Care Quality Commission (CQC) Comprehensive Inspection Quality Report

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1 Care Quality Commission (CQC) Comprehensive Inspection Quality Report Agenda Item: 10 Reference: WCT14/ Meeting Name: Trust Board Meeting Date: 3 December 2014 Lead Director: Sandra Christie Job Title: Director of Quality and Nursing Link to Business Plan: Has an Equality Impact Assessment (EQIA) been undertaken & attached? Has the Public & Stakeholders been consulted? Yes No N/A Yes No N/A To Approve To Note To Assure Financial Implications: E.g. What is the Impact on the Trust? Does it provide Value for Money? All costs should be clearly explained in the section below. Overall Cost / Pressure: Additional Funding Required: Identified Risks: Overall Income: Funding Already Ring Fenced: None identified Assurance to Board: The attached inspection report provides external assurances to the Board that services provided are safe, caring, responsive, effective and well. Publish on Website: Yes No Private Business: Yes No Report History Submitted to Date Brief Summary of Outcome No history

2 Wirral Community NHS Trust Care Quality Commission (CQC) Comprehensive Inspection Quality Report Purpose 1. The purpose of this paper is to present the final CQC Comprehensive Quality Report to the board following publication by the CQC and the action plan to address the areas of improvement for approval. Executive Summary 2. The CQC inspected the Trust as part of the comprehensive Wave 2 pilot community health services inspection programme. 3. The Wave 2 inspection model for community health services is a specialist, expert and riskbased approach to inspection. The aim of this testing phase is to produce a better understanding of quality across a wider range and greater number of service and to better understand how well quality is managed. 4. Before visiting the trust the CQC reviewed a range of information they hold about the Trust and asked other organisations to share what they knew. 5. They also received comments from people who had attended a listening event prior to the inspection. 6. The CQC carried out announced visits to the trust on 2, 3 and 4 September They also visited the trust unannounced out of hours on 3 September They visited health centres, dental clinics and walk in centres and went on home visits with district nursing, health visitors and palliative care specialist nurses. 8. During the visits they held focus groups with a range of staff who worked within the trust including nurses, therapists and healthcare assistants. 9. They talked with people who use trust services and observed how people were being cared for and talked with carers and/or family members and reviewed care or treatment records. Rationale and Implications 10. The CQC s overview report is included at Appendix One. 11. The CQC has introduced ratings as an important element of their new approach to inspection and regulation. 12. Their ratings are based on a combination of what they find at inspection, what people tell them, their Intelligent Monitoring data and local information from the trust and other organisations. 13. Ratings are awarded on a four-point scale: outstanding; good; requires improvement; or inadequate. 14. The overall rating awarded to the trust was:

3 15. The detailed rating for each service inspected was: 16. To be authorised as a Foundation Trust an applicant must be rated at least Good under the CQC s inspection regime. 17. The CQC identified several areas of good practice across the organisation: There was good multi-disciplinary working in most of the adult community services. The sexual health team were innovative and proactive in their efforts to engage young people and encourage the appropriate health tests. For example, the team gave presentations at local high-schools and set up information stalls promoting safe sex, providing information and goodie bags attractively and appropriately packaged at venues attended by young people such as Fresher s Fairs at local sixth form colleges and local music festivals. The Family Nurse Partnership were proactive in including teenage fathers in preparing them for caring for their child. Initiatives included men s groups and a football team which were used as means of initial engagement and enabling peer support for young fathers. The trust provided a specialist speech and language service for children with dysfluency (stammer) and this is not a standard provision for community trusts.

4 Dental care provided was high quality, person centred, individualised and based on evidence based guidelines, across all services, in particular at the Leasowe clinic. The streamline service and multi-disciplinary approach provided at Clatterbridge clinic provided patients with a joined up, comprehensive service. The End of Life Care Team had developed their own nutrition assessment to support community patients. 18. Several areas for improvement were identified by the CQC: Action the provider MUST take to improve The trust must review systems to report incidents across the community teams. The frequency of use of the incident reporting procedure varied and staff access to the electronic reporting system was inconsistent across the services. The trust must review the policies and procedures for safeguarding to ensure they are fit for purpose and provides staff with clear information to support them when reporting issues. Different record keeping systems were in place across services while a new IT system was being rolled out. There was some time consuming duplication of records. Together these may present emerging risk of under reporting of some types of incidents and trends being missed. This must be addressed by the trust. The impact of the Mental Capacity Act 2005 code of practice and Deprivation of Liberty safeguards was not well understood by most staff. This has an impact of staff ability to support patient s giving informed consent to treatment. The training that was provided must be reviewed. There was no single reference point for all of the different services provided for children by the trust. The trust must review the overall management arrangements for services for children and families to ensure there is a shared vision and that opportunities for joined up working are acted upon. Triage assessments were not always completed as quickly and efficiently as possible. Patients were often waiting in excess of 30 minutes to be seen by the triage nurse. The trust must ensure that good practice guidelines for triage assessment are fully implemented and monitored to ensure patients are seen as quickly as possible for initial assessment. Action the provider SHOULD take to improve The effectiveness of transition arrangements for children and young people to adult services should be reviewed as community nursing staff had no confidence in current arrangements, including liaison with mental health teams. The trust should ensure that community nursing teams are able to monitor and articulate outcomes for patients. Staff were not clear about how the trust was defining the difference between a complaint and a concern. This affected the way issues raised by patients were dealt with locally and could result in trends being missed by the trust. The trust should review the clarity of its message about complaints. The trust should address the issue of no facilities being available in clinic waiting areas to occupy children. Patients told us this added to the strain of attending for their children s and their own appointments.

5 The trust should make sure that infection control measures are effective, comprehensive and consistently applied in keeping with accurate infection control risk assessments or audits in the areas used by children, young people and their families and that all clinics have processes in place that encourage children, young people and families to clean their hands. The trust should continue reviewing the robustness of the plans in place for safeguarding children and ensure that plans cover all areas of disparity between interfacing services; ensure that all staff receive the appropriate training and updates in relation to safeguarding so that staff are clear about what needs to be referred to safeguarding, fully understand and the systems in place and routinely inform staff about the outcomes of their referrals. Patients should be prompted to wash their hands or use hand gel on entering the walk in centres. Hand gel was available but there were no posters or other information for patients about when and how the gel should be used. The walk in centres and minor injuries unit should be included in the local pathway for falls in older people. Older people who came to the walk in centres as a result of a fall were not offered a referral to the falls prevention team. Action the provider COULD take to improve Uptake of staff training specific to staff roles and patient needs could be improved. Bespoke training sessions were not well attended because staff reported having to do this in their own time. The walk in centre waiting areas could be improved to make adequate provision for children. Privacy for patients at reception desks in the walk in centres could be improved. There was no staff role identified within the walk-in centre service to promote good practice when caring for people living with dementia, such as a link nurse. This could be improved. Information for patients about how to make complaints could be more visible for patients in the clinic areas so they are aware of the trust s complaints process. The trust could develop more formal communication channels with the dental service leads to ensure they feel engaged in service development, design and commissioning. Although the trust is introducing SystmOne to the end of life team, record keeping and the review process could be improved to ensure that care and treatment is effectively documented. The working relationships with the hospice were on occasions disjointed and could be improved. 19. The action plan to address both the must and should do actions is included in Appendix The action plan has been revised following the informal feedback at the CQC Quality Summit on 11/11/ This action plan will be monitored monthly at the Quality and Governance Committee and progress will be presented to the board quarterly for assurance on progress.

6 22. The actions the trust could do to improve will be discussed further at the Quality, Patient Experience and Risk group and the group will also develop a communication plan to involve staff fin implementing the action plan. 23. The report was formally published by the CQC on Tuesday 18 November Board Action 24. The board asked to approve the action plan and to be assured of the quality of care within the trust. Sandra Christie Director of Quality and Nursing

7 Wirral Community NHS Trust Quality Report Good Wirral Community NHS Trust Old Market House Hamilton Street Birkenhead CH41 5AL Tel: Website: Date of inspection visit: September 2014 Date of publication: 11 November 2014 Core services inspected CQC registered location CQC location ID Community health services for children, young people and families Community health services for adults End of life care Urgent care St Catherine s Health Centre Old Market House Victoria Central Hospital Walk In Centre St Catherine s Health Centre Old Market House St Catherine s Health Centre Old Market House Eastham Walk In Centre Victoria Central Hospital Walk In Centre Arrowe Park Walk In Centre Riverside Park Call Centre RY701 RY7Y3 RY7X2 RY701 RY7Y3 RY701 RY7Y3 RY7X1 RY7X2 RY7X3 RY7Y4 This report describes our judgement of the quality of care at this provider. It is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from people who use services, the public and other organisations. 1 Wirral Community NHS Trust Quality Report 11 November 2014

8 Summary of findings Ratings We are introducing ratings as an important element of our new approach to inspection and regulation. Our ratings will always be based on a combination of what we find at inspection, what people tell us, our Intelligent Monitoring data and local information from the provider and other organisations. We will award them on a four-point scale: outstanding; good; requires improvement; or inadequate. Overall rating for community health services at this provider Good Are services safe? Good Are services effective? Good Are services caring? Good Are services responsive? Good Are services well-led? Good 2 Wirral Community NHS Trust Quality Report 11 November 2014

9 Summary of findings Contents Summary of this inspection Overall summary 4 The five questions we ask about the services and what we found 5 Our inspection team 9 Why we carried out this inspection 9 How we carried out this inspection 9 Information about the provider 9 What people who use the provider's services say 10 Good practice 10 Areas for improvement 10 Detailed findings from this inspection Findings by our five questions 12 Page 3 Wirral Community NHS Trust Quality Report 11 November 2014

10 Summary of findings Overall summary When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence. When aggregating ratings, our inspection teams follow a set of principles to ensure consistent decisions. The principles will normally apply but will be balanced by inspection teams using their discretion and professional judgement in the light of all of the available evidence. We found that the provider was performing at a level which led to a judgement of Good. At trust level, there were good systems put in place to monitor incidents and there was continued investment in processes and staff to lead this proactively. We saw good examples of how the trust is using data to improve reporting and some teams had excellent examples of how audits, incident reporting had changed practice. Good reporting occurred in teams where staff had had input from the trust s quality team. However this was not consistent across the Trust. Not all the teams we visited were using systems to their full potential or were clear about how to use them. Whilst staff knew how to report incidents, we did come across groups of staff who did not report and managed incidents or risks locally or who could not clearly identify what an incident was. All the places we visited were maintained to a good standard and we saw good evidence of infection control, although more could have been done in some areas to improve hand hygiene. We were concerned about the impact of high staff sickness on some services and staff did raise concerns about the potential impact this has on the quality of patient care. We saw there was a lack of understanding regarding deprivation of liberty and the Mental Capacity Act. Care was evidenced based and personalised to the patient. We saw many good examples of multidisciplinary working and positive working relationships. Staff across all the core services we inspected were caring and compassionate. We observed this approach not just from nursing staff but from a range of clinicians administrators and volunteers. We saw that staff worked hard, were polite and welcoming and in the majority of cases epitomised the 6Cs. We saw very many good examples of individualised care; in particular we saw excellent care in the end of life service. Staff across all the core services we inspected had examples of research and development and innovative practice. We observed many examples of a flexible, responsive service which met the needs of the local population they served. Although patients were treated and discharged within four hours in the walk-in centres, we found that many patients waited far too long to be seen by the triage nurse for initial assessment. All the staff we talked to during our inspection were able to tell us about the leadership team and their regular visits to the service. Staff knew the Chief Executive and Director of Nursing by name and were aware of the nonexecutive directors. Some staff we met during the inspection could not name their head of service and in some cases said they had not met them. It was also felt that there was a lack of clinical engagement in designing and commissioning the services they delivered. During this inspection, CQC also inspected the GP out of hours service provided by the trust at Arrowe Park Hospital. The inspection forund that services were safe but the trust should implement an annual review of incidents and ensure staff routinely receive feedback regarding individual incidents and complaints they had been involved in. The inspection also found that service were effective, caring and well-led but more could be done to publise the trusts complaints procedure. 4 Wirral Community NHS Trust Quality Report 11 November 2014

11 Summary of findings The five questions we ask about the services and what we found We always ask the following five questions of services. Are services safe? We judged this domain to be good but with some aspects requiring improvement. Most staff were able to demonstrate that they knew how to report incidents and felt their concerns were listened to but some staff reported that they received limited or no feedback on the outcomes and potential learning of the incidents they reported. In the last 12 months, the trust has started using the Datix system to report and collate information on a range of information management requirements around safety. In areas where this has been rolled out the trust is confident that incidents were being reported but there is less assurance in those areas where Datix is not readily available. This means there is a potential that there is some under reporting of incidents in some parts of the trust. Good Staffing levels and skill mix were generally safe and the trust are using the Safe Staffing NICE guidelines for wards and applying them to the community setting to restructure services. The clinic environments we visited were generally clean and well equipped. Although hand hygiene was well maintained amongst the majority of staff, there was limited or no prompting for patients to maintain good levels of hand hygiene. Medicines were managed safely. There were good arrangements in place to ensure the staff working alone out in the community were safe. We found that safeguarding presented an area which although we found no detriment to patients during our inspection, the arrangements in place posed an elevated risk to the trust. The organisational structure and policies to support staff in relation to safeguarding were over complicated and not clear to staff working in the trust. Are services effective? We assessed this domain to be good. Care was evidence based and personalised to the patient. We observed good verbal consent and documentation of consent. However, there was a lack of knowledge about the Mental Capacity Act in some areas of the trust. There were good levels of involvement from families, relatives and carers which ensured care was planned and implemented effectively. Good The trust were meeting the majority of the contractual Key Performance Indicators (KPI s). Where they were not meeting the monthly KPI s reasons had been identified to the commissioners. 5 Wirral Community NHS Trust Quality Report 11 November 2014

12 Summary of findings Staff had access to training opportunities, as well as appraisals. The trust was maintaining high levels of engagement with staff for both of these areas. Appraisals had been linked to the Culture of Compassionate Care 6 C s initiative. They had also been designed to help identify and support future leaders. There were many examples of good multidisciplinary working and positive working relationships were observed at handover, for example but this was not consistent across all services. A number of services were able to show us innovative practice and ongoing research in a number of areas. The trust had made links with other providers to ensure that they could meet the future needs of the patients it provided a service to. Are services caring? We considered this domain to be good. We saw many exemplary instances of caring, respectful and compassionate treatment. Patients were clearly involved in the decisions being made about their care and we saw many examples of self-management. Patients who were vulnerable were treated with a sensitive manner and emotional support was offered. Good Feedback from patients, relatives and families was overwhelmingly positive. It was evident that staff knew their patients very well and that service delivery had been tailored to suit individualised needs. Assessments were holistic and we saw child friendly services Are services responsive to people's needs? We considered this domain to be good, with some aspects requiring improvement. Many of the services we inspected were able to offer flexibility around appointment systems and we had many examples of where service delivery had been changed and adapted in response to patient feedback. We saw good use of interpretation services and creative use of online services in the walk in centres to address communication barriers. Good Patients using the walk in centre service were usually treated and discharged within four hours, often within two hours. However, patients frequently waited too long to be seen by the triage nurse for an initial assessment of their clinical needs. Because of a lack of integrated working with primary medical and social services, some patients were not always referred for further support as required from the walk in centre. Staff were able to demonstrate a good awareness of individual patients needs and were able to deliver care along with other services in order to support patients, such as direct referral systems. 6 Wirral Community NHS Trust Quality Report 11 November 2014

