CQC Quality Summit 2 February 2016 Lance McCarthy Chief Executive Content Key headlines Ratings Caring domain Areas of focus Must Dos Next 6 months Good & Beyond Summary Key headlines Requires Improvement overall improvement from Inadequate Improving - CQC saw material improvements had been made since their previous inspection Caring Good rating achieved in all of the service areas Leadership CQC feel the leadership team is able to continue with the implementation of the improvements required 14 Must Dos No compliance issues Recommendation that we remain in special measures to ensure ongoing additional support to further embed improvements Re-inspection soon (date tbd) Inconsistent leadership Material financial, quality and political challenges Circle franchise wound up in March 2015 Lack of traditional NHS governance structure Challenged health economy: system-wide transformation Context Special Measures Temporary Staff use (due to special measures & location) Material improvements over time 31 March 2015 Return to NHS management 2 February 2016 Today 2013/142014/152015/16 January 2015 CQC re-inspection September 2014 Initial CQC inspection October 2015 Second CQC re-inspection Ratings after September 2014 visit Ratings after January 2015 visit Ratings after October 2015 visit Changes to the ratings (Jan to Oct) Caring domain Good in all 7 service areas Inadequate in Sept 2014 (4 x good, 1 x RI, 2 x Inadequate) Requires Improvement in Jan 2015 (5 x good, 2 x RI) Good in Oct 2015 (7 x good) Good rating reflects the hard work and passion of all staff to provide good clinical services and accords with my view of our approach to patients Caring Positive comments: Good emotional support to patients on wards Excellent chaplaincy service Staff culture had improved Improved FFT ratings Almost universally positive feedback from patients Good call bell responses Caring CQC SAID Patient feedback about ED staff being too busy to provide care / answer questions Need to evidence EoLC conversations in notes better Further training in advanced comms for ward staff / doctors IMPROVEMENTS SINCE OCT Uplift to ensure that the nurse coordinator is supernumerary / supervisory as the norm EoLC strategy being rolled out WORK IN PROGRESS Review of shift patterns compared with demand for services & appropriate actions EoLC Strategy and AMBER bundle roll out Training review for difficult conversations to be undertaken (in EoLC strategy) Safe Positive comments: Proactive senior management team receptive to immediate feedback Good duty of candour documentation and discussions with families Good safeguarding training attendance Much improved safeguarding understanding and interaction and staff empowerment to raise concerns Appropriate grading of incidents Safe CQC SAID ED concerns with infection control, safety of MH patients and risks to the potentially deteriorating patient IMPROVEMENTS SINCE OCT IPC support to reduce variation with IC practices ED ligature risks removed MH assessment protocol revised and relaunched CPFT support to ED staff Nursing risk assessment documentation introduced in October 2015 MEWS protocol for ED revised Rapid assessment to triage protocol established and launched WORK IN PROGRESS Monthly audit and peer review Case review of random sample of patients to identify any care concerns Daily quality audit supported by site management team Two hourly multi-disciplinary board rounds Embedding of the RAT-ing process Safe CQC SAID Medicine lack of assessment of patient risk including hygiene control and allergies to medications Nurse staffing levels in ED were having an impact on the care for patients Lessons were not always learnt from incidents in a consistent way IMPROVEMENTS SINCE OCT Monthly AB audits most recent showed compliance with allergy identification on prescription charts Uplift to ensure that the nurse coordinator is supernumerary / supervisory as the norm Revised the SI policy Multi-disciplinary Trust learning events convened WORK IN PROGRESS Compliance monitored via Trust accountability framework and quarterly audits Review of shift patterns compared with demand for services & appropriate actions SI process included in external peer review of governance Revised governance & risk Board report with trends and National comparators Director of Nursing led weekly rapid review clinic Effective Positive comments: Most surgical audit outcomes in line with or better than national expectations Good multidisciplinary working across the Trust enhancing patient care Positive working with external MH and safeguarding services Good consent process Effective CQC SAID National audits not in line with expected outcomes Implementation of national guidance not robust Local audit plans not in place Minimal progression to improve or assess EoLC Bereavement Care policy still contained reference to LCP Non adherence to NICE guidelines for head injury & acute asthma IMPROVEMENTS SINCE OCT Strengthened CAE staffing and now report directly to the Medical Director EoLC strategy roll out and increased palliative care nursing staff at weekends Policy reviewed and LCP references removed Head injury guideline in line with NICE guidance WORK IN PROGRESS Review NICE guidance & local audit plans in February EoLC action plan is being formulated Acute asthma guideline under review Effective CQC SAID ECG test results in the ED had not been reviewed in a timely manner The sepsis audit had a marked decline in the results Communication with patients and relatives was not always robust IMPROVEMENTS SINCE OCT ECG review process complete and in place. Increased volume and frequency of sepsis audit to support improved management Communication sheets agreed WORK IN PROGRESS Continuous audit programme to be introduced to ensure compliance Embedding learning from audit results Roll out of communication sheets Responsive Positive comments: Improvements in LoS Good practice in meeting the needs of patients with dementia sensory bands on Apple Ward Prompt treatment in ambulatory care Named nurse for learning disabilities