trust board date: 2 august 2018 part: public agenda item ......trust board (cover sheet template...

Trust Board (cover sheet template from July 2018)

Trust Board Date: 2 August 2018 Part: Public Agenda item: 59/18ii

Title

CQC and QRP update

Sponsoring Director

Chief Nurse

Authors

Lynne Carter

Presented by

Lynne Carter

Exec Summary/Purpose

The CQC and QRP plans are presented monthly as an update

to the Quality and Safety Committee to show the actions taking place. The Board is asked to accept the actions updated as assurance that the plans are being completed and embedded across the Trust. In addition the Board is asked to note the continued plans as presented.

Previously considered at

Quality and Safety Committee as verbal updates CQC plan at regular weekly meetings with Clinical Managers Both considered by CCGs, NHSE, NHSI and meetings with local CQC Inspectors Quality and Safety Committee

Related Trust Objective/ Intentions Delete as applicable

Quality - To deliver high quality, safe and effective care which meets both individual and community needs Innovation & Collaboration – to deliver innovative and integrated care closer to home which supports and improves health, wellbeing and independent living Sustainability – to deliver value for money, be financially viable and commercially successful People – to be a highly effective organisation with empowered, highly skilled competent staff

Which BAF risks are addressed in this report? Delete as applicable

BAF 1 - Failure to implement and maintain sound systems of Corporate Governance BAF 2 – Failure to deliver safe & effective patient care BAF 3 – Managing demand & capacity BAF 4 – Financial sustainability BAF 5 – Staff engagement & morale BAF 6 – Staffing levels

Trust Board (cover sheet template from July 2018)

BAF 7a – Organisational sustainability – key relationships BAF 7b – Organisational sustainability – market place BAF 7c – Organisational sustainability – integration BAF 8 – IM&T systems which do not meet the requirements of the organisation

Other risks highlighted/addressed in this paper? (e.g. financial, quality, regulatory, other)

The main risk is the regulatory risk followed by reputational and financial with our commissioners

Equality Impact assessment

Not completed

Action Plan in place?

Action plans attached

Next steps

Continue actions and provide monthly updates

Recommendations

The Board is asked to note the recommendations in the paper and take assurance from the paper.

Why has the paper been presented to the Board? (Please tick): For Approval by the Board To provide assurance to the Board For the Board’s information / to note

1

Title CQC and QRP update

Author Lynne Carter

Date 9/7/18

Purpose Provide assurance to the Board of current actions and note approval for continued plans

Audience Trust Board

1.0 PURPOSE OF THE PAPER 1.1 The Board is asked to accept the actions updated as assurance that the CQC

and QRP plans are being completed and embedded across the Trust. In addition the Board is asked to note the continued plans as presented.

2.0 RATIONALE FOR PLANS 2.1 The Quality Risk Plan has been in place since May 2018 and is the response of

the Trust to concerns raised by CCGs and NHSE at the quality meeting of 24th April 2018. The Trust received a 3 month Enhanced Surveillance notice and regular updates of the QRP are provided to ensure that this is successfully completed within the 3 month timescale.

2.2 The Trust received notification in May 2018 that all of our performance

information and details of all services was required by the CQC in preparation for announced and unannounced visits. Whilst we do not have a definite date yet for a full well led inspection we believe that this will take place soon. We have a 4 day inspection of HMP Wymott planned for 17th July and preparation for this is underway. The CQC action plan covers all of the key themes of an inspection and is the successor to the previous plan which actioned concerns raised in the 2016 full CQC inspection which rated the Trust as Requires Improvement

3.0 JUNE UPDATE 3.1 The QRP plan continues to be implemented and is attached for reference. Of

note in June the following changes were made:

2b All actions now complete

2l Not completed due to lack of commissioner funding, a separate single site solution is currently being developed

3d Clarification was received and managers are working on service specific actions

3l/ All actions have now been moved to Woodview action plan which attached. 7h/ This is in response to the original performance notice in February 2018 7i plus the QRP but has been updated following a Serious incident in June

2

2018 which is currently being investigated.

7x This item in relation to HMP Wymott has resulted in a full business case which is now with NHSE and we expect a favourable response. The interim arrangements continue to be funded by NHSE.

1t Staff are to TUPE to EMIS however there has been a delay due to a need for them to redraft their original plan.

7p All actions now complete

6i Small improvement and work continues supported by staff side

6k Accurate data now being submitted

7q See attached CQC plan

7s AQuA are now involved in this area of development

2x Roll out continues and has been accelerated for Woodview

4z Serious Incident Review Panel has improved with greater attendance and Root Cause Analysis used for every incident. Lessons learned are shared across the Trust and there is evidence of staff actions following this.

4q A new process is now in place

3.2 CQC Plan has been shared widely across the Trust and is monitored via

weekly meetings with the Clinical Managers. There has been significant work undertaken by the senior nursing and quality governance teams and there is great engagement with the Clinical Managers, a copy of the notes from a recent meeting are attached. The attendance at the meetings is very positive with all present sharing good practice and innovative ideas. There is evidence of cascade through teams and Quality Visits are in place to support them. An additional resource has been put in place with an experienced CQC clinical preparation nurse who started work within the Trust on the 9th July. She will work within teams assisting those with complex and challenging agendas as well as planning Mock inspections using our senior managers and providing CQC interview preparation for those staff unfamiliar with the process.

4.0 FOR ASSURANCE

4.1 The Board is asked to agree that assurance is being provided by the updated QRP plan and to note the continuation of the actions

4.2 The Board is asked to agree that assurance is being provided by the updated CQC plan and to note the continuation of the actions.

5.0 ADDITIONAL ITEM 5.1 The Board is asked to note the Woodview plan and the continued actions. This

plan which is still subject to commissioner and NHSE approval will be updated and can form part of this regular update to the Board if required.