13 Summary of findings The trust had an equality and diversity strategy action plan in place and was working through that to completion. They had a dedicated equality and diversity manager to oversee and drive the action plan forward. The trust had a proactive and personalised approach to responding to complaints, comments and compliments. The trust took all patient observations and remarks seriously and endeavoured to resolve them. They then took the opportunity to learn from these to ensure they continually offered improved services. At board level patient experience was regularly reviewed. Are services well-led? We considered this domain to be good, with some aspects requiring improvement. Staff had confidence in the trust s Chief Executive and Director of Nursing and Quality. Staff were aware of the vision and values of the trust and were able to articulate them. They also had quality goals and staff were able to demonstrate that they knew what the goals were. Staff appraisal were linked to the trust vision and values and nearly all the staff we spoke to confirmed they had had an appraisal in the last 12 months. Front line staff spoke highly of local line managers and said they felt supported and had good access the training. Morale was generally good and this was reflected in the positive attitude we found from the staff we met during our inspection. However, local line managers did not feel sufficiently supported and divisional/middle managers were not visible enough. There was no overview or leadership of all the services the trust provided for children. This meant that services were working in silos and limited opportunities for cross-team working. Our inspection team were impressed with the community dental service and acknowledge some of the exemplary work being undertaken, however, the staff working in the service expressed that they did not feel recognised by the board and would like more clinical engagement around service design, development and commissioning. Risks were identified and mitigating actions reviewed and updated. However not all risks were identified and for some that were, no associated action plan was produced to reduce the risk. IT and data management presented an elevated risk to the trust. We found a number of areas where there were inconsistencies in data reported by the trust and actual performance. Lack of access to IT in Good 7 Wirral Community NHS Trust Quality Report 11 November 2014

14 Summary of findings some parts of the trust meant there were gaps in data and the incompatibility of some software programs across the organisation, limited the trusts ability to ensure robust management reporting was available. 8 Wirral Community NHS Trust Quality Report 11 November 2014

15 Summary of findings Our inspection team Our inspection team was led by: Chair: Professor Siobhan Gregory, Director of Quality and Clinical Excellence, Hounslow and Richmond Community Healthcare NHS Trust. Team Leader: Debbie Widdowson, Care Quality Commission The team of 28 included CQC inspectors and a variety of specialists: District Nurses and Tissue Viability Specialists, Ward Matron, Community Matron and Nurse Practitioner, Health Visitor, Therapists, a NHS Managing Director with expertise in governance, GP and a Dentist and four experts by experience Why we carried out this inspection We inspected the Trust as part of our comprehensive Wave 2 pilot community health services inspection programme. The Wave 2 inspection model for community health services is a specialist, expert and risk-based approach to inspection. The aim of this testing phase is to produce a better understanding of quality across a wider range and greater number of service and to better understand how well quality is managed. How we carried out this inspection To get to the heart of people who use services experience of care, we always ask the following five questions of every service and provider: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? Before visiting, we reviewed a range of information we hold about the Trust and asked other organisations to share what they knew. We also received comments from people who had attended a listening event prior to the inspection. We carried out announced visits on 2, 3 and 4 September We also visited the trust unannounced out of hours on 3 September We visited health centres, dental clinics and walk in centres. We went on home visits with district nursing, health visitors and palliative care specialist nurses. During the visits we held focus groups with a range of staff who worked within the service, including nurses, therapists and healthcare assistants. We talked with people who use services. We observed how people were being cared for and talked with carers and/or family members and reviewed care or treatment records. Information about the provider Wirral Community NHS Trust was first registered on 1 April 2011 and has 17 registered locations. It delivers a range of community services within the Wirral and some areas of Cheshire and Liverpool, across 145,000 households. It provides a range of services including nursing and therapy services as well as unplanned care, lifestyle support and primary care services. The Trust s annual revenue for 2013/2014 was 70 million. They employ approximately 1400 staff and serve a population of around 320,000, with more than 1.1 million patient contacts each year. The Trust delivers services in people s own homes, and from over 50 locations including health centres, hospitals, community settings and dental centres. 9 Wirral Community NHS Trust Quality Report 11 November 2014

16 Summary of findings CQC inspected seven registered locations between January 2012 and August All locations were fully compliant with the Essential Standards of Quality and Safety. What people who use the provider's services say On 12 August 2014, we held an event where a range of local community groups came to share their experiences of using the services. The group included local Healthwatch, groups representing older people, multicultural groups, advocacy organisations and groups representing people with physical disabilities. It was felt that there were examples of good treatment and care provided by the trust. However, they felt there was a lack of consistency in terms of communication, information, and access to treatment. The trust report in their Quality Account that 97% of patients agreed they would recommend the service they have received to friends and family. During our visit to the trust, people spoke very positively of the experiences of using services and told us the staff were supportive, considerate and respectful. Good practice There was good multi-disciplinary working in most of the adult community services. The sexual health team were innovative and proactive in their efforts to engage young people and encourage the appropriate health tests. For example, the team gave presentations at local high-schools and set up information stalls promoting safe sex, providing information and goodie bags attractively and appropriately packaged at venues attended by young people such as Fresher s Fairs at local sixth form colleges and local music festivals. The Family Nurse Partnership were proactive in including teenage fathers in preparing them for caring for their child. Initiatives included men s groups and a football team which were used as means of initial engagement and enabling peer support for young fathers. Areas for improvement Action the provider MUST or SHOULD take to improve The trust must review systems to report incidents across the community teams. The frequency of use of the incident reporting procedure varied and staff access to the electronic reporting system was inconsistent across the services. The trust must review the policies and procedures for safeguarding to ensure they are fit for purpose and provides staff with clear information to support them when reporting issues. Different record keeping systems were in place across services while a new IT system was being rolled out. There was some time consuming duplication of records. Together these may present emerging risk of under reporting of some types of incidents and trends being missed. This must be addressed by the trust. The impact of the Mental Capacity Act 2005 code of practice and Deprivation of Liberty safeguards was not well understood by most staff. This has an impact of staff ability to support patient s giving informed consent to treatment. The training that was provided must be reviewed. There was no single reference point for all of the different services provided for children by the trust. 10 Wirral Community NHS Trust Quality Report 11 November 2014

17 Summary of findings The trust must review the overall management arrangements for services for children and families to ensure there is a shared vision and that opportunities for joined up working are acted upon. Triage assessments were not always completed as quickly and efficiently as possible. Patients were often waiting in excess of 30 minutes to be seen by the triage nurse. The trust must ensure that good practice guidelines for triage assessment are fully implemented and monitored to ensure patients are seen as quickly as possible for initial assessment. The effectiveness of transition arrangements for children and young people to adult services should be reviewed as community nursing staff had no confidence in current arrangements, including liaison with mental health teams. The trust should ensure that community nursing teams are able to monitor and articulate outcomes for patients. Staff were not clear about how the trust was defining the difference between a complaint and a concern. This affected the way issues raised by patients were dealt with locally and could result in trends being missed by the trust. The trust should review the clarity of its message about complaints. The trust should address the issue of no facilities being available in clinic waiting areas to occupy children. Patients told us this added to the strain of attending for their children s and their own appointments. The trust should make sure that infection control measures are effective, comprehensive and consistently applied in keeping with accurate infection control risk assessments or audits in the areas used by children, young people and their families and that all clinics have processes in place that encourage children, young people and families to clean their hands. The trust should continue reviewing the robustness of the plans in place for safeguarding children and ensure that plans cover all areas of disparity between interfacing services; ensure that all staff receive the appropriate training and updates in relation to safeguarding so that staff are clear about what needs to be referred to safeguarding, fully understand and the systems in place and routinely inform staff about the outcomes of their referrals. Patients should be prompted to wash their hands or use hand gel on entering the walk in centres. Hand gel was available but there were no posters or other information for patients about when and how the gel should be used. The walk in centres and minor injuries unit should be included in the local pathway for falls in older people. Older people who came to the walk in centres as a result of a fall were not offered a referral to the falls prevention team. Action the provider COULD take to improve Uptake of staff training specific to staff roles and patient needs could be improved. Bespoke training sessions were not well attended because staff reported having to do this in their own time. The walk in centre waiting areas could be improved to make adequate provision for children. Privacy for patients at reception desks in the walk in centres could be improved. There was no staff role identified within the walk-in centre service to promote good practice when caring for people living with dementia, such as a link nurse. This could be improved. Information for patients about how to make complaints could be more visible for patients in the clinic areas so they are aware of the trust s complaints process. The trust could develop more formal communication channels with the dental service leads to ensure they feel engaged in service development, design and commissioning. Although the trust is introducing SystmOne to the end of life team, record keeping and the review process could be improved to ensure that care and treatment is effectively documented. The working relationships with the hospice were on occasions disjointed and could be improved.. 11 Wirral Community NHS Trust Quality Report 11 November 2014

18 Wirral Community NHS Trust Detailed findings Good Are services safe? By safe, we mean that people are protected from abuse * and avoidable harm * People are protected from physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse Summary of findings We judged this domain to be good but with some aspects requiring improvement. Most staff were able to demonstrate that they knew how to report incidents and felt their concerns were listened to but some staff reported that they received limited or no feedback on the outcomes and potential learning of the incidents they reported. In the last 12 months, the trust has started using the Datix system to report and collate information on a range of information management requirements around safety. In areas where this has been rolled out the trust is confident that incidents are being reported but there is less assurance in those areas where Datix is not readily available. This means there is a potential that there is some under reporting of incidents in some parts of the trust. Staffing levels and skill mix were generally safe and the trust are using the Safe Staffing NICE guidelines for wards and applying them to the community setting to restructure services. The clinic environments we visited were generally clean and well equipped. Although hand hygiene was well maintained amongst the majority of staff, there was limited or no prompting for patients and visitors to maintain good levels of hand hygiene. Medicines were managed safely. There were good arrangements in place to ensure the staff working alone out in the community were safe. We found that safeguarding presented an area which although we found no detriment to patients during our inspection, the arrangements in place posed an elevated risk to the trust. The organisational structure and policies to support staff in relation to safeguarding were over complicated and not clear to staff working in the trust. Our findings Staff knew how to report incidents using the electronic system. Staff were able to describe incidents they had reported and gave examples of what they would report. Patients that we spoke with told us that they felt safe using the services provided by the trust. We found that the trust had mechanisms in place to report and record safety incidents, concerns, near misses and allegations of abuse. This included the on line reporting tools, policies, procedures and audits. The trust had reported zero never events in the last twelve months. Between June 2013 and June 2014 the trust made a total of 2286 notifications to CQC via the NRLS system. 12 Wirral Community NHS Trust Quality Report 11 November 2014

19 Are services safe? Good By safe, we mean that people are protected from abuse * and avoidable harm Of these, 383 were considered to be of the type moderate, abuse, severe or death. During the same period there were 19 serious incidents at the trust, 18 of which were related to pressure ulcers. When compared to others, Wirral Community NHS Trust could be considered a low reporter of notifications and incidents. The trust scored below average for the percentage of staff reporting errors, near misses or incidents witnessed in the 2013 NHS Staff Survey. Additionally, the trust itself has identified that the incident reporting was decreasing and this posed a potential risk. The reason for this could be because there is low occurrence of incidences, but during our inspection we became aware of a number of barriers which could potentially prevent staff from reporting incidents. The one barrier was lack of access to the computerised reporting system. If operational staff working out in the community witnessed or were made aware of an incident in a patient s home, they would need to report it by completing an incident form when they returned to base. This would then have to be transcribed on the incident reporting system. (DATIX). The process was time consuming and took staff away from patient care. Senior management agreed that a rise in incident reporting was likely when staff had the mobile devices which would enable them to report at source. There was evidence that incidents had been downgraded at the time of reporting, or not reported at all due to the prompt action taken by the staff to deal with the situation with the result that they were not collected or reported corporately. Examples of this were given to us by the End of Life Care team. Some staff were very clear about what an incident was and what type of incident was their responsibility to report. Other staff were less clear. We found some staff indicated a reluctance to report problems to managers, and to access the computer systems that were used to report, assess and escalate incidents. During the inspection we spoke with senior staff regarding the processes involved with classification and investigating of incidents. We noted that there were inconsistencies in the classification of similar incidents, which then resulted in different follow-up management. This could indicate that the trust was missing the opportunities to learn from incidents they had incorrectly classified. Senior staff involved with the investigations of incidents had been trained in investigation techniques. We were told that this specialist training was going to be rolled out to further staff to improve their investigation skills. All incidents with a clinical element were reviewed by a clinician within 24 hours. The quality team told us that education from incidents was shared at team meetings and there were plans in place for learning to be shared via the trust s intranet. Drug incidents which were investigated also shared learning via an online publication. The trust has joined a national initiative called Sign Up To Safety. This initiative aims to deliver harm free care, champions openness and supports staff to improve safety for patients. In response to increasing numbers of pressure ulcers, audits were completed in July and November These identified compliance with best practice across the community nursing teams. Where less than optimal practice was identified an action plan had been produced and completed with the community nursing teams. However, within the Integrated Performance Report for July 2014 numbers of pressure ulcers graded 3 and 4 have increased since the last report. The reasons for this were not clear. Cleanliness, infection control and hygiene The 2013/14 Quality Account states that the trust had no avoidable healthcare acquired infections in their services. The trusts' catheter and new urinary tract infection rate for all patients and patients over 70 shows considerable fluctuation during the 12 month period between June 2013 and June 2014 however both rates were below the England average for almost the entire period. All the areas we visited were visibly clean. Staff were aware of current infection prevention and control guidelines and good infection prevention and control practices were observed. We saw most but not all staff using hand washing facilities and hand gel (Health visitors were observed not washing their hands). Patients also confirmed that they saw staff washing their hands and using hand gels. The staff wore trust uniforms and adhered to the trust uniform policy when working in the community. Regular audits took place across the services to ensure policies were adhered to. Patients were not prompted to wash their hands or use hand gel on entering the walk in centres or in some 13 Wirral Community NHS Trust Quality Report 11 November 2014

