working with GPs. (CQC84)
31 July 2016 Completed
Ensure there are effective arrangements in place to assess, monitor and improve
the quality of end of life care including auditing preferred place of care and
outcomes (strategy approved) (CQC85a)
31 July 2016 Completed
Ensure there are effective arrangements in place to assess, monitor and improve
the quality of end of life care including auditing preferred place of care and
outcomes (KPIs in place) (CQC85a)
31 August 2016 Completed
Address the continuing gap in clinical education in critical care including the
appointment of a Nurse Educator (CQC86)
31 August 2016 Completed
Eliminating Mixed Sex
Accommodation (EMSA)
Review and strengthen the Trust’s policy and arrangements to ensure there are
no mix sex accommodation breaches including improved escalation and
monitoring (CQC88)
1 April 2016 Completed
Increase awareness of the national guidance & Trust policy through training
(CQC89)
30 September 2016 Completed
Include the testing of the above arrangements in the existing assurance visits e.g.
Director Visit and CQC themed visits (CQC90)
31 May 2016 Embedded
CCG assurance visit to be undertaken to further test these arrangements (CQC93) 30 June 2016 Embedded
Review and agree with commissioners the time period for ‘step down’ patients
ready to leave a specialist unit (CQC92)
31 August 2016 Completed
Update the Trust’s patient information leaflet to raise patient awareness of EMSA
(CQC94)
31 July 2016 Embedded
11
Our Progress: ‘At a Glance’
Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Patient Flow & Access Improve on the number of fractured neck of femur patients who receive surgery
within 48 hours (CQC95)
31 July 2016 (revised action
plan) / Timescale for any
additional actions TBC
Completed
Evaluate the medical review of outlying medical patients on surgical wards to
improve consistency of cover arrangements and prevent unnecessary delayed
discharges including;
- implementation of ACP model (CQC96) 31 July 2016 Embedded
- review and re-introduction of the short stay ward (CQC97) 30 June 2016 Completed
- review of weekend discharge process on all 3 sites to ensure best practice
(CQC98)
31 October 2016 On Target
Review and strengthen the triage system with the A&E Departments including a
visit to a high performing Trust to view best practice with a view to introducing
within NLG (CQC99)
31 July 2016 Completed
NLAG to visit other Trusts who are outstanding in the area of Triage (CQC100) 31 July 2016 Completed
Continue to monitor the arrangements for patient transport (new contract awarded
by commissioners and n place from September 2016) (CQC101a)
31 October 2016 Embedded
NEL CCG to consider introduction of a 30 day bed model (CQC102) 30 September 2016 Completed
NL CCG to consider whether walk in service would be better led by GPs
(CQC103)
31 October 2016 Embedded
Review patient flow and reduce delayed discharges from ITU. NB. The Trust is
not an outlier in this area (CQC104)
31 August 2016 Completed
Review access and flow through the SGH angiography catheterisation lab to
reduce last minute cancellations, delays and wasted appointments including a full
capacity & demand review (CQC105)
31 July 2016 Completed
Review patient flow through the SGH short stay ward to ensure this does not have
an adverse impact on the flow of patients through the Clinical Decisions Unit
(CQC106)
31 July 2016 Completed
Review the effectiveness of the patient pathway for pre-assessment, the
timeliness of going to theatre and the number of on the day cancellations and
make changes as required (CQC107)
31 August 2016 Completed
12
Our Progress: ‘At a Glance
Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Strategy, Vision &
Engagement
Through the development of a Staff Engagement Strategy, ensure that staff
understand and can communicate the key priorities, strategies and implementation
plans for their areas and are involved in improvements and receive appropriate
support to carry out their duties (CQC108)
31 October 2016 Completed
Ensure the community teams are engaged in developing the vision and strategy
for their teams (CQC112)
31 July 2016 Completed
Develop an end of life care strategy and vision and KPIs that reflect national
guidance (CQC110)
30 June 2016 Embedded
Identify patient representatives to join the End of Life Strategy Group (CQC111) 31 May 2016 Embedded
Appraisal & Mandatory
Training
Ensure staff, especially in surgery, have appraisals and supervision (CQC113) Ongoing On Target
Ensure three monthly safeguarding supervision takes place for health visitors
(CQC114)
31 March 2016 Embedded
Ensure the delivery of the targets for appraisal and mandatory training for all staff
groups but specifically in respect of community and end of life care staff and
specifically to improve staff understanding of the assessment of capacity and the
use of restraint (including chemical restraint) (CQC116)
Ongoing On Target
Ensure IR(ME)R training is mandatory for radiology staff (CQC118) 31 July 2016 Embedded
Patient Feedback Seek and act on feedback from patients in radiology in order to evaluate and
improve services (particularly at Goole) (CQC119)
Immediate Embedded
Duty of Candour Ensure that all staff within OPD are aware of their responsibilities in relation to the
Duty of Candour (CQC120)
31 July 2016 Completed
13
Our Progress: ‘At a Glance
Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Learning Lessons Ensure that lessons learned from incidents / SIs / ‘Never Events’ / complaints &
PALS / claims are shared and there is evidence available to demonstrate this
including through the re-launch of the ‘Please Ask’ Campaign (CQC121 & CQC122)
31 July 2016 Completed
Ensure that staff can access and receive feedback and learning from incidents
(CQC124)
31 July 2016 Completed
Ensure ‘how staff learn lessons’ is linked to the wider Staff Engagement Strategy and
staff are asked to share their ideas on how the Trust can improve these
arrangements (CQC123)
30 September 2016 Completed
Agree and implement a standard template for use by all ward/department staff
meetings to ensure there is a standing item so share feedback and learning from
incidents etc. (CQC125)
30 September 2016 Completed
Review membership of Learning Lessons Group to include consideration of
representation from wards / departments and admin staff (CQC126)
30 June 2016 Completed
KPI to be developed in respect of feedback and learning (CQC127) 30 September 2016 Completed
Audit effectiveness of above arrangements as part of Internal Audit Programme
(CQC128)
30 September 2016 Completed
Promote the use of the Trust’s electronic incident reporting system (DatixWeb) within
Community Dental Service to ensure staff are aware of the requirement to report
incidents and that incidents are investigated and lessons learned (CQC129)
31 May 2016 Embedded
14
Our Progress: ‘At a Glance
Area Summary of Actions Agreed Timescale for
Implementation of
Immediate Actions
Progress
Summary
Management of Risk Ensure there are timely and effective governance processes in place in all areas to
identify and actively manage risks throughout the organisation (but specifically in
relation to critical care, staffing and ensuring essential equipment is included in the
Trust replacement programme) and ensure that all identified risks (Trust-wide and
at service level) are identified and recorded on the risk register – review to be
completed (CQC130)
31 July 2016 Completed
Ensure that there is discussion on the risk register at all Directorate / Group
governance meetings (CQC131)
31 May 2016 Completed
Staff Support Strengthen the support provided to nuclear medicine technologists by the
Administration if Radioactive Substances Advisory Committee (ARSAC) (CQC132)
30 June 2016 Embedded
Record Keeping Ensure that record keeping meets all appropriate registered body standards
(particularly in the community) (CQC133)
31 April 2016 Completed
15
CQC Action Plan Assurance Process
TRUST BOARD REGULATORY OVERSIGHT
MONTHLY HIGHLIGHT
REPORTS TO THE TRUST
BOARD FROM RELEVANT
BOARD SUB-COMMITTEES
CQC ACTION PLAN & KPIs:
UPDATE REPORT
SUBMITTED TO TRUST
BOARD
CQC ACTION PLAN & KPIs:
UPDATES SHARED WITH
OTHER EXTERNAL
STAKEHOLDERS
BOARD SUB-COMMITTEES EXECUTIVE TEAM / TMB
OVERSIGHT & ASSURANCE
OF CQC ACTION PLAN &
DELIVERY OF KPIs
FORMAL REVIEW OF PERFORMANCE
AGAINST DELIVERY OF CQC ACTION
PLAN & KPIs AND ESCALATION AS
APPROPRIATE (WEEKLY BY EXCEPTION &
MONTHLY ‘DEEP DIVE’ & CHALLENGE)
MONTHLY INDIVIDUAL CHALLENGE MEETINGS WITH
EXECUTIVE & ACTION PLAN LEADS / IMPROVEMENT
DIRECTOR / DIRECTOR OF PERFORMANCE ASSURANCE AND
DEPUTY DIRECTOOR OF PERFORMANCE ASSURANCE WITH
ESCALATION AS APPROPRIATE
DIRECTORATE / GROUP DELIVERY & OVERSIGHT
ON THE GROUND TESTING THAT ACTIONS ARE EMBEDDED
IMP
RO
VEM
ENT
DIR
ECT
OR
CH
ALL
ENG
E &
ASS
UR
AN
CE
INTE
RN
AL
AU
DIT
REV
IEW
OF
REL
EVA
NT
AR
EAS
WIT
HIN
TH
E C
QC
AC
TIO
N P
LAN
CHALLENGE, ESCALATION & ASSURANCE – HOW IT WILL WORK IN PRACTICE
MONTHLY CYCLE:
WEEK 1:
Individual Challenge meetings with Executive & Operational Action Leads / Improvement
Director / Director of Performance Assurance / Deputy Director of Performance Assurance –
with escalation of risks to delivery to ET and / or TMB as required
WEEK 2
CEO / ET / TMB ‘Deep Dive’ & challenge of progress
WEEK 3
Reports to & challenge by Trust Board Assurance Sub-Committees (e.g. Quality & Patient
Experience Committee, Trust Governance & Assurance Committee, Mortality Performance
Committee)
Relationship meeting with CQC / Improvement Director / Director of Performance Assurance
/ Deputy Director of Performance Assurance
WEEK 4
Trust Board oversight and challenge
Stakeholder meeting to review progress. Stakeholder attendees to include:
- NLG
- Improvement Director (Eric Morton)
- CQC
- NHSI
- CCGs
- HealthWatch
- OSCs
- MPs
REPORTING
One report – internally and externally – and combining:
Executive Summary
Detailed CQC Action Plan
Progress Against KPIs
Strengthened Assurance Process (first report)
Monthly Report from Improvement Director
Improvement Director Monthly Report
Trust Board – 25 OCTOBER 2016 Overall Assessed Status: AMBER
Overview (as at 18 OCTOBER 2016)
Monthly iterations of the CQC action plan and the output from the revised assurance process continue to be presented to monthly trust board meetings. This is the third such iteration.
During early October, progress meetings were again held with each executive action owner to review and update progress and to assess the position for reporting through the October cycle of Executive Team meetings, assurance committees and finally to this trust board.
The action plan continues to be reported using a BRAG system of rating, where actions are assessed at a joint meeting between the executive owner of the action, the assurance team and the ID. The position of each action is considered using evidence presented by the executive owner so the status can be determined as either:
o BLUE – action completed and evidence available to present to the appropriate assurance committee and trust board to demonstrate the completed action is now embedded and part of routine practice.
o RED – action is off plan and will not be completed in the target time scale. An explanation of why the action has fallen off track and measures the executive owner is taking to complete the action with a forecast completion date. The action remains RED, until the action is completed.
o AMBER – the action is on plan to complete by the target date. o GREEN – the action has been completed and is now in a period where the action is being embedded as part of routine practice.
Actions which were evidenced as embedded and where the executive owner can provide completing evidence that changes and actions taken are now part of routine practice have been assessed as BLUE and have been submitted to the appropriate assurance committee for consideration and ratification. These actions are reported on to this trust board for confirmation.
There has been a reduction in the number of actions being reported as RED. Plans have been discussed with the appropriate executive director consider measures to mitigate the impact of actions remaining off plan and to understand the measures being taken to bring these to bring these actions back on to plan as soon as practicable.
I remain confident that the action plan remains fit for purpose and provides a sound basis for all actions arising from the CQC inspection to be appropriately addressed, assessed and reported to the relevant assurance committee and trust board and shared with CQC (at the scheduled monthly engagement meetings) and NHSI.
The CQC re-inspection is now only one month away and whilst a significant number of actions are planned to be evidenced as embedded by the end of November, it is important for independent external testing of progress to be carried out. NHSI has made available senior staff to initiate this process and to set a series of reviews to test compliance and to assure that the actions which the trust has accepted as embedded remain fully in place
As the board is aware, it will not be possible to demonstrate embeddedness for a number of actions. In particular the waiting list backlog will not have been fully cleared by the time of the CQC re-inspection. However in such cases, there needs to be evidence of clear and credible plans to address the issue and a demonstration that progress against such plans has been sustained so as to be able to offer confidence that the plan will be delivered.
Actions have already been put in place to reduce the number of patients waiting for follow up appointments and further action is being planned by the trust and a dedicated member of staff to focus on waiting lists has now taken up post. In addition the Intensive Support Team at NHSI have also been to the trust to review, support and assure the actions being taken.
The challenge is significant but the development of clear actions and close working with clinical teams will allow significant in roads to be made. However it is not just a matter of clearing this backlog, it is critically important that the trust can demonstrate sound processes to ensure that such a situation cannot be repeated in the future. The support form the Intensive Support Team will be very helpful for this.
Overview (as at 18 OCTOBER 2016)
Last month, I revised my assessment of the position of the trust from RED/AMBER to AMBER. I am holding to that assessment for October. I have again based this assessment on the quality of the CQC plan, assurance processes and progress to date and the prospect of independent scrutiny of the plan being provided via colleagues from NHSI.
It is important that the trust leadership maintains strong progress on delivering against the CQC action plan in the next few weeks and in the run up to re-inspection. Both in terms of continuing to complete planned actions, evidencing that those actions are part of the day-to-day operation of the trust and preparing the trust and its staff for the inspection itself.
The trust has much to be proud of and the progress it has made over recent months has been significant. These achievements should be positively publicised, shared across the trust and celebrated across the trust and beyond, so that the trust and its staff can demonstrate and be proud of its strengths and achievements.
I have made no changes to my previous assessment of the main risks, which are set out on the following page.
Risks / Concerns Risk level
(High/Medium
/Low)
Recommended actions
Relatively short time available before CQC re-inspection, to complete actions and assemble compelling evidence that the completed actions are embedded as part of standard practice.
HIGH Continued monthly scrutiny and challenge of the CQC action plan.
Build confidence with external regulators CQC and NHSI, and also key stakeholders that good progress is being made and the trust will be in a good state of readiness for re-inspection in November.
HIGH Monthly meetings with CQC representatives where the action plan and progress is being shared will contribute significantly and it is also important to have a regular and open dialogue with senior CQC and NHSI colleagues.
In addition monthly Stakeholder Meetings are now also being held to share progress in a very open and transparent way.
Executive owners having time and resources to address their actions and make rapid progress towards completion and able to evidence that actions are embedded.
HIGH Executive owners must prioritise this work over the next few months to maximise progress and where possible exceed planned expectations.
The appointment of an interim COO will be major contribution to mitigating this risk in relation to the operational agenda.
Waiting lists – patients backlog. HIGH This is the most critical challenge. The recent revised reporting arrangements and the sharing of the position and weekly progress updates with commissioners, CQC and NHSI, demonstrates a clear intention of openness and engagement.
The appointment of an additional resource, dedicated to improving the management of waiting lists and the invitation to the Intensive Support Team is mitigating this risk.
Preparation for CQC inspection. HIGH Colleagues from NHSI are now working with the trust to undertake a series of CQC themed reviews across both main acute sites and raising concerns immediately to allow these to be addressed. In addition a comprehensive review is being developed to be carried out in the coming weeks to robustly test the state of preparedness of the trust for CQC re-inspection.
Date Activity Key work done & meetings attended (22 SEPTEMBER to 17 OCTOBER 2016)
22 Sept 2016 Claire Pacey - NHSI Meeting to develop arrangements for her to support the trust.
23 Sept 2016 NHSI Telephone conversation to agree NHSI support to the trust.
26 Sept 2016 Claire Pacey & Yvonne Evans (NHSI) & Wendy Booth & Kathryn Helley
Preparation meeting to agree scope of support from NHSI.
27 Sept 2016 Trust Board meeting
3 Oct 2016 Pam Clipson
Wendy Booth
CQC progress review meeting.
CQC progress review meeting.
5 Oct 2016 Lawrence Roberts
Jug Johal
Tara Filby
CQC progress review
meeting. CQC progress
review meeting. CQC
progress review meeting. 6 Oct 2016 Warren Brown & Owen Southgate (NHSI)
Karen Dunderdale, Karen Fanshaw and assistant chief operational officers
Vince Connolly (medical director NHSI)
Meeting with executive team.
CQC progress review meeting.
Telephone conversation.
11 Oct 2016 Neil Gammon
Executive team meeting
Wendy Booth
Telephone conversation.
CEO challenge on CQC action plan.
Progress meeting.
12 Oct 2016 Karen Dunderdale
Tara Filby
CQC & members of executive team
Chairman
Waiting lists.
Progress meeting.
Engagement meeting.
Progress meeting.
17 Oct 2016 Preparation of Improvement Director’s monthly report.
Key activities planned (for coming month)
Attend trust board meeting.
Attend Stakeholders meeting.
CQC progress review meetings with each executive action owner.
Attend trust board meeting.
Attend other meeting in the trust relating to progress on CQC action plan and preparation fro the re-inspection.
Liaise with NHSI as required.
Liaise with CQC as required.
----------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------
Overall status definitions
Good progress, no significant concerns or risks identified.
Reasonable progress, some concerns and risks that will need to be closely managed.
Progress is not sufficient, significant concerns and risks identified.
Any other comments
CQC Action Update – Assurance Template
CQC Action Number: 8a Current BRAG Rating Target BRAG Rating
CQC Recommendation: The Trust must ensure Achieved 31 August Target date for that there are sufficient skilled, qualified and 2016 evidence of experienced staff in line with best practice and embedding is end of national guidance, taking into account patients' On-going resizing October 2016 dependency levels. This must include but not be capacity according to limited to: medical staff within the emergency demand department (ED) and critical care, nursing staff within ED, medicine and surgery and midwives (DPOW). Action: Continue to resize available resource and capacity, enact where required on the grounds of safety and look to CCGs for support when issues are 'flushed out'.
Progress Update: Agreed standards for nurse staffing in place for inpatient wards with a minimum 1:8 nurse to patient ratio on days. Establishment review timetable in place (April 2016) as part of Sustainability plan. Reviews completed for Surgery & Critical Care, ECC, paediatrics, neonates and medicine and are in the process of implementation (August/September 2016). Maternity establishment currently based on last Birthrate Plus review (2014 data). Temporary uplift recommended to ET approved in
principle (12th August 2016). Birthrate Plus to be recommissioned by Women & Children’s Group.
Effective ward configuration discussed at Strategy & Planning meeting (July 2016) and is being linked into service review schedule (to be completed and pulled together by 3rd October).
Monitoring of short term impact of resizing capacity is reported through the monthly staffing capacity and capability reports with appropriate mitigation evidenced including temporary bed closures (from June 2016), usage of temporary bank/agency staff and redeployment. A whole ward (19 beds) closed 15th August temporarily to redeploy staff across the Medicine wards at SGH. Data for A&E fill rates to be included in the monthly report from September.
Evidence of Compliance and / or embedding * Supporting Documents ** Draft paper – principles discussed and agreed at Strategy & Planning
Further meeting held to review longer term configuration 19th August – follow up meeting to review outstanding queries in September 2016
Nurse staffing for
new bed model June
Temporary staffing establishments for reduced capacity wards agreed at Resource Committee September 2016
New bed model
August 2016.docx
Proposed bed configuration agreed via CEO Sustainability Challenge
meeting September 2016 Temp Staffing for
Reduced Capacity – I
Bed model paper
Sept 2016.docx
Monthly staffing paper to the Board
ECC fill rates included from September Board report onwards
NLG(16)310- Staffing
Capability and Capac
NLG(16)347 -
Monthly Capacity and
NLG(15)400 -
Staffing Capability an
6 monthly staffing report
NLG(16)339 - 6
monthly nurse staffin
Resizing capacity discussed at TMB to raise awareness re: impact and to seek clinician buy-in
FINAL TMB mins - 8th
August 2016.pdf
TMB mins - 22nd August 2016.pdf
On-going Monitoring Arrangements:*** Vacancy rate reported in monthly staffing report to Resource Committee and in staffing capacity and capability report to the Board – monitored by weekly operational delivery group and fortnightly oversight group as part of Nurse Staffing Improvement Sustainability programme KPIs in place for fill rate Agency issues escalated to ET Executive Director Responsible:
Tara Filby Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
Resource Committee
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: 13 Current BRAG Rating Target BRAG Rating
CQC Recommendation: The Trust must stop including newly qualified nurses awaiting professional registration (band 4 nurses) within the numbers for registered nurses on duty.
Achieved June 2016 Embedding by end of September 2016
Action: Ensure that clear guidance is developed and embedded within Trust Policy.
Progress Update: July: KPI in place – weekly report run from the electronic roster, validation by Operational teams with evidence of action taken by the Nurse Staffing Improvement Manager Roster rules revised and templates all updated August: weekly reports have identified a small number of B4 staff allocated in B5 shifts. On investigation this has been due to human error or delay in processing change form/roster template for staff who have received their PiN number – hence do not recommend Blue rating until further KPI monitoring and assurance is received. Evidence is captured weekly. September: weekly review undertaken. No Band 4 working in band 5 shifts. Errors have been made as above but corrected due to weekly comprehensive review and plan changed efficiently and effectively. This will be monitored ongoing via a KPI
Evidence of Compliance and / or embedding * Supporting Documents **
Email communications outlining process
Band 4 nurses.msg
Nurses awaiting
PiN.msg
NMAF assurance
FINAL - NMAF mins
(06 05 16).doc
FINAL NMAF minutes
- June 2016.doc
Sample weekly report and challenge
PRN wrong grade
shifts.msg
RE URGENT re PRN
wrong grade shifts.m
Kimberly Fernie.msg
Pre Pin nurses..msg
Evidence table
Band 4 Pre pin
nurses.docx
Band 4 Pre pin nurses.docx
On-going Monitoring Arrangements:***
Weekly KPI and challenge by Chief Nurse
Executive Director Tara Filby Board Sub Committee Resource Committee Responsible: Responsible for
Oversight (as per CQC Action Plan):
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: Number 17
Current BRAG Rating Target BRAG Rating
CQC Recommendation: The Trust must ensure there are always sufficient numbers of radiologists to meet the needs of people using the radiology service.
Action: Continue to work with HR Recruitment teams to source Radiologists on permanent, fixed term, or locum basis.
Completion 31st July 2016 Progress Update: The service has produced a matrix which shows presence of Radiologists in the departments each week from January to September 2016.
In terms of recruitment, two new radiologists were employed in December 2015 and April 2016 with a third person agreeing to a one year fixed contract.
Skype interview held 15/7/16, with Radiologist currently in Singapore – position offered but declined.
Continuing to look at CVs for further candidates. 3 further Skype interviews to be arranged.
Utilising existing links with Indian Teaching Hospitals to assess further interest – promotional literature has been delivered – follow up calls to be made by the recruitment team from October, and further literature to be circulated to other institutes.
Early Humber Coast & Vale (HCV) STP work is indicating potential opportunities, in terms of shared recruitment (split posts offering specialities which may help attract recruits) and also of collaborative ways of working which may help reduce the volume of work outsourced within HCV. Further meeting TBA to offer structured plans.
Evidence of Compliance and / or embedding * Supporting Documents **
Radiologist Establishment / Vacancy position
Radiologist Est/Vac Position
Details of Interviews held, job offers pending, status updates etc
Radiologist Recruitment Progress
Evidence of presence of Radiologists within departments, highlighting actions taken
Radiologist presence Jan-Sept
Evidence of reporting backlog with narrative giving context to numbers.
Unreported Position 10.10.16.xlsx
Unreported PTL shows position against TAT targets
Unreported PTL 10.10.16.xls
On-going Monitoring Arrangements:***
Weekly Radiologist Rotas produced and circulated 6 weeks in advance to enable lists to be planned accordingly, and to allow for advance planning regarding additional support with Reporting if required
Monitoring of Unreported Radiology Images via daily PTL which shows numbers waiting by modality, priority, and length of time waited. Diagnostic Reporting policy shows standards against which PTL is compared.
Diagnostic Imaging
Reporting Policy (DCP Unreported PTL
10.10.16.xls
Unreported studies are validated on a daily basis via the PTL attached above, and also on a weekly basis when unreported report is circulated to head of clinical support services. Any outliers in terms of patients waiting longer than expected are checked and escalated to radiologists via Soliton messenger – example of messages attached:
Soliton messages to escalate reports.pdf
To put into context regarding the numbers of unreported images - for week commencing 26.9.16, the total number of exams reported was 8110; the total number of outstanding unreported exams (5860) is well below 1 week's reporting capacity. Rather than just looking at the number of studies, the length of time of the backlog is also considered, and the two of these together are the trigger for outsourcing exams for external reporting.
In order to minimise risk, reporting is carried out according to the following:
o IP & A/E CT & MRI; All Cancer imaging; All urgent imaging; Routine work o Routine work is split by source – GP work is prioritised as these images are unlikely
to have been reviewed by anyone prior to the report being available, A/E images should all have been reviewed by a trained A/E doctor so these images carry the lowest risk of delayed diagnosis.
Working closely with NLaG radiologists to maximise reporting capacity, by offering additional sessional reporting.
Maintaining daily contact with external reporting companies to ensure as much reporting as possible is outsourced – capacity is limited at present so all alternatives are being considered.
Undertaking costing exercise to understand requirements to remove all backlog reporting – to be reviewed monthly after month end finance activities completed & reported at Branch Business meeting.
