Version 2 – 10th November 2016

Operational Resilience Plan

South Gloucestershire

2016 - 2017

Plan on a page 2016-17

Governance Representation at the A&E Delivery Board chaired by the CCG

Monthly S Glos performance meetings

Daily System Management calls

Gearing up For Seasonal Fluctuation using improved criteria and process management

Enhanced Flu vaccination programme 4x4 transport initiative Escalation Hub readiness for extreme

weather Review of Choice policy & application Use of Alamac and daily cross system

discussions Contribute to the Perfect week and

implement any agreed actions In reach rehab expertise at the front door to

reduce admissions

Strengthening Year Round Operational Resilience (core offer)

Roll out of IDS approach at NBT Enhanced community hospital capability

(GPsI & Advanced Nurse Practitioner utilisation on Elgar 2)

Implementation of the community cluster team model – enhanced MDT working

Embedding Active Ageing service Co-location of HAT and JCAP at

weekends to streamline access to services over 7 days

Improved JCAP processes to streamline patients to the correct pathway

Real time comms with JCAP to flex

Demand & Capacity Summary

The current planning for this winter 2016-17 does not have any additional ORCP monies however there has been investment in new services for Diabetes Dementia care advisors and falls. Current assumptions are that the demand for community services will be at least the same if not higher than last year’s demand. Demand and capacity are expressed as numbers of people from Nov 1st 2016 – 31st March 2017:

Step down demand forecast by NBT:

1814 South Gloucestershire residents requiring supported discharge (taken from winter 2015-16 figures plus anticipated 7% increase)

Step down capacity forecast by Sirona : 1863 capacity available for people to be supported

Variance: +49 additional capacity

Vision: To work with all partners in providing a co-ordinated whole system approach to maintaining the flow through our local health systems.

Background

The purpose of the winter plan for Sirona services within South Gloucestershire is to ensure that robust arrangements are in place to enable the flow of patients from hospital to home within the capacity available. The plan demonstrates how the services are able to be responsive to allow for increases in pressure felt within the acute trusts and to demonstrate resilience within the system. The responses to escalation over the winter now reflect the new operational pressures escalation level framework.

There is robust leadership over 24 hours 7 days a week provided by senior operational managers and by strategic director level. Clear communication channels will ensure effective and timely decisions are made to ensure clear decision making is communicated at all levels of the organisation.

Leadership and Escalation

Operational managers participate in daily system management calls with support as required from director level to manage escalation. All services have a minimum staffing level across 7 days per week including the bank holiday periods. There is an on call rota covering 365 days a year covering 7 days a week. Internal escalation actions are in place and activated through the on call escalation process (see appendix A)

Available Capacity 2016-17

Current plans for the winter of Nov 2016-March 2017 includes investment for additional resource with 4 permanent beds on Elgar ward and new service development for Dementia Advisors, Diabetes, Falls and Respiratory Care. The currently commissioned community health resources are expected to meet the demands of the urgent care system in South Gloucestershire

We have set targets for discharge to assess pathways for bedded and non-bedded facilities following our work with In power. Pathway 1 is set at 38 discharges per week and pathway 2 is 20 per week

South Glos front door in-reach is 1 per day Monday to Friday which is preventing admissions to specialist wards by supporting people to return home with additional support.

Community Hospital Beds 58 inpatient rehab bed – 20 in Thornbury Hospital and 38 Elgar 2 ward at Southmead Hospital.

Community Rehabilitation beds Pathway 2

21 beds in Nursing and Residential homes.

District Nursing teams 9633 contacts per month (currently running over capacity by 18%) – this

includes capacity to manage 6 new OD IV boluses per week

Community Rehabilitation Team 38 D2A per week plus Planned rehabECP Admission Avoidance 105 per weekMIU - Yate Yate MIU opens to patients from

08.00am until 7.30pm daily.Average attendance figures are currently around 1612 per month ( 36% increase from 2015)

We have developed escalation plans in line with system flow to ensure we work with our partners to flex capacity to react to pressures in the system. We regularly review and bring forward discharges as appropriate and review flexibility of criteria in Pathway 1 discharges in conjunction with social care Rapid Response at times of greatest pressure. Daily reviews of any available capacity are highlighted at the daily system management call (ALAMAC) and also use our capacity effectively for prevention of admissions. By participating in the daily calls we are able to monitor any available capacity and respond to requests from the call from partners. JCAP escalate to managers when capacity is reached and if demand is exceeding capacity

On-going work is happening with system wide partners to improve efficiencies in capacity management and flow through the IDS and enabling discharge work streams. We are currently participating on the ECIP work programme in relation to NHSI 30/60/90/120 days review with all partners to ensure robust and joined up vision to improve flow.