20 Are services safe? Good By safe, we mean that people are protected from abuse * and avoidable harm clinic reception areas. Hand gel was available but there were no posters or other information for patients about when and how the gel should be used. There is ample evidence that effective hand hygiene reduces the incidence and spread of infection. Maintenance of environment and equipment Patients were seen in a wide variety of locations throughout the trust ranging from GP surgeries, community hospitals, the new purpose built St Catherines Heath Centre, clinics and in their own homes. There were no concerns raised about the maintenance of the environment and equipment. All the areas we visited appeared well maintained. In dental services, for example, all sites were recently refurbished and had mostly all new equipment. Staff knew how to report any issues requiring repair or maintenance. Staff told us that repairs were usually carried out promptly. All the equipment we looked at was calibrated and maintained in keeping with the manufacturer s instructions. Medicines management Policies for the safe handling and administration of medicines were in place. Medicines were stored safely and comprehensive recording systems were in place. Controlled medications were stored appropriately in all the areas we visited. There were nurses working in the walk in centres who had undertaken additional training so that they could prescribe medicines. The competency of these nurses was monitored by a senior nurse. Staff were aware of medication protocols concerning children such as prescribing and administering medication in ratio to the weight of the baby or young child. Safeguarding Since registration, no safeguarding records have been raised for the trust with CQC. Staff were aware of safeguarding procedures and what may constitute a safeguarding concern. Staff spoken with demonstrated understanding and knowledge of the action they should take in the event they had suspicion or evidence of abuse. All staff that we spoke with told us they felt confident about speaking up if they had any concern about the welfare of a patient. We spoke with senior staff who told us that training for safeguarding was to be completed on a 2-yearly cycle, documents we reviewed supported this. However, we noted that this was a variation from the trust s safeguarding adults policy which stipulated that staff completed level one adult training annually and level two every three years. Within children s services did not attend (DNA) incidents were recognised as a trigger which could require a safeguarding referral. We reviewed the Safeguarding Children and Failure to Gain Access polices, both of which included advice to staff regarding actions to take when children did not attend booked appointments. We noted that the advice given to staff was not consistent across the two policies, which could potentially impact on when a safeguarding referral and result in the child not being seen for a longer period of time with inherent risks attached. Some teams had more contact with children which necessitated them being trained in safeguarding level three. For instance within the walk-in centres, onequarter of their work is with children, but only 13% of staff had completed this training for their role. The head of the safeguarding service had identified this risk and an action plan to address the issue was in place. The action plan set out an objective for 95% of staff requiring level three safeguarding would have received it by March This demonstrated effective delivery of their role and identification and mitigation of a safety risk. The team structure for safeguarding adults and children appeared to be over complicated and potentially confusing, containing 14.2 whole time equivalent (WTE) staff. There were 7.8 (WTE) staff in five named roles. We requested and were supplied with a number of documents including policies to demonstrate the processes involved with protecting vulnerable adults and children. We found that the arrangements were over-complicated and lacked cohesion across the policies supplied by the trust. The trust prepared and delivered an annual report of all safeguarding activity for the previous 12 months. We noted that grade three and four pressure ulcers were not mentioned as reported. It was unclear of the trust position with regard to raising safeguarding for patients who develop level three or four pressure ulcers. We did 14 Wirral Community NHS Trust Quality Report 11 November 2014

21 Are services safe? Good By safe, we mean that people are protected from abuse * and avoidable harm see a flow chart developed by Wirral CCG which indicated in what instances grade three and four pressure ulcers were to be reported, but this had only recently been developed. The trust had produced a safeguarding flow chart for staff to follow if they had a child safeguarding concern which was on display in most of the places visited. However, a review of the policy and discussion with health care professionals in different divisions indicated that the policy was not consistently followed. Awareness about the outcomes of safeguarding raised differed between individuals but staff from each division told us they had made successful referrals to safeguarding and had been involved in multiagency meetings and action had been taken to protect the child or young person from harm. Records, systems and management Staff understood the important role that good record keeping played in providing safe care. The trust had recently introduced SystmOne IT record and reporting system. This had been piloted by the health visiting service. Staff reported some initial problems but the majority of comments were positive in relation to communicating with the team leader at the base; updating records and having comprehensive information about their patients immediately available whilst in the field. In all the dental services we visited, clinical records were kept securely and could be located promptly when needed, confidential information was properly protected. All palliative care patients diagnosed as being in the last year of life had an advanced care plan in the form of a patient and carer assessment (PACA). The PACA was a comprehensive, holistic assessment which was in place to record the changing needs of patients and carers and their individual preferences. All patient records were held security and confidentially in the walk-in centres. Details of patients previous attendance at the walk in centres could be accessed quickly. Lone and remote working The trust had a policy and procedure for maintaining staff safety when they were working alone. Staff were aware of the policy and were able to describe how they ensured the team knew where everyone was located within the community. Community staff carried personal alarms, none of the staff that we spoke with raised any concerns about the arrangements for their safety at work. A GPS tracking system was planned but as yet there was no date for its implementation. Security staff were present in trust buildings in the evenings. Assessing and responding to patient risk The trusts rate for harm free care between June 2013 and June 2014 was consistently better than the average rate for all organisations where community services are provided by district nurses. Although the rate fluctuates over the 12-month period, the lowest is 94% and the highest 97%. The rate of harm free care for patients over 70 follows a similar pattern to that for all age groups. The trusts rate for new pressure ulcers also shows considerable fluctuation during the same 12-month period. The rate oscillated above and below the England average. In June 2014 the rate for the trust was 1.98% and the England average was 1.29%. The rate for falls with harm was well below the England average for the entire 12-month period, June 2013 to June For four of these months the rate was zero which would indicate no falls with harm or a lack of reporting for these months. Staff recognise and respond appropriately to changing risks within services. For example at Victoria Central walk in centre patients were initially assessed by the triage nurse to be directed for treatment by walk in centre or minor injuries unit staff. The triage nurses used defined criteria and professional judgement to assess who the patient should be seen by and how urgently they needed to be seen. Patients were referred to acute services if necessary, including accident and emergency. Staffing levels and caseload The trust are using the Safe Staffing NICE guidelines for wards and applying them to the community setting to restructure services. This initiative is mandatory for acute trusts but not for community trusts, 15 Wirral Community NHS Trust Quality Report 11 November 2014

22 Are services safe? Good By safe, we mean that people are protected from abuse * and avoidable harm demonstrating an innovative and proactive approach to assessing safe staffing levels. Where national guidance was in place for staffing levels such as dentistry and health visiting, this guidance was being followed. 14 community nursing teams had had their safe staffing levels identified. We saw an action plan produced to support this work and the trust was part way through identifying what the safe staffing numbers needed to be for the entire service. The trust had also worked head room into the formula enabling staff that had responsibility for appraisals and personal development time to complete this part of their role. The walk- in centres were the most advanced with safe staffing process. A computerised system had been implemented which gave them the ability to identify staff requirements well in advance, giving them the opportunity to ensure safe staff cover requirements were reached. The trust had a process for monitoring the number of staff required for both permanent and temporary roles. Senior management including trust board members, met weekly to review applications from divisional leads requesting resources to fill staffing gaps. The service leads were required to complete a business case for each position they needed to fill. One board member said they had not turned any requests down but had sometimes requested more information. This process had been in place for a few months. One board member said that this was time consuming and may not have needed such senior staff to be involved at such an operational level. Some senior staff mentioned that this approach did not empower them or enable them to utilise their clinical leadership skills. Staff sickness is an area that the trust had identified as a quality strategic goal and also a risk to safe patient care. The trust wants to reduce this to 4.2% for 2014/15. As at July 2014 it was 4.9% and had reduced from a previous spike of 5.3%. These figures were higher than the England average. The trust had identified that there was a lack of consistency within the services in the management of staff sickness and this was being actively addressed. It had also been identified as a risk to patients and impacted upon the trust ability to deliver quality care. Deprivation of Liberty safeguards There was limited understanding among most staff of the relevance of deprivation of liberties safeguarding (DoLS) and the application of the Mental Capacity Act to their work. It was not well understood by staff in services in clinics, the walk in centres or in the community nursing teams. However, we saw that there were good systems in place for obtaining consent to treatment. We found this conflicting level of understanding across a range of staff roles. There was a view held among some clinic staff that it was unlikely they would come into contact with patients who were living with dementia as the service would tend to see them in their own home. Yet a community manager told us that DoLS was covered as part of safeguarding training; they were aware that it applied to some patients within care homes, but not to patients being treated in their own homes where family members were assuming responsibility. This suggested that training was ineffective and the trust could not confidently assure itself that people were able to consent to their treatment. Managing anticipated risks The trust had a risk register in place. Risks were identified and mitigating actions reviewed and updated. Senior staff we spoke to were able to articulate the trusts key risk areas. For example, Pressure ulcer care has been identified as a priority for and action plans had been developed to manage the risk. However not all risks were identified and for some that were, no associated action plan was produced to reduce the risk. The trust had a staffing escalation policy which describes what actions staff are to take in relation to staffing pressures. Staff were able to tell us how and when they had used the policy to good effect Major incident awareness and training The trust had a major incident plan in place. This included specific details of the role of the unplanned care division in the event of a major incident. Some staff from the unplanned care division had taken part in a mock-up exercise of a major incident with the local acute trust in Managers had also attended a commissioner led table top exercise looking at the response to a major incident by all of the local health services. 16 Wirral Community NHS Trust Quality Report 11 November 2014

23 Are services effective? Good By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Summary of findings We assessed this domain to be good. Care was evidence based and personalised to the patient. We observed good verbal consent and documentation of consent. However, there was a lack of knowledge about the Mental Capacity Act in some areas of the trust. There were good levels of involvement from families, relatives and carers which ensured care was planned and implemented effectively. The trust were meeting the majority of the contractual Key Performance Indicators (KPI s). Where they were not meeting the monthly KPI s reasons had been identified to the commissioners. Staff had access to training opportunities, as well as appraisals. The trust was maintaining high levels of engagement with staff for both of these areas. Appraisals had been linked to the Culture of Compassionate Care 6 C s initiative. They had also been designed to help identify and support future leaders. There were many examples of good multidisciplinary working and positive working relationships were observed at handover, for example but this was not consistent across all services. A number of services were able to show us innovative practice and ongoing research in a number of areas. The trust had made links with other providers to ensure that they could meet the future needs of the patients it provided a service to. Our findings We assessed this domain to be good. Care was evidence based and personalised to the patient. We observed good verbal consent and documentation of consent. However, there was a lack of knowledge about the Mental Capacity Act in some areas of the trust. There were good levels of involvement from families, relatives and carers which ensured care was planned and implemented effectively. The trust were meeting the majority of the contractual Key Performance Indicators (KPI s). Where they were not meeting the monthly KPI s reasons had been identified to the commissioners. Staff had access to training opportunities, as well as appraisals. The trust was maintaining high levels of engagement with staff for both of these areas. Appraisals had been linked to the Culture of Compassionate Care 6 C s initiative. They had also been designed to help identify and support future leaders. There were many examples of good multidisciplinary working and positive working relationships were observed at handover, for example but this was not consistent across all services. A number of services were able to show us innovative practice and ongoing research in a number of areas. The trust had made links with other providers to ensure that they could meet the future needs of the patients it provided a service to. Planning and delivering evidence based care and treatment Staff under take comprehensive assessments which cover all health needs and develop plans for care and treatment which reflect nationally agreed guidelines and best practice. For example, in dental services conscious sedation provided by the service was delivered according to the standards set out by Royal College of Anaesthetists and the Department of Health Standing Committee Guidelines in Conscious Sedation 2007, the sexual health service followed best practice guidance on prevention of sexually transmitted infections and the Gold Standard Framework for end of life care was followed to enable people to receive coordinated care. We found that the walk in centres and minor injuries unit were not included in the local pathway for falls in older people. This meant that older people who came to the walk in centres as a result of a fall were not offered a referral to the falls prevention team. Managers told us that the onus was on GPs to read and act on the information sent to them regarding the patient s attendance and treatment at the walk in centre or minor injuries unit. This meant that patients may not have a timely referral to appropriate services to reduce their risk of falls Protocols for the treatment of minor injuries were currently being developed by a doctor recently appointed to do this. Patient information leaflets regarding knee and ankle injuries were also being developed. 17 Wirral Community NHS Trust Quality Report 11 November 2014

24 Are services effective? Good By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. All aspects of health visiting and services in support of babies and children under five years was based on best practice guidance. The infant feeding service provided literature, verbal and practical guidance in line with the UNICEF infant feeding guidelines. All care observed in relation to children under 5 s met in full the National Institute for Health and Care Excellence (NICE) Clinical Guidance (CG) 37. Service lead managers told us that they conducted regular audits of their services and we noted national audit information was collected to provide a comparison with the performance of other trusts regionally and nationally, for example in the cardiac rehabilitation clinic. Pain relief In the End of Life Care service patients told us that they had received good pain relief which was well managed with appropriate advice. Within the patient and carer assessment (PACA) each patient had their pain assessed and recorded at every visit. This assured the patient they would be pain free and gave the nurses good continuity of care. In their advisory role the specialist palliative care team supported patients to be pain free. They promoted the use of anticipatory prescribing to ensure analgesia was available when necessary. Patients were referred to the pain clinic at the hospice when pain control was unstable or staff felt that they would benefit from a second opinion. We were told that nerve blocks could be arranged for some pain cases. Counselling was available for patients in pain with contributing anxiety issues. We saw that patients were given appropriate advice about pain and pain relief in the walk-in centres. For example, a patient with a knee injury was advised on an appropriate medication to take to relieve pain and swelling; a patient with back pain was advised about exercise and the use of heat treatment and appropriate medication. Approach to monitoring quality and people's outcomes There was an approach to monitoring, auditing and benchmarking the quality of their service. There was an audit committee which oversaw the audits throughout the trust for all of the divisions. The Clinical Audit Annual Report 2013/2014 provided an overview of the audits completed and identified improvements and areas for further improvement as a result of audits. The trust was invited to participate in one national audit and took part in 36 clinical audits over 2013/2014. They also had 145 key performance indicators (KPI s) to report on that were agreed with their commissioners. We received documentation regarding KPI s and found that in the majority of cases the trust was on target to meet them on a year-to-date evaluation. However we noted in a report dated July 2014 that the trust was having some difficulty reporting on activities due a number of issues such as IT system failures, staff input problems and staff sickness absence. We spoke with stakeholders who told us they felt that there was some difficulty getting all of the data required from the trust at times. This made it difficult to plan the trajectory of future services. Patient outcomes performance The national performance target of 95%of patients in minor injuries units being discharged within four hours was being monitored by the trust and the local commissioners. Information provided by the trust showed that they had met or exceeded this target most weeks from April to August The head of the unplanned care division told us the best practice guideline was for patients to be seen by the triage nurse within 15 minutes of arrival at the walk in centre or minor injuries unit, (referred to as the triage time). However, some staff told us the triage time was 20 minutes and other staff said within 30 minutes. This lack of clarity for patients and staff meant staff were not working towards the same objective. We found that triage times were variable and patients frequently waited more than 30 minutes, sometimes up to 45 or 50 minutes. The percentage of patients on an end of life pathway at the time of death had fallen significantly over the last six months. It was reported that there were a number of factors which were out of the organisation s control in relation to this target and the performance had been queried by the commissioners. The trust integrated performance report in April 2014 stated that 38% of patients on the service list were on an end of life pathway at their time of death against target of 90% and was rated red in the report. 18 Wirral Community NHS Trust Quality Report 11 November 2014