Backlog Reporting
Costs
While it is acknowledged that the NLaG position is not ideal, it is being managed well, and some reassurance is taken from the fact that this is a National concern – see RCR census attachments:
RCR Census
Presentation.pptx RCR Census
Infographic.pdf
Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: CQC44 Lead: All ACOOs
Current BRAG Rating Proposed BRAG Rating
CQC Recommendation: The Trust must ensure that equipment is checked, in date and fit for purpose, including checking maternity resuscitation equipment and critical care equipment is reviewed and where required, included in the Trust replacement plan.
Action: Processes for ensuring that equipment is included in the Trust replacement plan and on the risk register to be shared again with Associate Chief Operating Officers to ensure compliance.
Completion Date: 30 June 2016
Progress Update:
A 'Medical Device Evaluation and Replacement Process' is in place within the Trust. This has been shared with the ACOOs and will be kept under review at the Equipment Group and will be further discussed at August's Equipment Group.
Evidence of Compliance and / or embedding * Supporting Documents **
Equipment Group minutes
Adobe Acrobat
Document
Demonstration that those items on the equipment replacement plan are up to date
Adobe Acrobat Document
Medical Devices Evaluation & Replacement Process
Medical Device
Evaluation and Replac
On-going Monitoring Arrangements:*** Equipment Group to review the replacement process in accordance with documentation control requirements
Executive Director Responsible:
Dr Karen Dunderdale, Deputy Chief Executive/Director of Operations
Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
Trust Governance and Assurance Committee
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: 52 Lead: Dawn Daly
Current BRAG Rating Proposed BRAG Rating
CQC Recommendation: The Trust must ensure that all substances which could be harmful are stored appropriately, specifically within the Ironstone Centre.
Action: Ensure that substances which could be harmful are stored correctly.
Completion Date: 30 June 2016
Progress Update: Ironstone building manager, Kirsty Dale. contacted to ensure the cleaning cupboard is locked at all times. She has confirmed that she has informed the cleaners of this action. Clinical staff do not access this cupboard, but have been asked to escalate immediately if they find the cupboard is unlocked whilst they are carrying our clinical sessions in the building.
Digilock fitted to cleaners cupboard where cleaning fluid stored.
Evidence of Compliance and / or embedding * Supporting Documents ** Team Lead/Lead clinician, responsible for checking that substances are stored correctly when using the clinical rooms at Ironstone. Spot checks carried out on service visits by managers.
Verbal assurance given by Tissue Viability sister and Team Leader. No issues regarding storage of cleaning fluid raised at recent mock CQC visits to the Ironstone.
CQC update for
Ironstone.msg
Confirmation of Digilock fitting to the cleaning cupboard 4. 7.16
FW Chronic wound
clinic.msg
Photo evidence
CQC 52 - photo of
lock on door.docx
On-going Monitoring Arrangements:***
Spot checks via mock CQC visits
Executive Director Responsible:
Dr Karen Dunderdale, Deputy Chief Executive/Director of Operations
Board Sub Committee Responsible for Oversight (as per CQC Action Plan)
Trust Governance & Assurance Committee
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: 53 Lead: Ashy Shanker
Current BRAG Rating Proposed BRAG Rating
CQC Recommendation: The Trust should ensure that there is a standard operating procedure for the use of the second theatre (anaesthetic room) to maintain patient safety with maternity.
Action: A standard operating procedure to be developed.
Completion Date: 30 June 2016
Progress Update: SOP agreed and in place. Approved by clinical governance group on 24/6/16.
Evidence of Compliance and / or embedding * Supporting Documents **
SOP
Microsoft Word 97 -
2003 Document
Minutes of Governance meeting
Microsoft Word 97 -
2003 Document
On-going Monitoring Arrangements:***
Theatre Utilisation report
Executive Director Responsible:
Dr Karen Dunderdale, Deputy Chief Executive/Director of Operations
Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
Quality & Patient Experience Committee
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: CQC58, 60 Lead: Ashy Shanker
Current BRAG Rating Proposed BRAG Rating
CQC Recommendation:
The Trust should ensure that within maternity services multiple use equipment and devices are cleaned or decontaminated between uses; that all areas are kept clean and records of cleaning are maintained.
Action: CQC 58 - Ensure that staff are aware of the need to ensure that multi-use equipment is cleaned between patients. Completion date: 31.05.16 CQC 60 - At DPOW, move to the use of single use monitoring belts. 31.05.16
Progress Update:
CQC 58 All managers have been instructed to ensure that multi use equipment is cleaned between patients and required to cascade this information. 1/6/16: Update: This requirement is being formally monitored by the Quality Matron as part of the monthly quality dashboard visits to determine level of staff awareness.
CQC 60 This has been enacted. The Head of Midwifery has confirmed that the use of reusable fabric monitor belts that required washing has now ceased and that disposable belts are now used instead. Disposable belts were ordered via supply chain purchase on 2 May 2016. The team are now on their 3rd box
Evidence of Compliance and / or embedding * Supporting Documents **
Audit to demonstrate multi use equipment is cleaned between patients
Audit to demonstrate that single use equipment is being used
Adobe Acrobat
Document
Works order for the monitoring belts – May 16
Reorder of monitoring belts – September 2016
Adobe Acrobat
Document
Advice note - monitor
belts reorder sept16.p
On-going Monitoring Arrangements:***
QM monthly audits
Executive Director Responsible:
Dr Karen Dunderdale, Deputy Chief Executive/Director of Operations
Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
Quality & Patient Experience Committee
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: CQC64 Lead: ACOOs
Current BRAG Rating Proposed BRAG Rating
CQC Recommendation: The Trust must have a process in place to obtain and record consent from patients and/or their families for the use of the baby monitors in critical care and for the use of CCTV in coronary care.
Action: Whilst there is a process in place for staff to follow, there are notices displayed and verbal consent is obtained from patients and / or relatives for the use of the cameras / monitors, consent needs to be recorded in patient' notes.
Completion Date: 31 August 2016
Progress Update: The requirements for the recording of consent in patients' notes has been reinforced and will be monitored by the Operational Matron. 1/6/16 Update: Monitoring visit undertaken by LSMS and all processes in place and being used. Additional monitoring visit to continue to test the application of the policy on CCU and Critical care with a Quality Matron visit to take place during June and with input from Operational leads. 'yes when they do the morning round, question the nurse in charge to ensure clearly documented evidence in the patient notes that the monitors are in use and the pt and family have been informed.' Helen Davis undertaking an audit of pts and evidence will be forwarded within the week – 15/9/16
October Update - W&C - There are 2 baby monitors on the neonatal unit at DPOW which are in the 2 rooms that can’t be seen from the nurses station – the isolation room (the door should be shut if baby in isolation therefore staff can’t hear a baby crying) and room 4 which are both situated off the main corridor. Work has been done with John Melville’s team to ensure these monitors are legitimate and signs are up on the unit informing parents that the monitor is in the room and the reasons why. Parents are also told verbally about the monitor if their baby is in the room.
The monitors are like ones you can have at home – two basic cameras, one in the room overlooking the baby in the cot, and the other at the nurses station so nurses can keep an eye on the baby from there. There is also sound on the monitor at the station so noise can be heard coming from the room.
Evidence of Compliance and / or embedding * Supporting Documents **
Process for the use of a visual monitor in critical care areas
Process for the use of
a Visual Monitor withi
Audit of consent for camera use in CCU
Audit of consent for camera use in neonatal care
Audit of consent for camera use in ITU
CQC 64 Use of
Camera in ITU audit s
Privacy Impact Assessment
Privacy Impact
Assessment CCTV Ca
Photos of signs confirming monitors are in use in SGH ICU
Shift leader checklist – ongoing monitoring of consent for cameras
CQC 64 - photo
evidence of cameras i
CQC Action 45 - SGH
ICU shift leaders chec
Security Surveillance Report – John Melville (excluding Coronary Care)
Security Surveillance
report
On-going Monitoring Arrangements:***
Executive Director Dr Karen Dunderdale, Board Sub Committee Trust Governance & Responsible: Deputy Chief Responsible for Assurance Committee
Executive/Director of Oversight (as per CQC Operations Action Plan):
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: 87 Lead: Karen Fanthorpe
Current BRAG Rating Proposed BRAG Rating
CQC Recommendation: The Trust must review the validation of mixed sex accommodation occurrences, ensure patients are cared for in an appropriate environment and report any breaches.
Action: For immediate review and action.
Completion Date: April 2016
Progress Update:
Update @ 29.9.16
The Board considered the position of the Trust in regard to EMSA at its meeting on 26th January 2016. This included feedback from the discussion with Monitor the previous week. As a result, the Board decided that the escalation route for any mixing of sexes would be at director level only and for this to take immediate effect. Communications to this effect were cascaded immediately – evidence attached
The Trust continues to operate this escalation route for the mixing of sexes which requires authorisation at director level, in advance (NB this does not apply to specialist units such as ICU, HDU where the mixing of male & female patients is permitted within the guidance)
The Trust took immediate action with regard to the Acute Medical Unit at DPOW (which was the location for the reported breaches following the CQC visit). With effect from 25th January 2016, the AMU and Short Stay Unit were amalgamated into a single unit which provided the flexibility required to prevent any further risk of breaches occurring on this unit.
The Trust has submitted a zero return for breaches every month since January 2016 – evidence is provided of the monthly returns
The WebV system has been developed to provide an automated alerting function – this system provides the assurance for the Trust to be able to declare compliance in the monthly returns – a screenshot of the WebV screen is attached as evidence. A flow chart showing how this system operates is attached. An analysis of the trigger alerts for September 2016 will follow
QPEC is the route by which the ongoing actions for Eliminating Mixed Sex Accommodation are monitored and reviewed. The latest report (July 2016) is attached as evidence. The next report is due in October 2016.
Evidence of Compliance and / or embedding * Supporting Documents ** Briefing issued to instigate zero tolerance approach to the mixing of
sexes plus instructions re new escalation process – issued on 26th
January 2016
CQC 87 EMSA - email
to directors from KG 2
QPEC report (July 2016)
Monthly UNIFY reports (January – August 2016 inclusive)
MSA unify returns
Jan-Aug16.zip
WebV trigger alerting flow chart
Analysis of trigger alerts for Sept 2016 – to follow
WebV icon snapshot
MSA Trigger
Response flowchart 2
CQC 87 MSA screen
shot - red & blue beds
Spot checks of staff in AMU re Mixed Sex occurrences, reporting and escalation process – to follow
On-going Monitoring Arrangements:*** QPEC is the route by which the ongoing actions for Eliminating Mixed Sex Accommodation are monitored and reviewed.
Executive Director Responsible:
Dr Karen Dunderdale, Deputy Chief Executive/Director of Operations
Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
Quality & Patient Experience Committee
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: Numbers 94 Lead: Karen Fanthorpe
Current BRAG Rating Target BRAG Rating
CQC Recommendation: The Trust must review the validation of mixed sex accommodation occurrences, ensure patients are cared for in an appropriate environment and report any breaches.
Action: Update of the Patient Information leaflet – with input/support from Health Watch
Completion date: 30 September 2016
Progress Update: June 2016: Draft of a revised leaflet has been completed for discussion via Task and Finish Group. This has been shared with commissioners for their comments – in the interim, Commissioners have requested that the existing leaflet is provided to all patients in critical care areas and this has been actioned.
10.8.16: Final version of the new leaflet for patients has been to both the Healthwatch groups in NL and NEL and suggested amendments incorporated
8.9.16: The Eliminating Mixed Sex Accommodation (IFP-704) leaflet was approved via the Trust’s IFP Group
Order for new leaflets (x500) has been placed
29.9.16: copies of the leaflet have been distributed to the specialist wards/units for distributing to patients as an interim measure until the printed leaflets are received
Evidence of Compliance and / or embedding * Supporting Documents **
Final version of the new leaflet
FINAL patient Leaflet
Single Sex Accommod
On-going Monitoring Arrangements:***
Leaflet will be reviewed in Sept 2019 in line with document control process
Executive Director Responsible:
Dr Karen Dunderdale, Deputy Chief Executive/Director of Operations
Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
Quality & Patient Experience Committee
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: Numbers 114 Lead: Dawn Daly
Current BRAG Rating Proposed BRAG Rating
CQC Recommendation: The Trust must ensure three-monthly safeguarding supervision takes place for health visitors.
Action: Ensure three-monthly safeguarding supervision takes place.
Completion date: 31 March 2016
Progress Update: All early help champions and practice teachers were trained as peer safeguarding supervisors in
October 2015
Three monthly peer safeguarding supervision has been implemented within the HV service
In addition, six monthly named nurse supervision is undertaken which provides external challenge
An early warning mechanism has been developed to flag when someone is due to go out of compliance in order that this can be addressed so that applicable compliance remains at 100%.
14.9.16 – All HV’s are compliant with 3 monthly supervision –verbal September report 100%
Evidence of Compliance and / or embedding * Supporting Documents **
Evidence from OLM that all eligible HV’s are compliant 3 monthly supervision has moved from 0% at the beginning of the year to 88% this month.
OLM report
All staff inform clinical development team of completion Group supervision summaries of discussions are added to personnel files
1:1 supervision evidence completed and attached to child’s electronic record
Staff email clinical development practitioner regarding completion of supervision so can be uploaded onto OLM
Personnel files SystmOne
Please find attached the safeguarding supervision compliance record. Report as of 12/08/2016 is at 88%. This equates to 5 staff members who have fallen out of compliance on 31.7.16, active management follow up occurring, (1 due to sickness)
OLM/ESR report from training and development
Recent safeguarding supervision audit demonstrates the embedding of the peer supervision in practice of those who undertook the audit and evaluates well. Please see below the relevant 3 monthly peer safeguarding supervision standards from the audit which evidence embedding. N=16
Safeguarding supervision audit-not yet published.
Standard 5 Achieved
For Early Help Peer Supervision the Supervisor should:
- Complete a practitioner supervision record that is signed off by both supervisor / supervisee during the session
- Retain a copy of the record for their records, kept in the supervisee’s supervision record.
13/13 (100%)
16/16 (100%)
Standard 12 Peer
For the Safeguarding Supervision meeting, this should:
Have protected time given 9/16 (56%)
Take place at a quiet venue with no interruptions 15/16 (94%)
Have mobile IT equipment and access be available 16/16 (100%)
Be supportive for the Supervisee 16/16 (100%)
Provide constructive feedback from the Supervisor to the Supervisee
16/16 (100%)
Review the progress of previously made initial or review supervision plans.
12/14 (86%)
Evidence from OLM – 3 monthly supervision Training programme for peer safeguarding supervision Six monthly named nurse supervision Evidence of early warning mechanism which flags out of compliance position Current position for safeguarding supervision as at end August
Training programme for peer safeguarding supervision
Microsoft Word 97 - 2003 Document
Six monthly named nurse supervision
Evidence of early warning mechanism which flags out of compliance position
Current position for safeguarding supervision as at end August
Microsoft Excel
97-2003 Worksheet
Standard 11 Peer
A copy of the supervision record should be:
- Retained by the practitioner for their records
- Kept In the supervisee’s supervision record in the Safeguarding Children Team office.
16/16 (100%)
16/16 (100%)
On-going Monitoring Arrangements:*** Clinical development practitioner/early help lead, head of CYPS service ,CYPS operational matron &
team leader and the head of safeguarding and named nurses are sent a report monthly which flags RAG compliance
The report is forwarded to the peer supervisors to monitor and ensure compliance of all team members
Amber compliant staff are emailed to remind regarding compliance
Once supervision has taken place staff send or email relevant documents to the clinical development practitioner/early help lead for uploading to OLM and placing in personnel file
Clinical development report during the HV professional meetings includes reminders for all staff regarding the compliance and process
Compliance and maintenance discussed at Early help champion meetings
Executive Director Responsible:
Dr Karen Dunderdale, Deputy Chief Executive/Director of Operations
Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
Trust Governance and Assurance Committee
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Action Update – Assurance Template
CQC Action Number: CQC132 Lead: Tracey Broom
Current BRAG Rating Proposed BRAG Rating
CQC Recommendation: The Trust should strengthen the support provided to nuclear medicine technologists by the ARSAC (administration of radioactive substances advisory committee) licence holder.
Action: Strengthen support as outlined in CQC action.
Completion date: 30 June 2016
Progress Update: A Consultant Radiologist from HEY is now our ARSAC Licence Holder – contract runs until March
2019. He provides support both remotely and in person when required. Consultant Radiologist &
ARSAC support will include:
reporting nuclear medicine scans for NLaG
documentation review 1-2 hours weekly
advice and guidance
Governance arrangements will include weekly visits by Hull physicists to NLaG
hospital sites
Audits as required
adhoc visits when required
training of NLaG Radiologists to report nuclear medicine scans
Evidence of Compliance and / or embedding * Supporting Documents **
Final Service Specification
CQC 132 - Nuclear
med Service Spec inc
ARSAC Certificate for Dr Ged Avery
CQC 132 - ARSAC
licence certificate for
Contract monitoring action plan
CQC 132 NLaG - HEY
Contract Meeting Sept
On-going Monitoring Arrangements:*** Ongoing contract meetings – if issues arise, 1:1 meetings with HEY will be set up to discuss and resolve issues
Executive Director Responsible:
Karen Dunderdale Board Sub Committee Responsible for Oversight (as per CQC Action Plan):
TGAC
* Describe the evidence you are providing to demonstrate compliance and / or embedding
** Please embed any relevant supporting documents
*** Describe method for ongoing monitoring eg. Group Governance Meetings, Team Meetings,
KPIs, Reports etc
CQC Visit October 2015 - v24 - 19 10 2016
Progress RAG
Rating
RED
The action is off plan and cannot be returned to the planned date or it
has already missed the planned completion date
AMBER
Current indications are that action is on target OR is off plan but action
is being put in place to mitigate the delay and the action is expected to
return to the planned completion date
GREEN
Action on plan or completed
BLUE
Action has been completed and there is now compelling evidence that
the action has been embedded in day to day processes so it is unlikely
that there will be a recurrence of the issue
ACTION PLAN
NUMBER
SOURCE RECOMMENDATION ACTION PROGRESS EXECUTIVE LEAD OPERATIONAL LEADS TIMESCALE IMPLEMENTATION AND
EMBEDDING OF ACTIONS
BRAG RATING
VERIFICATION OF
ACHIEVEMENT/
EVIDENCE OF IMPACT
METHOD OF
MEASUREMENT
BOARD SUB
COMMIITTEE
OVERSIGHT
Safe
Staffing Levels
CQC1 CQC 2015 The Trust must ensure that
there are sufficient skilled,
qualified and experienced staff
in line with best practice and
national guidance, taking into
account patients' dependency
levels. This must include but
not be limited to: medical staff
within the emergency
department (ED) and critical
care, nursing staff within ED,
medicine and surgery and
midwives (DPOW).
Review of medical staff within the
emergency department to be
undertaken - both short and long term.
Rotas in place. Longer term plan being discussed across STP. Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer
(Medicine), Stuart
Baugh, Associate
Medical Director, Paul
Kirton-Watson,
Associate Chief Nurse
(Medicine)
31 August 2016
(Revised rota to be
implemented)
31 March 2017
(HLHF work)
Date expected to be
fully embedded - 30
November 2016
Completed Appropriate staff in place
to deliver services
KPI308
Vacancy rate for doctors
KPI302
Number of shifts not
filled
Rotas
Resources
Committee
CQC2 Review of medical staff within critical
care to be undertaken and revised
arrangements implemented as
appropriate.
Terms of Reference for review agreed. Meetings taken place throughout September
around middle grade rota. DRS pattern has been fixed, however due to complexities
and nuances of anaesthetics training and cross skill mix, this is altered on a week by
week basis to enable training and activity cover as appropriate. Evidence demonstrates
that rotas are filled appropriately. Anaesthetics have also come up with a list of
improvements and best practice which will improve the rota further and this will enable
the activity planner to improve the process.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Maureen Georgiou,
Interim Associate Chief
Operating Officer
(Surgery),
31 July 2016
(annual leave)
Completed Appropriate staff in place
to deliver services
KPI309
Vacancy rate for doctors
KPI303
Number of shifts not
filled
KPI362
On the day cancellation
rates
Rotas
Resources
Committee
01/10/2016
(introduction of rotas)
Date expected to be
fully embedded - 31
December 2016
Completed
CQC3a Review of the nursing staff within the
emergency department to be
undertaken and revised arrangements to
be implemented as appropriate.
1Nursing establishment review for ECCs completed. Ambulance handover nurse in
place which has significantly improved position in both EDs. Daily & Weekly meeting
held to review staffing levels and patient throughput. At known exceptional times
plans put in place to increase staffing levels ie Bank Holiday Weekends. A monthly
retrospective review to be introduced July to ensure fill rates are maintained.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer
(Medicine), Stuart
Baugh, Associate
Medical Director, Paul
Kirton-Watson,
Associate Chief Nurse
(Medicine)
31/08/2016
Date expected to be
fully embedded - 31
October 2016
Completed Appropriate staff in place
to deliver services
KPI310 & KPI311 Vacancy
rate for nurses
KPI306
Number of shifts not
filled
KPI334
Resources
Committee
1
2
Introduction of Paediatric Nurses to the
ED.
As part of a review of establishments the Trust considered the introduction of
dedicated paediatric nurses for ED, not least due to the fact that there was the
Karen Dunderdale,
Deputy Chief
Peter Bowker, Associate
Chief Operating Officer
31/08/2016 Some slippage on original
date for completion
Datix incidents re capacity
Resources
Committee
possibility of redeployment of some of the paediatric nurses from childrens to A&E. If
this had occurred, the nurses would have required additional training to ensure that
Executive and
Director of
(Medicine), Stuart
Baugh, Associate
Date expected to be
fully embedded - 31 Rotas
they were dual trained in order for them to be able to see the wide range of patients Operations Medical Director, Paul January 2017 who come through the door in A&E. Following a review what other Trust have in place Kirton-Watson, in A&Es and in discussions with NHSI, it was identified that it would be more effective Associate Chief Nurse to adopt a pathway approach, as others have, thereby providing appropriate care to all (Medicine) groups of patients at all times. These ratified pathways are in place and plans are in place for them to be reviewed by NHSI for completeness. The pathways allow for paediatric care that is unable to be delivered by A&E nurses, to be delivered via the paediatric specialist team on site when required. Evidence to demonstrate the effectiveness of this model is currently being collated and will be available by the end of October 2016.
Review of the nursing staff within Nursing establishment process for Medicine Group has been completed in terms of Karen Dunderdale, Peter Bowker, Associate 31/07/2016 Completed Appropriate staff in place KPI316 & KPI317 Vacancy Resources
medicine to be undertaken. staffing profile. Engagement with ward managers has taken place. Deputy Chief Chief Operating Officer to deliver services rate for nurses Committee
Establishment review has been approved at Resources Committee in August. All Executive and (Medicine), Stuart Date expected to be rosters have been amended to commence 12th September 2016. Director of Baugh, Associate fully embedded - 31 KPI304 Operations Medical Director, Paul December 2016 Number of shifts not Kirton-Watson, filled Associate Chief Nurse (Medicine) KPI335 Datix incidents re capacity
Rotas
Review of the nursing staff within Following establishment reviews in May the new ward templates have been adjusted Karen Dunderdale, Maureen Georgiou, 31/08/2016 Completed Appropriate staff in place KPI314 & KPI315 Vacancy Resources
surgery to be undertaken. as from 15/8/16. Ward managers all refreshed regarding the reporting mechanism for Deputy Chief Interim Associate Chief to deliver services rate for nurses Committee
staff discussion at joint ward managers meeting on 20/6/16 – minutes available. Executive and Operating Officer Date expected to be Discussion of concerns re filling the rotas is resulting in reduction of beds within Director of (Surgery), fully embedded - 31 KPI305 surgical areas. Ongoing reassessment and review of occupancy, acuity and staffing Operations October 2016 Number of shifts not throughout the day with a daily and weekly review. Rosters now in place. filled
KPI336
Datix incidents re capacity
Rotas Review of number of midwives to be The midwifery staffing numbers have been reviewed against Birthrate Plus and meet Karen Dunderdale, Ashy Shanker, Associate 31 August 2016 Completed Appropriate staff in place KPI319 Resources
undertaken Trustwide. the requirements under this methodology. However, due to recent activity pressures Deputy Chief Chief Operating Officer (staffing changes to deliver services Vacancy rate for Committee
and the implementation of Trust policy to move to increased shift breaks, it has been Executive and implemented) Midwives identified that an additional 4.88 midwives are required. A proposal was presented to Director of ET in early June at which time, further information was requested. The revised paper Operations KPI307 will be discussed at the meeting on 19 July. The paper also recommends that the Trust Number of shifts not re-commissioners Birth-rate Plus to undertake a further review of the establishment. filled In the meantime, the additional shift required continues to be filled by substantive staff undertaking additional hours to ensure the safety of women within maternity wards. It KPI337 was approved by the executive team to support the increase in establishment on a Datix incidents re short term basis, and to support Birthrate plus being recommissioned. This however capacity would need to be reviewed against the trust reserve list and prioritised accordingly. Awaiting decision. KPI364 Ratio of midwives to births 31/12/2016
(Birth-rate Plus review
to have been
undertaken)
On Target
KPI365
1:1 figures for births
Maternity Dashboard
CQC3b
CQC4
CQC5
CQC6
CQC7 NLAG to continue to develop innovative
recruitment solutions in partnership with
other providers. NB: the Trust will
continue to seek support and advice
from national agencies to help with
recruitment.
Recruitment activities continue. Recruitment Strategy being developed at present, will
be circulated for comments across the Trust through November.