CQC ACTION PLAN

11-Jun 18-Jun 25-Jun 02-Jul 09-Jul 16-Jul 23-Jul 30-Jul 06-Aug 13-Aug 20-Aug 27-Aug 03-Sep 10-Sep 17-Sep 24-Sep 01-Oct

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 week 7 Week 8 Week 9 Week 10 Week 11 week 12 Week 13 Week 14 Week 15 Week 16 week 17 Week 18 Week 19 20

1 Lack of understanding

of CQC requirements

Update and

reprinting of Z

Cards

All Comms team Alison

Aspinall

Mike

Barker

2

Lack of understanding

of CQC requirements

Staff A5 guide to

CQC booklet All

Comms team Alison

Aspinall

Mike

Barker

Draft version completed

awaiting sign off and

publication 3 Improve

communication and

awareness

People posters to

be displayed in all

areas All

Comms Alison

Aspinall

Mike

Barker

Posters gone to print

comms team awaiting

for approval of roller

banners

4

Evidence of compliance

with CQC fundamental

standards framework

Update CQC hub

page to include all

key documents

and information

All

Quality and

Governance

and comms

team

Sharan

Arkwright

Lynne

Carter

5

Clarity of preparation

for staff

Meet with Clinical

Managers and

AD's to inform of

assessment

process, roles and

responsibilities All

Quality and

Governance

and comms

team

Sharan

Arkwright

Lynne

Carter

Meeting to commence

15th June invite to be

sent out. Rooms to be

booked for weekly

meetings. Agenda to be

developed

6

Clarity of roles and

responsibilities to

provide assurance of

systems and processes

for CQC preparation

Staff checklist

toolkit - staff self

assessments, team

leaders

assessment,

clinical manager

assessments, AD,

Execs

Assessments.

All

Quality and

Governance

Sharan

Arkwright

Lynne

Carter

Staff self assessment

tool completed.

7



standards framework

KLOE self

assessment

document

updated All

Quality and

Governance

Sharan

Arkwright

Lynne

Carter Documented updated

to be circulated

following presentations

at QSSG in week 5.

8



standards framework KLOE self

assessment flow

chart All

Quality and

Governance

Sharan

Arkwright

Lynne

Carter

Documented developed

to be circulated

following presentations

at QSSG in week 5.

9



standards framework

Annual Quality

Support visit

schedule

All

Quality and

Governance

Sharan

Arkwright

Lynne

Carter

Schedule currently

being updated.

Nominated corporate

support to be identified.

10



standards framework Quality support

visit template

update All

Quality and

Governance

Sharan

Arkwright

Lynne

Carter

Template updated

11

Improve awareness

Teams develop

and display quality

and safety board

to be displayed in

bases and clinics All

All Clinical

Services

ADs

Caroline

Williams /

Sharon

Barber

Pauline Hoskyn to be

approached to explore

whether BCP's can be

stored on the hub (JH).

End Date Progress Notes Goals to be achieved each week Ref No Issue Action Focus CQC Domains Service AD Responsible Exec Lead Start

Date

S:\Corporate Office PA Folder\LYNDA R\Board and Committees from 2015\(02) Board\2018\August 2018\Public\Attach 3 CQC Action Plan Week 7 - 29 06 18

CQC ACTION PLAN

12

Service safety

Business

Continuity plans

reviewed, updated

and staff aware of

these and how to

access them All

All services ADs

Caroline

Williams /

Sharon

Barber

Scoping exercise to be

undertaken by Clinical

Team Managers.

13

Increasing transparency

of service delivery "Data on the

door" information

displayed in

patient facing

clinical areas All

All clinical

services

ADs

Caroline

Williams /

Sharon

Barber

Template being

developed by Q&S lead.

Waiting times and

staffing levels.

14

Learning from incidents

Local evidence of

learning /changes

to practice from

complaints ,

incidents and

feedback All all services

ADs

Caroline

Williams /

Sharon

Barber

Teams to decide locally

how they can evidence

this, may be team

meeting minutes or

changes in practice -

what is the system in

their team?

15 Evidence of quality

improvement

Results of clinical,

record keeping

audits and related

action plans

displayed within

team areas.

Including infection

control, hand

hygiene and

medication

management

All

All Clinical

Services

ADs

Caroline

Williams /

Sharon

Barber

16 Evidence staff clinical

supervision and

support compliance

Local SOP for

clinical supervision

and compliance

monitored

All

All Clinical

Services

ADs

Caroline

Williams /

Sharon

Barber

17 Evidence staff

knowledge and skills

All mandatory

training to be

completed or

dates booked for

all staff in Q1 All

All services ADs

Caroline

Williams /

Sharon

Barber

18 Monitor safety of

clinical environment

Environmental

review by TL, CM's

and AD's in all

areas including

tidiness, PID not

on display, current

posters and out of

date documents

and information

removed. Fridges,

resus equipment,

COSH secured,

locked doors

All

All Clinical

Services

ADs

Caroline

Williams /

Sharon

Barber

Dump the junk!

Checklist of

environment for

included in toolkit

19 Maintain staff safety Evidence of local

lone working SOP

in line with Trust All

All Clinical

Services

ADs Caroline

Williams /

Sharon


CQC ACTION PLAN

20 Evidence of quality

improvement

Record keeping -

evidence of audits

and action plans

completed or in

progress. Local

processes in place

for oversight of

records for quality

and content.

All

All Clinical

Services

ADs

Caroline

Williams /

Sharon

Barber

21 IT Connectivity 1a)Not all teams

are able to update

records at the

source and have

to travel back to

base to update

records.

1b) Not all teams

have access to

ESR/Ulysses/Systm

One due to

Connectivity

All IT Dave Smith Sue Hill

22 Financial Ledger Staff are still

concerned that

the ledger does

not reflect their

team structure

and so when it is

uploaded into

ESR/Ulysses the

teams are not

reflected in the

electronic

systems.