25 Are services effective? Good By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. Competent staff The trust offered job role specific and mandatory/ essential training to staff. This was part of the process to ensure that staff were competent in delivering their roles. We noted that within the quality strategic goals set for 2014/15, 95% of staff were to have received mandatory training. The trust gave us documents to demonstrate they had achieved 96% of staff attending this training in However, further analysis showed that the trust had counted people who had attended more than once, making the percentage for some services over 100%. This meant that some staff may not have attended at all and raised concerns about data management. Within the trusts Quality Account 96% of staff had an annual appraisal in 2013/14, the highest of any community trust. One trust board member told us that the appraisals had been linked to the 6 C s (care, compassion, competence, communication, courage and commitment). The trust was seeking feedback from staff regarding the appraisal process to see if its introduction had been effective. We saw within an action plan that this process was completed in April 2013, but continuous monitoring would continue. The trust had a system in place to ensure healthcare workers professional registration was up to date. The trust had a contingency for staff failing to register but they had never needed to utilise this at the time of the inspection. The specialist end of life care team had all received advanced communication skills training and received clinical supervision sessions and support and advice from the oncology service at Clatterbridge Cancer Centre. Since April 2014 the team had been adopted by Macmillan and had benefitted from professional development and the provision of on-going education and advice. The health visitors were highly regarded by their peers in other organisations and had presented papers about the Wirral Community Trusts service at international forums such as the 25th International Networking for Healthcare Education 2014 conference at Cambridge University. We noted when we accompanied them on visits, that community nursing teams were well functioning and highly skilled. Community Matrons were competent to prescribe medications and met regularly for professional peer support and development. Multidisciplinary working and co-ordination of care pathways There was effective collaboration and communication amongst all members of the multidisciplinary team (MDT) to support the planning and delivery of patient centred care in the dental services. A good example of this was collaboration in relation to patients with head and neck cancer. Staff liaised with various specialists and the patient s own dentist to ensure that everyone was aware of the patients needs. We also found good examples of MDT working in the end of life care service and in the community nursing teams, for example, close work with specialist nurses, GPs and social workers to aid effective care delivery and smooth discharge. There was effective communication between midwives; health visitors and social workers. Health visitors had one hour protected time with the GP s meeting each week. There was little evidence of integrated working between primary care and the walk in centres / minor injuries unit. This had led to inappropriate referrals by GPs to the walk in centres. Examples of this were a patient sent to the walk in centre for ear syringing because the GP s own equipment for this was not working. The lack of integrated working was also partly responsible for patients returning to walk in centres for follow up of their treatment, such as redressing of wounds or removal of sutures, which is not an effective use of the trust s resources. 19 Wirral Community NHS Trust Quality Report 11 November 2014

26 Good Are services caring? By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Summary of findings We considered this domain to be good. We saw many exemplary instances of caring, respectful and compassionate treatment. Patients were clearly involved in the decisions being made about their care and we saw many examples of self-management. Patients who were vulnerable were treated with in a sensitive manner and emotional support was offered. Feedback from patients, relatives and families was overwhelmingly positive. It was evident that staff knew their patients very well and that service delivery had been tailored to suit individualised needs. Assessments were holistic and were saw many child friendly services. Our findings Compassionate care Patients and relatives we spoke to throughout our inspection spoke highly of the staff and told us they were caring, sympathetic and understanding. In dental services patients told us the staff were very good putting them at ease before and during treatment. We observed real compassion and respect for dignity across all of the services we visited. There are many examples of this in clinics, patient s own homes and in the walk in centres. All staff we observed were eager to be helpful to people. In a number of services managers told us that staff worked over their contracted hours to make sure patients got what they needed, including in the equipment store. Most staff that we met demonstrated a real pleasure at their work and seemed happy to be at work. A happy working atmosphere was generated by the majority of staff, I love my Job ; I m proud of the service. Dignity and respect Patients and families told us they were treated with dignity and shown respect. Relatives told us that the staff were very professional and sensitive. We observed nurses responding in a helpful, practical way to patients with sensitive issues. Staff knocked before entering closed treatment rooms. Patients were covered appropriately during their treatment and their privacy was respected at all times during treatments. We observed staff speaking respectfully to all patients, including those with disabilities. Patients could request a chaperone in the walk-in centre if they wanted someone with them during assessment and treatment. Patient understanding and involvement Most patients and families we spoke with told us that staff were very good at talking them through their treatment and providing information so that they felt involved in their care. We saw that throughout the trust there were information leaflets available on various conditions, accessing services and the types of support available. Staff confirmed that they could access interpreter services for patients. Patients treated in their own homes had a copy of their care and treatment plan and were made aware of what was in it. Those who we spoke with told us they felt part of their care and were pleased with their treatment. In the walk-in centres, patients were asked if they understood and were happy with the advice and treatment given. This was noted in the clinical records. A patient told us, The doctor explained everything. I know what to look out for. Emotional support During our visit we saw many examples of staff offering emotional support to patients and families to help them cope with their care and treatment. Staff were clear on the importance of emotional support when delivering care. We observed positive interactions between staff and patients, In the end of life care service, all patients were offered spiritual and religious support appropriate to their needs and preferences. We saw this documented in patient records. We observed in clinics and in community nursing services, empathetic responses made to sad news and the difficulties physical illness can put on the individual patient emotionally and their family. 20 Wirral Community NHS Trust Quality Report 11 November 2014

27 Good Are services caring? By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. Promotion of self-care We saw patients independence was respected and actively encouraged We observed staff talking with patients and involving them in planning their care A wide range of information leaflets and booklets about the different treatment of health conditions and after care had been produced by the trust. The trusts offered advice on self-care and seeking advice from a pharmacist for minor illnesses and injuries. Written information was backed-up with verbal advice, we saw examples of this in the walk-in centre and dental services. 21 Wirral Community NHS Trust Quality Report 11 November 2014

28 Are services responsive to people s needs? Good By responsive, we mean that services are organised so that they meet people s needs. Summary of findings We considered this domain to be good, with some aspects requiring improvement. Many of the services we inspected were able to offer flexibility around appointment systems and we had many examples of where service delivery had been changed and adapted in response to patient feedback. We saw good use of interpretation services and creative use of online services in the walk in centres to address communication barriers. Patients using the walk in centre service were usually treated and discharged within four hours, often within two hours. However, patients frequently waited too long to be seen by the triage nurse for an initial assessment of their clinical needs. Because of a lack of integrated working with primary medical and social services, some patients were not always referred for further support as required from the walk in centre. Staff were able to demonstrate a good awareness of individual patients needs and were able to deliver care along with other services in order to support patients, such as direct referral systems. The trust had an equality and diversity strategy action plan in place and was working through that to completion. They had a dedicated equality and diversity manager to oversee and drive the action plan forward. The trust had a proactive and personalised approach to responding to complaints comments and compliments. The trust took all patient observations and remarks seriously and endeavoured to resolve them. They then took the opportunity to learn from these to ensure they continually offered improved services. At board level patient experience was regularly reviewed. Our findings Service planning and delivery to meet the needs of different people They were currently working through their Equality and Diversity (ED) Strategy action plan. This would improve access to the services from nine protected groups. The trust was publicising this strategy via publications available to stakeholders, staff and the public. For example, they had produced a leaflet for all staff and published an article in a newsletter. The trust had a number of milestones on the strategy which had not been completed by the given deadline. For example, identification of training needs was overdue. It was not clear who the Director level lead for ED was. The trust had recently appointed a manager to oversee the ED strategy and the trust felt this was a positive step forward. The Wirral has a relatively high older population and a relatively low proportion of people in their twenties and thirties compared to England and Wales as a whole. 3.0% of the population in Wirral belong to non-white minorities. Staff across all of the services told us that data about patients age, ethnicity and other protected characteristics was collected when they accessed services. Staff were unable to tell us what this data was used for and said they were not asked by the trust to report on it. It was not clear if this data was being used to plan and develop services. The trust had a contract with a multicultural centre at Birkenhead for interpreter services. Staff told us that most patients could speak or understand sufficient English without the need for translation or interpretation. A telephone translation service was available for staff to use to communicate with patients who did not have English as their first language. Access to the right care at the right time People were able to access the right care at the right time There were a number of examples across the services we visited of flexible provision to enable patients to attend at times and place which fitted in with their lives. Patients could choose between different locations for some clinics to reduce travel. For example, the nurse led heart failure clinic and the equipment 22 Wirral Community NHS Trust Quality Report 11 November 2014

29 Are services responsive to people s needs? Good By responsive, we mean that services are organised so that they meet people s needs. store, scheduled extra services or staff shifts if demand rose. The heart failure clinic provided home visits by the specialist nurse if patients were unable to attend at one of the three locations. The walk in centres provided care and treatment for patients close to their homes. This was helpful for patients who would have to travel further to use the accident and emergency department if the walk in centre or minor injuries unit was not available. Waiting times for services were good on the whole, but there were some exceptions. Tissue viability nurses reported to us that their service had no waiting list and that people were generally seen within a week. The equipment stores monitoring of response routes showed a 100% response rate for emergency equipment calls (within 24 hours) and a 91% response for all other calls (within 7 days). However the Podiatry services staff told us that waiting times were poor especially for follow up appointments which could be five to six months. Podiatrists told us the target was to see routine cases within four weeks. We spoke with a patient who said they waited eight weeks for their appointment. Parents described the health visiting service as responsive. One parent said the service met my needs I was visited every week for the first seven weeks. Another told us handy being open five days a week because there is good availability. Information provided by the trust showed that the total time from arrival to discharge for most patients attending the walk in centres and the minor injuries unit was less than two hours. 56% of patients attending the minor injuries unit from April to August 2014 waited more than 15 minutes from arrival to seeing the triage nurse. We asked for the same information relating to patients attending the walk in centres, but this was not provided. We observed that some patients in the walk in centres were waiting in excess of 30 minutes to see the triage nurse. Records we looked at confirmed this. Triage is used to make a quick assessment of patients presenting problems to prioritise those in most urgent need. If patients are waiting to see the triage nurse, there is a risk of delay in urgently needed treatment for patients most in need. Discharge, referral and transition arrangements Arrangements for discharge or transfer between services were in place and generally met the patient s needs and happened in a timely manner. Patients and families told us that referrals to other services were made quickly and they were kept well informed. Communication between the trust and local acute hospitals were in place and were effective to ensure continuity of care for patients. For example, Community Matrons were involved with ward rounds in acute sector hospitals locally to contribute to the assessment of patients who were ready for discharge to community services. There were effective arrangements in place where patients needed referral to acute health services. For example, appointments for the fracture clinic were usually made before the patient left the walk in centre or minor injuries unit. Patients were transferred to the surgical or medical assessment units of the local acute trust and transport was arranged if needed. The trust is signed up to the Joint Strategy of Young People with Disabilities and Complex Needs from Children to Adult Services. Community Matrons told us they did not feel equipped to respond, as they were expected to do, to the needs of young people transferring from children s services. They told us children and young people, particularly those with learning disabilities, have been transferred from children s services, without the correct support in place from other adult services. Responding to and learning from complaints and concerns The trust listened to and acted on complaints and comments. For the period 01 December June 2014 the trust received 26 complaints, 354 concerns and 2479 compliments. When complaints and comments were received these were investigated and the complainant received feedback. If the complaint or comment required a change in practice the learning was shared with the staff group. We saw that a monthly summary was produced by the patient experience team which identified the types of complaints and concerns and for what service they occurred. We noted that the largest proportion of complaints were for unplanned care. 23 Wirral Community NHS Trust Quality Report 11 November 2014

30 Are services responsive to people s needs? Good By responsive, we mean that services are organised so that they meet people s needs. The trust had a Concerns and Complaints Policy which had been approved by the quality and governance committee. The trust policy was to respond to all complaints and concerns within three working days. We requested information from the trust regarding resolution timescales. The trust policy is to agree this with the complainant, and in the majority of cases 25 working days was agreed for resolution. For , 40 complaints were investigated of which half were resolved before the agreed resolution time. We noted that some complaints took much longer than this for resolution. We noted that within the Concerns and Complaints policy patients were given advice regarding who else they could complain to, but this was not presented consistently. This was not helpful to either staff or complainants wanting further information and support to complain. The Chief Executive told us he had telephoned complainants in the past and the Director of Nursing has visited complainants in their own homes to help the resolution process. This demonstrates a commitment to resolution and learning from the trust. During our visits to locations across the trust, we noted that information about how to raise concerns or complaints were not prominently displayed or provided in alternative formats. We noted that patient experience cards were very visible in most clinics and patients did use them. Staff told us the trust set targets for services to get returns of patient experience questionnaire forms. We did not see these questionnaires provided in any alternative formats in adult services and this could result in some groups of patient s being systemically excluded. We heard a number of good descriptions by staff of local handling of verbal concerns. The trust s website had information about how patients could raise concerns, complain or make comments about their care and treatment. Patients could make comments online through the trust s website. 24 Wirral Community NHS Trust Quality Report 11 November 2014