Jayne Adamson,
Interim Director of
People and
Organisational
Effectiveness
Claire Smaller, Head of
Employment Services
31 October 2016
Date expected to be
fully embedded - 31
March 2017
On Target Appropriate staff in place
to deliver services
KPI52
Vacancy rate for doctors
KPI319
Vacancy rate for
midwives
KPI51
Vacancy rates for nurses
KPI53
Vacancy rates for AHPs
KPI318
Vacancy Rate for
Unregistered Nurses
Resources
Committee
CQC8a Continue to resize available resource and
capacity, enact where required on the
grounds of safety and look to CCGs for
support when issues are 'flushed out'.
Agreed standards for nurse staffing in place for inpatient wards with a minimum 1:8
nurse to patient ratio on days. Establishment review timetable in place (April 2016) as
part of Sustainability plan. Reviews completed for Surgery & Critical Care, ECC,
paediatrics, neonates and medicine and are in the process of implementation
(August/September 2016). Maternity establishment currently based on last Birthrate
Plus review (2014 data). Temporary uplift recommended to ET approved in principle
(12th August 2016). Birthrate Plus to be recommissioned by Women & Children’s
Group.
Effective ward configuration discussed at Strategy & Planning meeting (July 2016) and
is being linked into service review schedule (to be completed and pulled together by
3rd October). Monitoring of short term impact of resizing capacity is reported through
the monthly staffing capacity and capability reports with appropriate mitigation
evidenced including temporary bed closures (from June 2016), usage of temporary
bank/agency staff and redeployment. A whole ward (19 beds) closed 15th August
temporarily to redeploy staff across the Medicine wards at SGH. Data for A&E fill rates
to be included in the monthly report from September.
Tara Filby, Chief
Nurse
Sue Peckitt, Deputy
Chief Nurse/ Associate
Chief Nurses
31 August 2016
Date expected to be
fully embedded - 31
October 2016
Ratified in principle at
Resources Committee on 19
October 2016
Appropriate staff in place
to deliver services
KPI52, KPI319, KPI151 &
KPI53
Vacancy rate for Nurses/
AHPs/ Doctors/ Midwives
KPI350
Number of service
reviews undertaken
KPI351
Number of services with
capacity plans
Rotas showing fill rates
Resources
Committee
CQC8b The MD office continues to provide oversight and scrutiny on the job plan project.
Concerns were raised in August Private Board regarding shortage of microbiologists
available in September. 93% of medical staff have a draft job plan, 30% have a signed
off job plan. Man marked job plan progress chart established to enable identification of
non-engagers
Lawrence Roberts,
Medical Director
Jane Heaton, Assistant
to the Medical Director
31 April 2016
Date expected to be
fully embedded - 31
March 2017
Completed Resources
Committee
CQC9a Processes need to be in place to
proactively plan for and monitor any
gaps in staffing.
As part of ‘Nurse Staffing Improvement’ Sustainability programme, processes have
been reviewed including: Establishment reviews – to match patient need to staffing in
terms of numbers and acuity/dependency – policy under development but reviews
undertaken at least annually with a review at 6 months – this uses Safer Nursing Care
Tool and a local model based on RCN & NICE guidance – output approved at Resources
Committee
SOP developed to archive approved rosters - archive created on shared drive. Roster
policy in place with KPIs to monitor compliance of e-Rostering – approved by Matrons.
Competency framework built into background of roster template – to be rolled out to
all areas to support effective skill mix distribution. Short term staffing policy in place -
New process under development for escalating “red” shifts and authorisation of ‘break
glass’ agency use – looking to include a strengthened proactive process as part of the
revised policy. Facility for identifying “red flag” events included on DATIX. Recruitment
plan and retention plan in place and monitored through oversight/stocktake. Head of
Clinical Rostering & Bank Services and e-Rostering Systems Manager part of Managing
Absence HR work stream. Deputy Chief Nurse has milestone plan in place to ensure
establishments reviewed at agreed intervals
Tara Filby, Chief
Nurse
Associate Chief Nurses
and Associate Medical
Directors (All
Groups)/Claire Smaller -
Head of Recruitment
31 August 2016
Date expected to be
fully embedded - 31
October 2016
Completed Appropriate staff in place
to deliver services
KPI52, KPI319, KPI151 &
KPI53
Vacancy rate for Nurses/
AHPs/ Doctors/ Midwives
Staff rosters
Use of bank and agency
staff
Board Papers
Resources
Committee
CQC9b Recruitment is part of the weekly directorate meetings covering clinical areas which are
governed to review establishments, approve vacancies and review priorities for each
area. This is a business partner model of working which is joined up in its approach to
ensure the recruitment team target the right skills and candidates needed to be
recruited working to local and national best practice. Minutes and notes of these
meetings are available. This is also managed within the sustainability meetings to which
recruitment report progress and escalate concerns. Current priority lists are under
review to ensure that the recruitment team are targeting the right skills and roles. A
number of posts have been offered and the team are currently working on the
conversion of these roles to ensure a quick and effective pre-employment phase
leading to a start date.
Lawrence Roberts,
Medical Director
Jane Heaton, Assistant
to the Medical Director
31 April 2016
Date expected to be
fully embedded - 31
October 2016
Completed Resources
Committee
3
4
CQC10a CQC 2015 The Trust must include a A review of this requirement was already All nurse managers have a proportion of protected time within their roster to support Tara Filby, Chief Associate Chief Nurses 31/08/2016 Completed Ward leaders report Staff Rosters Quality and Patient
review of dedicated underway prior to the CQC visit. managerial duties including PADRs, sickness support meetings etc. This is a minimum of Nurse (All Groups) having dedicated Experience
management time allocated to 9.5 hours and increases in accordance with number of areas managed and size of Date expected to be management time Feedback from Ward Committee
ward co-ordinators and nursing team. The Trust has prioritised a review of shift leader status but has the fully embedded - 31 Leaders managers. aspiration of increasing the proportion of protected time for managers in addition to October 2016 shift leaders within the next 12-24 months as evidenced in the paper to ET & Resource KPI349 Committee (April 2016). Number of wards with Amount of protected time has been reviewed as part of the establishment review dedicated management process – completed by end of August 2016. It has been identified that maternity is an time outlier as only has 7.5 hours currently. Paper to ET 14 August 2016 approved in principle to move towards standard minimum of 9.5 hours for equity with other inpatient areas.
CQC10b CQC2015 CQC Recommendation: The A review of this requirement was already April 2016: Resource Committee approved the first phase of implementation of shift Tara Filby, Chief Associate Chief Nurses 31/12/2015 Completed Ward leaders report Staff Rosters Quality and Patient
Trust must include a review of underway prior to the CQC visit. leaders on 5 wards. June 2016: Risk assessment completed with mitigation actions Nurse (All Groups) (options paper having dedicated Experience
dedicated management time identified including: daily staffing reviews, bay nursing, hourly care rounds, other roles presented to ET management time Feedback from Ward Committee
allocated to ward co- under development/pilot, identification of nurse in charge (red badge), Quality Matron 05/01/16 -completed) Leaders ordinators/shift leaders. nursing dashboard audits (care & patient experience), use of Safe Care Live tool and monthly oversight at the Board of fill rates and quality impacts on care. July 2016: shift 22/03/16 KPI349 leader for AMU/CDU in place on early and late shift, planned roll out of shift leaders (approval of proposed Number of wards with affected by recruitment difficulties and staff shortages on ward 22 and 25 so temporary way forward - dedicated management bed closures have been initiated. A shift leader on the early shift has been factored into completed) time the refreshed template. B2 shift leader to be rolled out July/August along with agreed establishment. September: shift leaders have been built into 5 ward areas as agreed in addition to ECC and ED however there have been difficulties with consistency of fill rate. Due to bed reductions it was agreed to move the pilot from ward 25 to ward 28 – this was only commenced on the September roster period. Feedback from each ward has been collated and is extremely positive as expected from front-line staff and ward sisters however it is limited due to time taken to recruit and fill the shifts. Medicine establishments for the 30 bed wards at SGH have had an agreed funded uplift to their establishment to 5 RNs which will give a 1:8 nurse to patient ratio plus a shift lead on days. A new bed reconfiguration has been reviewed at CEO challenge 28 September 2016 which proposes a move to a 24 bed model – with 4 RNs on Early and Late shift. This would ensure a 1:8 nurse to patient ratio plus a dedicated shift lead.
30 September 2016
(further actions to be
agreed following pilot)
Completed
CQC11 CQC 2015 The Trust must ensure Establishment review to be undertaken. Terms of Reference for review agreed. Meetings taken place throughout September Karen Dunderdale, Maureen Georgiou, 31/10/2016 Completed Shifts filled as per Trust Staff Rosters Resources
adequate out of hours Medical Director to source outside around middle grade rota. DRS pattern has been fixed, however due to complexities Deputy Chief Interim Associate Chief requirement Committee
anaesthetic staffing to avoid consultant to assist with this. Timescale and nuances of anaesthetics training and cross skill mix, this is altered on a week by Executive and Operating Officer Date expected to be KPI332 delays in treatment. estimated to be October 2016. In week basis to enable training and activity cover as appropriate. Evidence demonstrates Director of (S&CC)/ Dr Krishnan, fully embedded - 31 Incident reports due to addition meeting taking place by end of that rotas are filled appropriately. Anaesthetics have also come up with a list of Operations Clinical Lead for December 2016 lack of anaesthetist May 2016 with middle grade improvements and best practice which will improve the rota further and this will enable Anaesthetics anaesthetics to confirm new rota and the activity planner to improve the process. KPI367 (a-e) reinforce annual leave policy. On the day cancellations
CQC12a CQC 2015 The Trust should evaluate the Baseline data to be drawn from 7 day Trust has been able to access & analyse our data from national 7 day services survey Karen Dunderdale, Peter Bowker, Associate 31/07/2016 Completed Gap analysis in place Audit Data Resources
arrangements for consultant working audit to determine the gap in held in April 2016. Deputy Chief Chief Operating Office Committee
cover of the AMU to ensure a cover arrangements. Executive and (Medicine)/ Stuart consultant reviews all patients Director of Baugh, Associate daily, irrespective of length of Operations Medical Director stay. (Medicine)
CQC12b Programme of recruitment of ACPs to DPOW now has 5 long term locum ACPs operating from AMU additionally ACPs cover Karen Dunderdale, Peter Bowker, Associate 30/06/2016 Completed Patients reviewed KPI300, KPI301, KPI302, Resources
deliver a different model of care. from rotational basis at the weekend discharging alongside the junior doctor. The Deputy Chief Chief Operating Office (for recruitment to be appropriately KPI303, KPI304, KPI305, Committee
length of stay has reduced by 1 day. Executive and (Medicine)/ Stuart agreed) KPI306 & KPI307 Director of Baugh, Associate Clinical shifts unfilled Operations Medical Director (Medicine) KPI52, KPI319, KPI151 & KPI53 30 September 2016 Completed Vacancy rate for Nurses/ AHPs/ Doctors/ Midwives
5
CQC13 CQC 2015 The Trust must stop including
newly qualified nurses
awaiting professional
registration (band 4 nurses)
within the numbers for
registered nurses on duty.
Ensure that clear guidance is developed
and embedded within Trust Policy.
July: KPI in place – weekly report run from the electronic roster, validation by
Operational teams with evidence of action taken by the Nurse Staffing Improvement
Manager
Roster rules revised and templates all updated
August: weekly reports have identified a small number of B4 staff allocated in B5 shifts.
On investigation this has been due to human error or delay in processing change
form/roster template for staff who have received their PiN number – hence do not
recommend Blue rating until further KPI monitoring and assurance is received.
Evidence is captured weekly.
September: weekly review undertaken. No Band 4 working in band 5 shifts. Errors have
been made as above but corrected due to weekly comprehensive review and plan
changed efficiently and effectively. This will be monitored ongoing via a KPI
Tara Filby, Chief
Nurse
Associate Chief Nurses
(All Groups)/ Helen
Clarke, Clinical Lead for
E-roster Team
30/06/2016
Date expected to be
fully embedded - 30
September 2016
Ratified in principle at
Resources Committee on 19
October 2016
Rosters filled
appropriately
Staff Rosters
Establishment Reviews
KPI207
Pre pin usage
Resources
Committee
CQC14 CQC 2015 The Trust must ensure there
are adequate specialist staff,
training and systems in place
to care for vulnerable people
specifically those with
dementia.
Scope staffing requirements and develop
business case to take to Strategy &
Planning and for discussion with CCGs.
2 substantive appointments made – awaiting employment checks – 1 has 1 month
notice period, the other a 3 month notice period.
Member of staff working temporary hours on the bank from 5th September supporting
Quality Matron. Completion of national dementia audit is on track.
Tara Filby, Chief
Nurse
Rachel Greenbeck,
Quality Matron, Craig
Ferris, Head of
Safeguarding.
31 August 2016 Some slippage on original
date for completion
Revised Completion Date
31 October 2016
Appropriate care
delivered to vulnerable
patients
National Audit of
Dementia
KPI62
Dementia Training
Quality and Patient
Experience
Committee
CQC15 CQC2015 The Trust must ensure there
are adequate specialist staff,
training and systems in place
to care for vulnerable people
specifically those with learning
disabilities.
In North Lincolnshire, the NL CCG have commissioned RDash (mental health provider)
to recruit an ALD nurse to work between hospital and primary care (3 days hospital-
based). Recruitment to this post is underway. Following creation of a business case for
a post at the North East Lincolnshire end of the patch, a formal request was made to
NEL CCG to fund/commission a post. This request has not been supported. The
business case has been reviewed by NLAG ET against other priorities. Agreement has
been reached to fund a full time band 6 ALD liaison nurse post. Recruitment to this post
is currently underway. The Trust continues to receive positive feedback from a number
of sources in relation to delivery of person-centred care for patients with a learning
disability. In addition to the involvement of the lead Quality Matron, 2 other members
of staff with an Adult LD qualification have been offering advice and support on an ad-
hoc basis. The Chief Nurse has written to neighbouring providers to seek support in
relation to an interim position however at this stage no resource has been identified in
support but advice over the phone may be available to the QM lead re: recruitment as
required. Telephone calls are in the diary to discuss further with Care Plus Group and
Navigo. Recruitment process is now underway. One of the new dementia nurse
specialists has experience of working with LD patients and should be in post by late
October/early November so will be a resource to utilise. Additional resource identified
in KPMG review of the safeguarding team re: supporting MCA/DOLS. Issue identified to
ET for reserve list prioritisation. Recruitment to this post will also provide support for
staff in caring for patients with an LD. Meeting held with Head of Community &
Therapies and Lead Superintendant Physiotherapist for the Adult LD team to consider
how to strengthen inter-professional collaboration.
Tara Filby, Chief
Nurse
Rachel Greenbeck,
Quality Matron, Craig
Ferris, Head of
Safeguarding.
31 August 2016 Some slippage on original
date for completion
Revised Completion Date
31 October 2016
Appropriate care
delivered to vulnerable
patients
KPI355
Vulnerable Adults
Training
Quality and Patient
Experience
Committee
CQC16 CQC 2015 The Trust must ensure it acts
on its own gap analysis of
maternity services across the
Trust to deliver effective
management of clinical risk
and practice development.
At the time of the visit the Trust had put
together a business plan to support the
appointment of a dedicated Practice
Development Midwife to support risk
and practice development.
The Practice Development Midwife has been appointed to and commenced during April
2016. This post encompasses the requirements for Risk and Governance into one
combined post.
Initial feedback on the impact of the post is positive in terms of:
- Backlog of RCAs have been dealt with ( had about 40)
- New RCAs progressed quickly
- Complaints dealt with more responsively
- Policies and guidelines( incl NICE) for the group updated in time
- CTG training for midwives and medics implemented
- Additional workload on matrons eased
- Specific service development /quality improvement initiatives championed ( E.g
Bereavement room etc.)
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Ashy Shanker, Associate
Chief Operating Officer
(W&C)/ Julie Dixon,
Head of Midwifery
(W&C)
31 April 2016 Ratified at QPEC 10 August
2016
Governance & Practice
Development Midwife in
post
KPI342
Document control
KPI333
Incident RCAs
Quality and Patient
Experience
Committee
CQC17 CQC 2015 The Trust must ensure there
are always sufficient numbers
of radiologists to meet the
needs of people using the
radiology service.
Continue to work with HR Recruitment
teams to source Radiologists on
permanent, fixed term, or locum basis.
The service has produced a matrix which shows presence of Radiologists in the
departments each week from January to June 2016. In terms of recruitment, two new
radiologists were employed in December 2015 and April 2016 with a third person
agreeing to a one year fixed contract. Skype interview held 15/7/16, with Radiologist
currently in Singapore – position offered - currently negotiating salary & start date etc.
Continuing to look at CVs for further candidates. Utilising existing links with Indian
Teaching Hospitals to assess further interest – promotional literature to be delivered in
person over next 3 weeks.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Tracey Broom,
Associate Chief
Operating Officer (CSS)/
Oltunde Ashaolu,
Associate Medical
Director (CSS)
31 July 2016
Date expected to be
fully embedded - 31
October 2016
Ratified in principle at
Resources Committee on 19
October 2016
Reduction in the
radiology vacancy rate
KPI326, KPI327, KPI328,
KPI329, KPI330 & KPI331
Radiology reporting times
KPI363
Radiologist Vacancy Rate
Resources
Committee
Outpatient Capacity
CQC18 CQC 2015 The Trust must ensure that the
significant outpatient backlog
is promptly addressed and
prioritised according to clinical
need. It must ensure that the
governance and monitoring of
outpatients' appointment
bookings are operated
effectively, reducing the
Whilst the capacity issues within OPD are
known to the Trust and actions were
underway prior to the CQC visit to
resolve the backlog and there is
monitoring of the follow-up position and
actions through the Executive Team,
immediate steps to be taken ensure that
appointments are not being cancelled
without clinical input in to decision
In accordance with the Trust’s existing Access Policy and SOPs, an immediate
instruction was issued on Friday, 16th October 2015 to all clinical administration teams
that clinic appointments must not be cancelled without a clinical opinion (i.e.. existing
requirements were reinforced). Staff are also being empowered to escalate any
concerns or where they feel they are being asked to take actions which are outside of
this requirement. This latter requirement was reinforced as part of the above
instruction / briefing. Process continues to be followed with spot checks undertaken
by teams.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer,
(Medicine)/ Maureen
Georgiou, Interim
Associate Chief
Operating Officer
(S&CC)/ Ashy Shanker,
Associate Chief
Operating Officer
16 October 2015
Date expected to be
fully embedded - 31
November 2016
Completed Improved quality &
safety
Reduction in incidents
Reduction in complaints
& concerns
Waiting List Reports
Observational Audit
Director / ACOO Walk
rounds
KPI195
Reduction in Hospital
Quality and Patient
Experience
Committee
numbers of cancelled clinics
and patients who did not
attend, and ensuring
identification, assessment and
action is taken to prevent any
potential system failures, thus
protecting patients from the
risks of inappropriate or unsafe
care and treatment.
making. outpatient Cancelled
Appointments (by
patients)
KPI361
Outpatient Clinic Slot
Utilisation Rate
6
CQC19
CQC20
CQC21
CQC22
CQC23
CQC24
Compliance with the above instruction will be monitored daily through the clinical
administration supervisory staff and will be tested weekly by the Assistant Chief
Operating Officers (ACOOs). There will be further monitoring through observational
audit and KPIs.
(W&C) 16 October 2015
Date expected to be
fully embedded - 31
November 2016
Completed
A Root Cause Analysis (RCA) exercise was completed immediately this issue came to
light and in order to demonstrate that this practice was not systemic. The actions
arising from the RCA are included within the wider CQC action plan.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Jill Mill, Group Manager
Planned Care / Sarah-
Jayne Thompson,
Assistant General
Manager - Head & Neck
31/10/2015 Ratified at QPEC 10 August
2016
The Trust Access Policy was approved 10th November with a caveat to check clinical
involvement regarding cancellations. This is included in section 5.7.2
Pam Clipson,
Director of Strategy
and Planning
Kerry Carroll, Interim
Associate Director of
Strategy and Planning
10/11/2015
Date expected to be
fully embedded - 31
January 2017
Completed
In order to ensure consistency and oversight of the clinical administration systems and
processes which span the clinical groups, a senior over-arching lead has been identified
to co-ordinate and drive the required improvements proposed as part of the clinical
administration review. This post holder was in place from Monday, 2 November 2015.
Pam Clipson,
Director of Strategy
and Planning
Sarah Coombs, Service
Development &
Performance Manager
02 November 2015 Ratified at QPEC 10 August
2016
The series of Clinic Cancellation Workshops which were arranged as part of the
implementation of the Clinical Administration Review during 2015 and as part of the
wider series of staff engagement and awareness events were completed. However,
there are ongoing engagement events to test implementation of actions and as part of
the current Patient Admin Action Plan and these are in place until the end of 2016.
Progress against these actions are captured in CQC 24. There is good engagement from
SAT & Operational Management Teams at these events.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kate Conway,
Improvement Delivery
Manager
30/11/2015 Ratified at QPEC 10 August
2016
The Clinical Administration Review (CAR) was implemented by the end of November
2015. Monitoring and reporting on the impact of the changes has continued through
the weekly Sustainability Programme Stocktake Meeting and weekly by the Executive
Team. Oversight and challenge (and in turn assurance to the Trust Board) is also
provided through the monthly Resources Committee. The CAR has also been (and
continues to be) a standing item on the Trust Board agenda since August 2015.
Engagement events with staff continue including monthly time-outs. The time-outs
have provided the opportunity for further evaluation to changes and agreement of
further actions in response. Actions from the time-outs have been incorporated in to
the current patient admin action plan which will provide the work plan for the next 3 - 6
months. Oversight arrangements remain in place and recently strengthened. The
actions agreed and being progressed will further strengthened the arrangements in
place. Monitoring of the impact of the changes made continue via a range of
mechanisms e.g. incident reporting, KPIs etc. The Trust has also increased the
communications around this issue including briefings to MAC and HCC and TMB.
Weekly communications detailing progress also continue to be shared with the SAT /
operational teams. The key action remains to implement the current patient admin
action plan.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Karen Fanthorpe,
Interim Chief Operating
Officer
30/11/2015
(implementation of
CAR)
Completed
30 November 2016
(Implementation of
current patient admin
action plan)
Date to be fully
embedded - 28
February 2017
On Target
Quality and Patient
Experience
Committee
Quality and Patient
Experience
Committee
Quality and Patient
Experience
Committee
Quality and Patient
Experience
Committee
Quality and Patient
Experience
Committee
Quality and Patient
Experience
Committee
7
Quality and Patient
Experience
Committee
Quality and Patient
Experience
Committee
Resources
Committee
Quality and Patient
Experience
Committee
Quality and Patient
Experience
Committee
Resolution of the Backlog: Ophthalmology: validation of the ophthalmology patients Karen Dunderdale, Peter Bowker, Associate 31/12/2015 Some slippage on original
on the OPD waiting list whose appointment were overdue is already complete (please Deputy Chief Chief Operating Officer date for completion
refer to the Ophthalmology Recovery Plan and Dashboard). Of those patients Executive and (Medicine)/ Maureen Ongoing validated, a significant number were discharged and there are 431 patients left to see. Director of Georgiou, Interim Appointment dates will be offered to all of these patients by no later than the 31 Operations Associate Chief Revised timescale for December 2015. There is clinical input in to this process in order to assess and manage Operating Officer completion - 30 the clinical risks involved. Update as at 17/11/15: Appointment dates will be offered to (S&CC)/ Ashy Shanker, November 2016 all outstanding patients and all patients will be seen by 31 December 2015.Update as Associate Chief at 4/12/15: There are 150 patients left to see and all patients will be seen by 31 Operating Officer Date expected to be December 2015. Update as at 5/1/16: All patients now seen. Note: Whilst the Trust (W&C) fully embedded - 31 took action as above, there has remained a capacity shortfall which has resulted in a March 2017 further backlog in outpatient follow ups. The Trust has a clear improvement plan and trajectory which is being agreed with the CCGs and will include additional further capacity, consideration of external capacity, extensive validation of the list and discussions with the CCGs in relation to further referral avoidance measures. Progress against this plan will be reviewed weekly and shared with commissioners and the CQC.
Resolution of the Backlog: All Other Specialties: validation of all other patients on our 31/12/2015 Some slippage on original
OPD waiting list whose appointments are overdue is underway. The validation exercise date for completion
(administrative and clinical) will be completed and, all patients appointed by 31 Ongoing December 2015. There is clinical input in to this process in order to assess and manage the clinical risks involved. The Medical Director and Chief Operating Officer have met Revised timescale for with the consultant body to ensure they are cited on the above exercise and are fully completion - 31 engaged in the process. Update as at 5/1/16: First line validation complete - see December 2016 separate breakdown. Revised booking rules have been introduced. This means that patients requiring an appointment will only now be offered an appointment within 4 Date expected to be weeks of their due date. This will minimise the number of repeat appointment fully embedded - 31 cancellations. From the backlog, patients in need of an appointment within 4 weeks March 2017 have now been offered an appointment date. Those patients in need of an appointment 4 weeks+ have been flagged on the system and will be tracked through to appointment - capacity has been identified to see these patients. Note: Whilst the Trust took action as above, there has remained a capacity shortfall which has resulted in a further backlog in outpatient follow ups in some specialties. Plans have been developed as in ophthalmology and progress against these plans will be reviewed weekly and shared with commissioners and the CQC.
The risks identified in the September update still remain key risks however a number of
actions have been completed over the last month to ensure we are able to;-
• Quantify the outpatient supply and demand gap
• Progress with the job planning process at a quick a pace as we are able
• Some of the key actions identified through specialty specific business summaries have
come to fruition. This includes
- The commencement of the external sub contractor for ophthalmology services
- The consultant Orthodontist commenced in post during September as forecast
- Revised booking rules to increase throughput per session commenced in Cardiology
and initial areas in Ophthalmology
All of the above run in parallel to the immediate actions being taken by the Operations
Directorate to increase capacity albeit through premium rate sessions.