We ensure that we maximise the use of Community rehab beds (CRB’s) in Pathway 2 with a review of admission thresholds with flexibility to offer beds to Bristol in a shared home if no South Glos patients are suitable to transfer on that day. We offer regular support for patients at home with a higher acuity and dependency to enable them to remain safely at home rather than an admission to hospital. The frailty team has been of particular value in continuing to support such patients to remain at home much longer than previously.

Capacity across the South Gloucester community services are monitored on a weekly basis as below:

3-Oct-16 22-Oct-16 10-Nov-1629-Nov-16 18-Dec-16 6-Jan-17 25-Jan-17 13-Feb-17 4-Mar-17 23-Mar-170

20

40

60

80

100

120

140

Facilitated Discharges - ActualIV therapyCluster model inc CM, ECP and DN referralsNight sittingElgar WardRehabilitation BedsHenderson AdmissionsOther Hospital D/CD to A pathway 1

0

50

100

150

200

250

300

350

Admission Avoidance - ActualRespiratory ServicesDiabetesFrailtyIV therapy Cluster model inc CM, ECP and DN referralsNight SittingDirect Admissions to HendersonRehabilitation PlannedRehabilitation Urgent

Referrals are received via single point of access (JCAP) which is now a 7 day a week service via HAT /JCAP at weekends . Capacity continues to be monitored and tracked over a weekend via this access point. Sirona discharge team operate as part of the IDS team transferring to community beds and facilitating discharges over 7 days. Individual patient escalation plans are discussed in specific cases and at weekly LHPD meetings. We monitor and clinically review delays with partners weekly at those meetings.

Flu Vaccination

There is a planned programme in place to offer vaccinations for housebound patients meeting the criteria. Staff planned flu campaign is in operation where staff are given maximum opportunities to receive flu vaccinations (aiming for 75% take up for front line staff). Flu vaccination sessions are being held across Sirona services as below as well as attending team meetings for maximum coverage.

Tue 4 Oct 09.30 - 12.30 Room 16, First Floor, Keynsham Health Centre

Wed 5 Oct 13.30 – 15.30 Thornbury Hospital

Tue 11 Oct 14.30 – 16.00 Combe Lea CRC

Wed 12 Oct 09.30 – 12.30 Downend Clinic Meeting Room

Thu 13 Oct 09.30 – 13.30 Winter Garden Room, St Martins Hospital

Tue 18 Oct 09.30 – 12.30 Turner Room, Paulton Hospital

Tue 18 Oct 11.30 – 13.00 Charlton House CRC

Thu 20 Oct 12.00 – 14.30 Large Meeting Room, Bath NHS House

Tue 1 Nov 13.30 – 15.30 Yate Conference Room

Wed 2 Nov 09.30 – 12.30 Connections

Thu 3 Nov 09.30 – 11.00 Cleeve Court CRC

Tue 8 Nov 10.30 – 13.30 Turner Room, Paulton HospitalThu 10 Nov 11.00 – 13.00 Thornbury Hospital

Tue 15 Nov 09.30 – 11.30 Rose Room, Carrswood Day CentreThu 17 Nov 13.30 – 15.30 Room 16, Keynsham Health Centre

Tue 22 Nov 13.00 – 16.00 Room 2.2, The Hollies, Midsomer NortonWed 23 Nov 09.30 – 13.30 Winter Garden Room, St Martins Hospital

Infection control Management plans formulated with partners

Infection control is covered as part of induction and mandatory training for all clinical staff. Newsletters, training and awareness raising for staff to manage and contain an outbreak is highlighted through team meetings and the intranet. Infection control plans are in place for all services including pandemic flu plans. Senior leaders have all been involved with major incident scenarios.

Bank Holiday Service Delivery for Christmas and New Year

Robust plans in place for festive season with off duty published for all teams – this will be input into the NHSE template over the next 3 weeks.