ALL Finance Nick

Gallagher

Sue Hill


Key Actions Evidence Key Outcomes

Lead Executive

Officer Monitoring

Progress at

30/6/18 Status Date Completed

Effective partnership

working

2b Identify core

attendees at

contract meetings

identified

Notify CCG of core

attendees

Request further

clarity on QRP

notes

Meeting attendee

matrix

Commissioner

recognises core

representatives by

contract and

attendance is

consistent

Interim Director of

Operations

Quarterly at exec

to exec meeting

Reaffirmed

requirement with

individuals

CCGs notified of

attendees

Request sent to

NHSE 18.04.2018

clarification

received

Green

Green

Green

Complete

Complete

Complete

Assessment and

equipment

2l Draft options

appraisal

Negotiate to agree

most favourable

option

Options appraisal

drafted and

resolution agreed

Commissioner

agreement to fund

pressures or

agreement to

revise wheelchair

access criteria

Interim Director of

Operations

Monthly at

contract

performance

meetings

No additional

funds in the

system, resolution

not agreed.

Commissioners

will not agree t

Looking for single

site solution

Amber Not completed

still discussing

ACTION PLAN REGARDING QRP June 2018 updateTheme and reference

number

Partnership and Performance


Lead Executive

Officer Monitoring

Progress at

30/6/18 Status Date Completed Theme and reference

number

Pathways 2s Agree service line

action plans with

local commissioner

Action plans

implemented

Mutually agreed

action plans to

address areas of

concern

Interim Director of

Operations

Monthly at

contract

performance

meetings

Clarification

received and work

is underway

Amber To complete

31/08/18

Referral into secondary

care

Health & Justice services

2z Implement system

to capture onward

referrals and

waiting times

Anonymised extract

from system

System in place to

monitor referrals

made and waiting

time for treatment

Interim Director of

Operations

Complete System in place Green Complete

Waiting lists 3d Commissioner and

provider review of

services where

demand has

increased in excess

of contract

thresholds

Agree service line

action plans with

local commissioner

Agreed actions to

manage demand

Action plans

Mutually agreed

action plans to

address areas of

concern

Interim Director of

Operations

Monthly at

contract

performance

meetings

Clarification

received and work

is underway

Amber To complete

31/08/18

Healthwatch concerns

MOVED TO WOODVIEW

PLAN

3t CCG to share

concerns with the

Trust

Copy of Healthwatch

report

Understand and

address concerns

Interim Director of

Operations

Monthly at

contract

performance

meetings

Request sent to

NHSE 18.04.18

Report due by end

of May 2018

Amber To complete

31/08/18


Lead Executive

Officer Monitoring

Progress at


number

Specific clinic services &

Specific pathways

Halton Community

Paediatrics

MOVED TO WOODVIEW

PLAN

7h

7i

Convene quality

summit to address

concerns raised in

the performance

notice

Implement service

improvements

CCG to share

service deep dive

report

Performance notice

action plan

implemented

Service

improvement action

plan implemented

Copy of deep dive

report

Commissioner and

provider satisfied

that the concerns

raised have been

addressed

Interim Director of

Operations

Monthly at

contract

performance

meetings

Summit took place

Service

improvement

programme

commenced

Expected at CQPG

on 24.05.2018

Complete

Amber

Amber

Specific site

Community Paediatrics

MOVED TO WOODVIEW

PLAN

Specific site

Garth & Wymott

7j

7j

Equipment 7k Clarify whether

this is covered in 2l

Clarification query

sent to NHSE

18.04.2018

Clarification

received

Green Complete

Please see 7h&i

Please see 7x

To complete 31/08/18


Lead Executive

Officer Monitoring

Progress at


number

Reputational risk issues

Community Paediatrics

MOVED TO WOODVIEW

PLAN(please see above)

HMP Garth & Wymott

7x Agree revised

staffing model with

NHSE

Safe staffing model

business case

Agree, fund and

implement safe

staffing model

Interim Director of

Operations

Monthly Interim funding

continues but

supported clinical

model.Awaiting

financial

agreement for

final version

expected

04/07/18

Amber To complete

31/07/18

Diabetic retinopathy 1t Undertake 72 hour

review of the

incident

Log incident no

36368 on StEIS

Undertake root

cause analysis of

the incident

Completed SI 72

hour review update

preformat

StEIS Ref No is

2018/8007

Completed root

cause analysis and

recommendations

Identify and

implement

learning from the

incident

Interim Director of

Operations

Monthly Proforma complete

on 23.03.2018

StEIS reported on

23.03.2018

Admin failsafe

staff to TUPE to

EMIS

Public Health

England met with

and not satisfied

with plan, now

with EMIS to

redraft

Green

Green

Amber

Complete

Complete

To complete

31/7/28

Finance


Lead Executive

Officer Monitoring

Progress at


number

Proportion of temporary

staff

Use of agency staff

5z

6n

Deliver agency

workforce within

cap

Cap compliance /

Benchmarking

against other NHS

Trusts

Reduced agency

usage

Interim Director of

Operations

Quarterly reviews BCHFT: 48%

reduction in 2

years

HMP G&W: Final

business case

being reviewed by

NHSE

Amber Review due

31/07/18

Significant financial

challenges/risks

7w Deliver finance

within control total

Control total

compliance

NHSI Approved

18/19 final plan

Director of Finance 31/03/2019 Failed CT in 17/18;

Plan approved by

NHSI

Red

Green

Complete

Aggressive CIP plans 7o Includes CIP

delivery

CIP plans delivered

without negative

impact.