31 Are services well-led? Good By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. Summary of findings Instructions We assessed this domain as good with some aspects requiring improvement. Staff had confidence in the trust s Chief Executive and Director of Nursing and Quality. Staff were aware of the vision and values of the trust and were able to articulate them. They also had quality goals and staff were able to demonstrate that they knew what the goals were. Staff appraisal were linked to the trust vision and values and nearly all the staff we spoke to confirmed they had had an appraisal in the last 12 months. Front line staff spoke highly of local line managers and said they felt supported and had good access the training. Morale was generally good and this was reflected in the positive attitude we found from the staff we met during our inspection. However, local line managers did not feel sufficiently supported and divisional/middle managers were not visible enough. Staff reported a blockage in communication and said they did not always feel listened to by that level. Not all staff groups could articulate from where or who was their professional lead at board level. There was no overview or leadership of all the services the trust provided for children. This meant that services were working in silos and limited opportunities for cross-team working. Our inspection team were impressed with the community dental service and acknowledge some of the exemplary work being undertaken, however, the staff working in the service expressed that they did not feel recognised by the board and would like more clinical engagement around service design, development and commissioning. Risks were identified and mitigating actions reviewed and updated. However not all risks were identified and for some that were, no associated action plan was produced to reduce the risk. IT and data management presented a potential elevated risk to the trust. We found a number of areas where there were inconsistencies in data reported by the trust and actual performance. Lack of access to IT in some parts of the trust meant there were gaps in data and the incompatibility of some software programs across the organisation, limited the trusts ability to ensure robust management reporting was available. Our findings Instructions Vision and strategy for this service Staff throughout the organisation were able to articulate the trust s vision and strategy. We noted that the vision and strategy was published and available to the trust staff, public and stakeholders. The quality goals were all measurable with action plans associated with them such as the safer staffing quality goal which we saw that the trust was on target with. We also saw that the innovation and research action plan which was associated with the quality goal was establishing a funding stream for innovation and research. This meant that the quality goals were planned for and implemented with the associated action plan. The action plans were dated and had staff identified as responsible for the completion within the timescales. They were all attached to a committee or group for continuous monitoring. The trust had identified they lack the capacity to identify and pursue new business opportunities and we were made aware of examples of this. The trust had agreed to deliver an additional service requested by commissioners, which was supporting patients and care staff within care and nursing homes. We were told that additional funding was not agreed for this therefore no additional staff were employed to deliver this service. This put extra pressure on existing staff. The trust have produced action plans with achievements required such as identifying future leaders within the trust and making strategic partnerships to strengthen their business skills. Dental staff told us they were not aware of strategic plans for the organisation. Staff were anxious that the service was going out to tender. They were uncertain of the future for all of the clinics and felt there was a lack of communication with the trust at times. There were plans to reduce the domiciliary care visiting service over the next three years with a vision to stopping it 25 Wirral Community NHS Trust Quality Report 11 November 2014

32 Are services well-led? Good By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. altogether. Staff felt it was a vital service to the local community and there would be a gap in provision of care to those who are housebound. Staff felt they had not had opportunity to discuss their concerns with trust leaders or the commissioners. At the time of our inspection a tendering process was underway in the Wirral for all community services for children and young adults aged 0-19 years. This would include school nurses. The trust had submitted a bid for this service and were awaiting the outcome. The trust were keen to secure this service and had clear strategies in place if their bid was successful. Individual specialist teams used by children, young people and families had strategies and vision in relation to their area of expertise and within their divisions. However the trust did not have a single point of contact with a total overview of the quality of care and future visions for all the services used by children, young people and families throughout the trust. Governance, risk management and quality measurement The trust had a system of governance in place. The governance structure of groups and committees fed into the trust board. The Board Assurance Framework was not being fully utilised to identify key risks and set objectives to achieve quality targets. The individual risks on the board assurance framework were not always clearly articulated with clear, measurable objectives. This means that it is difficult for the trust to accurately measure whether a risk is reducing. We identified three areas where the data may not be relied upon: incident reporting categorisation, safeguarding training numbers, and mandatory training numbers. The trust had reported that their internal IT systems did not always support them to report. This had been added to the board assurance framework document and an associated action plan was in place. Where actions were required to reduce the risk, associated action plans were usually in place. However, where no gaps had been identified, therefore generating no action plan, it was not clear how the trust would reduce an overall risk rating from its current to its target risk rate. There was an issue with the delayed roll-out of mobile devices for community based staff. These devices would enable staff to record information whilst working out in the community, rather than having to return to base. This would have clear benefits for staff. All of the senior members of the trust board were aware of the delay, but the reasons cited by managers we spoke to for the delay were different. Additionally, affected staff had not been told about the delay. This demonstrated for this particular issue a number of failings on the part of the trust to manage the implementation of this system. The trust had failed to re- recruit a project manager to keep the plan on target. They had failed to effectively communicate the delays to operational staff, and there was a cost implication if training had to be undertaken a second time. However the trust does recognise that this is a risk and it has been identified and is present on their trust-wide risk register. The trust effectively used DATIX (a data management tool) to identify risks to the service. The highest rated risks which have strategic or reputational risk are collated and placed on the board assurance framework document. However, as access to the system is not universal across the trust then there are gaps in the collection and dissemination of information from the system. A May 2014 review of the service undertaken by Wirral Clinical Commissioning Group provided an overview of the specialist palliative care team commissioned by Wirral CCG from Wirral Community NHS Trust. The focus of the review was on its integration between the three settings of the community, hospital and hospice and it also looked at the activity of the PAIL jointly provided by Wirral Community NHS Trust and Wirral Hospice St John s. The recommendations following this included improved communication and further integrated working. Leadership Staff told us that the Chief Executive was a good leader and was visible within the trust. It was clear that staff had a rapport with him and we only heard positive comments about his abilities. Staff said he was well respected and led by example. The board members engaged in monthly visits to various services. These were opportunities to talk to staff and patients and share news and information 26 Wirral Community NHS Trust Quality Report 11 November 2014

33 Are services well-led? Good By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. about the trust. The directors all had questionnaires to complete, which covered areas such as patient safety, infection control and leadership. Board members we spoke to said they enjoyed these visits which sometimes took place out of hours. They told us staff felt comfortable to share their concerns with them. A summary of the visits were produced quarterly and presented to the trust board. This allowed the board to see first-hand what staff were dealing with and whether messages they communicated were being shared and acted on. Middle management arrangements appeared to be overly complicated, with staff at an operational level finding this confusing. The trust was in the early stages of addressing this with the restructure. Additionally, non-nursing clinical staff could not articulate who on the board was their professional lead. Health professionals and staff from different divisions which provided a service to children, young people and families were unable to articulate which senior member of staff had an overall view of or responsibility for ensuring the services provided where consistent in their approach Culture across the provider We found highly motivated, committed and caring staff working in this service. Staff told us that in general the trust was a good place to work and they felt supported to do their jobs well. They said there was a positive culture. Staff told us about the genuine open door policy of the senior management and executives. Staff in the Health Visiting teams told us there is a forward thinking culture of development and good leadership progression. One member of staff told us the service has been developed with cohesion and provides positive outcomes and another said we have a good supportive relationship with the board. Staff were aware of the Whistleblowing policy known as speaking out safely they were encouraged by management to use it and they felt confident that staff would if necessary. Staff felt that the Lead Nurse and Clinical Director would act in a prompt manner if they raised any concerns to them. Public and staff engagement The trust regularly seeks to understand patient s experiences when using their services. Trust board members told us they regularly heard patient stories at board meetings. The patient experience story presented in May 2014 resulted in the production of an action plan to improve the service. The trust had a patient experience team who undertook innovative practice to ensure they captured patients opinions of the service. In addition to leaflets and posters requesting feedback the trust also took adverts in the local press to get feedback from the public. The trust undertook feedback called the Friends and Family Test. For the period of April March 2014 the trust returned results that 97% of patients agreed they would recommend the service they have received to friends and family. The trust proactively took steps to engage with staff through a staff council. The staff council had representation at committee level which fed into the board, although it was felt that more representation from community nurses and health visitors would enhance it further. A staff survey was undertaken in % of staff took part in the survey and the trust scored better than the England average for 19 out of 28 measures. They were worse than average for 4 out of 28 measures. The trust had as one of its quality goals for 2014/15 the Friends and Family Test for staff. This will give the trust, with one measure, the staff impression of the service overall. Innovation, improvement and sustainability The trust promoted learning throughout the organisation. It placed high importance on staff continual development and had identified mandatory training and appraisals as a quality goal for 2014/15. We noted in the board assurance framework two risks had been identified which an HR action plan was associated with around management and succession planning. The trust wanted to identify and develop its own leadership and proposed to do this by implementing a leadership development academy. We note in the HR action plan the trusts commitment to support innovation in teams and staff. Which would help to keep the staff engaged and ultimately improve patient outcomes. The trust placed great importance on innovation. During our inspection we were made aware of a number of research programmes in place. We were told about research to support patients improve their inhaler 27 Wirral Community NHS Trust Quality Report 11 November 2014

34 Are services well-led? Good By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture. technique. Another example was the services provided by the infant feeding Team. This included engagement with local shop keepers and cafes and developing infant feeding champions from different communities, encouraging the development of support groups and one to one mentorship. This team had also developed a Breast Safe App which had now been taken up by 25 other NHS trusts. The trust was also part way through a process to enable staff to access funds for innovation regarding patient safety. A model of integrated care with local community, social and primary medical services had been developed by the trust and agreed with the local commissioners to sustain services. There were plans to put this into action. Managers told us about plans for the minor injuries unit to become nurse led. This was in response to the difficulty in recruiting doctors for this service. 28 Wirral Community NHS Trust Quality Report 11 November 2014

35 Appendix 2. Care Quality Commission (CQC) Comprehensive Inspection Quality Report Action Plan Action Plan KEY (Change status) 1 Recommendation agreed but not yet actioned 2 Action in progress 3 Recommendation fully implemented 4 Recommendation never actioned (please state reasons) 5 Other (please provide supporting information Action plan lead Director of Quality and Nursing Actions Which MUST Be Taken To Improve Action by date Person responsible Comments/action status Change stage (see Key) The trust must review systems to report incidents across the community teams. The frequency of use of the incident reporting procedure varied and staff access to the electronic reporting system was inconsistent across the services. The trust must review its policies and procedures for safeguarding to ensure they 31/12/214 Head of Quality and Nursing 31/01/2015 Head of Quality and Nursing Review incident reporting policy Updated policy used as a vehicle to raise the profile of incident reporting and address the inconsistencies identified in the report Review access to incident reporting system across teams and improve or remove any barriers to access Focus on incident reporting at Directors, team briefing and in staff bulletin focus on Develop a safeguarding Strategy Review all safeguarding policies for consistency and clarity

36 are fit for purpose and provides staff with clear information to support them when reporting issues. Different record keeping systems were in place across services while a new IT system was being rolled out. There was some time consuming duplication of records. Together these may present emerging risk of under reporting of some types of incidents and trends being missed. This must be addressed by the trust. The impact of the Mental Capacity Act 2005 code of practice and Deprivation of Liberty safeguards was not well understood by most staff. This has an impact of staff ability to support patient s giving informed consent to treatment. The training that was provided should be reviewed. 31/12/214 Head of IT Head of Quality and Nursing 31/03/2015 Head of Quality and Nursing Continue to monitor the implementation of the safeguarding children and adult action plans in relation to updating policy and procedures Review incident reporting process for safeguarding incidents Introduce safeguarding walkabouts and use them to test out staffs understanding of safeguarding policies and processes Review and risk assess current systems for any emerging risks and develop a mitigation plan Review current record keeping process and ensure any duplication is minimised or stopped Ensure the newly revised Mental Capacity and Best Interests form is available on Staff Zone and all staff know about it and can access it Revise MCA training for staff based on the new guidance Access CCG training on the awareness of MCA / DoLS Focus on MCA at Directors briefing, team briefings, in staff bulletin and safeguarding walkarounds

37 There was no single reference point for all of the different services provided for children by the trust. The trust should review the overall management arrangements for services for children and families to ensure there is a shared vision and that opportunities for joined up working are acted upon. Triage assessments were not always completed as quickly and efficiently as possible. Patients were often waiting in excess of 30 minutes to be seen by the triage nurse. The trust must ensure that good practice guidelines for triage assessment are fully implemented and monitored to ensure patients are seen as quickly as possible for initial assessment. Actions Which SHOULD Be Taken To Improve 30/03/15 Director of Operations / Director of Quality and Nursing As part of the divisional restructure review the overall management arrangements for services for children and families to ensure there is a shared vision and that opportunities for joined up working are acted upon 31/03/2015 Nurse Consultant Review current performance against good practice guidelines for triage assessment Identify model required to fully implement the guidelines Implement agreed model and monitored to ensure patients are seen within agreed timeframe for initial assessment. Action by date Person responsible Comments/action status Change stage (see Key) The effectiveness of transition arrangements for children and young people to adult services should be reviewed as community nursing staff had no confidence in current arrangements, including liaison with mental health 30/03/15 Head of Quality and Nursing and Operational Nurse Manager As part of the divisional restructure review the overall management arrangements for services for children and families to ensure there is a shared vision and that opportunities for joined up working are acted upon Join task and finish group to strengthen

38 teams. The trust should ensure that community nursing teams are able to monitor and articulate outcomes for patients. Staff were not clear about how the trust was defining the difference between a complaint and a concern. This affected the way issues raised by patients were dealt with locally and could result in trends being missed by the trust. The trust should review the clarity of its message about complaints. The trust should address the issue of no facilities being available in clinic waiting areas to occupy children. Patients told us this added to the strain of attending for their children s and their own appointments. The trust should make sure that infection control measures are effective, comprehensive and consistently applied in keeping with accurate infection control risk assessments or audits in the areas used by children, young people and their families and that all clinics have processes in 30/03/15 Director of Operations / Director of Quality and Nursing/Director of Finance and Performance 30/03/15 Head of Quality and Nursing 30/03/2016 Director of Operations / Head of Estates 31/12/14 Head of Infection Prevention and Control the transition to adult services for young people needing continuing care Review KPIs and quality goals with CCG as part of contract negotiation for 2015/16 Ensure all staff are aware of KPI s and quality goals through a communication plan Work with partners including Healthwatch to develop a communication plan to raise awareness of complaints and concerns with both patients and staff as part of 2015/16 quality strategy Review and improve facilities in all waiting areas for children as part of estates strategy Review of infection prevention and control risk assessments to include hand washing advise for children, young people and families Poster campaign on hand washing in all areas used by children, young people and families

39 place that encourage children, young people and families to clean their hands. The trust should continue reviewing the robustness of the plans in place for safeguarding children and ensure that plans cover all areas of disparity between interfacing services; ensure that all staff receive the appropriate training and updates in relation to safeguarding so that staff are clear about what needs to be referred to safeguarding, fully understand and the systems in place and routinely inform staff about the outcomes of their referrals. Patients should be prompted to wash their hands or use hand gel on entering the walk in centres. Hand gel was available but there were no posters or other information for patients about when and how the gel should be used. The walk in centres and minor injuries unit should be included in the local pathway for falls in older people. Older people who came to the walk in centres as a result of a fall were not offered a referral to the falls prevention team. 30/03/15 Head of Quality and Nursing 31/12/14 Head of Infection Prevention and Control Continue to monitor the implementation of the safeguarding children and adult action plans Review of safeguarding training for all staff Regular updates on staff zone in relation to safeguarding news Review incident reporting process for safeguarding incidents including feedback mechanisms Poster campaign on hand washing in entrances to Walk In Centres 30/03/15 Nurse Consultant Review falls pathway to include walk in centres and minor injuries unit Audit effectiveness of revised pathway