With the supply and demand gap quantified in outpatients and the critical specialties,
delivery of the key actions to increase capacity or reduce demand in the medium term
are being taken. A sample business summary which demonstrates the core actions is
embedded below as is the outpatient summary position. The Trust has raised with its
two main commissioners the need to deliver outpatient care differently and have
requested this be contained within their commissioning intentions with real actions to
deliver. The Trust has also compiled an action plan to aid delivery of this which
commences with a survey which will run through October.
Pam Clipson,
Director of Strategy
and Planning
Kerry Carroll, Interim
Associate Director of
Strategy and Planning
31 October 2016 On Target
There is improved reporting and monitoring in place in respect of the live waiting list Wendy Booth, Karen Fanthorpe, Immediate & Ongoing Completed
position including patients who are overdue their follow-up appointments. The new Director of Interim Chief Operating weekly waiting list report is shared extensively internally and with relevant external Performance Officer / Pam Clipson, Date expected to be stakeholders. Assurance & Trust Director of Strategy & fully embedded - 31 Secretary Planning November 2016
With effect from week commencing 26 October 2015, the Executive Team received 27 October 2015 Completed
weekly OPD appointment cancellations including repeat cancellations. Date expected to be fully embedded - 30 November 2016
CQC25
CQC26a
CQC26b
CQC27
CQC28
CQC29 Trust systems were also strengthened to more accurately capture and report on short
notice / on the day cancellations. This latter report will be in place from November
2015.
1 November 2015
Date expected to be
fully embedded - 30
November 2016
Completed Quality and Patient
Experience
Committee
CQC30 Whilst there is ongoing of actions in place, external audit of the Trust’s actions was
undertaken by KPMG. The findings and recommendations from the audit have been
captured within the Trust’s patient admin action plan which is ongoing. No significant
concerns were highlighted from that audit but need for pace in delivery actions
reinforced. KPMG have more recently been asked to audit the Trust’s management of
its waiting list.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Sarah Coombs, Service
Development &
Performance Manager /
Claire Jenkinson, Head
of Performance
30/11/2015
(completed & ongoing)
NB. TOR for 'external'
audit being finalised.
Auditors on site w/c 7 &
14 December 2015)
Completed Quality and Patient
Experience
Committee
31/03/16
(date for completion of
audit and receipt of
report)
Completed
30 November 2016
(implementation of
current patient admin
action plan)
Date to be fully
embedded - 28
February 2017
On Target
CQC31 CQC 2015 NEL CCG have placed a focus upon
mobilising Cardiology and Respiratory
services out of hospital and this could be
a pilot. NELCCG to confirm structure for
out of hospital cardiology and
respiratory service to enable NLAG to
understand how it could develop
accordingly.
North East Lincolnshire CCG have commissioned provision of these services external to
NLaG. Care Plus group deliver community cardiology services from Weelsby View
Primary Care Centre. The out of hospital service is due to go live during October. The
Trust has given a commitment to support in terms of joined up systems. This will be
monitored as the service mobilises and embeds. During September, a Trust Respiratory
Consultant (Dr O’Flynn) commenced training of primary care nursing staff to deliver
community based COPD clinics. The impact upon secondary care will be monitored as
the service embeds
Pam Clipson,
Director of Strategy
and Planning (Trust
Lead)
Accountable
Officers (External
Lead)
Jan Haxby (NELCCG)
Jane Ellerton (NLCCG)
31/10/2016 Completed Plans in place for
cardiology and
respiratory
Reduction in the number
of patients treated in
hospital
KPI356 (a&b)
Reduction in Cardiology
referrals
KPI357 (a&b)
Reduction in Respiratory
referrals
Resources
Committee
CQC32 Potential for support and guidance for
pre referral to be explored.
This was linked to outpatients access, if
support/guidance was available for GPs,
content of the physical referrals would
be improved and may not be needed at
all. Requested by CCG at Quality
Summit.
At the Quality Summit on 25 April 2016, the health community agreed to work together
on these actions. A meeting has been arranged with representatives from medicine
and general practice at North Lincs. Jan Haxby to discuss internally the possibility of
being part of this work to ensure a co-ordinated approach across the patch. GPs may
contact any consultant by phone for advice. A proof of concept project is working with
Market Hill and Roxton practices on a central referral pathway. Dir of Strategy and
planning will today offer the ability to request a pre-referral opinion, which should be
electronic and written to maintain an audit trail. The proof of concept runs through
September and if successful will roll out on a wider basis from October.
Lawrence Roberts,
Medical Director
Robert Jaggs-
Fowler, NLCCG
Jan Haxby
(NELCCG)
Stuart Baugh, Associate
Medical Director
(Medicine) (NLAG)/
Clinical Leads/ GPs
31/10/2016
Date expected to be
fully embedded - 31
March 2017
On Target Reduction in referrals to
the Trust
KPI347 (a&b)
Reduction in the number
of referrals to the Trust
Quality and Patient
Experience
Committee
CQC33 MSK pathway to be progressed,
including therapy services at North
Lincolnshire.
Suggest this action is closed. It is the Trust understanding that NL CCG awarded MSK to
a private provider during quarter 4. Unsure why this was raised at the quality summit
in April.
Pam Clipson,
Director of Strategy
and Planning (Trust
Lead)
Accountable
Officers (External
Lead)
Jane Ellerton (NLCCG) 31/10/2016 Ratified at Resources
Committee on 21 September
2016
MSK Pathway in
operation
Not Applicable - service
not provided by the Trust
Resources
Committee
CQC34 Enter and View' patient surveys within
out-patients to be undertaken to assess
the impact of the changes the Trust has
made.
Report received and shared with OPD management team. Response received re:
actions in train and development of a written response.
Tara Filby, Chief
Nurse (Trust Lead)
Stakeholder
Executive Quality
Leads (External
Lead)
Stakeholder Operational
Quality Leads
31/10/2016 Completed Improvement in patients
experience of out patient
services
Results of the Quarterly
Out Patient Survey
Quality and Patient
Experience
Committee
Environment and Equipment
8
CQC35 CQC 2015 The Trust must ensure that all
risks to the health and safety
of patients with a mental
health condition are removed
in Scunthorpe emergency
department (ED). This must
include the removal of all
ligature risks, although must
not be limited to the removal
of such risks. The Trust must
undertake a risk assessment of
the facilities (including the
clinical room and trolley areas,
but not be limited to those
areas), with advice from a
suitably qualified mental
health professional.
For immediate review and action to
mitigate the risks in the short and longer
term including completion of risk
assessment in conjunction with RDASH.
The works to create the ligature free room 10 on ECC was completed in March 2016. Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Kay Newton,
Operational Matron
(Medicine) / Claire
Thirwall, Lead Planning
Co-ordinator
13/11/15
(Risk Assessment -
completed)
20/11/15
(costings to be available
- completed)
11/03/16
(completion of works* -
completed)
Ratified at TGAC 18 August
2016
Improved safety Risk Assessment
Observational audits /
spot checks
KPI353
Incidents in A&E relating
to health and safety of
mental patients
KPI352
SIs in A&E relating to
health and safety of
mental patients
Trust Governance
and Assurance
Committee
CQC36 Low risk patients with sitter: (current) visitors room to be utilised. Steps have been
taken to remove, as far as reasonably possible, the ligature risks from this room.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Kay Newton,
Operational Matron
(Medicine)
13/11/2015 Ratified at TGAC 18 August
2016
Trust Governance
and Assurance
Committee
CQC37 Low risk patient who do not consent to a sitter: Room 10 to be utilised. Whilst work is
undertaken on Room 10, Cubicles 2 & 3 which are directly opposite the nurses' station,
to be utilised. In the event that these cubicles get full, Cubicles 6 & 7 to be utilised. All
ligature risks to be removed in accordance with the agreed guidance and process which
has been shared with all staff in the department.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Kay Newton,
Operational Matron
(Medicine)
13/11/2015 Ratified at TGAC 18 August
2016
Trust Governance
and Assurance
Committee
CQC38 For those patients who are considered to be high risk (and until the required
modifications have been made to Room 10: Cubicles 2 & 3 to be utilised. In addition a
sitter will be with the patient at all times. At the point the patient is admitted to the
cubicle, all ligature risks will be removed in accordance with the guidance and process
which has been shared with all staff in the department.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Kay Newton,
Operational Matron
(Medicine)
13/11/2015 Ratified at TGAC 18 August
2016
Trust Governance
and Assurance
Committee
CQC39 Introduce mental health risk assessment
tool.
A 'mental health assessment in self-harm patients' tool' has been developed by NLG in
conjunction with the Lead Consultant Psychiatrist in Mental Health at RDASH. The tool
has been shared for comment. Linked to this action - consideration is also being given
to comments within the MHA Monitoring Report on the absence of an 'observation
policy'. Update as at 4/12/15: Tool in use.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Kay Newton,
Operational Matron
(Medicine)
30/11/2015
(Review and
consultation to be
completed)
Completed Trust Governance
and Assurance
Committee
CQC40 Provide dedicated awareness training for
staff.
All mandated staff have now received training with the exception of long term sick and
overseas nurse.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Kay Newton,
Operational Matron
(Medicine)
20/11/15
(Schedule of Training
Dates - confirmed)
29/02/16
(Date for Completion of
Training)
Revised completion
date 31/8/2016
Revised completion
Completed Trust Governance
and Assurance
Committee
CQC41 Install an alarm in both triage rooms. Blick Minder System is already in use within A&E. The Blick Minder System is a portable
alarm system which enables staff to take an alarm into any area within A&E and
radiology and will inform security of the member of staff’s location. This system can be
used for staff working in lone working areas, when dealing with violent patients,
patients with MH issues etc. Advice was sought from the Trust’s Local Security
Management Specialist, who confirmed that this system would be suitable to address
the recommendation above. There are currently 10 alarms within A&E, but a further
10 alarms are due to be moved from blue sky unit imminently.
Staff have had training updates on the system to ensure they feel confident using the
system, and this training is ongoing.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Kay Newton,
Operational Matron
(Medicine) / Claire
Thirwall, Lead Planning
Co-ordinator / John
Melville, LSMS
30/11/15
(costings to be available
- completed)
11/03/16
(date for completion of
upgrade work) -
completed
29/02/16
(date for completion of
staff training-
completed)
Ratified at TGAC on 15
September 2016
Trust Governance
and Assurance
Committee
9
CQC42 CQC 2015 The Trust must ensure that the
recently constructed treatment
rooms at Scunthorpe ED that
were previously used as
doctors' offices are suitable for
the treatment of patients on
trolleys. This must include
ensuring that such patients can
be quickly taken out of the
room in the event of an
emergency.
Risk assessment to be completed. All completed and handed over. Pam Clipson,
Director of Strategy
and Planning
Kay Newton,
Operational Matron
(Medicine) / Claire
Thirwall, Lead Planning
Co-ordinator
20/11/15
(costings to be available
- completed)
11/03/16
(completion of works -
completed)
Ratified at TGAC 18 August
2016
Improved safety and
patient experience
Risk Assessment Trust Governance
and Assurance
Committee
CQC43 CQC 2015 The Trust must ensure that
equipment is checked, in date
and fit for purpose, including
checking maternity
resuscitation equipment and
critical care equipment is
reviewed and where required,
included in the Trust
replacement plan.
The Equipment group to review the
Terms of Reference to ensure they are fit
for purpose.
Equipment Group Terms of Reference have been reviewed and approved. Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Associate Chief Nurses
(All Groups)/ Chair of
the Equipment Group
(Nicola Parker)
30/06/2016
(Review of terms of
reference)
Completed Equipment clean and fit
for purpose
Spot Checks
Cleaning/ maintenance
schedules
Trust Governance
and Assurance
Committee
20 September 2016
(Additional actions
completed and
feedback to TGAC)
Date expected to be
fully embedded - 31
Completed
CQC44 Processes for ensuring that equipment is
included in the Trust replacement plan
and on the risk register to be shared
again with Associate Chief Operating
Officers to ensure compliance.
A 'Medical Device Evaluation and Replacement Process' is in place within the Trust.
This has been shared with the ACOOs and will be kept under review at the Equipment
Group.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Associate Chief
Operating Officers
30 June 2016
Date expected to be
fully embedded - 30
September 2016
Ratified at TGAC on 17
October 2016
Equipment clean and fit
for purpose
Spot Checks
Cleaning/ maintenance
schedules
Trust Governance
and Assurance
Committee
CQC45 Confirmation of processes for checking
that equipment is checked, in date and
fit for purpose to be reviewed and
shared with relevant staff with particular
emphasis on maternity resuscitation
equipment and critical care equipment.
S&CC are piloting named individuals per shift to complete the wards
daily/weekly/monthly checklist. Matrons are undertaking a secondary weekly check to
ensure wards are following process, and the pilot will end July 2016. Any amendments
will then be made and taken to August's Equipment Group for review and approval and
then rolled out to other groups.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Associate Chief
Operating Officers
31/07/2016
Date expected to be
fully embedded - 31
October 2016
Completed Equipment clean and fit
for purpose
Spot Checks
Cleaning/ maintenance
schedules
Trust Governance
and Assurance
Committee
CQC46 Raise awareness with staff in relation to
the need for checking equipment, e.g.,
monthly 'Check It' date.
All medical equipment is checked by Medical Engineering and the Equipment group
ensures that they are represented at every meeting. Any issues with broken or end of
life equipment is always picked up by them if not by the clinical area. Work is underway
with wards and departments to ensure that equipment checks are embedded in to
practice. Compliance with this is monitored via the daily/weekly/monthly checklist and
the matron's audit. It is also included in the CQC Mock Visits.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Associate Chief Nurses
(All Groups)/ Sarah
Mainprize/ Chair of
Equipment Group
(Nicola Parker)
31/07/2016
Date expected to be
fully embedded - 31
October 2016
Completed Evidence of awareness
raising campaign
Spot Checks
Cleaning/ maintenance
schedules
Trust Governance
and Assurance
Committee
CQC47 Build in monitoring processes to existing
assurance visits, e.g., CQC Mock visit.
This has been actioned. Equipment checks have been included in the internal CQC
themed visit process which is ongoing. These arrangements will be further tested
through the themed inspection visits being undertaken by NHSI during October 2016
and again during the CQC visit in November 2016.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kathryn Helley, Deputy
Director of Performance
Assurance
31/05/2016
Date expected to be
fully embedded - 31
October 2016
Completed Equipment clean and fit
for purpose
Spot Checks
Cleaning/ maintenance
schedules
Quality and Patient
Experience
Committee
CQC48 CQC 2015 The Trust must ensure that
community EQUIPMENT is
cleaned in line with cleaning
schedules.
Continue to ensure that medical
equipment in community bases is
cleaned to manufacturers guidelines.
A Decontamination Policy is in place. All areas have Infection Control Link Workers who
are responsible for doing monthly audits, which are reported centrally. Cleaning
Schedules are required in all clinical areas which have multiple use. Items of equipment
which are re-used have the green tape applied to show when they were cleaned and by
whom. All these are monitored through Mock CQC visits & infection control audits.
C&TS are currently producing an audit tool for staff to use themselves when in
community clinic areas, to be processed at the next governance meeting.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Dawn Daly, Head of
Therapy Services,
Community and
Therapy Services
31/07/2016
Date expected to be
fully embedded - 31
October 2016
Completed Equipment clean and fit
for purpose
Spot Checks
Cleaning/ maintenance
schedules
Quality and Patient
Experience
Committee
CQC49 CQC 2015 The Trust must ensure that
community ENVIRONMENTS
are cleaned in line with
cleaning schedules.
Estates and Facilities to assess all
properties to ensure cleaning contract is
in place.
All community venues, staff to ensure
cleaning schedules updated at the end of
all treatment sessions
All multiple use areas have cleaning schedules which are monitored through infection
control audits & mock CQC visits. Audit tool being presented to governance for
clinicians to reassure that all clinical areas in total meet requirements. Lines of
responsibility for cleaning schedules being requested at SMT 27/06/16. Confirmation
received that all cleaning schedules in place and named people identified for
monitoring.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Dawn Daly, Head of
Therapy Services,
Community and
Therapy Services
31/07/2016
Date expected to be
fully embedded - 31
October 2016
Completed Equipment clean and fit
for purpose
Spot Checks
Cleaning/ maintenance
schedules
Quality and Patient
Experience
Committee
10
CQC50a CQC 2015 The Trust must ensure that all
community equipment is
tested for electrical safety and
evidence is available to show
that equipment is serviced in
line with manufacturers
recommendations.
Estates and Facilities to work with
Community and Therapy Services Group
to ensure all Portable Appliance Testing
(PAT) is completed.
Update: There are 2 properties to conduct PAT, these will be completed by 31st
October 16. The 2 outstanding properties are Pilgrim Primary Care Centre and Stirling
Medical Centre. A total of 30 properties have been completed.
Jug Johal, Director
of Estates and
Facilities
Simon Tighe, Deputy
Director of Estates and
Facilities
30/09/2016
Date expected to be
fully embedded - 31
December 2016
Some slippage on original
date for completion.
Revised Completion Date
31 October 2016
All equipment tested
appropriately
Spot Checks
Maintenance Schedules
Register
KPI348
Buildings where PAT
testing complete
Trust Governance
and Assurance
Committee
CQC50b Medical Engineering to continue to work
with Community and Therapy leads to
ensure equipment is retrieved for
routine service & electrical safety testing
Medical Engineering test the medical equipment listed in the Trust spreadsheet. The
external contractor PAT tests everything else. They also test the electrically powered
plinths and chairs which are not listed on the medical equipment spreadsheet. The
contractor is able to identify what requires testing by Medical Engineering as
everything they maintain will have the blue equipment control number sticker and next
test due sticker. Under the Trust system the next test due sticker indicates that the
equipment has been serviced, tested and or calibrated and the appropriate electrical
safety test is carried out as part of the inspection. The Trust do not attach dedicated
PAT stickers to the equipment, only a next test due label as per Trust policy. This will
be monitored at CQC Mock Visits.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Gavin Cogley, Head of
Medical Engineering
30 September 2016
Date expected to be
fully embedded - 31
October 2016
Completed All equipment tested
appropriately
Spot Checks
Maintenance Schedules
Register
KPI348
Buildings where PAT
testing complete
Trust Governance
and Assurance
Committee
CQC51 CQC 2015 The Trust should ensure the Ensure that the intravenous fluid room in This has been addressed and locks are now on the doors in Scunthorpe. The doors Karen Dunderdale, Ashy Shanker, Associate 06/05/2016 Ratified at TGAC on 15 Fluids stored safely and Spot Checks Trust Governance
lock on the intravenous fluids maternity at Scunthorpe General have also been checked at Diana, Princess of Wales Hospital and this is also secure. Deputy Chief Chief Operating Officer September 2016 securely and Assurance
room in maternity at Hospital is secure. Executive and (W&C)/ Julie Dixon, Committee
Scunthorpe hospital is in Director of Head of Midwifery/ working order to ensure safe Operations Simon Tighe, Deputy storage of fluids. Director of Estates and Facilities
CQC52 CQC 2015 The Trust must ensure that all Ensure that substances which could be The cleaning fluids are now kept in the cleaners cupboard as this is the appropriate Karen Dunderdale, Tina Sykes, Associate 30/06/2016 Ratified at TGAC on 17 Review undertaken Spot Checks Trust Governance
substances which could be harmful are stored correctly. place for them to be stored. The cupboard is locked at all times and the cleaners and Deputy Chief Chief Nurse (C&TS)/ Bill October 2016 and Assurance
harmful are stored the NHS Property Estates Co-ordinator have a key to the cupboard. The Chronic wound Executive and Parkinson, Head of Fire, Date expected to be Committee
appropriately, specifically Sister also confirmed that after speaking to the cleaners following the issue being Director of Health and Safety fully embedded - 30 within the Ironstone Centre. raised they have removed the floor cleaning solution bottle and this is now in a Operations September 2016 permanently locked store cupboard.
CQC53 CQC 2015 The Trust should ensure that A standard operating procedure to be SOP agreed and in place. Approved by clinical governance group on 24/6/16. Karen Dunderdale, Ashy Shanker, Associate 30/06/2016 Ratified at QPEC on 12 Standard Operating Theatre Utilisation Quality and Patient
there is a standard operating developed. Deputy Chief Chief Operating Officer October 2016 Procedure in place Report Experience
procedure for the use of the Executive and (W&C)/ Maureen Date expected to be Committee
second theatre (anaesthetic Director of Georgiou, Interim fully embedded - 30 room) to maintain patient Operations Associate Chief September 2016 safety with maternity. Operating Officer (S&CC)/ plus AMDs
CQC54 CQC 2015 The Trust should undertake Address the environment issues as Works were scheduled to commence 30th August 2016, complete 2nd December 2016 Pam Clipson, Alex Afifi, Group 30 September 2016 On Target Works undertaken Observation Resources
work in a reasonable time- identified by the CQC. however as the cost for the building works on this project were over £250k (After a Director of Strategy Manager, Unplanned (Building work to have Committee
frame that will lead to the full cost analysis) authorisation was needed from monitor, a paper with a full and Planning Care (Medicine), Kay commenced by) Board Minutes creation of separate waiting breakdown of costs was sent to monitor and this was approved, the final decision was Newton, Operational and treatment areas for then taken to the Trust Board on Tuesday 30th August 2016 where final approval was Matron (Medicine)/ 30 November 2016 children in the Scunthorpe ED given. Due to the financial value the director of finance signed the order on Thursday 1s Claire Thirwall, Lead (Building work that are safe and secure. September 2016 and clugstons have confirmed receipt of this and agreed a start date Planning Co-ordinator completed) of Monday 19th September with completion on 23rd December 2016. Programme will be as follows: Phase 1 – 19th September – 17th October 16 - Creates a new majors entrance, New consulting room, consulting room 3 (Children’s room) and works to the security wall – works commenced on schedule Phase 2 – 18th October 16 – 29th November 16– Creating a dedicated children’s waiting area/play area and toilet Phase 3 - 30th November 16 – 23rd December 16 – modifications to the reception desk to bring to DDA compliant (not part of the CQC need but because area is changing, need to be DDA compliant)
11
CQC55 CQC 2015 The Trust should undertake
work in a reasonable time-
frame that will lead to the
creation of separate entrances
in Scunthorpe for ED for
patients self-presenting with
minor injuries or illnesses, and
those conveyed by ambulance
with serious injuries.
Address the environment issues as
identified by the CQC.
Works were scheduled to commence 30th August 2016, complete 2nd December 2016
however as the cost for the building works on this project were over £250k (After a
full cost analysis) authorisation was needed from monitor, a paper with a full
breakdown of costs was sent to monitor and this was approved, the final decision was
then taken to the Trust Board on Tuesday 30th August 2016 where final approval was
given. Due to the financial value the director of finance signed the order on Thursday 1s
September 2016 and clugstons have confirmed receipt of this and agreed a start date
of Monday 19th September with completion on 23rd December 2016.
Programme will be as follows:
Phase 1 – 19th September – 17th October 16 - Creates a new majors entrance, New
consulting room, consulting room 3 (Children’s room) and works to the security wall –
works commenced on schedule
Phase 2 – 18th October 16 – 29th November 16– Creating a dedicated children’s
waiting area/play area and toilet
Phase 3 - 30th November 16 – 23rd December 16 – modifications to the reception desk
to bring to DDA compliant (not part of the CQC need but because area is changing,
need to be DDA compliant)
Pam Clipson,
Director of Strategy
and Planning
Alex Afifi, Group
Manager, Unplanned
Care (Medicine), Kay
Newton, Operational
Matron (Medicine)/
Claire Thirwall, Lead
Planning Co-ordinator
30 September 2016
(Building work to have
commenced by)
30 November 2016
(Building work
completed)
On Target Works undertaken Observation
Board Minutes
Resources
Committee
CQC56 CQC 2015 The Trust should ensure there
is sufficient space and seating
for patients and their
supporters in the outpatients
department.
OPD Managers to discuss with Strategy
and Planning Team and offer areas
identified as a risk with seating,
mitigating plans and longer term
solutions that will require working up
and plans agreeing.
Additional outpatient space has been identified in zone 4 with funds agreed through
Charitable Funds.
Order placed
Pre-start meeting – Wed 7/9/16, contractors will present programme detail.
Works commence – Mon 19/9/16
Completion due – 10/10/16
Update: the contractor has found a gas pipe hidden behind a kitchen unit that will
require removing. A gas shutdown is being organised to remove pipe asap, current
indication is that this will not affect programme schedule however this will be kept
under review whilst pipe is removed.
Pam Clipson,
Director of Strategy
and Planning
Tracey Broom,
Associate Chief
Operating Officer (CCS)/
Louise Hobson, Planned
Care Manager (CSS)/
Kerry Carroll, Interim
Associate Director of
Strategy and Planning
30/06/2016
(additional seating
identified)
31 October 2016
(Completion of
additional works)
On Target Increase in seating
available
Patient experience
surveys
Quality and Patient
Experience
Committee
CQC57 CQC 2015 The Trust should ensure the
premises and location of the
ophthalmology department is
suitable for the purpose for
which it is being used.
To meet demand the Trust needs to
increase its workforce. This is not
possible due to space. Working with
strategy and planning to identify a new
location in order to expand the service to
meet the demand.
An area has been identified to increase the clinical footprint by a further clinic room on
the Grimsby site. This is to accommodate the workforce strategy in place within the
team. Works commenced 12th September and completed 23rd September 16. Room
now available. Mobilisation plan in progress for clinic room to become live (staffing
and equipment).