Visibility of CIP &

QIPP 18/19 plans

with

Commissioners;

Review of CIP

target in light of

Kirkup guidance

with NHSI;

Agreed 18/19 plan

Director of Finance Quarterly reviews CIP agreed as

above

Plans in place with

QIA process

ongoing

Green CIP target for

18/19 set at 2%

and agreed

QIA process

strengthened


Lead Executive

Officer Monitoring

Progress at


number

Contractual

issues/breaches

7p Complete actions

on performance

notices live in

Halton (Comm

Paeds), Warrington

(SI’s and service

resilience)

EMIS care (DESP)

Completion of action

plans

Areas of concern

resolved to

commissioners

satisfaction

Interim Director of

Operations/Chief

Nurse

Fully complete

September 2018

Warrington-

resilient services

actions complete

Warrington - SI's

Halton - comm

paeds

EMISS Care

Green

Green

Green

Green

Complete

Complete

Complete

Complete

Leadership

Significant change in

Executive Team

Gaps in statutory roles

7v

8b

7q

Ensure stability of

Executive Team

Implement Target

Operating Model

to ensure Borough

All key roles

appointed to with

suitably experiences

and competent

professionals

Full implementation

across the Trust

The Trust has an

Executive Team

who can deliver

the elements of

the well led

domain and ensure

CQC compliant

services

Chief Executive

Director of

Strategy

100% permanent

appointments by

31/7/18

As final plan

One outstanding

post appointed

01/05/18

Model final version

in DRAFT

Green

Amber

Complete

To commence

implementation

01/09/18

The providers

organisational approach

to the safety of staff

8a Ensure that all staff

are safe during

their working

hours by renewing

current processes

Staff survey results

Incident reporting

Reduce incidents

relating to staff

against 17/18

baseline

Improved staff

survey results on

17/18

Chief Nurse Monthly

Annual Staff

Survey with Pulse

check monitoring

quarterly

Processes

reviewed Baseline

complete for 17/18

Last pulse check

positive next one

planned

Amber Monitor pulse

check quarterly

Leadership

Workforce


Lead Executive

Officer Monitoring

Progress at


number

NHS Staff Survey 7r Continue LiA work

Embed Staff

Engagement

Champions and

plan

Staff survey results

Incident reporting

Response rate to

be in top third of

all comparable

Trusts

Chief Nurse Annual Staff

Survey with Pulse

check monitoring

quarterly

Staff Engagement

Champions in place

Relaunch planned

for 01/07/18

Amber Relaunch July 2018

Monitor annual

results

Issues related to skill mix 7m Continue skill mix

reviews including

activity, acuity and

dependency

NHSI reporting Trust

website

Staff satisfaction

Complaints

Skill mix to be

appropriate for the

delivery of each

service at National

Guidelines where

these exist

Chief Nurse Review complete

by 30/6/18

Monthly

monitoring 6

monthly review

Workplan agreed

and commenced

Hurst tool piloted

re: acuity and

dependency

Staffing level in

place bedded units

Community team

levels being

confirmed

Yellow Launch community

team levels and

monitoring

31/07/28

Issues identified with %

Safeguarding Supervision

7g Continue current

processes to

ensure all staff

involved in

safeguarding

adults or children

will receive

appropriate

supervision

Staff supervision

records

Increase staff

satisfaction

Reduce stress

levels

Improved

competence

Chief Nurse Quarterly Quality audits

planned Processes

in place.

Monitoring current

rates

Staff in place Stock

take of

outstanding staff

identified and

places being

booked

Yellow All staff to be

compliant by

31/08/18

Clinical Supervision Introduce audit of

supervision

documented on

patient records

Supervision will be

available to other

groups using various

methodologies

Increase staff

satisfaction

Reduce stress

levels

Improved

competence

Chief Nurse Quarterly Audit terms of

reference in draft

Pilot planned for

July 2018

Amber Pilot complete by

01/08/18 for

further review and

final roll out

October 2018


Lead Executive

Officer Monitoring

Progress at


number

Safe staffing levels 6c Develop work in

7m to agreed safe

staffing levels.

Publish staffing

levels on Trust

website

Staffing levels will be

at National

guidelines where

these exist and in

line with contracted

service activity and

NHSI returns

Benchmarked as

good or better

than National

guidelines

Chief Nurse Monthly and 6

monthly review

Developing see 7M

plus AHP CHPPD to

commence June

2018

Amber Benchmarked all

areas by 01/09/18

publish monthly as

roll out 6 monthly

review 31/10/18

Staff Sickness rates 6i Ensure all

processes are

followed

compassionately

and provide

additional support

to hot spot areas

Staff sickness will

reduce by 1%

against 17/18

baseline each year

until at or below

National average

Sickness levels at

or below target

Chief Nurse Monthly See 7m

Short term

sickness shows

some

improvement

Staff engagement

plan continues

Staff side

developing plans

to support

Amber


Lead Executive

Officer Monitoring

Progress at


number

Staff turnover and

vacancy rates

6k Refresh current

processes and

develop Workforce

strategy and plan

Staff turnover will

reduce by 2%

against 17/18 level

each year until at

National benchmark

for similar

organisations All

vacancies will be

approved and

advertised in line

with National best

practice standards

Turnover at target

Vacancy within

target

Chief Nurse Monthly Process reviewed.