40 Actions Which COULD Be Taken To Improve Action by date Person responsible Comments/action status Change stage (see Key) Uptake of staff training specific to staff roles and patient needs. Bespoke training sessions were not well attended because staff reported having to do this in their own time. The walk in centre waiting areas could be improved to make adequate provision for children. Privacy for patients at reception desks in the walk in centres could be improved. There was no staff role identified within the walk-in centre service to promote good practice when caring for people living with dementia, such as a link nurse. This could be improved Information for patients about how to make complaints should be more visible for patients in the clinic areas so they are aware of the trust s complaints process. The trust could develop more formal communication 30/03/15 Nurse Consultant Review of service specific training in Walk in Centres and availability for staff 30/03/15 Nurse Consultant Review facilities for children in walk in centre waiting areas and develop an improvement plan 30/03/15 Nurse Consultant Review privacy in waiting areas in walk in centre waiting areas and develop an improvement plan 30/03/15 Nurse Consultant Review and introduction of link role or something similar in Walk in Centres 30/03/15 Head of Quality and Nursing 30/03/15 Director of Operations / Communications plan on making complaints to be developed Poster campaign on how to make complaints in all clinic areas Review senior clinical leadership links with dental service and provide

41 channels with the dental service leads to ensure they feel engaged in service development, design and commissioning. Although the trust is introducing SystmOne to the end of life team, record keeping and the review process should be improved to ensure that care and treatment is effectively documented. The working relationships with the hospice were on occasions disjointed and could be improved.. Actions added following Quality Summit Director of Quality and Nursing Medical Director 30/03/15 Divisional Manager/ Community Nursing Operational Manager 30/03/15 Director of Operations Divisional Manager/ Community Nursing Operational Manager Action by date Person responsible opportunities for staff involvement in service development, design and commissioning Review and improve record keeping in End of Life Care team Implement relevant findings from the CCG review of Specialist Palliative Care on Wirral to improve communication Comments/action status Change stage (see Key) Ensure all staff are aware of their clinical or professional lines of accountability and leadership Internal audit of staffs awareness of professional lines of accountability and leadership Strengthen leadership skills in staff at band 7 and 8 by developing a leadership framework in the organisation 30/09/2015 Director of Quality and Nursing Director of Human Resources and OD 30/03/2015 professional lines of accountability and leadership 30/03/2015 Director of Human Resources and OD As part of divisional restructure ensure all staff are aware of their clinical or professional lines of accountability and leadership As part of internal audit programme for 2014/15 Review leadership support offered to those staff at band 7 and 8

42

43 Monthly Complaints and Concerns Report ( 01 October 31 October 2014) Agenda Item: 11 Reference: WCT14/ Meeting Name: Lead Director: Job Title: Trust Board Meeting Date: 3 December 2014 Sandra Christie Director of Quality and Nursing Link to Business Plan: Has an Equality Impact Assessment (EQIA) been undertaken & attached? Has the Public & Stakeholders been consulted? Meets NHSLA/CQC requirements. Provision of high quality services Yes No N/A Yes No N/A To Approve To Note To Assure Financial Implications: E.g. What is the Impact on the Trust? Does it provide Value for Money? All costs should be clearly explained in the section below. None identified Overall Cost / Pressure: Overall Income: Additional Funding Funding Already Required: Ring Fenced: Identified Risks: None identified Assurance to Board: The monthly Complaints and Concerns Report provides assurance to the trust board of the delivery of safe, effective and quality services across the organisation. Publish on Website: Yes No Private Business: Yes No Report History Submitted to Date Brief Summary of Outcome Regular reports submitted each month.

44 Wirral Community NHS Trust Monthly Complaints and Concerns Report (0l October 31 October 2014) Purpose 1. The purpose of the monthly Complaints and Concerns Report is to provide assurance to the trust board of the delivery of safe, effective, quality services during the reporting periods 01 October to 31 October Executive Summary 2. Wirral Community NHS Trust Board recognises that quality is an integral part of their business strategy and for the trust to be most effective; quality must become the driving force of the organisation s culture. 3. We are committed to ensuring that quality forms an integral part of its philosophy, practices and business plans and that responsibility for driving this is accepted at all levels of the organisation. 4. The organisation s Quality Strategy represents Wirral Community NHS Trust s philosophy towards quality improvement and is built on these principles. Included in the Quality Strategy are four quality themes: Our Patients and Communities Our Services Our People Our Sustainability 5. This report provides the trust board with assurance regarding trends and theme analysis relating to quality and patient experience and demonstrates how the organisation is performing in relation to the quality outcome goals relating to: Our Patients and Communities Our Service 6. The reporting period for this monthly Complaints and Concerns Report is 01 October to 31 October Board Action 7. Wirral Community NHS Trust Board is asked to be assured of the delivery of safe, effective, quality services across the organisation for the reporting period 01 October 31 October Sandra Christie Director of Quality and Nursing Contributors: Sylvia Reynolds Complaints and Claims Manager

45 Number of Formal Complaints Registered with the Complaints Team Complaints, concerns and compliments summary: 1. The graph bellows show the number of complaints, concerns and compliment received in month order. Twelve months of data are shown to enable the run rate to be better understood:

46 Complaints and concerns in month detail October 2014: Complaints: 2. Complaints should be acknowledged within 3 working days. 100% of complaints received in October 2014/15 were acknowledged within 3 working days of receipt. Where possible the complaint is discussed with the complainant by telephone, this helps to clarify the issues, establish the complainant s expected outcome and agree a time scale for response. 3. During October 2014 nine complaints were received. 4. The graphs below show a break down in complaints received by division and subject matter for October 2014.

47 4. All the complaints received in October 2014 are now being investigated and will be reported next month. 5. The 11 complaints received in September 2014 were being investigated at the time of compiling the report for the November board meeting. These investigations have now been concluded. Of the 11 complaints received in September 2014, 5 were upheld wholly or partially. A summary of these complaints can be found in appendix The graphs below show the number and reasons for delayed responses by month and division.

48 7. Patients or relatives raising a complaint are offered the opportunity of sharing their story with the trust board. Number of Concerns Registered with the Patient Experience Service 8. For the reporting period (01-31 October 2014) 53 concerns were received. 9. Concerns should be acknowledged within 3 working days. 100% of concerns received in October 2014/15 were acknowledged within 3 working days of receipt. Where possible the concern is discussed with the service user by telephone, this helps to clarify the issues, establish the service user s expected outcome and agree a timescale for response. 10. The graphs below show a breakdown in the number of concerns received in comparison with the number of contacts made to the Patient Experience Service and the number of concerns received by division and subject matter for October 2014.

49 11. The learning and actions resulting from concerns are discussed at the divisional governance groups and monitored at the Quality, Patient Experience and Risk Group. 12. Patients or relatives raising a concern are offered the opportunity of sharing their story with the trust board. Number of Compliments Registered with the Patient Experience Service 13. The graphs below show the overall number of compliments received and the number of compliments received by division.

50 14. Parliamentary and Health Service Ombudsman Trusts are expected to resolve complaints locally were possible; however, if a complainant remains dissatisfied with the trust s response they have the right to refer the matter to the Parliament and Health Service Ombudsman (PHSO). No communications were received from the PHSO in October Correspondence from Members of Parliament Correspondence was received by the Trust in October 2014 from a Member of Parliament. Angela Eagle MP contacted the trust on behalf of a constituent about attendance at a clinic when no appointment was booked. Investigation appears to identify that the patient did not attend on the day the appointment was booked. Sandra Christie Director of Quality and Nursing Contributors: Sylvia Reynolds Complaints and Claims Manager

51 Appendix 1 Details of complaints upheld, wholly or partially, in the period September Therapies (Podiatry) Length of time between appointments. Patient s carer dissatisfied with the increased length of time between podiatry home visit appointments for her mother. Learning: Significant change to service specification as set by commissioners led to increased waiting times and less flexibility in the way clinics are provided. Action: Commissioners advised of impact of agreed changes. In agreement with commissioners, waiting times being reduced. 621 Therapies (Podiatry) Length of time between appointments. Patient dissatisfied with the length of time between podiatry appointments and their chemotherapy treatment is not being taken into account. Learning: Significant change to service specification as set by commissioners led to increased waiting times and less flexibility in the way clinics are provided. Action: Commissioners advised of impact of agreed changes. In agreement with commissioners, waiting times being reduced. 623 Unplanned Care (Walk in Centre, APH) Aspects of clinical treatment Misdiagnosis of a malignant skin lesion. Learning: Carcinoma of the skin is increasing in its incidence therefore should have been considered as an alternative differential diagnosis, and the history of the presenting illness explored more fully. Action: Matter discussed at teams clinical supervision session to promote recognition of these lesions and to fully explore how to manage patients when presenting at Walk in Centre. The learning from the clinical supervision session to be disseminated to all Walk in Centre staff including a test so that staff can self-assess their competence in this area. 667 Unplanned Care (Walk in Centre, VCH) Attitude Patient was unhappy with the manner in which the practitioner carried out the consultation when presenting with a condition they found embarrassing. Learning: Failure to recognise the patient s anxiety and embarrassment, therefore, resulting in poor communication with the patient. Action: Discussion with practitioner regarding their communication skills when dealing with patients who are showing signs of anxiety and upset when presenting with a condition they find embarrassing.

52 678 Unplanned Care (Walk in Centre, VCH) Attitude Parent of patient not happy with comments made relating to patient s behaviour. Learning: Recognition that comments made about patient s behaviour was unprofessional. Action: Practitioner undergone a period of clinical supervision by a senior member of staff and discussions have taken place with regard to their communication skills when conversing with upset children and their parents.

53 Update Report on the Implementation of the Action Plan Following the Mid-Staffordshire NHS Foundation Trust Public Inquiry Quarter 2, 01 July 30 September 2014 Agenda Item: 12 Reference: WCT14/ Meeting Name: Trust Board Meeting Date: 3 December 2014 Lead Director: Simon Gilby Job Title: Chief Executive Link to Business Plan: Has an Equality Impact Assessment (EQIA) been undertaken & attached? Has the Public & Stakeholders been consulted? Yes No N/A Yes No N/A To Approve To Note To Assure Financial Implications: E.g. What is the Impact on the Trust? Does it provide Value for Money? All costs should be clearly explained in the section below. None identified at present Overall Cost / Pressure: Additional Funding Required: Identified Risks: n/a Overall Income: n/a n/a Funding Already Ring Fenced: n/a None identified at present a full risk assessment of individual action plans will be completed in due course. Assurance to Board: This paper provides assurance to the Trust Board of what actions the Trust will take to ensure implementation of appropriate recommendations contained in the Robert Francis report (2013) across Wirral Community NHS Trust and the process for monitoring. Publish on Website: Yes No Private Business: Yes No Report History Submitted to Date Brief Summary of Outcome Quarterly updates presented to board since 4 March 2013

54 Wirral Community NHS Trust Update Report on the Implementation of the Action Plan Following the Mid-Staffordshire NHS Foundation Trust Public Inquiry Quarter 2, 01 July 30 September 2014 Purpose 1. At the March 2013 Trust Board, the recommendations of the Francis Inquiry Report (2013) and revised and validated the actions required by Wirral Community NHS Trust were discussed. These were categorised into the following 4 areas: Introduction Those that require action by the Trust and will have clear and direct implications for the Trust and the services it provides. Those that require action by other NHS Providers e.g. Acute Trusts but should be reviewed by the Trust to ensure that they do not apply to the Trust e.g. Ward Managers. Those that require a Government response these will require additional review following this response as subsequent action by the Trust may be required. Those that relate to regulatory bodies e.g. CQC/Monitor/Professional Bodies these will require additional review as subsequent action by the Trust may be required. This paper presents an update on the action plan agreed for those recommendations which have clear and direct implications for the Trust and the services it provides for the reporting period quarter 1, 01 April 30 June The Trust Board is fully committed to responding to the Francis Inquiry Report (2013) and will continue to build on the work achieved to date and will specifically undertake to: Ensure patients and staff are genuinely at the heart of the way we do our business. Ensure our common values are explicit and shared with all staff and patients. Identify and promote a set of core fundamental standards that underpin all we do. Be open and transparent in the way we do business and that we identify quickly and clearly with patients and their families what could be improved. Ensure that all our staff are equipped to discharge their responsibilities and are caring and compassionate. Sustain visibility across all areas and support leadership at all levels of the organisation through leadership safety walks and patient experience events Ensure all the above is underpinned by robust and useful information that tells us what is happening. 3. Part of this commitment is ensuring the recommendations of the Francis Inquiry Report (2013) have clear and direct implications for the Trust and the services it provides are implemented and progress on these, and the actions required from the subsequent Cavendish, Keogh and Berwick reports, can be found in Appendix The board is asked to note that all actions due for completion in quarter two 01 July 30 September 2014 have been completed. 5. All actions due for completion in quarter three 01 October 31 December 2014 have been reviewed to ensure that they remain on track to be implemented within the agreed timescales. 6. Actions 12 and 37 have been updated to reflect a revised completion date of 31 March 2015 as the trust is awaiting the findings from the national pilots of the Care Certificate following the Cavendish Review.