Adequate staffing is in place for bank holidays Staffing levels have been determined with allowance to flex the workforce to

meet the demands around bank holiday days and in between Christmas and New Year

Escalation plans are in place with On call director/managers as per rota below. (Escalation card in appendix A)

On Call Manager Christmas Rota 2016 Via St Martin’s Switchboard 01225 831500

From: 5pm to 8am - workdays 8am to 8am - weekends and Bank Holidays

CHRISTMAS WEEK 2016date On call manager

Sat 24th Bev Mason Richard TarringSun 25th Simon Allen Clive BassettMon 26th Rosemary Carroll Julie SharmaTues 27th Sue Parris Liz RichardsWed 28th Alison Tucker Liz RichardsThurs 29th Alison Tucker Liz Richards

Fri 30th Alison Griffiths Linda Frankland

Sat 31st Cathy Daffada Janet Rowse

Sun 1st Geoff Watson Janet Rowse

Mon 2nd Carrie Wedgwood Janet Rowse

Tuesday 3rd -8th Jan 17 Carrie Wedgwood Linda

Frankland

ON CALL flow chart

On Call other TasksEPRR Exercises Telephone cascades

Table topTeleconferencesLive play (role play)

Escalation Setting up an ICC / Running an ICC /

Recovery – Hot and cold debrief delivery Managing Major Incidents and Business

Continuity incidents Undertake appropriate training as

recognised by NHS England or internal awareness training on an annual basis

When on Call you MUST: Carry your phone with you at all times Ensure On Call pack is easily

accessible You have pocket log book and pens You have mobile phone signal and/or

landline telephone number for contact Be within 2hrs of an ICC Be sober Ensure EVERYTHING is logged

Call Received Via Switchboard or

direct

LOCAL RESOLUTION

SIRONAMon – Fri

8am – 5pm

COMPLETE LOGComplete log book immediately and transfer information onto ‘T’ Drive or

Huddle at first opportunity

Examples: Staffing issues Facilities

queries Agency Request RUH Escalation Infection

Control CCG escalation Commence

Major Incident Business

Continuity Media and

Press Enquiries

NB: For IT issues telephone:

01225 831400, giving full details of what, who and where. This number will feed to the On Call technician.

SIRONAMon-Fri & wkds

5pm – 8am

Deal with as normal within

departments (Inc Lifetime)

SIRONA MAJOR INCIDENTMon – Fri

8am – 5pmON CALL MANAGER

SIRONAON CALL

MANAGERExamples: Major Incidents Financial

Expenditure Business

Continuity CCG Escalation Missing Staff Media / Press Unexplained

Death

SIRONAON CALL

DIRECTOR

NO

Areas of Identified Risk

Both district nursing and ECP demands have grown significantly this year with no additional capacity Risk has been discussed with commissioners and measures have been put in place to manage demands within capacity (e.g. defining IV capacity resource as only for OD bolus IVs)

Perfect week

Sirona is involved with partners in the planning of a perfect week event for the week commencing 9th January.

Appendix A: Escalation cards

NBT Declared Level 1 statusOr Sirona Declared Level 1 as below

Team Manager or nominated deputies Provide community capacity across the system.

Provide capacity, staffing and delays information to JCAP by 8.30 daily via capacity report – acceptable levels are for local determination.

Maintain staffing capacity assessment. Maintain routine demand and capacity planning processes

including a review of non-elective inpatient cases. Active monitoring of infection control issues. Maintain routine active monitoring – external risk factors:

Influenza and Severe Weather. (Horizon Scanning) – Liaise with EPRR.

Alamac report by 11am daily Daily alamac operational conference call at 11am

Report number of green patients awaiting discharge, DTOCs, Rehab bed capacity to JCAP by 09.00

Triage referrals, site meeting or Ward MDT attendance on a daily basis to highlight where there are requirements to manage flow. Identify patient pathways and co-ordinate movement.

Escalate decision making requirements to Head of Adult Services (HoAS) / Senior Leadership Team (SLT) where needed.

Patient flow demand is matched with available capacity

Overnight services (DNs, support ward staff and Rehabilitation) reporting good staffing levels

Rehab beds available for transfer Rehab beds full but with clear flow defined on

a daily basis, including weekends No beds closed with infection Capacity in Pathway 2 teams to support

discharge into the community Delayed Transfers of care identified with

clear strategies in place for patients’ effective discharge

Specialist services availability to manage patients from NBT and Community

Choice protocol effectively implemented

Locality Managing

JCAP team

IDS

Urgent Care Lead / Nominated deputy

Community Care - Community capacity available across system.