Plan in place to

support staff

Workforce strategy

being developed

Task and finish

group commenced

Reports now

accurate and show

only BCHFT staff

not including

those who have

TUPed out of the

organisation

Amber Strategy to be in

place with full plan

by 01/08/18

Use of agency staff 6n See 5z

Agency staff will

continue to be

used to ensure

staffing levels only

and quality of care

will be monitored

Amber

Compliance with

Mandatory and Statutory

training

6x Implement

refreshed training

plan and processes

Mandatory training

levels will be 95%

across the Trust in

each subject

Mandatory

training at or

above target

Chief Nurse Monthly Training refreshed

and figures

improving. All

outstanding staff

being booked onto

courses

Amber To complete

31/08/18


Lead Executive

Officer Monitoring

Progress at


number

% Staff appraisal / PDR 4g Embed PDR

process and

develop audit for

quality of

appraisals

Appraisal rates will

be at Trust target

Audit baseline of

quality in august

2018 and set

improved trajectory

Appraisal rates at

or above target

Audit shows

increasing

satisfaction with

quality of appraisal

on initial result

Chief Nurse Monthly Annual

Audit following

initial baseline

Plan in place for

PDRs in Q1 Audit

developing

Appraisals taking

place with PDRs

Audit in draft

Amber To complete

appraisals by

31/08/18 Baseline

audit of quality to

commence

31/08/18

Staff FFT % recommended

care at work

1l Linked to 7r and all

other areas on this

action plan

Staff FFT

recommendation as

a place of work will

improve by 3% each

year to top third of

National benchmark

Recommendation

at or above target

Chief Nurse Annual staff survey

plus quarterly

Pulse Check

See 7r Amber Monitor via pulse

check

Governance


Lead Executive

Officer Monitoring

Progress at


number

CQC 7q Refresh and

continue CQC

action plan. Plan to

be accelerated to

20 week timescales

Trust will be CQC

compliant and

improve from

Requires

Improvement to

Good in next

assessment

Good CQC result Chief Nurse Monthly

monitoring and

CQC assessment

Refreshed action

plan launched

Clinical managers,

associate directors

and governance

teams meeting

weekly to update.

Good feedback

from staff on new

plan with good

level of

engagement

Continued liaison

with CQC and

regular updates

Green Weekly

monitoring to

continue until

inspection date

Complete

Organisations approach

and culture to risk

management and

governance

7s Refresh and

implement

incident, risk and

governance plans

Embed quality

improvement into

governance

Staff will engage

fully in quality

improvement

projects which

encourage a

measured approach

to risk and a positive

culture

Improved

processes and

systems meeting

best practice.

Baseline survey of

current attitude

with improvement

trajectory

developed

Chief Nurse Monthly

incident/risk/comp

laint number

improved results

on baseline

quarterly

Quality

improvement

methodologies

assessed. Plan in

development for

roll out Quality

improvement plans

being developed

with AQuA support

Amber Baseline survey

delayed frfom

June 2018 as

awaiting AQuA

information

Quality

improvement

linked to CQC

action plan and

evidence of

improvement

actioons is being

collated


Lead Executive

Officer Monitoring

Progress at


number

The Providers

organisational approach

to the safety of patients

7z Linked to 7s Patient safety

requirements will be

met across the Trust

Improved patient

safety indicators

on 2017/18

baseline to or

above national

benchmarks

Chief Nurse Monthly See 7s Amber See above

Lack of evidence of

systematic learning from

incidents/near misses

7n Relaunch learning

lessons approach

and embed in

quality

improvement

process

Serious Incident

Review Panel

(SIRP) amended

with new TORs to

ensure RCA and

learning across

Trust

Continue work

with AQUA

The learning from

incident, complaints,

concerns and

feedback will be

embedded across

the Trust

Reduced recurring

incidents/risks

against 2017/18

baseline to or

above National

benchmarks SIRP

minutes will

document RCA and

lessons learned

Chief Nurse Monthly rates and

6 monthly review

Learning Lessons

developed across

the trust. Weekly

SIRP has improved

with more staff

attneding to learn

and share lessons

RCA template now

used for all SIs

with action plans

being monitored

by the SIRP.

Amber Further learning

newsletters being

developed. Group

supervision event

being planned

around an SI RCA.

Staff feeding back

initiatives from

practice at weekly

SIRP and CQC

meeting for all to

share.

Carer engagement 3z See 4a


Lead Executive

Officer Monitoring

Progress at


number

Quality issues with paper

based clinical systems

2x Continue and

accelerate where

possible EPR plan.

Assess current

paper based

systems.

Link to 6v

The Trust will

continue electronic

clinical system roll

out and mitigate

against any risks to

its existing paper

based system

Trust will achieve

EPR to planned

timescales

Incidents relating

to records will

reduce from

2017/18 baseline

Chief

Nurse/Medical

Director

Quarterly Plan in place.

Borough dates for

EPR roll out are in

place.

Amber EPR plan

continues. Paper

record audit to

complete all areas

by 01/09/18

Safeguarding Issues 6d Link to 7g

Review all

safeguarding

processes and

have significant

input into all

Safeguarding

Board restructures

The Trust will

continue to improve

adult and children

safeguarding

Trust will be

compliant with all

statutory

requirements and

will achieve or

exceed best

practice against

National guidelines

Chief Nurse Monthly See 7g Amber See 7g

SI Rate 6e Continue to

encourage

reporting and

embed near miss

reporting culture

across the trust

Jointly report Sis

with Health &

Justice

The Trust will

benchmark its

reporting rate

against similar

organisations

The Trust will

achieve or exceed

National

benchmarks for

similar

organisations

Chief Nurse Monthly and

annual review

Ongoing and will

be added to

lessons learned

relaunch

Amber Monthly

monitoring in place

with Executive

overview (Chief

Nurse)

Significant Controlled

Drug issues

6f Continue

Medicines

Management

review and

implement plan

Reduction in

incidents

CQC compliance

plus meeting

statutory

obligations and

reduce incident

rate on 17/18

baseline

Medical Director Monthly and

Annually

In place and team

now appointed

Amber Monthly

monitoring in place

with Executive

overview (Medical

Director)