Pam Clipson,
Director of Strategy
and Planning
Maureen Georgiou,
Interim Associate Chief
Operating Officer
(S&CC), Kerry Carroll,
Interim Associate
Director of Strategy and
Planning
31/10/2016 Completed Patients receive care in
appropriate environment
Patient experience
surveys
Ophthalmology Action
Sheet
Resources
Committee
CQC58 CQC 2015 The Trust should ensure that
within maternity services
multiple use equipment and
devices are cleaned or
decontaminated between
uses; that all areas are kept
clean and records of cleaning
are maintained.
Ensure that staff are aware of the need
to ensure that multi-use equipment is
cleaned between patients.
All managers have been instructed to ensure that multi use equipment is cleaned
between patients and required to cascade this information. 1/6/16: Update: This
requirement is being formally monitored by the Quality Matron as part of the monthly
quality dashboard visits to determine level of staff awareness.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Ashy Shanker, Associate
Chief Operating Officer
(W&C), Julie Dixon,
Head of Midwifery
(W&C)
31/05/2016
Date expected to be
fully embedded - 30
October 2016
Ratified at TGAC on 17
October 2016
Improved patient
experience
Spot checks
Ward Reviews
CQC Mock Visits
Trust Governance
and Assurance
Committee
CQC59 E&F teams to evidence cleaning regimes. All complete. Jug Johal, Director
of Estates and
Facilities
Simon Tighe, Deputy
Director of Estates and
Facilities
31/05/2016
Date expected to be
fully embedded - 31 July
2016
Ratified at TGAC 18 August
2016
Cleaning Regimes FLO audits
PLACE
Environmental Audits
Trust Governance
and Assurance
Committee
CQC60 At DPOW, move to the use of single use
monitoring belts.
This has been enacted. The Head of Midwifery has confirmed that the use of reusable
fabric monitor belts that required washing has now ceased and that disposable belts
are now used instead. Disposable belts were ordered via supply chain purchase on 2
May 2016. The team are now on their 3rd box
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Ashy Shanker, Associate
Chief Operating Officer
(W&C), Julie Dixon,
Head of Midwifery
(W&C)
03/05/2016
Date expected to be
fully embedded - 30
September 2016
Ratified at TGAC on 17
October 2016
Improved patient
experience
Spot checks
Ward Reviews
CQC Mock Visits
Trust Governance
and Assurance
Committee
CQC61 Ensure that all areas are kept clean and
records of cleaning are maintained.
Monitoring processes have demonstrated that there are pockets of areas where
cleaning needs to be improved. For this reason, it was decided at the Executive
Chellenge meeting that this action should be revised to green until monitoring
processes demonstrate that this has been embedded.
Jug Johal, Director
of Estates and
Facilities
Ashy Shanker, Associate
Chief Operating Officer
(W&C), Julie Dixon,
Head of Midwifery
(W&C)
31/05/2016
Date expected to be
fully embedded - 31 July
2016
Revised to Completed at
October Challenge Meeting
Improved patient
experience
Environmental Audits
CQC Mock Visits
Trust Governance
and Assurance
Committee
CQC62 CQC 2015 The Trust must review the rate
of cancellations of outpatient
appointments and rates of 'did
not attend' at Goole and take
action to improve these in
order to ensure safe and timely
care and to meet the Trust's
own standards of 6%.
Please note: this work is taking place
Trustwide.
Clinic Cancellations & DNAs are part of
the work contained within the
Sustainability plan for OPD Trust wide.
An A3 report is published monthly and
shared with the OPD Sustainability
Group. A dashboard of group KPI
summary reports is shared by
Sustainability Programme Governance
Office for Medicine, Surgery and Women
and Children.
The average number of attendances and DNAs in the last 12 months was 35,781. July
16 saw a figure of 32,789 Attendances and DNAs and therefore lower than the average
of the last 12 months, for all sites, including Goole, which is currently just above 8%.
DPOW current position, 12 months to end July 16 = 15.0% (9.5% in July 16 compared
with 8.9% in June 16). Increase in most recent month but overall 12 month trend =
decreasing.
SGH current position, 12 months to end July 16 = 12.9% (10.6% in July 16 compared
with 7.9% in June 16). Increase in June and July but overall 12 month trend =
decreasing.
GDH current position, 12 months to end July 16 = 13.5% (14.6% in July 16 compared
with 8.5% in June 16). Increase in most recent month but overall 12 month trend =
decreasing
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Tracey Broom,
Associate Chief
Operating Officer (CSS)/
Louise Hobson, Planned
Care Manager (CSS)
30/06/2016
(review undertaken)
31 September 2016
(Data collection to be
completed)
31 October 2016
(Decision taken re pilot
rollout)
Date expected to be
fully embedded - 31
December 2016
Completed Improved patient
experience
Decrease in DNA rate
KPI182 & KPI338
DNA rate
KPI322 & KPI323
Cancellation rate
Trust Governance
and Assurance
Committee
Consent
12
CQC63 CQC 2015 The Trust must have a process
in place to obtain and record
consent from patients and/or
their families for the use of the
baby monitors in critical care
and for the use of CCTV in
coronary care.
For immediate review and action as
appropriate.
Cameras/monitors in use are commercial baby monitors which have visual and sound
capability but no recording capacity. Following the receipt of earlier legal advice, the
Trust is alive to the potential issues surrounding the use of cameras including the need
to consider alternatives wherever possible and also in relation to issues such as privacy
and dignity and consent to their use in terms of being compliant with Article 8 of the
ECHR. The current legal advice and advice from the Trust's Health & Safety Manager
and LSMS is that this type of "visualisation", rather than the monitoring and/or
gathering of information, is a ‘grey area’ for the purposes of the current legislation on
surveillance. The Trust does recognise that the previous legal advice obtained in 2007
pre-dates the current legislation, and in light of this, intends to be proactive and treat
the cameras as "surveillance" for the purposes of the current legislation. To this end, a
Privacy Impact Assessment and related actions has been undertaken. The Policy has
also been updated. Regular walk rounds are undertaken by the LSMS to monitor
compliance. A register is also in place outlining areas of the Trust where cameras/
monitors are in place and this is maintained by the LSMS. The LSMS monitors these
arrnagements.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Bill Parkinson, Health &
Safety Manager / John
Melville, Local Security
Management Specialist
(LSMS)
31/10/2015
(completion of Privacy
Impact Assessment)
16/11/2015
(approval of Privacy
Impact Assessment by
Trust Governance &
Assurance Committee
(TGAC)
Date expected to be
fully embedded - 31
August 2016
Ratified at TGAC on 15
September 2016
Improved patient
experience (privacy &
dignity)
Audit of Consent
Director Visits & Walk
rounds
Register of CCTV
Trust Governance
and Assurance
Committee
CQC64 Whilst there is a process in place for staff
to follow, there are notices displayed
and verbal consent is obtained from
patients and / or relatives for the use of
the cameras / monitors, consent needs
to be recorded in patient' notes.
The requirements for the recording of consent in patients' notes has been reinforced
and will be monitored by the Operational Matron. Monitoring visit undertaken by
LSMS and all processes in place and being used. Additional monitoring visits continue
to test the application of the policy on CCU and Critical care with a Quality Matron visit
to take place during June and with input from Operational leads.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Operational Matrons,
Medicine and Surgery &
Critical Care
November 2015
Date expected to be
fully embedded - 30
September 2016
Ratified at TGAC on 17
October 2016
Improved patient
experience (privacy &
dignity)
Audit of Consent
Observational Audits
Director Visits & Walk
rounds
Trust Governance
and Assurance
Committee
CQC65 CCTV Policy to be amended to capture
the above requirements.
Policy updated (incorporating legal advice) and approved at Trust Governance and
Assurance Committee in February 2016.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Bill Parkinson, Health &
Safety Manager / John
Melville, Local Security
Management Specialist
(LSMS)
02/12/2015
(policy updated -
completed)
18/01/16
(final approval -
completed)
Date expected to be
fully embedded - 31
Ratified at TGAC on 15
September 2016
Improved patient
experience (privacy &
dignity)
Compliance with
statutory and good
practice requirements
KPI183
Document Control
Trust Governance
and Assurance
Committee
Medicines Management
CQC66 CQC 2015 The Trust must ensure the safe
storage and administration of
medicines. The Trust must
ensure staff check drug fridge
temperatures daily and record
minimum and maximum
temperatures. Additionally it
must ensure staff know that
the correct fridge
temperatures to preserve the
safety and efficacy of drugs
and what action they need to
take if the temperature
recording goes outside of this
range.
For immediate review and action. The drug fridge on Ward 23 was immediately decommissioned and alternative
arrangements made. A new fridge has been purchased.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Michelle Long,
Operational Matron -
Medicine
01 November 2015 Ratified at TGAC 18 August
2016
Improved quality &
safety
CQC Mock Visits
Weekly Monitoring
Trust Governance
and Assurance
Committee
CQC67 Reinforce Trust policy and procedure. March 2016: drug fridge audit reviewed. Revised drug fridge checklist approved for use
March 2016 via NMAF. Drug fridge checklist rolled out to all clinical areas. Process in
place for Quality Matron review monthly on environmental audit. June 2016 –
commenced spot check audit weekly with zero tolerance escalation to ET/TMB.
Tara Filby, Chief
Nurse
Associate Chief Nurses/
Sue Peckitt, Deputy
Chief Nurse
31 March 2016 Ratified at TGAC 18 August
2016
Improved compliance
with Trust Policy
Improved quality &
safety
CQC Mock Visits
Weekly Monitoring
Trust Governance
and Assurance
Committee
CQC68 Ensure ongoing monitoring and testing. March 2016: drug fridge audit reviewed. Revised drug fridge checklist approved for use
March 2016 via NMAF. Drug fridge checklist rolled out to all clinical areas. Quality
Matrons review on environmental audit. June 2016 – commenced spot check audit
weekly with zero tolerance escalation to ET/TMB. ACOOS/TMB reminded of zero
tolerance process. Nil return process initiated for robust assurance – not all returns in
place – being followed up by relevant ACN.
Tara Filby, Chief
Nurse
Mike Urwin, Chief
Pharmacist / Quality
Matrons
30 June 2016
Date expected to be
fully embedded - 30
October 2016
Completed Improved compliance
with Trust Policy
Improved quality &
safety
CQC Mock Visits
Weekly Monitoring
Trust Governance
and Assurance
Committee
CQC69 Consider longer term solution. The CQC action is to ensure that the safe storage and administration of medicines
especially drug fridge temperatures. The immediate action has been taken to ensure
there is a manual check operating across the Trust, CQC reference 68. As part of the
Trusts IM&T strategy, where a manual process can be developed electronically to
improve efficiency and/or alleviate non clinical workload given the recruitment
challenges faced, drug fridge monitoring is an area where the Trust has agreed to
compliment the current manual process with an electronic monitoring system. The
CQC action is to ensure drug fridge temperatures are monitored. A manual process is
in place which satisfies this need with oversight through the Chief Nurse (CQC68). The
electronic solution provides an additional fail safe for monitoring drug fridge
temperatures. The BRAG rating is n/a as the manual process meets the CQC
requirement. The electronic solution enables the Trust to go a step further.
Pam Clipson,
Director of Strategy
and Planning
Mike Urwin, Chief
Pharmacist / Hazel Tait,
Medicines Manager
31/10/2016
Date expected to be
fully embedded - 28
February 2017
Not Applicable Improved compliance
with Trust Policy
Improved quality &
safety
CQC Mock Visits
Weekly Monitoring
Trust Governance
and Assurance
Committee
13
CQC70 CQC 2015 The Trust must ensure the safe
storage of oxygen cylinders on
the intensive care unit at
DPOW hospital.
Estates and Facilities team to assess
cylinder storage.
Assessment currently underway. Update as at 27/5/16: This piece of work has been
expanded to cover all three sites and therefore timescale has been extended. In the
interim, monitoring is taking place via the Health and Safety team and via CQC Mock
visits. Update: Review complete and areas for action identified. The full report from
BOC is awaited. For the majority of the wards the ward sister/charge nurse was in
attendance for the walk around and so any issues were feedback at the time of the visit
and this also acted as a learning opportunity. As part of the review, the Assistant
Director of Nursing and BOC attended ITU at DPOW and were shown the cylinder
storage and they were all stored in suitable containers and in one area of the unit. It
was agreed to obtain clear signage that medical gases are stored. There were no issues
with the storage. A lead clinician (Mr Chambers) has been identified to help develop
and engage staff. This will be complete by 31st August 2016.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Jen Orton, Interim
Deputy to the Associate
Chief Nurse (S&CC),
Simon Tighe, Deputy
Director of Estates and
Facilities.
30 June 2016
(Assessment to be
completed)
To be ratified at TGAC once
all elements complete
Improved safety CQC Mock Visits Trust Governance
and Assurance
Committee
31 July 2016
(Remedial work in ITU
to be complete)
To be ratified at TGAC once
all elements complete
31 August 2016
(Awareness raising with
staff complete)
Date expected to be
fully embedded - 31
October 2016
Completed
CQC71 CQC 2015 The Trust must ensure the
DPOW hospital discharge
lounge has a facility and
process for safe storage for
medicines.
A review of the current storage
processes to be undertaken in
conjunction with pharmacy management
to identify any changes required.
A new cabinet is in place. All staff have received training by the medicine management
team on correct storage procedure
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer
(Medicine), Paul Kirton-
Watson, Associate Chief
Nurse (Medicine)
30/06/2016 Ratified at TGAC on 15
September 2016
Improved safety Spot checks
Ward Reviews
CQC Mock Visits
Trust Governance
and Assurance
Committee
CQC72 Education of staff to take place to ensure
that they are aware of correct storage
procedures.
A new cabinet is in place. All staff have received training by the medicine management
team on correct storage procedure
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer
(Medicine), Paul Kirton-
Watson, Associate Chief
Nurse (Medicine)
31/05/2016
Date expected to be
fullly embedded - 31
October 2016
Ratified at TGAC on 15
September 2016
Improved safety Spot checks
Ward Reviews
CQC Mock Visits
Trust Governance
and Assurance
Committee
CQC73 CQC 2015 The Trust must ensure that
procedures for managing
controlled drugs in patients'
homes are standardised and all
staff follow guidelines for the
safe management and
documentation in relation to
controlled drugs.
Review of the Medicines Code to be
undertaken to ensure that it captures
requirements for management of
controlled drugs in patients' homes.
Medicine code amendments ratified at the Safer Medicine Business Group meeting on
17 May 2016. The newly amended code e-mailed out to all registered Community
Nurses within C&T group. Read receipts being collated by admin team, also discussed
within network teams by the EOL lead nurse. Copy available on the C&T intranet site.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Tina Sykes, Associate
Chief Nurse (C&TS)
31/05/2016 Ratified at TGAC 18 August
2016
Improved safety Audit Trust Governance
and Assurance
Committee
CQC74 CQC 2015 Ensure that staff are aware of the
processes for the management of
controlled drugs in patients' homes.
All registered community nurses who are involved in prescribing or administering
medication complete the medicine management self-assessment work book which has
a section regarding disposal of controlled drugs in the patient home. The July
mandatory training report shows that there are 3 staff requiring completion of the
booklet out of 110 community nurses. They have been contacted by their team leader
and have been given until 31.8.16 to complete. The mandatory training report will be
run again at this time to verify completion. The revised Medicine Code with section
5.17, community services has been uploaded to the Intranet and shared and reinforced
with all staff. The revised policy has been e-mailed out to all community nurses with a
requirement to return a signed receipt that they have read and understood the
amended code. This was sent out on 25th July, 36 read receipts have been returned as
of 31st July these are being monitored and any outstanding will be followed up by the
team leader at the end of August.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Tina Sykes, Associate
Chief Nurse (C&TS)
30/06/2016
Date expected to be
fully embedded - 31
October 2016
Completed Improved safety Staff experience survey Trust Governance
and Assurance
Committee
CQC75 CQC 2015 Patient Group Directions for
medication within ED must be
reviewed and in date.
PGDs to be reviewed to ensure that they
are in date.
PGDs updated and in date. Staff made aware through A&E Huddle and Senior Nurse
Meetings.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Alex Afifi, Group
Manager, Unplanned
Care (Medicine), Tess
Tasker, Operational
Matron (Medicine)
31 August 2016 Ratified at TGAC on 15
September 2016
Improved safety KPI183
Document control
Trust Governance
and Assurance
Committee
Mortality
14
CQC76 CQC 2015 The Trust must ensure that
action is taken to address the
mortality outliers and improve
patient outcomes in these
areas.
The Mortality Performance Assurance
Committee meets on a monthly basis. A
monthly mortality report is presented at
this meeting to provide updates on the
areas that have been identified as having
the highest numbers of people dying
within the trust. These areas have
clinically led groups that meet regularly
and work towards action plans that have
been generated through notes reviews
and observations of where pathways of
care can be improved.
Monthly meetings monitor both crude mortality as well as being aware of the quarterly
SHMI report. Whilst the focus has been on being sighted on areas of high mortality, the
focus is shifting to areas where quality of care can be identified as being improved. This
work is ongoing, with introduction of Quality Improvement work across the
organisation which will be an additional tool for improving patient outcomes. The
mortality outliers report was written and minutes and improvement plans from
speciality specific M&M meetings are produced for MPAC. There is now a move to
monitor and view these minutes and improvement plans through the group specific
business and governance meetings. This allows groups focus on the improvements that
need to be made to pathways that are relevant to the individual specialities. Any
problems identified that are not easily changed/dealt with are escalated to the
respective overarching clinical governance groups (and then TGAC) as well as MPAC.
August MPAC received a worksatream 7 update and the stroke mortality report
Lawrence Roberts,
Medical Director
Kate Wood, Deputy
Medical Director
16 August 2016
Date plan signed off at
MPAC
Ratified at MPAC on 20
September 2016
Improved mortality and
morbidity of patients
KPI01
SHMI
Minutes of MPAC
Mortality
Performance and
Assurance
Committee
CQC77 CQC 2015 The Trust should introduce
critical care specific morbidity
and mortality meetings.
Introduce critical care specific morbidity
and mortality meetings.
These meetings commenced in July 2016 and there will be 2 meetings per month, one
for SGH and one for DPOW.
Lawrence Roberts,
Medical Director
Dr Dharmarajah,
Clinical Lead for Critical
Care
31 July 2016 Ratified at MPAC 16 August
2016
Improved mortality and
morbidity of patients
KPI01
SHMI
Minutes of M&M
Meeting
Mortality
Performance and
Assurance
Committee
Pressure Ulcers
CQC78 CQC 2015 The Trust should review the
use of pressure relieving
equipment and prevention
blood clot equipment within
theatres.
Review the availability of suitable
equipment and make recommendations
for improvements.
Review complete. All equipment deemed to be appropriate. The review has been
written and awaiting comments from Surgery & Critical Care re: recommendations. The
VTE policy and pressure ulcer policy will be reviewed to identify any implications for
theatre. Review of DPOW undertaken – minimal action required (see attachment).
Incident data requested re: harm attributable to Theatres. Review of Goole requested
for complete assurance. Full review completed. Inventory of equipment being
catalogued by Theatre managers. Guidance and RCA tool to be amended following
review at PUG.
Tara Filby, Chief
Nurse
Denise White, Associate
Chief Nurse/ Brendan
Forman, Quality Matron
31/07/2016
Date expected to be
fully embedded - 30
September 2016
Completed Improved patient
experience
KPI05
Pressure Ulcers
Trust Governance
and Assurance
Committee
Effective
Evidenced Based Practice and Monitoring
CQC79 CQC 2015 The Trust must ensure the
reasons for Do Not Attempt
Cardio-Pulmonary
Resuscitation (DNACPR) are
recorded and is implemented
in line with best practice within
surgical services.
Training with staff
dissemination through clinical leads and
business meetings. Audit of DNACPR to
be undertaken.
Training continues with both medical and nursing staff.. Additional training and support
has already taken place within the Anaesthetic Business meetings and further
dissemination continues through clinical leads and identified via the surgical specialty
business meetings. S&CC participate in the audit of DNACPR to ensure increased
compliance with DNAR policy. This will be monitored via the Trust Governance and
Assurance Committee.
Lawrence Roberts,
Medical Director
Jen Orton, Interim
Deputy to the Associate
Chief Nurse (S&CC)/
Steve Heath,
Resuscitation Officer/
Kelly Burcham, Head of
Risk and Clinical Audit
31/07/2016
Date expected to be
fully embedded - 31
March 2017
Completed Increased compliance
with DNAR policy
Audit Trust Governance
and Assurance
Committee
CQC80 CQC 2015 The Trust must ensure the Five
Steps for Safer Surgery
including the WHO checklist is
consistently applied and
practice is audited.
This is included in the audit calendar. Re audit currently underway, improvement plan in place through a Task and Finish
Group, an example of one of the actions is a planned qualitative survey of staffs
attitude to the ability to challenge in theatres should the WHO not be started.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Tracey Broom,
Associate Chief
Operating Officer (CSS)/
Maureen Georgiou,
Interim Associate Chief
Operating Officer
(S&CC)/ Kelly Burcham,
Head of Risk and Clinical
Audit
31/08/2016
Date expected to be
fully embedded - 31
October 2016
Completed Increased compliance
with WHO
Notes audit
Observational Audit both
announced and
unannounced
Trust Governance
and Assurance
Committee
CQC81 CQC 2015 The Trust should continue to
work towards delivering care
and treatment that is in line
with national guidance and
Core Standards for Intensive
Care.
Long and short term critical care strategy
document has been developed taking
account of necessary guidance. Working
towards longer term measures which
cover core standards for intensive care.
The strategy document has a number of
milestones within it which are spread
across the next 3 financial years.
Consultant Intensivist Expansion by 1 per year on each site over 3 years after which the
rota can be split. Job descriptions submitted to college and awaiting approval. In the
interim, Locum Consultant posts have been advertised and awaiting appointments.
Nursing establishment being expanded to meet standards. Policies being updated.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Jen Orton, Interim
Deputy to the Associate
Chief Nurse (S&CC)/ Dr
Dharmarajah, Clinical
Lead for Critical Care
31 March 2018
(with milestones
throughout the period
of the strategy. These
will be monitored
through the monthly
updates)
Date expected to be
fully embedded - TBC at
monthly 1:1 challenge
meeting
On Target Compliance with Care
Standards of Intensive
Care
Minutes of critical care
provision meeting
Quality and Patient
Experience
Committee
15
CQC82 CQC 2015 The Trust must ensure policies
and guidelines in use within
clinical areas are compliant
with NICE or other similar
bodies. The Trust must ensure
that staff are aware of the
updated policies, especially
within maternity, ED and
surgery.
Continue to ensure that Trust complies
with NICE guidance and that policies
remain in control.
Document control and implementation of NICE guidance is a regular item on the Group
and Directorates Governance Meetings. Monthly reports demonstrating compliance
are provided and KPIs for both areas form part of the Trust Performance Framework.
Current compliance for NICE stands at 77.6% and document control 78.2%.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Jeremy Daws, Head of
Quality Assurance
31/03/2017
Date expected to be
fully embedded - 30
June 2017
On Target Compliance with
necessary best practice
guidance
KPI183
Document control
KPI342
Document control -
maternity
KPI343
Document control - ED
KPI03 (a&b)
NICE
Trust Governance
and Assurance
Committee
CQC83 CQC 2015 The Trust should ensure all the
maternity policies are up to
date and reflect current
guidance and that staff are
aware of the up dated policies.
Develop process for ensuring that
guidelines are identified 6 months prior
to the review date in order that they
remain in date.
Action plan is kept by the governance secretary of any outstanding guidelines.
Reminders sent out 6 months prior to review date. Update as at 27/04/16: Currently
stands at 90%. Update: Guidelines are uploaded to the intranet as soon as they are
approved in order that staff only have access to the most up to date versions. The
Service has a Clinical Standards Review Group which undertakes the review of the
documents prior to the sign off at the Governance Meetings. Consultants, midwives
and any other relevant staff attend the CSRG to ensure a wider discussion can take
place. When a policy has been written or amended, all relevant staff are made aware
via email and it is reported in the group newsletter. Update September 16: Current
policy recommends a review at 3 months in advance, and the current figures are 132
maternity documents of which 122 are in date making a percentage of 92.4. The
target is for 90%.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Ashy Shanker, Associate
Chief Operating Officer
(W&C), Julie Dixon,
Head of Midwifery
(W&C)/ Mahadeva
Manohar, Associate
Medical Director
30/04/2016 Ratified at TGAC on 15
September 2016
Compliance with
necessary best practice
guidance
KPI183
Document control
KPI342
Document control -
maternity
KPI03 (a&b)
NICE
Trust Governance
and Assurance
Committee
CQC84 CQC 2015 The Trust should ensure
consistency with the role of the
health visitor link to GP
practices.
Standard Operating Procedure to be
developed for the HV role when working
with GPs.
SOP currently being consulted on and will then go through clinical governance to
ensure a consistent approach is adopted. SOP approved. Discussions taken place with
the CCG to ensure that primary care are aware of changes and SOP shared with staff.
The SOP will be audited twice a year.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Tina Sykes, Associate
Chief Nurse (C&TS)
31/07/2016
Date expected to be
fully embedded - 31
October 2016
Completed SOP in place Audit data Quality and Patient
Experience
Committee
CQC85a CQC 2015 The Trust must have effective
systems in place to assess,
monitor and improve the
quality of the end of life care
services, including auditing
preferred place of care and
other patient outcomes.
An end of life care strategy is being
written encompassing the whole of the
care pathway for patients approaching
end of life (regardless of location).