Conditions: Who Local Actions

Sirona Local Actions – In addition to Green Escalation – Level 1 – Normal Operating Process

OPEL Level 1 (Green)Normal Operating/Working

NBT declaring Level 1 and Sirona Level 1 (at least 5 conditions apply)

OPEL Level 2 (Amber) EscalationNBT or Sirona Declaring Level 2

4 or more conditions apply

Conditions:

• Capacity only in one community hospital for transfer

• Infection control issues reported with potential bed closures

• Specialist teams reporting no capacity for >2 days

• Patient flow levels not maintained for >1 week

• Rehab reporting limited capacity for urgent

• Rehab beds full with no discharges expected for 3 days

• Numbers of DTOCs above required level (1% in NBT, 5% in community hospital)

Patients identified appropriately as green unable to access suitable pathways

JCAP Inform all team managers / nominated deputies and Urgent Care Lead of increased escalation status.Participate in 11:00 tactical call if requested to feedback actions taken

Escalate any impact / decisions needed to Urgent Care Lead

Patient Flow Coordinator, Discharge Liaison Nurses,

Delays in transfers identified and action plans expedited

Patients expected to transfer into Community hospitals identified early and all information communicated between teams

Community Hospital Teams Review of bed base to ensure demand will be met and any potential requirement to change actionedAdditional ward rounds initiated to expedite discharge and review EDD Daily.

Team Managers or nominated deputies

Review caseloads to identify where patients could be discharged with support from other agencies to create additional capacityIdentify people waiting for dom care and escalate to urgent care lead

Liaise with staff to identify those that could support other teams where required

Report outcome of actions to JCAP by 11

Urgent Care Lead Expedite patients waiting for PoC to the council

National Requirement National Actions

Community Care Community Care Providers

Patients in community and/or acute settings waiting for community care capacity

Lack of medical cover for community beds

Infection control issues emerging

Some unexpected reduced staffing numbers (due to: e.g. sickness, weather conditions) but are sufficient to maintain services.

Maximise use of Reablement beds/ intermediate care beds.

Bring forward discharges to allow transfers as appropriate.

Maintain liaison with Healthcare providers to expedite discharge from community hospitals.

Escalation information to be cascaded to all community providers with the intention of avoiding pressure wherever possible. Maximise use of re-ablement / intermediate care beds

Task community hospitals to bring forward discharges to allow transfers in as appropriate. Community hospitals to liaise with Social and Healthcare providers to expedite discharge from community hospitals.

Additional ward rounds within community providers to expedite discharge and create capacity

Community providers to lower admission / treatment thresholds wherever possible through implementation of previously agreed flexible working arrangements to alleviate pressure.

Apply flexibility regarding beds and staffing to increase capacity where possible.

Expedite rapid assessment by multidisciplinary team (MDT) including Social Services assessment.

OPEL Level 3 (RED) EscalationDeclared when all actions from Level 2 have been implemented & still un met demand

Sirona declaring level 3 - 4 or more conditions in placeSirona Local Actions – in addition to Green and Amber actions

Conditions:

No capacity in community hospitals with no planned discharges for 2 days

Beds closed due to infection >3 days

Patient flow not maintained for >2 weeks

Excessive DToCs in NBT and Community Settings > 2% affecting flow

Community Rehab teams reporting >24 hours wait for urgent and >3 weeks for planned referrals

Staffing shortages reported in teams >10% and limited access to bank/agency

No capacity in Rehab Beds with no discharge >7 days

Care home sector has limited capacity

Specialist services reporting no capacity for >1 week

Locality teams reporting increased referrals from all areas

JCAP Inform Urgent Care Lead of escalation status and brief re action taken / decision authorisation needed.

Team Leads / Nominated deputy All teams to prioritise caseload, identifying how additional capacity could be released, staffing required and durationIdentify where additional resource is required to manage caseload effectively and promote flow, including additional dom care support and feedback to Urgent Care LeadReview staff absences and ensure actions identified to provide potential solution and take to capacity meeting on a daily basis.To review staffing and identify where internal staff movement will support teams at risk (i.e. non-essential staff essential services)To identify clinics that can be postponed and highlight effect on waiting times and KPIs and feedback to Urgent Care Lead

Urgent Care Lead Follow up any actions needed to expedite discharge or increase capacity

Liaise with Head of Adult Services and Head of Specialist Service re cancelling of routine therapy clinics and re-direction of staff to Rehab teamsAgree Bank usage to expand DN and Ward capacity if required

Escalate and brief HoAS on action taken, impact and any authorisation needed

Head of Adult Services /On Call Manager (OOH)