Lead Executive

Officer Monitoring

Progress at


number

Vaccination and

immunisation uptake

6o Implement plan for

dedicated team

Continue to

increase current

uptake

Improved situation

for patients and staff

Trust will meet

requirements and

targets

Chief Nurse Quarterly Recruitment in

place Recruitment

and retention plan

out for comment

Amber Link to Workforce

Strategy and Plan

Clinical records,

management and record

keeping

6v Linked to 2x plus

Audit

Improved

performance against

audit baselines plus

reduced incidents in

relation to this area

Reduced incidents

to or above

National

benchmarks

Improved audit

results

Chief Nurse Monthly incident

rates and annual

audit

Commenced Amber See 2x

Compliance with Hygiene

Code

6y Continue

partnership with

cleaning providers

in Prisons

Embed IPC

standards across

the Trust

Improved results

and compliance

IPC report and

meet Hygiene

Code

Chief Nurse Monthly IPC

reports and

quarterly Hygiene

Code

Commenced and

improving position

Amber Monitoring in

place

Quality Issues identified

through Patient

engagement and

participation groups

including good quality

4a Define specific

issues and themes

Implement

improved patient

and carer

experience plan

Reduced complaints

Improved

carer/patient

feedback

Evidence of inclusion

in developing and

planning services

Surveys show

positive regard and

recommendations

for the Trust

Reduced

complaints

Chief Nurse Monthly

complaints rates

and annual survey

Development

commenced

Service User group

actively engaged in

this process Work

with national

Voices planned

Amber Carer/Patient

Engagement plan

to be fully

complete by

30/09/18


Lead Executive

Officer Monitoring

Progress at


number

Patient Safety

Thermometer HFC

Pressure ulcers - new

4z Implement

improved pressure

ulcer policy and

plan

Improved reporting

rates

Healing rates

reduction in Trust

acquired avoidable

pressure ulcers at all

stages

Reduce harm

incidents at or

below benchmark

for similar

organisations.

Reduce

deterioration in

avoidable pressure

ulcers.

Improved harm

free care scores

from 17/18

baseline

Chief Nurse Monthly

complaints and

annual review

RCAs improved

with use of new

template and

increased scrutiny

from SIRP. Staff

have developed

pressure ulcer

safety huddles in

the community

and have begun to

share their

learning across

teams. Revised

processes being

implemented

Amber Monitor monthly

Persistent non-

compliance with NICE

guidelines

1n Improved

partnership

needed

Raised with CCG and

Council

Consistent in

application of NICE

guidelines across

services

Chief Nurse Monthly review Commenced and

continues.

Amber Review position

31/08/18

Outstanding or late

responses to NHSE/NHSi

patient safety alerts and

other alerts

4q Improved

processes for

responding to

alerts

Process refreshed

and in place

Meeting national

requirements

Chief Nurse Monthly In place and team

now appointed.

New process

commenced for

review in 2

months

Yellow Review position

31/08/18

Potential underreporting

of patient safety incidents

5w See 6e


Lead Executive

Officer Monitoring

Progress at


number

Proportion of patient

safety incidents that are

harmful

5y See 6e and 4z Completed Meeting national

requirements

Chief Nurse Quarterly Complete Green

NHSI 8b

Policy on Trust

internet

Theme Key Actions Evidence Key Outcomes Lead Executive

Officer

Monitoring Service/Operational

Lead

Status Date Completed

Information and

communication

Develop parent/carer user guide

Arrange appropriate out of hours

messaging and access

Review format and content of GP

letters

Develop real time feedback

mechanism as part of

Healthwatch/Stakeholder work

User guide to

services

Answerphone

messages.

Clear OOH

instructions given to

parents/carers

Agreed GP letter

template

Feedback tool in

place agreed with

stakeholders

Parents and carers

express

satisfaction with

service

information.

Reduction in

complaints and

concerns from

parents/carers

against 2017/2018

baseline .

GP satisfaction

with letters

Improved feedback

Chief Nurse Monthly via

complaints/concer

ns reporting

Via FFT Regualr

reports to CQPG

Michelle Bradshaw Red

Amber

Red

Red

30/9/18 Draft guide

6/7/18 all answerphone

messages complete

31/8/18 Draft template

31/9/18 Draft tool

Parent/carer engagement Set up parent/carer group.

Arrange joint stakeholder event with

Healthwatch and share outcomes

with CCG

Agreed terms of

reference for a

group to support

and exchange views

to improve

Woodview

Stakeholder event

Reduced

complaints and

concerns from

2017/2018

baseline

Evidence of

parent/carer

involvement

Chief Nurse Monthly at

contract

performance

meetings via

complaints/

concerns

Action plan from

stakeholder event

Service engagement

lead

Red 31/7/18 Group set up

31/7/18 Stakeholder event

arranged

ACTION PLAN REGARDING WOODVIEW COMMUNITY PAEDIATRICS JUNE 2018


Officer


Lead


Coordination and case

management

Existing caseloads to be allocated to

staff.

All children to be assigned Care

Coordinator within 48hrs of referral

Care Coordinators have designated

role with clear expectations

Audit of care

coordinator

assignment

Role definition

agreed with staff

and discussed

through

parent/carer

engagement group

Audit results

Care plans showing

evidence of

coordinator

Reduction in

parent/carer

complaints and

improved FFT

scores

Chief Nurse Via record keeping

audit Via FFT

and other feedback

Associate Chief Nurse Red

Red

Red

Care cordinators to be in

place for existing caseload by

31/7/18

Process for new coordinator

allocation complete by

31/7/18

Role descriptor complete by

31/7/18

Complaint managements All complainants to be contacted

verbally by Service Lead within 48hrs

of complaint

Target complaint management times

to be met

Reduction in

complaints and

reopened

complaints.