Within this strategy are a number of
work streams, each with specific actions
and KPIs that are being developed and it
is being ascertained that these can be
robustly measured
The final version of the strategy was ratified in July (with review date in October). KPIs
are under development but have not yet been finalised. Target date for agreement of
KPIs is end of August 2016. The Trust is also engaged in the national audit, but is also
undertaking a local audit EOL KPIs developed and mechanism for monitoring is in
place.
Tara Filby, Chief
Nurse
Kate Wood, Deputy
Medical Director/ Sue
Peckett, Deputy Chief
Nurse/ Tina Sykes,
Associate Chief Nurse
(C&TS)
31/07/2016
Strategy Approved
Completed Monitoring processes in
place
Audit
KPI345
End of Life Care
Complaints
Quality and Patient
Experience
Committee
31 August 2016
KPIs developed and in
use
Date expected to be
fully embedded - 31
October 2016
Completed
CQC85b CQC 2015 Concern raised in respect of
the service provided to
patients with a mental health
condition in A&E at SGH
NLG to work with CAMHS provider to
review the current CAMHS Team Support
to ensure children presenting in the A&E
Department with mental distress receive
timely specialist assessment of their
needs.
Pathways revised and revised and due to be ratified at the ECC Governance & Business
Meeting on 23 February 2016. Training for staff has been arranged for 22 February, 1
March and 22 March 2016.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Pete Bowker, Associate
Chief Operating Officer -
Medicine / Ashy
Shanker, Associate Chief
Operating Officer,
Women's' & Children's'
3/11/15
(Date of meeting with
CAMHS)
29/02/16
(Final resolution plan
including
implementation of
revised pathways -
completed)
Date expected to be
fully embedded - 31
October 2016
Completed Improved patient safety Risk Assessment
Incident/SIs
Pathways in place
Quality and Patient
Experience
Committee
Clinical Education
CQC86 CQC 2015 The Trust should, as a matter
of urgency, address the
continuing gap in clinical
education in critical care.
This specific action relates to the
appointment of a Nurse Educator post
within critical care.
Educators now appointed Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Jen Orton, Interim
Deputy to the Associate
Chief Nurse (S&CC)/
Nick Harrison, Nurse
Consultant for the
Deteriorating Patient
31 August 2016
Date expected to be
fully embedded - 31
October 2016
Completed Improved training
experience for staff
Training reports Quality and Patient
Experience
Committee
Caring
Please note: no actions relating to the domain of Caring were identified during the October 2015 visit.
Responsive
Eliminating Mixed Sex Accommodation
16
17
CQC87 CQC 2015 The Trust must review the For immediate review and action. The Board considered the position of the Trust in regard to EMSA at its meeting on Karen Dunderdale, Paul Kirton-Watson, 01 April 2016 Ratified at QPEC on 12 Zero Mixed Sex KPI346 Quality and Patient
validation of mixed sex 26th January 2016. This included feedback from the discussion with Monitor the Deputy Chief Associate Chief Nurse - October 2016 Accommodation MSA Experience
accommodation occurrences, previous week. As a result, the Board decided that the escalation route for any mixing Executive and Medicine Breaches leading to Committee
ensure patients are cared for in of sexes would be at director level only and for this to take immediate effect. Director of improved patient an appropriate environment Communications to this effect were cascaded immediately – evidence attached. The Operations experience (privacy & and report any breaches. Trust continues to operate this escalation route for the mixing of sexes which requires dignity) authorisation at director level, in advance (NB this does not apply to specialist units such as ICU, HDU where the mixing of male & female patients is permitted within the guidance). The Trust took immediate action with regard to the Acute Medical Unit at DPOW (which was the location for the reported breaches following the CQC visit). With effect from 25th January 2016, the AMU and Short Stay Unit were amalgamated into a single unit which provided the flexibility required to prevent any further risk of breaches occurring on this unit. The Trust has submitted a zero return for breaches every month since January 2016 – evidence is provided of the monthly returns. The WebV system has been developed to provide an automated alerting function – this system provides the assurance for the Trust to be able to declare compliance in the monthly returns – a screenshot of the WebV screen is attached as evidence. A flow chart showing how this system operates is attached. An analysis of the trigger alerts for September 2016 will follow. QPEC is the route by which the ongoing actions for Eliminating Mixed Sex Accommodation are monitored and reviewed. The latest report (July 2016) is attached as evidence. The next report is due in October 2016.
CQC88 Review of existing training opportunities i) presentational material finalised through task & finish group (27.9.16) – attached as Karen Dunderdale, MSA Task and Finish 30/06/2016 Completed Zero Mixed Sex KPI346 Quality and Patient
for staff, including new starters who join evidence. Deputy Chief Group Accommodation MSA Experience
the Trust, e.g., Care Camp, to be ii) there are 4 cohorts of new staff who will be returning to care camp for follow up Executive and Breaches leading to Committee
undertaken. sessions. These sessions are arranged to run between 4th November and 16th Director of improved patient December 2016. Training on MSA has been included as part of the programme for this Operations experience (privacy & session and will be delivered by Ops Matrons/Quality Matrons. A copy of the EMSA dignity) presentation is attached as evidence. iii) Existing staff will receive training via a cascade method from ward managers. Arrangements have been made for the HoN for each of the three service groups to deliver the training to ward manager meetings in October/November. iv) on call manager training has been arranged for 21st October and 4th November – the training presentation will be used for the session on EMSA
CQC89 Gaps in training opportunities to be i) presentational material finalised through task & finish group (27.9.16) – attached as Karen Dunderdale, MSA Task and Finish 30/06/2016 Completed Zero Mixed Sex KPI346 Quality and Patient
identified and a plan to close the gaps to evidence. Deputy Chief Group (Initial Scoping) Accommodation MSA Experience
developed. ii) there are 4 cohorts of new staff who will be returning to care camp for follow up Executive and Breaches leading to Committee
sessions. These sessions are arranged to run between 4th November and 16th Director of 30 September 2016 improved patient December 2016. Training on MSA has been included as part of the programme for this Operations (Awareness Raising) experience (privacy & session and will be delivered by Ops Matrons/Quality Matrons. A copy of the EMSA dignity) presentation is attached as evidence. iii) Existing staff will receive training via a cascade method from ward managers. Arrangements have been made for the HoN for each of the three service groups to deliver the training to ward manager meetings in October/November. iv) on call manager training has been arranged for 21st October and 4th November – the training presentation will be used for the session on EMSA
CQC90 Include the need to review mixed sex The revised Director Visit pro-forma was updated and approved at the Trust Board Wendy Booth, Kathryn Helley, Deputy 31/05/2016 Ratified at QPEC on 14 Zero Mixed Sex KPI346 Quality and Patient
accommodation and test staff meeting in May 2016. This is now in use. Reports from all visits are shared with the Director of Director of Performance September 2016 Accommodation MSA Experience
knowledge in existing assurance visits, relevant Managers / Directors for follow-up and summary reports are also shared Performance Assurance Date expected to be Breaches leading to Committee
e.g., Director Visits. through QPEC and the Trust Board Assurance & Trust fully embedded - 31 improved patient Secretary August 2016 experience (privacy & dignity) CQC91 Further explanation required on how the Head of Children's Services working with operational leads to ensure guidance is Karen Dunderdale, Amanda Jackson, Head 30/06/2016 Completed Zero Mixed Sex KPI346 Quality and Patient
national guidance applies to children and appropriately applied to children. Update: Practical application been reviewed with Deputy Chief of Children's Services Accommodation MSA Experience
the practical application of the policy wards, process being applied in line with guidance. Discussed the paragraph within the Executive and Date expected to be Breaches leading to Committee
locally. trust policy for children, young people and adults which has been shared with Director of fully embedded - 31 improved patient commissioners to ensure it is clear in relation to accommodating parents and ensuring Operations October 2016 experience (privacy & the privacy and dignity is maintained. dignity)
CQC92 Review, agree and implement the time Assurance visits by commissioners regarding mixed sex accommodation took place Karen Dunderdale, Jenn Orton, Interim 31/07/2016 Completed Zero Mixed Sex KPI346 Quality and Patient
period for “step down” patients when during June 2016 and the outcome was shared at the Quality Contract Review meeting Deputy Chief Deputy to the Associate Response from Accommodation MSA Experience
ready to leave a specialist unit in July 2016. The Commissioners’ stance is that the Trust must comply with the Executive and Chief Nurse Commissioners Breaches leading to Committee
(agreement is for local determination) – national critical care guidance that patients are transferred within 4 hours of being Director of improved patient agreement for CCGs to work with the deemed medically fit (this is different to the current, locally agreed arrangement, of Operations 31 August 2016 experience (privacy & Trust to agree a common approach. transfer within 24 hours). The policy is at a final stage but is awaiting agreement with Implemented dignity) CCGs & NLAG commissioners regarding the status of the HOBs unit as a specialist unit. The final draft includes comments are shown in red as it is still a working document and it is essential Date expected to be that the outstanding issues are clearly identified. Work is underway to amend the fully embedded - 31 HOBs documentation in anticipation that commissioners will then agree this is a October 2016 specialist unit. The policy will then need to be shared with commissioners in its entirety – this will include the opportunity to confirm whether there is a “clock stop” arrangement over night. Then it can proceed through the normal governance approval routes.
CQC93 Agree date for commissioners to visit the
Trust to undertake an assurance visit
These visits were undertaken on 17/6/16 to Scunthorpe General Hospital and on
20/6/16 to Diana, Princess of Wales Hospital.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kathryn Helley, Deputy
Director of Performance
Assurance/ CCG Leads
to be identified
31/05/2016
(date to be agreed)
30 June 2016
(first visit to be
undertaken)
Date expected to be
fully embedded - 31 July
2016
Ratified at QPEC 10 August
2016
Zero Mixed Sex
Accommodation
Breaches leading to
improved patient
experience (privacy &
dignity)
KPI346
MSA
Quality and Patient
Experience
Committee
CQC94 Update of the Patient Information leaflet
– NLAG/Health Watch
Draft has been completed for discussion at Task and Finish Group in July 2016. This has
been shared with commissioners for their comments who have requested all patients
in critical care areas receive the leaflet. The Eliminating Mixed Sex Accommodation (IFP
704) leaflet was approved at the IFP Group on 8th September 2016.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
MSA Task and Finish
Group
31/07/2016
Date expected to be
fully embedded - 30
September 2016
Ratified at QPEC on 12
October 2016
Zero Mixed Sex
Accommodation
Breaches leading to
improved patient
experience (privacy & dignity)
KPI346
MSA
Quality and Patient
Experience
Committee
Patient Flow and Access
CQC95 CQC 2015 The Trust must ensure it
continues to improve on the
number of fractured neck of
femur patients who receive
surgery within 48 hours.
The Trust to review the fractured neck of
femur action plan and ensure that all
necessary actions are taken.
Daily trauma meetings are facilitated on both sites consistently. The business case for
the Saturday Trauma list is now completed and awaiting decision. The fractured neck
of femur action plan has been reviewed and the majority of actions have been
completed. Therefore a full refresh of the plan is currently being undertaken and this
will be complete by 31 July 2016. At this point, a revised timescale will be provided for
the completion of any new actions identified. The Trauma Co ordinator has
commenced in post in DPOW. With this in mind we should see an improvement in our
compliance of this target and close monitoring is on going monthly.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Maureen Georgiou,
Interim Associate Chief
Operating Officer
(S&CC)/ Sairam Alavala,
Clinical Lead
30/06/2016
Review of action plan
Completed Improved patient
experience
KPI19
#NOF
Quality and Patient
Experience
Committee
31 July 2016
(revised action plan to
be developed)
Completed
Implementation of
actions - 30 September
2016
Date expected to be
fully embedded - 31
December 2016
Completed
CQC96 CQC 2015 The Trust should evaluate the
medical review of outlying
medical patients on surgical
wards to improve consistency
of cover arrangements and
prevent unnecessary delayed
discharges.
To implement the ACP model across the
DPOW site.
The DPOW leave calendar shows that from 15th August we have increased to 5 ACPs
(Dr Hamod, Dr Sanyal, Dr Abdelgabar, Dr Adebayo, Dr Abu Subhu). We increased to 5
ACPs to ensure we have cover for annual leave so at any time of year there should be 4
ACPs.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer/
Stuart Baugh, Associate
Medical Director/ Paul
Kirton-Watson,
Associate Chief Nurse
31/07/2016
Date expected to be
fully embedded - 31
August 2016
Ratified at QPEC on 14
September 2016
Improved patient
experience
Reduction in number of
outlying patients
Reduction in delayed
KPI18
Reduction in patient
outliers
KPI17
Reduction in delayed
transfers of care
Quality and Patient
Experience
Committee
CQC97 Review and reintroduction of the short
stay ward.
As part of the ACP model and successful recruitment to the 4 positions the Short Stay
Ward function will re-established. Expected date for implementation is 31st July.
Following review it has been agreed that short stay patients arrangements to remain as
is on AMU and Icon to be put on Web V to identify 'short stay' patients so they can be
prioritised. This will be monitored on a monthly basis by patient length of stay on Unit.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer/
Stuart Baugh, Associate
Medical Director/ Paul
Kirton-Watson,
Associate Chief Nurse
30/06/2016
Date expected to be
fully embedded - 31
October 2016
Completed Improved patient
experience
Reduction in number of
outlying patients
Reduction in delayed
KPI18
Reduction in patient
outliers
KPI17
Reduction in delayed
transfers of care
Quality and Patient
Experience
Committee
CQC98 Review the weekend discharge processes
in place at all three sites and ensure
consistency with best practice.
Discussions held with physicians on both main sites and agreement in principle to
review rotas with the view of introducing a second 1:8 weekend rota. Target date for
implementation of new rota is the end of October 2016. In the interim the current
arrangements will remain in place. Agreed at meeting with commissioners to organise
a joint event where issues surrounding the discharge process would be discussed. Out
of hours services, social care and community services would also be involved in this
event.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer
(Medicine)
Richard Young (NLCCG)
31/07/2016
review complete
31 October 2016
(implementation of
rotas)
Date expected to be
fully embedded - 31
On Target Improved patient
experience
Reduction in number of
outlying patients
KPI18
Reduction in patient
outliers
KPI17
Reduction in delayed
transfers of care
Quality and Patient
Experience
Committee
CQC99 The Trust to consider having more senior
staff on triage and directing patients to
more appropriate services if not an
emergency.
Interim arrangements of Triage Nurse at A&E reception introduced. This will remain in
place until the visit to Derby takes place and any additional actions for the Trust are
identified. Ambulance Handover nurses introduced and creation of 'pit-stop' facility.
Ambulance handover data is currently showing SGH and DPOW as high achieving in
terms of handover times across the region.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer
(Medicine)
Richard Young (NLCCG)
31/07/2016
Date expected to be
fully embedded - 31
October 2016
Completed Improved patient
experience
Reduction in number of
outlying patients
KPI18
Reduction in patient
outliers
KPI17
Reduction in delayed
Quality and Patient
Experience
Committee
18
CQC100 NLAG to visit other Trusts who have
been rated as outstanding in the area of
triage.
Visit to Derby proposed due to Strike Action rearranged for 13 October. Several staff
have attended NHSI meetings and national study days and shared their learning
experience within the units. RAT model and front loading triage(nurse on reception)
have been introduced as trial at DPOW. Greater use of ENPs to share triage role
implemented SGH. Other areas of good practice being examined include amb care in
reach and consultant decision making front hospital (this will form part of PDSA and
shared at NHSI study day 14/10/20.) Following visit to Derby it is expected that further
chages will be considered and potentially introduced.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Peter Bowker, Associate
Chief Operating Officer
(Medicine)
31/07/2016
Date expected to be
fully embedded - TBC at
monthly 1:1 challenge
meeting
Completed Improved patient
experience
Reduction in number of
outlying patients
KPI18
Reduction in patient
outliers
KPI17
Reduction in delayed
transfers of care
Quality and Patient
Experience
Committee
CQC101a CQC 2015 Issues identified regarding patient New contract awarded. Both North and North East Lincolnshire CCGs have confirmed Pam Clipson, Jane Ellerton (NLCCG) 31/10/2016 Ratified at Resources Improved patient Improved patient Resources
transport after 6pm. Need to consider award to commence 1st October 2016. Director of Strategy Committee on 21 September outcomes. experience Committee
whether the service needs to go out to and Planning (Trust 2016 tender. Lead) KPI18 Reduction in patient Accountable outliers Officers (External Lead) KPI17 Reduction in delayed
transfers of care CQC101b The CCGs have commissioned Thames transport to provide this service.
Planned discharge service Monday to Friday 0900 – 2100 / Saturday 10.00 – 19.00.
Karen Dunderdale,
Deputy Chief
Graham Jaques,
Operations Centre
30/09/2016 Completed Quality and Patient
Experience
Same day discharge service 7/7 11.00 – 23.00 ( 2 x double crew stretcher vehicle. This
will commence on 1 October 2016.
Executive and
Director of
Operations
Manager Date expected to be
fully embedded - 31
December 2016
KPI320 & KPI321
Decrease in on the day
cancellations
Committee
CQC102 North East Lincolnshire CCG to consider North East Lincolnshire CCG has not commissioned the Trust to deliver a 30 day bed Pam Clipson, Jan Haxby (NELCCG) 30/09/2016 Completed Resources
the introduction of a 30 day bed model. model. The Trust Board believe it is not appropriate for people to continue to reside in Director of Strategy Committee
an acute bed when they are ‘acute fit’. Direct negotiations by the Trust therefore and Planning (Trust Date expected to be commenced with a local residential home. This agreement is to ensure people who are Lead) fully embedded - 28 acutely fit receive the social care they need within the appropriate setting. The service February 2017 is planned to go live week commencing 3rd October. Accountable Officers (External Lead)
CQC103 Consideration to be given in North CCG feedback from the July stakeholder meeting was that a proposal could come from Pam Clipson, Jane Ellerton (NLCCG) 31/10/2016 Ratified at Resources Resources
Lincolnshire as to whether the walk-in either provider or CCG. Provider is not looking to increase the GP provision in the front Director of Strategy Committee on 21 September Committee
service would be better led by GPs. door currently however will keep under review as out of hospital and the A&E and Planning (Trust 2016 workforce strategy develops. Suggest closure given no party can see additional benefit Lead) in changing the structure in advance of the UEC system recommendations being taken forward as part of the STP. Accountable Officers (External Lead)
CQC104 CQC 2015 The Trust should review Continue to review ICNARC data at the Numbers reviewed through ICNARC and discussed monthly at critical care provision Karen Dunderdale, Jen Orton, Interim 31 August 2016 Completed Improved patient KPI17 Quality and Patient
patient flow and reduce the Critical Care Provision Meeting. meeting. Data is reviewed to see if the Trust is in an outlying position. A member of Deputy Chief Deputy to the Associate experience Reduction in delayed Experience
number of delayed discharges the Network attends these meetings. Update as at 10/6/2016: Data demonstrates Executive and Chief Nurse Date expected to be transfers of care Committee
from ITU. that the Trust is not an outlier. Update: The Critical Care Strategy plans to increase Director of fully embedded Reduction in number of beds. Building work commences January 2017 with a completion date of August 2017. Operations 31 October 2016 delayed discharges KPI339 This will increase capacity and allow flow into the service to improve. In the meantime, Delayed discharges from the Trust is concentrating on flow out of the service in order to reduce delayed ITU discharges. Latest data demonstrates DPOW at 4.7% with national average being 4.8% and SGH 5.8% - this is an improving picture over the last 6 months. For both these parameters the Trust is within 2 Standard Deviations and therefore not an outlier. The Critical Care Strategy plans to increase beds. Building work commences January 2017 with a completion date of August 2017. This will increase capacity and allow flow into the service to improve. In the meantime, the Trust is concentrating on flow out of the service in order to reduce delayed discharges
CQC105 CQC 2015 The Trust should review access Full review of capacity & demand being Activity flows through the catheter labs currently under review to ensure improved use Karen Dunderdale, Alistair Wickham, 31/07/2016 Completed Improved patient KPI324 Quality and Patient
and flow through the undertaken within the Cath Labs at both of available capacity. Audit of start finish times underway. Process mapping session to Deputy Chief Planned Care Manager experience Complaints relating to Experience
Scunthorpe angiography DPoWH and SGH be arranged to review flow through department. Pre and post Bank Holidays and Executive and (Medicine), Tony Date expected to be delays and cancellations Committee
catheterization lab to reduce weekend sessions to prioritise inpatient demand. All referrals carefully vetted by Director of Dawson, Operational fully embedded - 30 Reduction in in Cath Lab last minute cancellations, medical staff to ensure patients are seen in strict priority order. Monday and Friday Operations Matron/ Cardiology November 2016 cancellations delays and wasted reduced elective lists have been reduced and inpatients clinically prioritised to ensure Lead KPI325 appointments. minimal delays. Reprioritising of lists / sessions, planned increase of number of Incidents relating to sessions provided per week on the DPoWH site. Introduction of formal MDTs on each delays and cancellations site. The additional sessions and MDTs will support with the reduction of last minute in Cath Lab cancellations, delays and wasted appointments. In addition to this, elective cases are no longer planned on Fridays and Mondays in order to allow for non-elective cases to be prioritised, again, meaning less delays and last minute cancellations. The Critical Care Strategy plans to increase beds. Building work commences January 2017 with a completion date of August 2017. This will increase capacity and allow flow into the service to improve. In the meantime, the Trust is concentrating on flow out of the service in order to reduce delayed discharges
19
20
CQC106 CQC 2015 The Trust should review Work with ACPs and the Operations Initial indications are that the Improved management of the short stay patients via the Karen Dunderdale, Peter Bowker, Associate 31/07/2016 Completed Improved patient KPI18 Quality and Patient
patient flow through the Centres to ensure the appropriate use of site managers to ensure the appropriate patients are placed on the short stay ward is Deputy Chief Chief Operating Officer/ experience Reduction in patient Experience
Scunthorpe short stay ward to short stay. proving positive. Monthly review of length of stay for patients on Ward 2 will be Executive and Alex Afifi, Group Date expected to be outliers Committee
ensure this does not have an monitored through Medicines Operations and Performance Meetings. NB recent data Director of Manager, Unplanned fully embedded - 31 impact on the flow of patients published internally shows the significant improvement in the average LOS for non- Operations Care (Medicine)/ Kay November 2016 through the clinical decisions elective patients in the Medicine Group at SGH. For the 12 months up to June 2015, Newton, Operational unit. the average LOS for this cohort was 6.3 days. For the 12 months up to June 2016, the Matron/ Kerry Carroll, average LOS is now 5.6 days. This compares to the local peer average of 5.7 days and Interim Associate the national average of 5.8 days. The short stay ward at SGH has been closed to Director of Strategy and support nurse staffing across Medicine. This has provided an opportunity to integrate Planning the short stay service and an additional opportunity to test out two models of delivery across the organisation
CQC107 CQC 2015 The Trust must review the Review is ongoing of pathway looking at Pre-assessment review completed. Due to complexity of pathway’s implementation Karen Dunderdale, Denise White, Associate 31/08/2016 Completed Improved patient KPI320 & KPI321 Quality and Patient
effectiveness of the patient improvements in: has slipped to the middle of October. Approximately 6 week’s slippage. New Deputy Chief Chief Nurse/ experience On the day cancellation Experience
pathway from pre-assessment - Booking into Preassessment preassessment documentation has been shared with clinical staff and comments Executive and Improvement Delivery Revised completion rate Committee
through to timeliness of going - Accuracy and Capacity of received. DPOW feedback due 14th September. Director of Facilitator date - 30 September Reduction in on the day to theatre, and the number of Preassessment Feedback from Surgery Ops Teams prefers allocated clinic slots divided by speciality. Operations 2016 cancellations on the day cancellations for - Information output from Capacity and demand of preassessment shows shortfall in clinics and staffing required patients awaiting operations. preassessment to meet number of patients requiring elective surgery. Business case prepared to meet Date expected to be On the Day cancellations are reviewed capacity shortfall. Accommodation increase identified at DPOW. Preassessment Nurse fully embedded - 31 on a weekly basis and additional support banding at DPOW was not in line with both trust and national profile. Consultation has December 2016 and training is being given to Service been undertaken, completed and pay protection has been applied. Managers to ensure RCA's are robust.
Well-Led
Strategy, Vision and Engagement
CQC108 CQC 2015 The Trust must ensure that Staff engagement strategy is being Discussions are being held with Executive leaders and their senior teams to capture Jayne Adamson, Angie Davies, Assistant 31/10/2016 Completed Staff aware of Trust/ Staff Experience Surveys Quality and Patient
staff at core service/ divisional developed, alongside the how they communicate the key priorities, strategies and implementation plans for their Interim Director of Director Organisational, Service vision and Experience
level understand and are able communications strategy and workforce directorates. Following discussions a plan will be created to produce work streams and People and Quality & Staff Date expected to be strategy Committee
to communicate the key planning and all are a part of the support given to the groups Engagement events are being held with admin and theatre Organisational Development fully embedded - 31 priorities, strategies and overarching P&OD Strategy. staff, as a result of which a number of service improvements have been captured, Effectiveness March 2017 implementation plans for their which has placed staff at the heart of change, making staff agents of change. Senior areas. Leaders within Directorates have been asked to cascade the staff engagement policy to their teams across the Trust. The comms team continue to support directorates with service improvements and organisational changes though comms channels i.e. direct mailing, weekly bulletins, CEO cascade, Podcasts, twitter and Facebook.