To participate in external conference call

To review clinics and cancel where appropriate to release capacity, notably OP therapies.Cancel all non- mandatory training for frontline staff

Briefing on a daily basis to on call managers

Inform Commissioners of escalation status and request authorisation of cancelled elective activityEnsure actions from external conference call and capacity meeting are effectively cascaded to Service Leads

National Requirement National Actions

Community Care

Community capacity full

Significant unexpected reduced staffing numbers (due to: e.g. sickness, weather conditions) in areas where the causes increased pressure or patient flow

Community Care Providers

All community care teams to review all patients awaiting assessments (with single point of access) in order to expedite discharge or transfer – this to include in reach teams, deliberate self-harm, community hospitals

Community providers to continue to undertake additional ward rounds and review admission and treatment thresholds to create capacity where possible

Community providers to expand capacity wherever possible through additional staffing and services, including primary care

Community providers to consider the use of wider group of agencies (e.g. higher cost agencies) to increase staffing capacity

Patients waiting at home for admission to be referred to Community Teams (by in reach nurses) and/or single point of access and EMU

OPEL Level 4 Black escalationDeclared when all actions from Red escalation have been implemented & there is still un met demand

2 or more conditions in place

Sirona Local ActionsConditions: No capacity in Community

Hospital beds Beds closed due to infection

>5 days Patient flow not maintained

for >2+ weeks Reablement reporting >48

hours wait for urgent referrals

HAT reporting increased referrals from all areas

Staffing shortages reported in teams >20% and no additional availability for bank/agency

No capacity in Reablement beds with no discharges for >10 days

Specialist services reporting no capacity for >2 week

Excessive DToCs in NBT? > 3%

JCAP Following Sitrep collation of black status inform all Service Leads, Lead for Urgent Care and Head of Adult Services / On Call ManagerCo-ordinate team feedback and internal team meeting/conference call.

Service Leads All teams to prioritise caseload, identifying how additional capacity could be released, including reviewing frequency of visits and length of visit. Report back to JCAPUrgent visits prioritised with non- essential visits cancelled. Service Leads to ensure clear communication with patients and referrers is maintainedIdentify where additional resource is required to manage caseload effectively and promote flow, feedback to Lead for Urgent Care / On Call ManagerReview staff absences and ensure actions identified to provide potential solution and take to capacity meeting on a daily basis, e.g. cancel all leaveTo review staffing and identify where internal staff movement will support teams at riskTo allocate additional resources to relevant frontline servicesAttend daily capacity management meeting / call

Head of Adult Services /On Call Manager (OOH)=

Daily capacity meeting initiated with service leadsTo participate in external conference call, agree additional actions with strategic partnersFeedback to Director of Operations if requirement identified to cancel all training and Annual Leave for frontline staffBriefing on a daily basis to on call managers and Senior Leadership Team (SLT)Service Leads to identify staff that could be relocated to support teams with reduced capacity, including all clinical/social care staff in non- frontline roles, for example training team and managers. Head of Adult services to authorise staff moves within teams and feedback to Director of Operations to authorise redeployment of staff in non- frontline roles to frontline teams.Authorise spot purchase of nursing home bed where relevant to prevent admission, create capacity. If number required exceeds 3, to refer to Director of Operations for further authorisation

Ensure actions from external conference call and capacity meeting are effectively cascaded to Service Leads

Director of Operations/ On Call Director (OOH)

To initiate external conference call with relevant providers where required, ensuring actions required are feedback to CEO and Head of Adult Services (On Call Manager for OOH)Authorise move to escalation hub management at strategic site to manage services across a localityTo agree communications if clinics are postponed, particularly to patients, primary care and commissionersTo agree additional resource for staffing if required on a long term basis in order to restore capacity (as identified in capacity meeting)To authorise cancellation of all training for frontline staff

To review and authorise requirement for spot purchasing of nursing home beds where number exceed s 3 at any periodTo advise all GP practices all community services will be coordinated at locality level

Briefing on a daily basis for On Call Director

National Requirement National Actions

Community Care

No capacity in community services

Unexpected reduced staffing numbers (due to: e.g. sickness, weather conditions) in areas where this causes increased pressure on patient flow is at a level that compromises service provision / patient safety.

Local regional office notified of alert status and involved in decisions around support from beyond local boundaries.

CCGs will act as a hub of communication for all parties involved including Sirona.

Post escalation: Work with EPRR and complete a root cause analysis and prepare a lessons learnt process in accordance with SI process.