Evidence of

parent/carer

satisfaction through

randomised

feedback audit

Complaints dealt

with according to

timescales

Reduction in

number of

complaints

Reduction in

reopened

complaints

Chief Nurse Monthly and

quarterly at

contract

performance

/CQPG meetings

Michelle Bradshaw Red 15/7/18 for verbal contact to

be in place


Officer


Lead


Waiting lists Commissioner and provider review of

services where demand has increased

in excess of contract thresholds

Agree service line action plans with

local commissioner

Agree communication process for

ensuring parents/carers are kept

informed

Develop specific questions re this in

real time feedback tool

Agreed actions to

manage demand

Action plans

SOP and audit

Mutually agreed

action plans to

address areas of

concern

Clarity of waiting

times and reason

System in place to

monitor referrals

made and waiting

time for treatment

Increased

satisfaction levels


contract

performance

meetings /CQPG

Via FFT

Michelle Bradshaw Red

Red

Red

Red




Feedback tool in draft

31/9/18

Referral process Urgent plan in place to deal with

backlog

Review current processes and

timescales for referral actions

Rapid Improvement event with

parents/cares, CCG. Healthwatch and

Borough council

Develop full roll out plan for e referral

including full IT timescales for e

referral

Develop and

implement

streamlined process

Improved referral

process with

feedback to

referrer and/or

[parents in place


contract

performance

/CQPG meetings

Michelle Bradshaw Amber

Amber

Amber

Amber

Plan in draft 29/6/18 for

agreement and

implementation

Review commenced to

complete 31/8/18

Date for event agreed by

31/7/18

EPR roll out plan in place

needs IT e referral plan to be

included by 30/09/18


Officer


Lead


DNA management Review current processes for DNAs

Develop a system for ensuring follow

up after DNA

Consider "opt out" and "opt in "

processes and risk assess

Agreed DNA

management

process with audit

process

Evidence of follow

up not automatic

discharge

Implemented

process embedded

Reduced DNAs

No child discharged

without full

decision making

and risk

assessment


contract

performance

meetings

Michelle Bradshaw Complete

Amber

Amber


NICE guidance and

medicines management

(This relates specifically to

meds management all

other NICE guidelines are

covered in the action on

QRP)

Review current practices against NICE

guidance to develop baseline and

action plan

Ensure NICE guidance is shared with

partners for their action i.e. Ed Psych

from Borough Council

Review prescribing practice and

ensure process in place for

prescribing against guidance is in

place

Ensure no repeat prescribing unless

chid reviewed and monitored

Agreed process for

reviewing all

relevant NICE

guidance in place

and working

All prescribing

practice reviewed

for each clinician

with action plans

where necessary

Revised SOP for

repeat prescriptions

in place and audited

NICE guidance

compliance

Prescribing

practice improved

Repeat prescribing

audited.

Medical Director Via agreed process Michelle Bradshaw and

Sarah Quinn

Red 31/08/2018


Officer


Lead


Voice of the child Ensure this is evident in all care plans

for existing caseload

Implement process for ensuring this

happens consistently for each new

child referred

Update staff

awareness

Process in place

Parent/carer

satisfaction

improvement


audit and reports

to CCG

Michelle Bradshaw Red To complete 31/08/18 for

existing caseload Report of

audit will ensure all current

children have robust plans in

place. Process to be

implemented by 30/09/18

Assessment process Update all staff re correct process

including reassessment process,

mental capacity consideration and

appropriate feedback mechanism

All assessments

complete and plans

in place

Comprehensive

care plans

Reduction in

complaints from

parents /carers

regarding recurrent

questioning and

information

gathering from

professionals

Chief Nurse Via FFT and

complaints

monitoring to

CQPG

Associate Chief Nurse Red To complete by 31/07/18

Flagging CPP and CIC Review all of current caseload and

update SystmOne Develop

and implement process for flagging

all future referrals

All children on CPP

or CIC flagged on

system

All flags in place to

ensure

comprehensive

and consistent

information flows


audit and reporting

to CQPG

Michelle Bradshaw Amber Flags in place for some

children but full review of

current caseload by

31/07/18 Process to be

implemented by 31/08/18


Officer


Lead


Transition to adult

services ( This includes all

children with appropriate

pathways for children and

young people with specific

diagnosis or dual

diagnosis)

Develop shared process with adult

services

Implement flagging system for all

children with 12 month alert before

transition

Work specifically with Halton ADHD

service to develop specific pathways

for this group

Identify current children due to

transition in 12 months and ensure

plans are in place

Ensure full multi-disciplinary

involvement in all the above

Audit satisfaction of

parent/carer/

young adult with

process

Monitor pathways in

place by each Care

coordinator

Successful

transition for all

children

Medical Director Annual satisfaction

survey of all

children and

parents /cares who

have transitioned

Michelle Bradshaw Red System to be developed by

31/08/18

Arrange workshop with

ADHD service by 31/07/18

Current children

transitioning to be identified

and care plans in place by

31/08/18

Medication monitoring Immediately review all children who

have not been monitored as per NICE

guidance.

Develop consistent process for all

children on medication Stop

repeat prescribing without review

Audit compliance

with prescribing

guidelines

All children to be

monitored

Compliance with

NICE guidelines

and medicines

management

Medical Director Quarterly reviews Miichelle Bradshaw

and Sarah Quinn

Red Children identified and

monitored by 31/08/18

Process implemented by

31/09/18

Repeat prescribing without

review to stop immediately

29/06/18


Officer


Lead


MDT working and Panel

meetings

Determine consistent membership

and ensure each person has a

formally designated deputy to attend

in their place

(These actions require CCG input and

shared responsibility)

Review TORs for meetings to include

actions to take place following

meetings

Agree with Local Authority

Educational Psychology input as per

NICE guidance

Invite CAMHs as required

Review referral forms as in and

ensure all background information is

complete prior to meetings

Comprehensive MDT

meetings and panels

with care plans and

pathways identified

and communicated

with child and

parents/care plus

other partner

agencies

MDT and panel

members from

BCHFT identified

with deputies

TORs in place and

reviewed annually

Local Authority

provide Educational

or Clinical

Psychology

Parent carer

satisfaction

improves

Children have

appropriate

assessment,

planning and care

delivery

Medical Director Via FFT and annual

parent/carer

survey

Via record keeping

audit

Michelle Bradshaw Red Complete membership

identified by 31/07/18

TORs reviewed by 31/08;/18

Local authority agreed

representation by 31/07/18


Officer


Lead


Administration SOP for monitoring follow up after

panel/MDT etc.