CQC109 CQC 2015 The Trust must improve its Staff engagement strategy is being Staff engagement activities as noted above and detail captured through the Directorate Jayne Adamson, Angie Davies, Assistant 31/10/2016 Completed Staff aware of Trust/ Staff Experience Surveys Quality and Patient
engagement with staff to developed, alongside the Delivery Plan. Involvement in service improvements to be captured through Director Interim Director of Director Organisational, Service vision and Experience
ensure that staff are aware, communications strategy and workforce walkabouts, mock cqc visits, senior team walkabouts and reflected through staff People and Quality & Staff Date expected to be strategy Committee
understand and are involved in planning and all are a part of the stories. further staff feedback to be captured through staff stories and other staff Organisational Development fully embedded - 31 improvements to services and overarching P&OD Strategy. feedback. staff engagement workshops have been undertaken with community nursing Effectiveness March 2017 receive appropriate support to and therapy staff, themes have been captured and reported to the interim ACOO for carry out the duties they are the Group, awaiting a steer from her re: further actions to be undertaken, proposed employed to perform. that the report is shared in the first instance with the community staff to agree actions going forwards. OD team will continue to support. ET discussion re: organisational strategy for service / quality improvement to be taken forwards by Exec Lead.
CQC110 CQC 2015 The Trust must ensure it has an The end of life care strategy and vision is The final version of the strategy was ratified in July (with review date in October). All Tara Filby, Chief Kate Wood, Deputy 30/06/2016 Ratified at QPEC 10 August Staff aware of Trust/ Staff Experience Surveys Quality and Patient
end of life care vision and currently being developed with input staff members who had previously been engaged in EOL care were able to be involved Nurse Medical Director/ Sue 2016 Service vision and Experience
strategy in place supported by from all stakeholder groups involved in in the development of the strategy. Social media videos are to be developed to try and Peckett, Deputy Chief strategy Committee
key performance indicators care towards the end of life. This has get more info out to colleagues in addition to the traditional methods such as the staff Nurse/ Tina Sykes, that reflects national guidance been written in conjunction with the bulletin and roadshows. Associate Chief Nurse and ensure staff are included in national guidance available. (C&TS)/ Jane Ellerton the development of these. (NLCCG)
CQC111 Local Healthwatch and CCG Healthwatch and CCG are attending the EOL meetings and are representing the Tara Filby, Chief Kate Wood, Deputy 31 May 2016 Ratified at QPEC 10 August Staff aware of Trust/ Staff Experience Surveys Quality and Patient
representatives to support the Trust in patient/carer perspective. Request made for stakeholders to identify and co-opt Nurse Medical Director/ Sue 2016 Service vision and Experience
identifying patients to join the End of Life appropriate lay representation for strategy group/subgroups as appropriate due to the Peckett, Deputy Chief strategy Committee
Strategy Group. sensitivities involved in this area of work Nurse/ Tina Sykes, Associate Chief Nurse (C&TS)/ Kirsten Spark (Healthwatch/ Jane Ellerton (NLCCG)
CQC112 CQC 2015 The Trust should ensure the DEPCEO team to undertake specific Workshops have been undertaken, report compiled of the themes gathered from staff Jayne Adamson, Angie Davies, Assistant 31/07/2016 Completed Staff aware of Trust/ Staff Experience Surveys Quality and Patient
community teams are engaged piece of work with the Community and views, and shared with Interim ACOO for C&TS. Awaiting a steer from her re actions to Interim Director of Director, Deputy Chief Service vision and Experience
in developing the vision and Therapy Group re staff engagement. take forwards, have proposed the report is shared with staff and they are involved in People and Executive/ Tine Sykes, Date expected to be strategy Committee
strategy for their team(s). crafting the solutions. Organisational Associate Chief Nurse fully embedded - 31 Effectiveness (C&TS)/ Dawn Daly, March 2017 Head of Therapies Appraisal and Mandatory Training
21
CQC113 CQC 2015 The Trust must ensure that Monthly reporting received identifying Requirement for appraisal for all staff being reinforced via Executive Team and is a Karen Dunderdale, Maureen Georgiou, Work in progress - On Target Achievement of Trust KPI63 Trust Governance
staff, especially within surgery, percentage of staff trained. Action plan monthly item on their agenda. Monthly reports are in place for appraisal and Deputy Chief Interim Associate Chief ongoing targets for mandatory Mandatory Training and Assurance
have appraisals and to be developed for all areas to have supervision compliance, across the Trust for all Groups. Further training or access to Executive and Operating Officer training, PADR and compliance rate Committee
supervision, and that actions robust plans to release staff and/ or to alternative support to be fed into the Education Training & Development team from Director of (S&CC)/ Harriet Date expected to be supervision identified in the appraisals are utilise online training and workbooks in Surgery and Critical Care Group to enable progress of actions. Operations Stephens, Head of fully embedded - 30 KPI64 acted upon. order to embed mandatory training. Education, Training and June 2017 with stepped PADR compliance rate Managers must also diarise PADRs over Development targets of 85% by 31 the full year. December 2016 and KPI156 95% by 31 March 2017. Clinical Supervision
CQC114 CQC 2015 The Trust must ensure three- Ensure three-monthly safeguarding All early help champions and practice teachers were trained as peer safeguarding Karen Dunderdale, Tina Sykes, Associate 31/03/2016 Ratified at TGAC on 17 Trust Governance
monthly safeguarding supervision takes place. supervisors in October 2015. Three monthly peer safeguarding supervision has been Deputy Chief Chief Nurse (C&TS) October 2016 and Assurance
supervision takes place for implemented within the HV service. In addition, six monthly named nurse supervision Executive and Committee
health visitors. is undertaken which provides external challenge. An early warning mechanism has Director of been developed to flag when someone is due to go out of compliance in order that this Operations can be addressed so that applicable compliance remains at 100%.
CQC115 CQC 2015 The Trust must ensure all staff Continue to monitor compliance with Requirement for appraisal and mandatory training for all staff being reinforced via Karen Dunderdale, Tina Sykes, Associate Work in progress - On Target Trust Governance
are up to date with appraisal mandatory training and PADR Executive Team and is a monthly item on their agenda. Mandatory training and PADR Deputy Chief Chief Nurse (C&TS)/ ongoing and Assurance
and mandatory training compliance. is a standard agenda item on staff meetings. Team Leaders/Service leads access the Executive and Dawn Daly, Head of Committee
(particularly in community monthly report and support staff to attend mandatory training and complete Director of Therapies (C&TS)/ Date expected to be services). The Trust should workbooks and PADR's proactively. Mandatory training and appraisal are also Operations Harriet Stephens, Head fully embedded - 30 continue to improve against monitored at the Community and Therapy governance meeting. Mandatory training of Education, Training June 2017 with stepped the target of all staff receiving and appraisal are also monitored at the Team Performance Meetings with analysis of and Development targets of 85% by 31 an annual appraisal. plans to achieve. December 2016 and 95% by 31 March 2017.
CQC116 CQC 2015 The Trust should continue to Continue to monitor compliance with MT reports continue to be shared across the groups and Directorates twoice weekly Jayne Adamson, Rachel Greenbeck, Work in progress - On Target Trust Governance
improve on its mandatory mandatory training. which can be drilled down to staff member level. Reported at several Meetings. Interim Director of Quality Matron/ Craig ongoing and Assurance
training targets to achieve its Proposal to be taken to TGAC and Trust Board re interim targets to be set for People and Ferris, Head of Committee
own compliance level of 95% achievement - 85% by end of December 2016 and 95% by the end of January 2017. Organisational Safeguarding/ Harriet Date expected to be and specifically ensure that Effectiveness Stephens, Head of fully embedded - 30 staff have a better Education, Training and June 2017 with stepped understanding of the Development targets of 85% by 31 assessment of capacity and the December 2016 and use of restraint (including 95% by 31 March 2017. chemical restraint).
CQC117 CQC 2015 The Trust should ensure all end Continue to monitor compliance with Appraisal system in place. Need to ensure that team are clearly labelled on ESR to Karen Dunderdale, Tina Sykes, Associate Work in progress - On Target Trust Governance
of life care staff are up to date mandatory training and PADR provide the correct data. As at 31.03.16 - Macmillan Health care team - Mandatory Deputy Chief Chief Nurse, Community ongoing and Assurance
with managerial appraisal of compliance. training 89%, Macmillan specialist Nurses community 86%. PADR Macmillan HHCT Executive and and Therapy Services. Committee
their work performance and 96%, Macmillan specialist nurses 86%. Monitored monthly at SMT and Governance Director of Date expected to be mandatory training. meeting. Service Leads, Operational Matrons and team leaders liaising with staff Operations fully embedded - 30 individually regarding mandatory training and PADR compliance. June 2017 with stepped targets of 85% by 31 December 2016 and 95% by 31 March 2017.
CQC118 CQC 2015 The Trust should ensure Continue to monitor compliance with Current position 95% compliance as of 16/8/16. This will be monitored ongoing via Karen Dunderdale, Tracey Broom, 31/07/2016 Ratified at TGAC on 15 Trust Governance
IR(MER) training is mandatory mandatory training. regular mandatory training reports. Deputy Chief Associate Chief September 2016 and Assurance
for radiology staff. Executive and Operating Officer (CSS)/ Committee
Director of Ruth Kent, Head of Operations Radiology Services/ Harriet Stephens, Head of Education, Training and Development Patient Feedback
CQC119 CQC 2015 The Trust must seek and act on CSS has a patient survey on satisfaction The survey results from Goole were overwhelmingly positive. Results have been fed Karen Dunderdale, Tracey Broom, 30 June 2016 Ratified at QPEC on 14 Increase in patient Patient experience Quality and Patient
feedback from patients in of services throughout the year. Patient back to staff during team brief and discussed at governance meetings. The service has Deputy Chief Associate Chief September 2016 satisfaction surveys Experience
radiology in order to evaluate feedback requiring actions will be an annual timetable for patient satisfaction surveys showing when they will be Executive and Operating Officer (CSS)/ Date expected to be Committee
and improve the services incorporated into an action plan completed and the month they will go to governance for discussion. Director of Ruth Kent, Head of fully embedded - 31 (particularly at Goole). monitored at governance meeting Operations Radiology Services August 2016
Duty of Candour
CQC120 CQC 2015 The Trust should ensure that Being Open Policy to be given to each All staff have received the Being Open Policy and have signed to say that they have Wendy Booth, Tracey Broom, 30/06/2016 Completed Duty of Candour Results of Quiz Trust Governance
all staff within outpatients are member of staff with an explanation read and understood the duty of candour briefing. In order to measure staff Director of Associate Chief (Training Complete) undertaken and Assurance
aware of their responsibilities about it at the team brief and/or knowledge a quiz is being carried out at team brief to test out understanding. In Performance Operating Officer (CSS), appropriately KPI359 & KPI360 Committee
in relation to the Duty of individually if required. Signatory list to addition to this, the Head of Complaints has undertaken some walk rounds in the Assurance & Trust Louise Hobson, Planned 31 July 2016 Duty of Candour Candour. be kept from staff signing to agree "read department to discuss with staff and test understanding. There is also monitoring of Secretary Care Manager (CSS) (staff awareness Increase in staff and understood" wider Duty of Candour requirements via a related KPI. testing) knowledge regarding Duty of Candour Date expected to be fully embedded - 31
Learning Lessons
CQC121 CQC 2015 a) The Trust should ensure that
more robust evidence is
available to show that sharing
of lessons learned from
incidents/ never events/ safety
thermometer outcomes/
audits/ actions plans
(communication in general) are
shared across the teams.
b) The Trust must ensure staff
can access and receive
feedback and learning from
incidents.
c) The Trust must ensure there
is a robust process for
providing consistent feedback
and learning from incidents.
d) The Trust should ensure that
robust processes are in place
for sharing lessons learned
from complaints within
community services.
Reinforce existing policy requirements
(Please ASK Campaign). Staff have a
responsibility to ask for feedback from
incidents as much as managers have a
responsibility to be given it.
A mandatory field has been added to Datix which requires Managers to input the
feedback information they have given staff who have requested it. This has been
developed into a KPI and was reported on for the first time in the July 2016 Integrated
Performance Report. Communication plan developed and campaign has commenced.
Incident leaflet attached to July 2016 payslips. Frequently asked questions leaflet
developed. Updates provided in weekly bulletin. Serious Incident One Page Learning
the Lessons is part of Hot Topics on intranet. Further communications planned i.e. staff
newsletter (weekly bulletin) at a later date to keep up the momentum. Key messages
delivered via training and induction relevant to Risk and Governance Team. Junior Dr
Patient Safety Forum attended and incident reporting discussed with Junior Doctors.
Update 25/08/16: Incident leaflet is handed out at inductions to capture new starters
to the Trust. Care Camp are changing the way the training is delivered and the
expected format is to have 1 week for Care Camp followed by 3 hours sessions that are
delivered 1 per month over 6 months. As part of the programme, the lead tutors are
considering input from the Governance Team on learning lessons at one of the 3 hour
sessions and will notify the team following a meeting on 1 September 2016. A
presentation on the actions to strengthen the Trust’s mechanisms to feedback /
learning lessons has been provided to commissioners through the Quality Contract
Review and SI Collaborative groups.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kelly Burcham, Head of
Risk and Clinical Audit/
Learning Lessons
Review Group (How
Staff Learn Lessons)
30/06/2016
(Campaign Planned)
31 July 2016
(Campaign
Implemented)
Date expected to be
fully embedded - 31
October 2016
Completed Increase in staff who
report receiving
feedback from incidents
Trust continues to be a
high reporting
organisation
KPI341
Staff receiving feedback
ASK Campaign
Promotional Literature
Learning Lessons
Newsletters
Minutes of Learning
Lessons Review Group
Decrease in numbers of
incidents relating to sub
groups of Learning
Lessons Review Group
Trust Governance
and Assurance
Committee
CQC122 Awareness of the above campaign to be
communicated:
a) re-issue Please ASK Campaign
b) promote above message through
intranet, all staff email and through
incident reporting training
c) where appropriate, incorporate the
above message into other existing
training, e.g., Care Camp.
A mandatory field has been added to Datix which requires Managers to input the
feedback information they have given staff who have requested it. This has been
developed into a KPI and was reported on for the first time in the July 2016 Integrated
Performance Report. Communication plan developed and campaign has commenced.
Incident leaflet attached to July 2016 payslips. Frequently asked questions leaflet
developed. Updates provided in weekly bulletin. Serious Incident One Page Learning
the Lessons is part of Hot Topics on intranet. Further communications planned i.e. staff
newsletter (weekly bulletin) at a later date to keep up the momentum. Key messages
delivered via training and induction relevant to Risk and Governance Team. Junior Dr
Patient Safety Forum attended and incident reporting discussed with Junior Doctors.
Update 25/08/16: Incident leaflet is handed out at inductions to capture new starters
to the Trust. Care Camp are changing the way the training is delivered and the
expected format is to have 1 week for Care Camp followed by 3 hours sessions that are
delivered 1 per month over 6 months. As part of the programme, the lead tutors are
considering input from the Governance Team on learning lessons at one of the 3 hour
sessions and will notify the team following a meeting on 1 September 2016. A
presentation on the actions to strengthen the Trust’s mechanisms to feedback /
learning lessons has been provided to commissioners through the Quality Contract
Review and SI Collaborative groups.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kelly Burcham, Head of
Risk and Clinical Audit/
Sarah Mainprize, Head
of Communications and
Marketing
30/06/2016
(Campaign Planned)
31 July 2016
(Campaign
Implemented)
Date expected to be
fully embedded - 31
October 2016
Completed Trust Governance
and Assurance
Committee
CQC123 How Staff Learn Lessons' to be linked to
the wider staff engagement strategy,
e.g., staff to be asked to share their ideas
as to how we can improve the current
arrangements and how they would like
to receive feedback, e.g., text,
automated e-mail message, etc.
A presentation on the actions to strengthen the Trust’s mechanisms to feedback /
learning lessons has been provided to commissioners through the Quality Contract
Review and SI Collaborative groups.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kelly Burcham, Head of
Risk and Clinical Audit/
Karl Roberts, Clinical
Quality & Patient
Experience Lead
30/06/2016
(Method identified)
Completed Trust Governance
and Assurance
Committee
30 September 2016
(Monitoring of
Effectiveness)
Date expected to be
fully embedded - 31
October 2016
Completed
CQC124 Ensure that staff are clear that they may
be asked to share their experiences of
receiving feedback and learning and
ensure staff are clear on the use of
language, i.e., how the question may be
asked.
Key messages have been developed around how lessons will be shared and feedback
provided from reported incidents. This is being shared as part of wider communication
campaign outlined below. Communication plan developed and campaign has
commenced. Incident leaflet developed and attached to July 2016 payslips. Also given
to new starters at Corporate inductions and Junior Dr inductions. Frequently asked
questions leaflet developed and available on the intranet. Updates provided in weekly
bulletin and learning the lessons newsletters – signposted to FAQ leaflet on incident
reporting. Key messages reinforced through training. Key questions for staff to
consider regarding feedback from incidents and learning lessons have been
incorporated into the CQC leaflet.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kelly Burcham, Head of
Risk and Clinical Audit/
Learning Lessons
Review Group (How
Staff Learn Lessons)
30/06/2016
(Campaign Planned)
31 July 2016
(Campaign
Implemented)
Date expected to be
fully embedded - 31
October 2016
Completed Trust Governance
and Assurance
Committee
22
CQC125 Agree a standard template for use by all
ward/department staff meetings to
include an item on sharing feedback and
lessons learnt from incidents/SIs,
complaints/PALs and claims. This will
ensure consistency of approach and
provide auditable evidence that this is
happening or not. Include a review of
this requirement as part of Director
Visits or other ward visits and
inspections.
The “Standards for providing feedback to Staff following incidents / Clinical Audit /
Complaints & Claims including the Production of Local Level (Directorate / Group)
‘Learning Lessons’ Newsletters” and Newsletter template were approved at TGAC on
18 August 2016. A communication brief will be provided in the Staff Weekly Bulletin.
The documents will also be added to the Governance Group agendas for discussion
with an action to disseminate accordingly and ensure the key messages within the
standards documents are communicated effectively. The Trust Wide Learning the
Lessons Newsletter will include them as one of the main topic areas with a focus on
providing feedback to staff. The requirement for feedback to staff following incidents
continues to be promoted Trust-wide.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kelly Burcham, Head of
Risk and Clinical Audit
30/06/2016
(Template Developed)
31 July 2016
(Template Issued)
Completed Trust Governance
and Assurance
Committee
30 September 2016
(In place for meetings)
Date expected to be
fully embedded - 31
October 2016 2016
Completed
CQC126 Learning Lessons Review Group to be
asked to review its membership to
include consideration of representation
from wards/departments and from
admin staff.
Terms of Reference reviewed at 7 June 2016 and agreed that membership was
appropriate as staff are involved in the working groups for each of the themes
identified and it was felt that this was more appropriate. Update 25 August 2016: A
learning the lessons event is currently being organised that will include representation
from different wards / departments / specialities and will include clinical, managerial
and admin staff. All in attendance will be able to contribute to understanding the
issues in respect of the 5 key themes and help to determine solutions to the identified
problems.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kelly Burcham, Head of
Risk and Clinical Audit
30/06/2016
Date expected to be
fully embedded - 31
October 2016
Completed Trust Governance
and Assurance
Committee
CQC127 KPI to be developed in respect of
feedback and learning. For example,
when staff report an incident they are
required to tick to indicate whether they
require feedback. A separate field will be
added to datix to include feedback
provided. This KPI will be included in the
Integrated Performance/ KPI Report and
will be formally reported through
appropriate forums and will inform
Group Performance Reviews.
Central testing on July’s incidents has commenced and will be completed by the end of
September 2016 including identifying any actions to improve the process and
compliance.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kelly Burcham, Head of
Risk and Clinical Audit/
Sarah Davy, Legal
Services Manager/
Claire Jenkinson, Head
of Performance
30/06/2016
(amendments to datix
and development of
KPI)
31 July 2016
(Reporting of KPI as
part of integrated
performance report)
Date expected to be
fully embedded - 31
October 2016
Completed Trust Governance
and Assurance
Committee
CQC128 Independent re-audit to be requested to
validate actions taken, e.g., Verita, KPMG
as part of Internal Audit Programme
Further review / strengthening of the Trust’s arrangements for managing SIs including
interface with stakeholders to be undertaken further to QSG discussion – meeting to be
held on Friday 14 October 2016, facilitated by NHSE.
Wendy Booth,
Director of
Performance
Assurance & Trust
Secretary
Kelly Burcham, Head of
Risk and Clinical Audit
31/08/2016
Scope to be agreed
Completed Trust Governance
and Assurance
Committee
30 September 2016
Audit to be undertaken
Date expected to be
fully embedded - 31
October 2016
Completed
CQC129 CQC 2015 The Community Dental Service
should promote the use of the
Trust electronic incident
reporting system to ensure
proper investigation of
incidents and sharing of
lessons learnt across the Trust.
Ensure that staff in the Community
Dental Service are aware of and
appropriately using the Trust incident
reporting system.
This is now embedded and uptake will be monitored through quarterly incident
analysis reports. Update: Monthly team meetings are being used to monitor & discuss
lessons learnt.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
Dawn Daly, Head of
Therapies (C&TS)/ Kelly
Burcham, Head of Risk
and Clinical Audit
31/05/2016
Date expected to be
fully embedded - 31
August 2016
Ratified at TGAC on 15
September 2016
Increase in staff
knowledge of incident
reporting systems
Staff Feedback
Incident Reports
Trust Governance
and Assurance
Committee
Management of Risk
CQC130 CQC 2015 a) The Trust must ensure there
are timely and effective
governance processes in place
to identify and actively manage
risks throughout the
organisation, especially in
relation to critical care, staffing
and ensuring the essential
equipment is included in the
Trust replacement programme.
Full review of Risk Register to take place. Risk Register Confirm and Challenge Meeting Terms of Reference and Risk Register
Policy updated and approved by TGAC. Work ongoing with groups/ departments to
ensure that the register is complete.
Karen Dunderdale,
Deputy Chief
Executive and
Director of
Operations
All Associate Chief
Operating Officers/
Kelly Burcham, Head of
Risk and Clinical Audit/
Strategy and Planning
Lead to be identified
30/06/2016
strategic risks
Completed Risk Register Complete
and updated Monthly
Minutes of Governance
Meetings
Trust Governance
and Assurance
Committee
31 July 2016
directorate/groups
Date expected to be
fully embedded - 31
October 2016
Completed
23
CQC131 b) The Trust should ensure that
all identified risks for the
services are held on the risk
register.
Review of Terms of Reference for
Group/Directorate Governance Meetings
to take place to ensure review of risk
register is on the agenda.
Groups/directorates have confirmed that discussion of the risk register is discussed at
their governance/business meeting. This will be audited. Full review of Terms of
Reference taking place to review other governance requirements.
31/05/2016
Date expected to be
fully embedded - 30
September 2016
Completed Risk Register Complete
and updated Monthly
Minutes of Governance
Meetings
Trust Governance
and Assurance
Committee
Staff Support
CQC132 CQC 2015 The Trust should strengthen Strengthen support as outlined in CQC A Consultant Radiologist from HEY is now our ARSAC Licence Holder. He provides
support both remotely and in person when required. An SLA is in the process of being
drawn up to formalise the agreement. Case of need to be presented at Strategy and
Planning on 9th May outlining request for funding requirements to support service as
per budget setting agreement. Update as at 27/5/16: Support arrangements in place.
Dr Avery now performing the role formally. Funding agreed on 9/5/2016 for 1 year
including training of NLAG Radiologists for reporting. Update as at 7/6/16: A
Consultant Radiologist from HEY is now our ARSAC Licence Holder. He provides
support both remotely and in person when required. Support arrangements in place.
Dr Avery now performing the role formally in line with SLA with HEY. Funding agreed
on 9/5/2016 for 1 year including training of NLAG Radiologists for reporting.
Karen Dunderdale, Tracey Broom, 30/06/2016 Ratified at TGAC on 17 Support arrangements in Staff Experience Surveys Trust Governance
the support provided to action. Deputy Chief Associate Chief October 2016 place and Assurance
nuclear medicine technologists Executive and Operating Officer/ Ruth Date expected to be Committee
by the ARSAC (administration Director of Kent, Head of Radiology fully embedded - 30 of radioactive substances Operations Services (CSS) September 2016 advisory committee) licence holder.
Record Keeping
CQC133 CQC 2015 The Trust must ensure that This related to a specific issue regarding Staff concerned at the CDC centre were informed to immediately stop this practice at Karen Dunderdale, Dawn Daly, Head of 31 April 2016 Completed Record Keeping Policy Results of Record Quality and Patient
record keeping meets all the use of records for MDT meetings. their MDT meetings. The process for case conferences follows LSCB guidance in that Deputy Chief Therapies (C&TS)/ Tina Keeping Audit Experience
appropriate registered body any case conference information is sent to the chair electronically and any copies Executive and Sykes, Associate Chief Date expected to be Achievement of Record Committee
standards (particularly in the printed stay at the meeting for destruction, not transported outside. All community Director of Nurse (C&TS) fully embedded - 31 Keeping Standards community). staff have mobile solutions (laptops). Operations October 2016
24
QUALITY DEVELOPMENT PLAN INDICATORS
For The Period 1st April 2016 to 31st August 2016
For The Period
Performance Metric
Threshold
Threshold
Type
Apr 16
Performance
May 16
Performance
Jun 16
Performance
July 16
Performance
Aug 16
Performance
In month
movement
Month End
Position
August 16
Trend line Comments
Staffing Levels KPI300 Drs Unfilled Shifts - Medicine 0 61 42 38 ↑ Medicine shifts are an accumulation of medicine and ED shifts.