55 7. Action 49 has been updated to reflect this will be achieved with the implementation of the statutory duty of candour which comes into effect on 27 November Action 63 has been updated to reflect the paper which was presented to the October Quality and Governance Committee agreeing the way in which the trust will receive assurance on the CQC fundamental standards from April Recommendations 9. The Board is asked to receive this report and be assured that there are adequate and effective processes in place to ensure implementation of the appropriate recommendations contained in the Robert Francis report (2013) across Wirral Community NHS Trust and a process for monitoring them. Simon Gilby Chief Executive

56 Appendix 1 Wirral Community NHS Trust Action Plan KEY (Change Status) Action Plan in Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Report, 2013) Not Applicable recommendation identifies national body to lead Further Information required recommendation may in part apply to Wirral Community NHS Trust Title: Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Report, 2013) Action Plan Lead: Chief Executive Revised Number Report Theme Recommendations Local action required (if any) Action by Date 1 Implementation of the recommendations A tool or methodology such as a cultural barometer to measure the cultural health of all parts of the system. Monthly Mini staff surveys to be completed and published on website as a local tool to measure cultural health Review of the most effective way to measure the cultural health of the organisation This will be in the form of the national staff friends and family test which will is a national CQUIN for 2014/15 and will be implemented in April 2014 and the first data published in July 2014 for quarter 1 On-going 31 March July 2014 Person Responsible Director of HR & Organisational Development/Director of Quality and Nursing Comments/action status

57 2 All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts of employment 3 A common culture made real throughout the system an integrated hierarchy of standards of service It should be an offence for death or serious injury to be caused to a patient by a breach of these regulatory requirements, or, in any other case of breach, where a warning notice in respect of the breach has been served and the notice has not been complied with. It should be a defence for the provider to prove that all reasonably practicable steps have been taken to prevent a breach, including having in place a prescribed system to prevent such a breach To be added to contracts of employment and communicated to staff in the staff bulletin and on the staff zone The Being Open Policy should be reviewed to include Root Cause Analysis investigations to be carried out by a reviewer independent of the service/division for all incidents which cause serious harm or death and the findings to be reviewed by the Director of Operations and Performance/Executive Nurse and Medical Director who will decide if further action needs to be considered for any individual involved. 30-Apr Oct December September 2013 Director of HR & Organisational Development Director Operations/Director of Quality and Nursing/Medical Director

58 4 The healthcare regulator must be free to require or recommend immediate protective steps where there is reasonable cause to suspect a breach of fundamental standards, even if it has yet to reach a concluded view or acquire all the evidence. The test should be whether it has reasonable grounds in the public interest to make the interim requirement or recommendation 5 The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local relationship managers. Any bureaucratic or legal A process to be put in place to ensure that all incidents involving serious harm or death of a patient or service user to be reported to the CQC by the Responsible Person A process to be put in place to ensure Mandated returns about patterns of complaints, how they were dealt with and outcomes to be submitted as requested to the CQC 30 September September 13 Director Operations/Director of Quality and Nursing/Medical Director Director Operations/Director of Quality and Nursing/Medical Director

59 obstacles to this should be removed. 6 The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes. Patient safety alerts should continue following the transfer of the Patient Safety 7 Agency s functions in June 2012 to the NHS Commissioning Board. A process to be put in place to ensure Mandated returns about patterns of complaints, how they were dealt with and outcomes to be submitted as requested to the CQC A process should be put in place to ensure all none compliance with action plans or decisions not to implement a patient safety alert is to be escalated to the Quality and Governance Committee. 30 September September 13 Director Operations/Director of Quality and Nursing/Medical Director Director of Quality and Nursing

60 8 The Council of Governors and the board of each foundation trust should together consider how best to enhance the ability of the council to assist in maintaining compliance with its obligations and to represent the public interest. They should produce an agreed published description of the role of the governors and how it is planned that they perform it. Monitor and the Care Quality Commission should review these descriptions and promote what they regard as best practice. 9 Arrangements must be made to ensure that governors are accountable not just to the immediate membership but to the public at large it is important that regular and constructive contact between governors Development plan to be agreed once the Council is in place Public meeting timetable to be agreed once the Council is in place Date to be agreed once the Council is in place Date to be agreed once the Council is in place Director of HR & Organisational Development Director of HR & Organisational Development

61 and the public is maintained. 10 Monitor and the NHS Commissioning Board should review the resources and facilities made available for the training and development of governors to enhance their independence and ability to expose and challenge deficiencies in the quality of the foundation trust s services. Development plan to be agreed once the Council is in place Date to be agreed once the Council is in place Director of HR & Organisational Development

62 11 Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff to undertake this role, and employers and unions must regularly review the adequacy of the arrangements in this regard. 12 There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title. Review of nursing representation to be undertaken Implications from the Cavendish review to be added to the action plan when available 31 March September 2014 Partnership agreement review underway 31 March September 2014 Revised as part of work for divisional restructure Date revised to 31 March 2015 as awaiting the findings from the national pilots of the Care Certificate following the Cavendish Review Director of HR & Organisational Development and Director of Quality and Nursing Director of HR & Corporate Affairs and Director of Quality and Nursing/Director of Operations

63 13 Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse. New Uniform for all nursing staff which ensures that a healthcare support worker is easily distinguishable from that of a registered nurse to be introduced 31 Decembe r January 2014 Director of Operations 14 There needs to be effective teamwork between all the different disciplines and services that together provide the collective care often required by an elderly patient; the contribution of cleaners, maintenance staff, and catering staff also needs to be recognised and valued. Model for Integrated Care to be developed for the organisation 31 March 2014 Director of Operations

64 15 All staff and visitors need to be reminded to comply with hygiene requirements. Any member of staff, however junior, should be encouraged to remind anyone, however senior, of these. 16 In the absence of automatic checking and prompting, the process of the administration of medication needs to be overseen by the nurse in charge of the ward, or his/her nominated delegate. A frequent check needs to be done to ensure that all patients have received what they have been prescribed and what they need. This is particularly the case when patients are moved from one ward to another, or they are returned to the ward after treatment. Posters to be developed for all bases to remind staff and patients of our obligations and how to raise concerns where this does not happen A yearly plan of medication audits to be agreed at Board and results presented for assurance 31 December March 2014 Director of Infection Prevention and Control Medical Director

65 17 Information There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one. If possible, the summary care record should be made accessible in this way. Shared database for information reporting to be developed (data warehouse) Post of records manager to review the process in place currently and make recommendations for improvement 31 March March 2014 Director of Finance Director of Quality and Nursing

66 Systems should be designed to include prompts and defaults where these will contribute to safe and effective care, and to accurate recording of information on first entry. A process to be introduced which includes a governance review of all new systems introduced 31 December 2013 Director of Finance Systems should include a facility to alert supervisors where actions which might be expected have not occurred, or where likely inaccuracies have been entered. A process to be introduced which includes a governance review of all new systems introduced 31 December 2013 Director of Finance Systems should, where practicable and proportionate, be capable of collecting performance management and audit information automatically, appropriately anonymised direct A process to be introduced which includes a governance review of all new systems introduced 31 December 2013 Director of Finance

67 from entries, to avoid unnecessary duplication of input. Systems must be designed by healthcare professionals in partnership with patient groups to secure maximum professional and patient engagement in ensuring accuracy, utility and relevance, both to the needs of the individual patients and collective professional, managerial and regulatory requirements. Systems must be capable of reflecting changing needs and local requirements over and above nationally required minimum standards. 18 All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: A process to be introduced which includes a governance review of all new systems introduced A process to be introduced which includes a governance review of all new systems introduced 31 December December 2013 Director of Finance Director of Finance

68 Effective real-time information on the performance of each of their services against patient safety and minimum quality standards; The information derived from such systems should, to the extent practicable, be published and in any event made available in full to commissioners and regulators, on request, and with appropriate explanation, and to the extent that is relevant to individual patients, to assist in choice of treatment. 19 It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in specialties. Service based quality metrics to be developed and published on staff zone Prodecapo/quality goals Service based quality metrics to be developed and published on website Prodecapo/quality goals Service based quality metrics to be developed and published on staff zone Prodecapo/quality goals 31 March March March 2014 Medical Director/Director of Quality and Nursing/Director of Operations Medical Director/Director of Quality and Nursing/Director of Operations Medical Director/Director of Quality and Nursing/Director of Operations

69 20 In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review. 21 All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission. 22 Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry. 23 The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and where Service based quality metrics to be developed and published on staff zone and the Clinical Forum to be used to review and update annually Prodecapo/quality goals Service based quality metrics to be developed and published on staff zone/web site Prodecapo/quality goals Quality and Governance Service and Information Team to work closely on data collection/presentation Prodecapo/quality goals Quality and Governance Service and Information Team to work closely on data collection/presentation/validatio n Prodecapo/quality goals 31 March March March March 2014 Medical Director/Director of Quality and Nursing/Director of Operations Medical Director/Director of Quality and Nursing/Director of Operations Director of Finance and Performance /Director of Quality and Nursing Director of Finance/Director of Quality and Nursing

70 possible improved. 24 Coroners and inquests making more of the coronial process in healthcarerelated deaths The terms of authorisation, licensing and registration and any relevant guidance should oblige healthcare providers to provide all relevant information to enable the coroner to perform his function, unless a director is personally satisfied that withholding the information is justified in the public interest. 25 There is an urgent need for unequivocal guidance to be given to trusts and their legal advisers and those handling disclosure of information to coroners, patients and families, as to the priority to be given to openness Procedure to be introduced to ensure Information requested by the coroner to be provided in a timely manner Procedure to be introduced to ensure Information requested by the coroner to be provided in a timely manner 30 September September 2013 Medical Director/Director of Quality and Nursing/Director of Operations Medical Director/Director of Quality and Nursing/Director of Operations

71 over any perceived material interest. 26 It is of considerable importance that independent medical examiners are independent of the organisation whose patients deaths are being scrutinised. 27 So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge of a patient s case or treatment. Procedure to be introduced to ensure Information requested by the coroner to be provided in a timely manner To train 50%of the Band 6 practitioners on the verification of death 30 September March 2014 Medical Director/Director of Quality and Nursing/Director of Operations Medical Director/Director of Quality and Nursing/Director of Operations

72 To train 50%of the Band 6 practitioners on the verification of death 31 March 2015 Medical Director/Director of Quality and Nursing/Director of Operations 28 Both the bereaved family and the certifying doctor should be asked whether they have any concerns about the death or the circumstances surrounding it, and guidance should be given to hospital staff encouraging them to raise any concerns they may have with the independent medical examiner. Procedure to be introduced to ensure Information requested by the coroner to be provided in a timely manner 30 September 2013 Medical Director/Director of Quality and Nursing/Director of Operations

73 29 New actions following the Government response to the report Statutory Duty of Candour The duty is for the NHS and its staff to make sure that they tell patients, families, carers and/or advocates if something goes wrong with their care (this is set out in the NHS Constitution). Being Open Policy to be reviewed to ensure it meets the requirements of the duty of candour and 30 Terms of reference for the Board and Committees to be reviewed to ensure terms of reference to make sure that they include a requirement to capture instances where the Duty of Candour is applied; and where there may be breaches of that duty Revised Being Open Policy to included how RCA training is provided and how disclosures are made under FOI requests and policy be presented to the Quality and Governance Committee for approval Revised Terms of Reference to be agreed 30 October October December 2013 Director of Quality and Nursing Board Secretary

74 31 Lead Executive for the duty of candour to be identified To be agreed at the September Board September 2013 Board Secretary 32 Trained Lead Officer to be identified as family liaison for complex complaints and investigations To be identified in Being Open Policy and training provided 30 October 2013 Director of Quality and Nursing

75 33 Raising Concerns policy to reflect this duty Revised policy to be presented to the Education and Workforce Committee for approval 30 October 2013 Director of HR and Organisational Development 34 Corporate Induction presentation to raise the NHS constitution and duty of candour Corporate Induction presentation to be reviewed to ensure staff understand the NHS constitution and duty of candour 30 October December 2013 Director of HR and Organisational Development

76 35 Essential Learning presentation to raise the NHS constitution and duty of candour Essential learning presentations to be reviewed to ensure staff understand the NHS constitution and duty of candour 30 October 2013 Director of Quality and Nursing 36 Cavendish Review An Independent Review into Healthcare Assistants and Support Workers in the NHS and social care settings Certificate and Higher Certificate of Fundamental Care for healthcare assistants to be developed by NMC and sector skills bodies Learning and Development Group to advise Educational and Workforce Committee on the implementation locally of the certificate Quarterly update to Committee Director of Quality and Nursing

77 37 NHs Employers/HEE/Skills for Care to work with employees to set out a robust development framework for health and social care support staff When national guidance is available the following should be reviewed: Job roles Job title (nursing assistant) Job descriptions Core competencies 30 April September 2014 Revised as part of work for divisional restructure Date revised to 31 March 2015 as awaiting the findings from the national pilots of the Care Certificate following the Cavendish Review Director of Quality and Nursing/Director of Operations 38 New actions which relate to other reports about quality and patient safety which have been published since 2 April 2013 Keogh Report Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report Ambition 1 We will have made demonstrable progress towards reducing avoidable deaths in our hospitals, rather than debating what mortality statistics can and can t tell us about the quality of care hospitals are providing. Review the use of an early warning system and clinically appropriate escalation procedures for deteriorating, high-risk patients - in particular at weekends and out of hours to help understand the causes of and reduce avoidable deaths. Deteriorating Patient policy based on national best practice and incidents 30 October 2013 Medical Director/Director of Quality and Nursing

78 reported on datix reviewed by QGS and if appropriate RCA completed 39 Ambition 2 The boards and leadership of provider and commissioning organisations will be confidently and competently using data and other intelligence for the forensic pursuit of quality improvement. They, along with patients and the public, will have rapid access to accurate, insightful and easy to use data about quality at service line level. The Board must take collective responsibility for quality within their organisation and across each and every service line they provide. They should ensure that they have people with the specific expertise to know what data to look at, and how to scrutinise it and then use it to drive tangible improvements. A Board development session will be provided to discuss data for quality improvement and to assure the Board that board members have someone with the breadth of skills required to scrutinise data. 31 March 2014 d on 9 Dec 2013 Medical Director/Director of Quality and Nursing

79 40 Ambition 3 Patients, carers and members of the public will increasingly feel like they are being treated as vital and equal partners in the design and assessment of their local NHS. They should also be confident that their feedback is being listened to and see how this is impacting on their own care and the care of others. 41 Ambition 4 Patients and clinicians will have confidence in the quality assessments made by the Care Quality Commission, not least because they will have been active participants in inspections. The Trust should forge strong relationships with local Healthwatch who will be able to help them engage with patients and support their journey to ensuring more comprehensive participation and involvement from patients, carers and the public in their daily business The Trust should apply aspects of the methodology used for this review to their own organisations in quality visits to help them in their quest for improved quality Mock CQC inspections 31 December March 2014 Medical Director/Director of Quality and Nursing Medical Director/Director of Quality and Nursing

80 42 Ambition 5 No hospital, however big, small or remote, will be an island unto itself. Professional, academic and managerial isolation will be a thing of the past The Trust to promote releasing staff to support improvement across the wider NHS, including future CQC hospital inspections, peer review and education and training activities, including those of the Royal Colleges, recognising the benefits this will bring to improving quality in their own organisations 31 December 2013 Chief Executive 43 Ambition 6 Nurse staffing levels and skill mix will appropriately reflect the caseload and the severity of illness of the patients they are caring for and be transparently reported by trust boards Director of Quality and Nursing should use evidence-based tools to review staffing levels for all clinical areas on a shiftby-shift basis. Boards should sign off and publish evidence-based staffing levels at least every six months, providing assurance about the impact on quality of care and patient experience. 31 March 2014 Director of Quality and Nursing On going work in safe staffing action plan

81 44 Ambition 7 Junior doctors in specialist training will not just be seen as the clinical leaders of tomorrow, but clinical leaders of today. The NHS will join the best organisations in the world by harnessing the energy and creativity of its 50,000 young doctors 45 Ambition 8 All NHS organisations will understand the positive impact that happy and engaged staff have on patient outcomes, including mortality rates, and will be making this a key part of their quality improvement strategy Directors of Quality and Nursing and Medical Director to harness the loyalty and innovation of medical students, junior doctors and student nurses, who move between placements, so they become ambassadors for the Trust, promoting innovative practice and knowing how to raise concerns about the quality of care provided This will be through the Clinical Forum Clinical Forum to be introduced to engage staff from every service in the quality goals and strategy development 31 March March 2014 Medical Director/Director of Quality and Nursing Medical Director/Director of Quality and Nursing