SOP for filing and case note

management

All key roles

appointed to with

suitably experiences

and competent

professionals

Full implementation

across the Trust

Processes in place

to efficiently

manage admin

pathway

Chief Nurse Via

complaints/concer

ns

Michelle Bradshaw Red SOP to be in place by

31/07/18

Documentation and

record keeping

Update training for all staff

Increase sample size of regular audit

and include additional questions e.g.

Voice of the Child evident, CPP

flagged

Continue roll out of EPR

All records

consistent,

contemporaneous

and contain

comprehensive

assessments and

plans

Compliance with all

policies


audit

Associate Chief Nurse Red Updates delivered by

31/07/18

EPR roll out continues as per

plan

1

CQC - Time to Shine

CQC Prep Meeting – Week 7 – Friday 29.06.18

Attendees

Lynne Carter Chief Nurse (LC) Chair Sharan Arkwright Associate Director Quality Governance (SA) Notes Georgina Clark Associate Chief Nurse West (GC) Kristine Brayford-West Associate Director Safeguarding (KBW) Kelly Hunt Head of Healthcare HMP Wymott (SR) Greg Field Clinical Manager Warrington Specialist Services (GF) Susan Burton Clinical Manager Warrington 0-19 (SB) Theresa Woods FNP Supervisor 0-19 Halton (TW) Louise Southward FNP Supervisor Warrington (LS) Maxine Dickinson Quality Matron West (MD) Janet Rawlings Quality Matron East (JR) Nicola Monaghan Clinical Manager Bolton 5-19 (NM) Sylvia Mills FNP Supervisor Oldham 0-19 (SM) Louise Simpson Operations Manager Dental Network GM (LS) Corina Casey-Hardman Head of Midwifery (CCH0 Julie Banat Clinical Manager Wigan HV/SN (JB) Julie Griffiths Clinical Manager Podiatry (JG) Jim Eatwell Named Nurse Adult Safeguarding (JE) Jayne Hopwell Strategic Lead Safeguarding (JHW) Tracey Spurr Senior Manager H&J (TS) Neil Gregory Assistant Director St Helens (NG) Karen Plant Assistant Director H&J (KP) John Jordan Head of Healthcare HMP Wymott (KH) Steve Morley Head of Healthcare HMP Risley (SM) Lyn Gordon Community Macmillan, Specialist Palliative Care (LG) Jacqui Stott Clinical Manager Specialist Services St Helens (JS) Sarah Wilson Named Nurse Safeguarding Children’s Halton (SW) Cathy McGinn Named Nurse Safeguarding Children’s Warrington & St Helens (CM) Vanessa Woodall Named Nurse Safeguarding Children’s Oldham (VW) Lynda Cunliffe Named Nurse Safeguarding & Children in Care (LC) Rachel Ayer Community Specialist Palliative Care Nurse Halton (RA) Apologies Jeanette Hogan Associate Chief Nurse East (JH) Berni Hardman Associate Chief Nurse End of Life and Health & Justice (BH) Jannine Grundy Clinical Manager Adult Nursing Warrington (JG) Anne Doyle Assistant Director Children’s Services (AD) Gill Eaves Clinical Manager (GE) Barry Hutton Assistant Director (BH) Claire Davies Quality & Safety Lead West (CD) Lynne Hall-Bentley Associate Director Wigan Adults (LHB)

2

1. Welcome and Apologies

2. LC asked the teams to feedback on how they have engaged staff in the process. KW spoke

about the Tree of Evidence and shared it with the group. This was discussed as a good idea that could be shared on the hub. The concept has already been tweeted by the team.

Action: KW to send to the Quality & Safety Lead (CD) for it to be uploaded onto the HUB.

3. LC asked the group what were the blockages to success. The group stated IT Connectivity and the Financial Ledger. Action: SA has added these to the CQC plan (29/6/18)

4. Actions from the meeting 22nd June 18:

12 Service Safety Wigan BCPs not currently up to date:

Currently being reviewed

Scoping exercise being undertaken

Training for BCPs – SB queried if this is this available from Pauline Hoskyns

All AD’s /CM

Please use the attached excel sheet to review BCPs for services. Plans received to date:

Adults (Halton and Warrington) No plans received: 7 Plans in action card format only: 4 Plan not in BWR template: 1 (service is led by HBC and uses their template) Plan in previous version of BWR template: 11 Plan in current version of BWR template: 11 Adults (St Helens) No plans received: 0 Plans in action card format only: 2 Plan not in BWR template: 0 Plan in previous version of BWR

3

template: 4 Plan in current version of BWR template: 11 Adults (Wigan) No plans received: 16 Plans in action card format only: 2 Plan not in BWR template: 0 Plan in previous version of BWR template: 8 Plan in current version of BWR template: 3 Children (Halton, St Helens, Warrington) No plans received: 0 Plans in action card format only: 0 Plan not in BWR template: 0 Plan in previous version of BWR template: 2 Plan in current version of BWR template: 11 Children (Wigan, Bolton, Oldham) No plans received: 1 Plans in action card format only: 0 Plan not in BWR template: 0 Plan in previous version of BWR template: 7 Plan in current version of BWR template: 2 Health & Justice No plans received: 1 Plans in action card format only: 0

4

Plan not in BWR template: 0 Plan in previous version of BWR template: 5 Plan in current version of BWR template: 0 Dental No plans received: 3 Plans in action card format only: 0 Plan not in BWR template: 5 Plan in previous version of BWR template: 0 Plan in current version of BWR template: 1

16 Clinical Supervision Quality matrons are working with teams to update their own SOPS. These will then sit under the Trust Policy on the Hub.

21 IT Connectivity Added to the plan

22 Financial Ledger Added to the plan

AOB RPIR data This can be shared with the AD’s and will be e mailed to them 29/6/18

5. Date, Time and Venue of Next Meeting

Friday 6th July 2018, 9.00-11:00, Bevan House, Rooms 2&3

trust board date: 2 august 2018 part: public agenda item ......trust board (cover sheet template...

Documents