KPI301 Dr Unfilled Shifts - Surgery 0 0 7 9 ↓ KPI302 Drs Unfilled Shifts - ED 0 13 22 32 ↓ KPI303 Drs Unfilled Shifts - CC 0 0 0 4 ↓ KPI304 Registered Nursing unfilled working hours - Medicine 80% 91.6% 90.6% 87.9% 87.8% 101.2% ↑ The KPI is monitoring is monitoring unfilled working hours for inpatients
areas which is extracted from the monthly Safer Staffing Unify submission
apart from ED shifts which isn't a requisite for the submission therefore is
sourced from e rostering data. The performance target is the actual
percentage where as the Unify return is the average percentage of day and
night shifts.
KPI305 Registered Nursing unfilled working hours - Surgery 80% 96.7% 95.0% 93.8% 92.5% 109.7% ↑
KPI306 Registered Nursing unfilled working hours - ED 80% 92.4% 91.3% 88.4% 88.4% 87.9% ↓
KPI307 Midwife unfilled working hours 80% 94.9% 94.5% 93.2% 92.7% 98.4% ↑ KPI207 No Band 4s are rostered to RN shifts at roster approval stage 0 0 0 → KPI53 Reduction in AHP vacancy rate 6.86% 6.87% 7.44% 6.12% 6.12% 6.12% → KPI52 Reduction in medical staffing vacancy rate 14.17% 16.3% 18.9% 19.1% 19.8% 20.7% ↓ KPI308 Doctors Vacancy Rates - ED 14.17% 28.9% 33.9% 31.9% 34.0% 34.4% → KPI309 Doctors Vacancy Rates - CC 14.17% 1.73% 1.45% 3.55% 1.93% (10.3%) ↑ KPI310 Nursing Vacancy Rates - ED Registered 6% 16.8% 6.9% 10.3% 14.5% 9.8% ↓ KPI311 Nursing Vacancy Rates - ED Un registered 6% (12%) (17.6%) (28.76%) (24.45%) (21.48%) ↓ KPI312 Nursing Vacancy Rates - CC Registered 6% 3.0% 6.9% 4.3% (0.72%) (0.72%) → KPI313 Nursing Vacancy Rates - CC Un registered 6% 33.6% 33.6% (0.14%) 19.4% 13.0% ↑ KPI314 Nursing Vacancy Rates - Surgery Registered 6% 10.6% 11.0% 12.2% 13.2% 14.2% ↓ KPI315 Nursing Vacancy Rates - Surgery Un Registered 6% (6.68%) (16.53%) (5.76%) (3.89%) (3%) ↓ KPI316 Nursing Vacancy Rates - Medicine Registered 6% 15.0% 15.3% 15.8% 17.1% 16.5% ↑ KPI317 Nursing Vacancy Rates - Medicine Un registered 6% (2.58%) (2.07%) (2.23%) (0.26%) 1.1% ↓
KPI51
Reduction in nursing vacancy rate - Registered
6%
9.7%
10.0%
10.4%
10.4%
10.9%
↓ Review meetings held every week. Recruitment incentive packages
developed and agreed, European recruitment ongoing, University
partnerships developed, Retention plan progression including band 5+,
Nursing academies and return to practice, Enhanced pay for bank staff
within ‘specialist areas’.
KPI318
Reduction in nursing vacancy rate - Un registered
6%
(1.62%)
(1.65%)
(1.44%)
0.9%
1.5%
↓
KPI319 Midwife Vacancy Rates 6% (0.75%) 3.2% 2.6% 2.3% ↑ KPI363 Reduction in Radiologist vacancy rates 14.17% 45.7% 41.1% 41.1% 36.5% 36.5% → Clinical Strategies & Pathways KPI320 Theatre 'On the Day' Cancellation Rate (Hospital only for clinical reason) 4.30% 3.9% 4.5% 3.4% ↑ July and August data is not currently available due to the transition of
theatre systems from ORMIS to WEBV which is impacting on monthly
reporting. KPI321 Theatre 'On the Day' Cancellation Rate (Hospital only for non-clinical reason) 2.50% 2.2% 2.6% 3.1% ↓ KPI362 Theatre 'On the Day' Cancellation Rate - Surgery 5% 8.9% 11.5% 8.9% ↑ KPI367(a) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Elective Surgery 0 0 0 0 →
These measures are to monitor any theatre lists that have been stood down
due to lack of medical cover in Surgery for Elective, Emergency and Urgent
operations. July and August data is not currently available - Transition of
theatre systems from ORMIS to WEBV is impacting on monthly reporting
KPI367(b) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Emergency Surgery 0 0 0 0 → KPI367(c) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Urgent Surgery 0 0 0 0 → KPI367(d) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Elective Surgery 0 0 5 2 ↑ KPI367(e) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Emergency Surgery 0 8 4 1 ↑ KPI367(f) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Urgent Surgery 0 0 0 0 → KPI322 Hospital Outpatient Cancelled Appointments - Trust wide 5% 13.1% 8.5% 8.5% 10.3% 8.5% ↑ KPI323 Hospital Outpatient Cancelled Appointments - Goole 5% 15.2% 8.3% 8.5% 14.4% 10.5% ↑ KPI324 Complaints relating to delays or cancellations in Angiography Catherization Lab SGH 1 0 0 0 0 0 → KPI325 Incidents relating to delays or cancellations in Angiography Catherization Lab SGH 1 0 0 0 0 0 → KPI326 Rdlgy Reporting times Urgent CT/MRI GP Referrals within 72 hours 90% 32.1% 28.9% 41.9% 31.5% 29.9% ↓ KPI327 Rdlgy Reporting times Urgent CT/MRI Outpatients within 72 hours 90% 27.4% 30.9% 43.1% 44.9% 46.3% ↑ KPI328 Rdlgy Reporting times CT/MRI Inpatient within 24 hours 90% 91.1% 91.7% 92.7% 93.4% 93.3% ↓ KPI329 Rdlgy Reporting times 31/62 GP Referrals within 24 hours 90% 54.1% 60.5% 66.3% 65.0% 74.3% ↑ KPI330 Rdlgy Reporting times Outpatients within 24 hours 90% 43.2% 50.1% 53.1% 67.2% 75.6% ↑ KPI331 Rdlgy Reporting times Routine within 168 Hours (7 days) 90% 68.3% 73.4% 78.1% 87.0% 79.4% ↓ KPI195 Reduction in Hospital Outpatient Cancelled Appointments rates by Patients 1% 0.0% 0.2% 0.5% 0.0% 0.5% ↓ KPI361 Out Patient Clinical Slot Utilisation Rate 94% 82.8% 85.3% 84.4% 83.3% 85.1% ↑ KPI356 (a) Reduction in the number of Cardiology Referrals NE Lincolnshire 5% 2.3% (-12%) 7.6% 5.7% 16.5% ↓ New referrals only includes accepted referrals in the data set. Measure is
monitoring the reduction of referrals based on the same monthly period
the previous year to allow for seasonal variations. This is to monitor what
impact the new GP referral protocol is having on referral numbers. Figures
in red signify a reduction on last years returns. Figures in red represents the
KPI356 (b) Reduction in the number of Cardiology Referrals North Lincolnshire 5% 32.6% 35.9% 24.3% 22.8% 46.0% ↓ KPI357 (a) Reduction in the number of Respiratory Referrals - NE Lincolnshire 5% (-8.9%) (-27%) 1.8% 15.5% 22.0% ↓ KPI357 (b) Reduction in the number of Respiratory Referrals - North Lincolnshire 5% 7.6% 34.2% 18.6% (-11.1%) 47.3% ↓ Safety KPI332 Emergency Care Incidents - no anaesthetic staff 0 1 0 0 0 0 → KPI368 Pressure Ulcers - Theatres harm free care 0 0 0 0 0 0 → KPI333 Maternity Incidents that have an RCA 5 11 12 12 7 5 ↑ KPI334 Nursing Capacity incidents - ED 7 2 1 2 3 19 ↓
Increase in incidents could be attributed new additional l 'red flag' triggers,
historically there was only 1 trigger 'staffing levels'
KPI335 Nursing Capacity incidents - Medicine 41 10 7 3 63 77 ↓ KPI336 Nursing Capacity incidents - Surgery 2 6 1 2 13 16 ↓
Performance Metric
Threshold
Threshold
Type
Apr 16
Performance
May 16
Performance
Jun 16
Performance
July 16
Performance
Aug 16
Performance
In month
movement
Month End
Position
August 16
Trend line
Comments
KPI337 Midwife Capacity incidents 5 10 0 2 5 11 ↓
Performance Metric
Threshold
Threshold
Type
Apr 16
Performance
May 16
Performance
Jun 16
Performance
July 16
Performance
Aug 16
Performance
In month
movement
Month End
Position
August 16
Trend line
Comments
KPI348 Community Buildings where PAT testing is completed 70% 26.9% 38.5% 100% ↑ KPI364 (a) Ratio of midwives to births - DPoW 01:28 1.34 1.34 → KPI364 (b) Ratio of midwives to births - SGH 01:28 1.30 1.30 → KPI365 1:1 figures for births 100% 100% 99.5% 98.7% 99.5% 98.5% ↓ Responsive
KPI19
Fractured Neck of Femur patients operated on within 36 hours
75%
64.3%
60.0%
73.7%
52.9%
56.1%
↑
There is discrepancy currently e around conciliating data on the National Hip
Fracture Database compared to PAS. The operation group is in the process
of procuring more administration support into #NOF validation. The
performance is representative of the current information available.
KPI182
DNA Rate - Trust wide
6%
8.6%
9.2%
9.9%
9.7%
9.1%
↑
Call reminder service resources allocated to specific specialities to be rolled
out to all specialities following implementation of the new clinical admin
structure. Monthly data is rebased to reflect historic changes. KPI338 DNA Rate - Goole 6% 7.1% 8.5% 9.5% 8.4% 8.5% ↓
KPI339
Delay Discharges Intensive Therapy Unit DPoW - Intensive Care Unit SGH
67.8%
50.0%
43.9%
44.4%
↓ Performance is based on medically fit patients that have a delayed
discharge onto another ward of more that 4 hours. This data is extracted
quarterly and presented to the Critical Care Provision Group. Updated data
will be available in September.
KPI17 Delayed transfer of care at or below national benchmark rate 3.8% 3.3% 2.1% 2.5% 3.1% 2.6% ↑ KPI 18 Outliers on medical and surgical wards 3.0% 5.6% 4.4% 4.3% 4.3% 3.8% ↑ KPI359 Duty of Candour - SUIs - met in all relevant instances 100% 100% 100% 100% 100% 100% → KPI360 Duty of Candour - Moderate Harm (non SUIs) - met in all relevant instances 100% 100% 100% 100% 100% 100% → Well Led KPI340 Health Visitors - 3 monthly peer supervision 92% 88.9% 86.1% 88.9% 84.7% 74.3% ↓
KPI56
Nurses to have received supervision
95%
76.7%
77.4%
76.5%
78.0%
77.4% ↓ Compliance with supervision requirements continues to be monitored at all
levels of the Trust.
KPI341 Learning Lessons - Feedback on incidents to be provided 100% 86.0% 79.9% 76.3% ↓
KPI63
Mandatory training compliance rate
95%
93.3%
93.1%
91.8%
91.6%
92.3%
↑
Failure to achieve this indicator has been escalated to and discussed at the
Trust's Governance & Assurance Committee. A range of actions were
identified and these will be undertaken over the coming months. Monthly
reports are distributed to group managers highlighting staff who are
nearing the cut off point for training compliance.
KPI64
Staff to have undertaken an annual Vision & Values PADR
95%
85.3%
77.9%
78.4%
76.3%
76.3%
→ This continues to be monitored at all levels of the Trust. Monthly reports
are distributed to group managers highlighting staff who are nearing the cut
off point for PADR compliance.
KPI349
Number of wards with dedicated management time
100%
42.9%
26.0%
46.9%
37.3%
29.4%
↓
KPI349 (a) Provision of protected management time for ward charge nurses 100% 90.2% 71.1% 61.6% ↓
KPI349 (b) Dedicated shift leader on days 80%
KPI355
Relevant staff have received training in managing patients with a learning disability
A local Education and Training Strategy for LD care to reflect the new Health
Education England training for learning disability guidance is currently being
developed. Once this has been sanctioned a training programme with be
delivered Trust wide.
KPI62 Relevant staff have received dementia awareness training 60% 67.6% 68.7% 70.0% 71.1% 84.4% ↑ Effectiveness
KPI01
SHMI - hospital within expected range
95
109
(Dec - 15)
107
(Jan - 16)
107
(Feb - 16)
107
(Mar - 16)
108
(Apr - 16)
↓
This is a Trust quality priority which is monitored at monthly QPEC and
MPAC meetings. A range of work streams have been implemented focusing
on: care for patients at the end of life, accuracy of information and coding,
6 clinical led Multi Disciplinary Teams looking at quality/morality agenda.
Case note reviews are also looking at care quality and a monthly detailed
Mortality report is overseen by MPAC and Trust Board.
KPI02
SHMI - weekend within expected range
95
114
(Dec - 15)
109
(Jan - 16)
110
(Feb - 16)
109
(Mar - 16)
112
(Apr - 16)
↓
KPI342 Documents in compliance within the Document Control System - Maternity 90% 91.1% 93.4% 94.9% ↑ KPI343
Documents in compliance within the Document Control System - Patient Group Directions for
Medication within ED 90% 100% 100% 100% 100% 83.7% ↓
KPI183
Documents in compliance within the Document Control System
90%
78.6%
79.3%
77.9%
79.5%
81.2%
↑
Operational groups have implemented various work streams to improve
such as using trackers, dedicated section on governance agenda and general
management direct control.
KPI03a Adherence to NICE guidance TAG 100% 92.3% 93.2% 90.0% 88.9% 82.2% ↓ Work streams implemented to support healthcare professionals to assess
the increasing numbers of guidelines within the required timescales. TGAC
monitoring monthly performance. KPI03b Adherence to NICE guidance - CG & NG 90% 76.5% 75.7% 80.8% 68.4% ↓ KPI350 Number of service reviews undertaken 14.3% 14.3% 14.3% → KPI351 Number of services with capacity plans 46.2% 46.2% 46.2% → Patient Experience KPI344 Complaints/PALS - Midwifery 5 8 2 3 5 2 ↑ KPI345 End of life Care (Complaints) 1 0 0 0 1 2 ↓ KPI346 MSA - sleeping breaches 0 0 0 0 0 0 → KPI352 Sis in A&E Department - anti-ligature risks 0 0 0 0 0 0 →
Performance Metric
Threshold
Threshold
Type
Apr 16
Performance
May 16
Performance
Jun 16
Performance
July 16
Performance
Aug 16
Performance
In month
movement
Month End
Position
August 16
Trend line
Comments
KPI353
Incidents in A&E Department - anti-ligature risks
0
0
0
0
0
1
↓
Incident escalated to Matron for further investigation. Appropriate action
taken by staff, staff were reminded of the importance of 1:1 consultations
with mental health patients.
Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Trend Analysis
Staffing Levels
KPI300 Drs Unfilled Shifts - Medicine 0 61 42 38 KPI301 Dr Unfilled Shifts - Surgery 0 0 7 9
KPI302 Drs Unfilled Shifts - ED 0 13 22 32 KPI303 Drs Unfilled Shifts - CC 0 0 0 4
KPI304 Registered Nursing unfilled working hours - Medicine 80% 91.6% 90.6% 87.9% 87.8% 1.012 KPI305 Registered Nursing unfilled working hours - Surgery 80% 96.7% 95.0% 93.8% 92.5% 1.097
KPI306 Registered Nursing unfilled working hours - ED 80% 92.4% 91.3% 88.4% 88.4% 87.9% KPI307 Midwife unfilled working hours 80% 94.9% 94.5% 93.2% 92.7% 98.4% KPI207 No Band 4s are rostered to RN hours at roster approval stage’ 0 0 0
KPI53 Reduction in AHP vacancy rate 6.86% 6.9% 7.4% 6.1% 6.1% 6.1% KPI52 Reduction in medical staffing vacancy rate 14.17% 16.3% 18.9% 19.1% 19.8% 20.7%
KPI308 Doctors Vacancy Rates - ED 14.17% 28.9% 33.9% 31.9% 34.0% 34.4%
KPI309 Doctors Vacancy Rates - CC 14.17% 1.7% 1.5% 3.6% 1.9% (10.3%) KPI310 Nursing Vacancy Rates - ED Registered 6% 16.8% 6.9% 10.3% 14.5% 9.8% KPI311 Nursing Vacancy Rates - ED Un registered 6% (12%) (17.6%) (28.76%) (24.45%) (21.48%)
KPI312 Nursing Vacancy Rates - CC Registered 6% 3.0% 6.9% 4.3% (0.72%) (0.72%)
KPI313 Nursing Vacancy Rates - CC Un registered 6% 33.6% 33.6% (0.14%) 19.4% 13.0% KPI314 Nursing Vacancy Rates - Surgery Registered 6% 10.6% 11.0% 12.2% 13.2% 14.2% KPI315 Nursing Vacancy Rates - Surgery Un Registered 6% (6.68%) (16.53%) (5.76%) (3.89%) (3%) KPI316 Nursing Vacancy Rates - Medicine Registered 6% 15.0% 15.3% 15.8% 17.1% 16.5%
KPI317 Nursing Vacancy Rates - Medicine Un registered 6% (2.58%) (2.07%) (2.23%) (0.26%) 1.1%
KPI51 Reduction in nursing vacancy rate - Registered 6% 9.7% 10.0% 10.4% 10.4% 10.9% KPI318 Reduction in nursing vacancy rate - Un registered 6% (1.62%) (1.65%) (1.44%) 0.9% 1.5%
KPI319 Midwife Vacancy Rates 6% (0.75%) 3.2% 2.6% 2.3% KPI363 Reduction in Radiologist vacancy rates 14.17% 45.7% 41.1% 41.1% 36.5% 36.5%
Clinical Strategies & Pathways
KPI320 Theatre 'On the Day' Cancellation Rate (Hospital only for clinical reason) 4.30% 3.9% 4.5% 3.4% KPI321 Theatre 'On the Day' Cancellation Rate (Hospital only for non-clinical reason) 2.50% 2.2% 2.6% 3.1% KPI362 Theatre 'On the Day' Cancellation Rate - Surgery 5% 8.9% 11.5% 8.9%
KPI367(a) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Elective Surgery 0 0 0 0 KPI367(b) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Emergency Surgery 0 0 0 0 KPI367(c) Theatre 'On the Day' Cancellation Rate due to lack of Anaesthetist Cover - Urgent Surgery 0 0 0 0
KPI367(d) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Elective Surgery 0 0 5 2
KPI367(e) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Emergency Surgery 0 8 4 1 KPI367(f) Theatre 'On the Day' Cancellation Rate due to lack of Surgeon Cover - Urgent Surgery 0 0 0 0
KPI322 Hospital Outpatient Cancelled Appointments - Trust wide 5% 13.1% 8.5% 8.5% 10.3% 8.5% KPI323 Hospital Outpatient Cancelled Appointments - Goole 5% 15.2% 8.3% 8.5% 14.4% 10.5% KPI324 Complaints relating to delays or cancellations in Angiography Catherization Lab SGH 1 0 0 0 0 0 KPI325 Incidents relating to delays or cancellations in Angiography Catherization Lab SGH 1 0 0 0 0 0
KPI326 Rdlgy Reporting times Urgent CT/MRI GP Referrals within 72 hours 90% 32.1% 28.9% 41.9% 31.5% 29.9%
QUALITY DEVELOPMENT PLAN INDICATORS
For The Period 1st April 2016 31st August 2016
Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Trend Analysis
KPI327 Rdlgy Reporting times Urgent CT/MRI Outpatients within 72 hours 90% 27.4% 30.9% 43.1% 44.9% 46.3%
KPI328 Rdlgy Reporting times CT/MRI Inpatient within 24 hours 90% 91.1% 91.7% 92.7% 93.4% 93.3%
KPI329 Rdlgy Reporting times 31/62 GP Referrals within 24 hours 90% 54.1% 60.5% 66.3% 65.0% 74.3%
KPI330 Rdlgy Reporting times Outpatients within 24 hours 90% 43.2% 50.1% 53.1% 67.2% 75.6%
KPI331 Rdlgy Reporting times Routine within 168 Hours (7 days) 90% 68.3% 73.4% 78.1% 87.0% 79.4%
KPI195 Hospital Outpatient Cancelled Appointments rates by Patients 1% 0.0% 0.2% 0.5% 0.0% 0.5%
KPI361 Out Patient Clinical Slot Utilisation Rate 94% 83.0% 82.8% 82.8% 82.7% 0.0%
KPI356 (a) Reduction in the number of Cardiology Referrals NE Lincolnshire 5% 2.3% (-12%) 7.6% 5.7% 16.5%
KPI356 (b) Reduction in the number of Cardiology Referrals North Lincolnshire 5% 32.6% 35.9% 24.3% 22.8% 46.0%
KPI357 (a) Reduction in the number of Respiratory Referrals - NE Lincolnshire 5% (-8.9%) (-27%) 1.8% 15.5% 22.0%
KPI357 (b) Reduction in the number of Respiratory Referrals - North Lincolnshire 5% 7.6% 34.2% 18.6% (-11.1%) 47.3%
Safety
KPI332 Emergency Care Incidents - no anaesthetic staff 0 1 0 0 0 0
KPI368 Pressure Ulcers - Theatres harm free care 0 0 0 0 0 0
KPI333 Maternity Incidents having an RCA 5 11 12 12 7 5
KPI334 Nursing Capacity incidents - ED 7 2 1 2 3 19
KPI335 Nursing Capacity incidents - Medicine 41 10 7 3 63 77
KPI336 Nursing Capacity incidents - Surgery 2 6 1 2 13 16
KPI337 Midwife Capacity incidents 5 10 0 2 5 11
KPI348 Community Buildings where PAT testing is completed 70% 26.9% 38.5% 100%
KPI364 (a) Ratio of midwives to births - DPoW 1.28 1.34 1.34
KPI364 (b) Ratio of midwives to births - SGH 1.28 1.30 1.30
KPI365 1:1 figures for births 100% 100% 99.5% 98.7% 100% 98.5%
Responsive
KPI19 Fractured Neck of Femur patients operated on within 36 hours 75% 64.3% 60.0% 73.7% 52.9% 56.1%
KPI182 DNA Rate - Trust wide 6% 8.6% 9.2% 9.9% 9.7% 9.1%
KPI338 DNA Rate - Goole 6% 7.1% 8.5% 9.5% 8.4% 8.5%
KPI339 Delay Discharges ITU DPoW - ICU SGH 3.8% 67.8% 50.0% 43.9% 44.4%
KPI17 Delayed transfer of care at or below national benchmark rate 3.8% 3.3% 2.1% 2.5% 3.1% 2.6%
KPI18 Outliers on medical and surgical wards 3.0% 5.6% 4.4% 4.3% 4.3% 3.8%
KPI359 Duty of Candour - SUIs - met in all relevant instances 100% 100% 100% 100% 100% 100%
KPI360 Duty of Candour - Moderate Harm (non SUIs) - met in all relevant instances 100% 100% 100% 100% 100% 100%
Well Led
KPI340 Health Visitors - 3 monthly peer supervision 92% 88.9% 86.1% 88.9% 84.7% 74.3%
KPI56 Nurses to have received supervision 95% 76.7% 77.4% 76.5% 78.0% 77.4%
KPI341 Learning Lessons - Feedback on incidents to be provided 100% 86.0% 79.9% 76.3%
KPI63 Mandatory training compliance rate 95% 93.3% 93.1% 91.8% 91.6% 92.3%
KPI64 Staff to have undertaken an annual Vision & Values PADR 95% 85.3% 77.9% 78.4% 76.3% 76.3%
KPI349 Number of wards with dedicated management time 100% 42.9% 26.0% 46.9% 37.3% 29.4%
KPI349 (a) Provision of protected management time for ward charge nurses 100% 90.2% 71.1% 61.6%
KPI349 (b) Dedicated shift leader on days 80%
KPI355 Relevant staff have received training in managing patients with a learning disability
KPI62 Relevant staff have received dementia awareness training 60% 67.6% 68.7% 70.0% 71.1% 84.4%
Effectiveness
KPI01 SHMI - hospital within expected range 95 109
(Dec - 15)
107
(Jan - 16)
107
(Feb - 16)
107
(Mar - 16)
108
(Apr - 16)
KPI02 SHMI - weekend within expected range 95 114
(Dec - 15)
109
(Jan - 16)
110
(Feb - 16)
109
(Mar - 16)
112
(Apr - 16)
KPI342 Documents in compliance within the Document Control System - Maternity 90% 91.1% 93.4% 94.9%
Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Trend Analysis
KPI343 Documents in compliance within the Document Control System - Patient Group Directions for
Medication within ED 90% 100% 100% 100% 100% 83.7%
KPI183 Documents in compliance within the Document Control System 90% 78.6% 79.3% 77.9% 79.5% 81.2%
KPI03 a Adherence to NICE guidance TAG 100% 92.3% 93.2% 90.0% 88.9% 82.2%
KPI03 b Adherence to NICE guidance - CG & NG 90% 76.5% 75.7% 80.8% 68.4%
KPI350 Number of service reviews undertaken 14.3% 14.3% 14.3%
KPI351 Number of services with capacity plans 46.2% 46.2% 46.2%
Threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Trend Analysis
Patient Experience
KPI344 Complaints/PALS - Midwifery 5 8 2 3 5 2
KPI345 End of life Care (Complaints) 1 0 0 0 1 2
KPI346 MSA - sleeping breaches 0 0 0 0 0 0
KPI352 Sis in A&E Department - anti-liagture risks 0 0 0 0 0 0 KPI353 Incidents in A&E Department - anti-liagture risks 0 0 0 0 0 1