and good staff training Good telephone translation service Named nurse for dementia Good RTT performance Cancelled operation % lower than national average Good feedback folders on wards Proactive staff engagement on Juniper Responsive CQC SAID Delays accessing EoLC services Delays in discharge despite dedicated services High number of bed moves overnight Inconsistent delivery of the four hour standard for ED, not linked to bed availability Paediatrics ED did not meet national environment g/ance SALT services were not commissioned to provide care for patients with dysphasia Only two nurses trained to undertake basic swallow assessments IMPROVEMENTS SINCE OCT More palliative care nursing Ongoing liaison with wider community DToCs < 5% Fallen in last year (CQUIN achieved) Ongoing work to improve flow of patients within the ED / internal standards adherence Paediatric review complete and being implemented In process of reviewing SLA with CCS (SALT team provider) Training package for swallow assessment sourced (spot purchase and e-learning) WORK IN PROGRESS Continuous audit programme System actions & plans for the Health Campus OJEU) Ongoing plans to reduce bed moves overnight Ongoing implementation of ED action plan to support 4 hour standard Implementation of paediatric improvements wall agreed Review of commissioning of stroke rehab and SALT provision ** Implement training programme Well led Positive comments: Staff felt valued and respected by the senior team Staff reported things had got better and morale improved Drive and enthusiasm to change practice Staff felt empowered to speak out when they had concerns Staff aware of the values and vision of the Trust Executives able to articulate the risks of the Trust New governance framework praised by senior staff Appropriate challenge at Board meeting Divisions to be managed by a tripartite of managers Executive demonstrated skills and leadership to undertake their roles Most staff reported that the leaders are visible Trust engages with patients through a number of initiatives Well Led CQC SAID Interim CEO in post for 6/52 Governance processes not yet embedded Nursing strategy was not clear Staff voice was not always captured UEC leadership Inadequate & EoLC leadership had only recently begun to improve Number of posts in the senior team were interim IMPROVEMENTS SINCE OCT CEO appointed 2-year FT Further development and embedding ongoing Better Exec attendance at TPF / more open fora for staff Divisional structure supporting leadership / key roles appointed to CEO appointed WORK IN PROGRESS Ongoing embedding of clear governance processes March launch of N&M Strategy Ongoing development of open and honest culture Continued development of EoL services through the new leadership team MD interviews on 15 Feb and FD date tbd (Feb) * Discussions with CCG re: refocussing inspections thematic & less regular Strong regional union officer support for developments 14 Must Dos Must DoProgress All staff aware of need to report incidents & investigate fully Datix fully rolled out on 9 Nov Continued roll out of communications. All relevant staff had adequate SALT training in supporting feeding SLA under review. Training to be completed in February. End of Life Care (EoLC) risk register includes all relevant risks All risks identified and risk register updated. EoLC strategy drafted and will go to Board in March. Patient outcomes monitored and auditedCAED Action Plan development underway. To be monitored by Q&S committee. Robust incident reporting system and learning shared widely Datix fully rolled out on 9 Nov Strengthened dissemination of learning through new governance framework. Effective governance and risk management systems Systems clear., approved and in place. Embedding ongoing. Ensure effective processes for monitoring ECGs and observations in ED In original ED plan. Action complete. Regular audits to be undertaken. 14 Must Dos Must DoProgress Review ED environment to ensure suitable for paediatrics Review complete and changes to be made in March. Lego wall ordered. Time to treatment in ED is reviewed and times improved Reviewed. New standards in place. Audit to be undertaken. Triage process for ambulances to be reviewedReviewed. New process in place. Improve infection control processes in ED reducing variations IPC review complete. Audits are ongoing and ED is being intensively supported by IPC team. Processes for checking ED equipment is improved In original ED plan. Systematic process in place during Feb. Regular equipment audits tbd. Ensure allergies are recorded on medicines charts Audit tool on all wards. Monthly audit as part of antimicrobial audit and safety thermometer audit. Ensure MH patients safe from ligatures in EDComplete. Ligature risks removed. RA complete and signed off by HSE representative Areas of Focus for next 6 months Strategy / role in the system transformation programme Reducing variation / consistency / excellent at the basics Leadership (consistency and quality at all levels) Embedding the governance structure Morale, engagement, recruitment special measures effect Good & Beyond Identification of what Good is in every domain for all 7 services Integrated composite quality action plan including all relevant actions (finance, performance, quality) Linked to refreshed values and behaviours (Feb May) OD and Leadership programmes to support this (Feb onwards) Supported by patient and staff smartphone apps (April) and Schwartz rounds (implementation in April) Progress managed through the performance meetings with oversight at HMC and board committees reinforcing governance structure Programme focusing the whole organisation on getting to good and then to outstanding Summary Disappointed to remain in special measures Concern about the impact of this on recruitment / perception But: 60% of grid is rated as good Caring and compassion of all has been well recognised Evidence of material progress in the last 16 months Further progress made since October already Welcome an early re-inspection Thank you Any questions?