82 46 New actions which relate to other reports about quality and patient safety which have been published since 2 April 2013 A promise to learn a commitment to act. Improving the Safety of Patients in England Recommendation 1 The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning The wording of quality goals should be reviewed for the quality strategy in 2014/15 and the words zero harm replaced with the goal of continual reduction as patient safety is a continually emerging property 31 March 2014 Medical Director/Director of Quality and Nursing 47 Recommendation 2 All leaders concerned with NHS healthcare political, regulatory, governance, executive, clinical and advocacy should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support. The skills required to be able to identify and help to reduce risks to the safety of patients to be included in the following learning and development opportunities: Corporate induction Essential Learning Management Skills Programme Risk Management Training 30 September 2014 Director of Quality and Nursing

83 48 All leaders and managers within the organisation should have the skills to address poor teamwork and poor practice of individuals. Individual skills gaps should be should be identified and addressed through the annual appraisal/revalidation system and should focus on: Learning Support Listening Continual improvement 30 June 2014 Director of Human Resources and Organisational Development Performance framework introduced as part of annual appraisal process 49 Once developed the NHS England safety leadership behaviours should be used during: Recruitment Appraisals Leadership development 30 April November 2014 Director of HR & Organisational Development/Director of Quality and Nursing Embedded within: Duty of Candour

84 50 A Patient Safety Strategy should be developed that clearly describes the organisations patient safety goals which can be measured and regularly reviewed 51 Recommendation 3 Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts Time extended to allow for staff consultation: 1. Draft strategy to QPER August 2. QGC 18 for comments 3. Staff Council 21 for comments 4. Board 3 September for approval 5. Clinical Forum 16 September for information A Patient Engagement Strategy should be developed clearly describe how patients are involved in: Care planning including risks and alternatives Decision making Care design Quality goal setting Quality improvement Patient and Staff Quality Groups Measuring and monitoring patient safety 31 March June September March 2014 Director of Quality and Nursing Director of Quality and Nursing

85 Giving general feedback 52 Recommendation 4 Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS s needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported A six monthly clinical staffing report should be presented to the Board to support them in taking responsibility for ensuring that clinical areas are adequately staffed. This will be a monthly board report from April March April 2014 Medical Director/Director of Quality and Nursing/Director of Operations On going work in safe staffing action plan

86 53 The report should take account of varying levels of patient acuity and dependency and based on best evidence and NICE guidance. To support this the following tools need to be developed/implemented: Workforce assurance tool Patient acuity tool Safe staffing levels tool based on nurse to patient ratios and skill mix between registered and unregistered staff by team This will be a monthly board report from April Staff should work in wellstructured teams. This should be measured annually through the NHS staff survey. 31 March April 2014 Medical Director/Director of Quality and Nursing/Director of Operations On going work in safe staffing action plan 31 December 2013 Director of HR & Organisational Development 55 Staff should feel supported through having managers who : 31 March July 2015 Director of HR & Organisational Development/Director of Quality and Nursing

87 Deliver excellent human resources and who have completed the Management Skills Programme Deliver the wellbeing agenda in their team Cultivate a positive organisational culture Involve staff in decision making and innovation Provide staff with helpful feedback Recognise good performance Address systems performance Make sure staff feel safe, supported, respected and valued at work Set challenging and measurable team objectives Facilitate good communication within and about teams This should be measured by using a cultural barometer for the organisation and the results and any action plans being shared at the Education and Workforce Committee This will be in the form of the national staff friends and family test which will is a national

88 CQUIN for 2014/15 and will be implemented in April 2014 and the first data published in July 2014 for quarter 1 56 The organisation should implement any systems recommended by professional regulators for assessing performance and revalidation Nurse revalidation will be introduced in December 2014 for full implementation by December Recommendation 5 Mastery of quality and patient safety sciences and practices should be part of initial preparation and lifelong education of all health care professionals, including managers and executives Recommendation 6 The NHS should become a learning organisation. Its leaders should create and support the capability for learning, and therefore change, at Invest in building capacity to enable all staff to contribute to improving quality and safety by Quality and Patient Safety Science (including the principles and practice of patient safety, on measurement of quality and patient safety and skills for engaging patients actively) being developed at every level of the organisation: As part of Essential Learning programme by E learning As part of the Management Skills Programme Using the IHI Open School Through the lead nurses/lead clinicians forum 31 March December March March 2015 Revised to take account of local CQUIN 2014/15 Medical Director/Director of Quality and Nursing Director of Quality and Nursing

89 58 Recommendation 7 Transparency should be complete, timely and unequivocal. All data on quality and safety, whether assembled by government, organisations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public. scale, within the NHS Through the Board Development programme Through working with partners e.g. Royal Colleges, HEE, North West Leadership Academy, AQUA and IHI to equip expert quality leaders with an in-depth understanding of safety and improvement This will also form part of a local CQUIN in 2014/15 All data on quality of care and patient safety that is collected should be shared with anyone who requests it in a timely fashion with due protection for individual patient confidentiality and published on staff zone and website. 31 March July 2014 Revised as Trust now part of the open and honest reporting programme with first data to be published in July Medical Director/Director of Quality and Nursing Recommendation 8 All organisations should seek out the

90 patient and carer voice as an essential asset in monitoring the safety and quality of care. 59 A peer review system of the organisations quality and patient safety formal systems should be developed through partnership with another organisation to facilitate learning and use of best practice 60 An agreed set of local early warning signs of quality and patient safety problems should be developed and include: 31 March 2015 Medical Director/Director of Quality and Nursing The voice of the patient The voice of the staff Staffing levels The reliability of critical processes Quality metrics 31 March 2014 Medical Director/Director of Quality and Nursing These should be routinely collected, analysed and responded to by the Quality and Governance Committee and escalated to the Board as appropriate 61 In addition to the current aggregated quality and patient safety data being reported to the Committees and Board data on the CQC fundamental 31 March 2014 Medical Director/Director of Quality and Nursing

91 62 Recommendation 9 Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction. standards should be reported at team level Prodecapo/Quality Goals A system to be introduced to ensure all Patient Safety alerts which are relevant to the organisation should be reported to the Quality and Governance Committee with evidence they have been implemented promptly. Any problems with implementation should be escalated to the Board 63 The CQC fundamental Standards for Community Trusts should be fully implemented within the organisation and evidence of compliance with these standards monitored at the Compliance group with escalation of any compliance issues through the Quality and Governance Committee to the Board 30 September April July April 2015 Director of Quality and Nursing Medical Director/Director of Quality and Nursing This action has been updated to reflect the national timescale for the introduction of the fundamental standards July 2014 The consultation on

92 fundamental standards has now closed. The fundamental standards will come in to force for all providers in April 2015, and at the same time, subject to Parliament, the fit and proper person requirement and the duty of candour will be extended so they also cover all providers from then on. Paper presented to October Quality and Governance committee agreeing how assurance on the fundamental standards will be presented to the organisation 64 Recommendation 10 We support responsive regulation of organisations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to wilful or reckless neglect or mistreatment. Support for staff around the implementation of the Being Open Policy and the reporting of serious incidents should be included as part of implementing the reviewed policy 31 March 2014 Director of Quality and Nursing

93 Quality Dashboard 01 November 30 November 2014 Agenda Item: 14 Reference: WCT14/ Meeting Name: Trust Board Meeting Date: 3 December 2014 Lead Director: Sandra Christie Job Title: Director of Quality and Nursing Link to Business Plan: Has an Equality Impact Assessment (EQIA) been undertaken & attached? Has the Public & Stakeholders been consulted? Ensures essential levels of quality and safety are met and drives forward continuous improvement for: Patient, Community and Commissioners Care Delivery People and Resources Enabling Functions Yes No N/A Yes No N/A To Approve To Note To Assure Financial Implications: E.g. What is the Impact on the Trust? Does it provide Value for Money? All costs should be clearly explained in the section below. None identified at present. Overall Cost / Overall Income: Pressure: Additional Funding Funding Already Required: Ring Fenced: Identified Risks: The continued reporting of community acquired grade 3 and 4 pressure ulcers has been identified as a risk by the Community Nursing Service; this has been appropriately escalated to the risk register. A Pressure Ulcer action plan has been submitted to the July 2014 Quality and Governance Committee to provide assurance regarding the actions being implemented in relation to this identified risk. Following analysis of triangulated data, a programme of deep dives will be conducted, initially focusing on two community nursing teams to identify areas for quality improvement. Assurance to Board: The Quality dashboard provides assurance to the board of the delivery of safe, effective and quality services and a monthly high level summary of achievement against the organisations quality goals. Publish on Website: Yes No Private Business: Yes No

94 Wirral Community NHS Trust Quality Dashboard 01 November 30 November 2014 Purpose 1. The purpose of this monthly report is to present the organisaitons quality dashboard to the board and to provide assurance of the delivery of safe, effective and quality services in a monthly high level summary of achievement against the organisations quality goals for the reporting period 01 November 30 November Executive Summary 2. Wirral Community NHS Trust Board recognises that quality is an integral part of their business strategy and for the Trust to be most effective; quality must become the driving force of the organisation s culture. 3. We are committed to ensuring that quality forms an integral part of its philosophy, practices and business plans and that responsibility for driving this is accepted at all levels of the organisation. 4. The five year quality strategy is structured around the organisations strategic priorities which are; Our Patients, Our People, Our Services and Our Sustainability. 5. The quality goals which ar ealigined ot each of those strategic priorites are: 6. The Quality and Governance Committee is the responsible committee for ensuring trends identified in the quality daschboard are monitored and the appropriate action taken to improve patient care. 7. The quality dashboard will be tabled at the board to ensure the information is current and any current quality concerns raised.

95 Board Action 8. The board is asked to approve the quality dashboard for the reporting period 01 November 30 November 2014 and be assured of the delivery of safe, effective, quality services across the organisation. Sandra Christie Director of Quality and Nursing Contributors: Paula Simpson Head of Quality and Nurisng

96 Infection Prevention and Control Assurance Report (01 July September 2014) Agenda Item: 15 Reference: WCT14/ Meeting Name: Trust Board Meeting Date: 3 December 2014 Lead Director: Sandra Christie Job Title: Director of Quality & Governance/Director of Infection Prevention & Control Link to Business Plan: Has an Equality Impact Assessment (EQIA) been undertaken & attached? Have the Public & Stakeholders been consulted? Yes No N/A Yes No N/A To Approve To Note To Assure Financial Implications: E.g. What is the Impact on the Trust? Does it provide Value for Money? All costs should be clearly explained in the section below. None identified Overall Cost / Pressure: Additional Funding Required: Overall Income: Funding Already Ring Fenced: Identified Risks: Non-compliance with The Health and Social Care Act 2008 Code of Practice on the Prevention and Control of Infections and related guidance may affect the Trust s registration with the Care Quality Commission. Non-compliance increases the risk of Healthcare Associated Infections and associated litigation. Lack of progression and/or resolution relating to Risk ID 151,152 and 155 Assurance to Board: This report provides assurance to Wirral Community NHS Trust Board in relation to the Trust s requirements to implement The Health and Social Care Act 2008 Code of practice on the Prevention and Control of Infections and related guidance. Publish on Website: Yes No Private Business: Yes No Report History Submitted to Date Brief Summary of Outcome No history

97 Wirral Community NHS Trust Infection Prevention and Control Assurance Report (01 July September 2014) Purpose 1. The purpose of this paper is to: Provide assurance to Wirral Community NHS Trust Board of its requirements to implement the Code of Practice on the Prevention and Control of Infection (DH 2008) and to demonstrate compliance with the Care Quality Commission Outcome 8: Regulation 12 Cleanliness and Infection Control. Provide assurance to the Trust Board regarding implementation of the Code of Practice during the period 01 July September Executive Summary 2. The Infection Prevention and Control Service (IPCS) provides a service to all Clinical and Corporate Divisions within Wirral Community NHS Trust (WCT). Reducing the risk of infection through robust infection control practice is a key priority for WCT. The IPCS aims to optimise the individual s care, whilst protecting patients, staff and others from the risk of infection, to support the provision of high quality services for patients and a safe working environment for staff. 3. Effective Infection Prevention and Control structures, the commitment of Wirral Community NHS Trust Board and all employees is essential to the effective control of Healthcare Associated Infection (HCAIs). Wirral Community NHS Trust Update (01 July September 2014) 4. WCT does not have national HCAI objectives for Clostridium difficile and actively supports a zero tolerance in respect of MRSA bacteraemia. All community attributed Clostridium difficile cases are reported against Wirral Clinical Commissioning Groups (WCCG) objective as it is WCCG has responsibility for HCAI reduction across the Health Economy. There have been no MRSA bacteraemia cases attributed to the trust during the reporting period. During the reporting period 01 July September 2014; there have been 15 community attributed Clostridium difficile Post Infection Reviews (PIR) undertaken by the IPCS. The PIR in each case did not identify that any care provided by WCT contributed to or was the root cause of an avoidable infection; however the prescribing of Loperamide in patients with diarrhoea accessing GP Out of Hours Service is under review to ensure risk factors for Clostridium difficile are considered prior to prescribing. 5. The Infection Prevention and Control Service facilitated 8 infection control mandatory training sessions.

98 Completion of Mandatory Training - 30th September 2014 The blended approach of ELearning and short supplementary face to face session for clinical staff introduced in April 2014 continues to be delivered. There has been improvement since quarter 1 reporting in the completion of mandatory infection prevention and control Elearning, although the Level 2 module remains slightly under target. Monitoring of mandatory training continues via the Learning and Development Group. 6. For the reporting period 01 July September 2014; 19 trust services/premises were audited against the Infection Prevention Society Quality Improvement standards. Action plans have been issued to relevant service leads. The audit pathway has been reviewed and implemented to increase the efficacy of follow up both at divisional level and at the Infection Prevention and Control Group. 7. Essential Steps is a framework that allows the trust to measure compliance with Infection Prevention and Control standards to ensure the quality and safety of clinical interventions. It is a requirement of Wirral Clinical Commission Group contract with WCT. For the reporting period 01 July September 2014; 842 eligible staff completed the mandatory Hand Hygiene Observational Audit; this represents 77% of the eligible workforce. During the same reporting period, all services reported 100% compliance with Tool One: Hand Hygiene with the exception of the following services: Livewell 99% All services were requested to review the data and provide actions plans to manage areas requiring review and/or improvement. Issues relating to the IT provider continue with the INCA system. The system transferred to the trust April 2014 to the Performance and Intelligence Team to enable development work, however the IT provider has now withdrawn all routine support e.g. creation of accounts. The IPCS is awaiting the outcome of a review of the system by the Head of Business Intelligence to determine if development can be undertaken. INCA is currently on the risk register with a risk score of During this reporting period the Trust was inspected by the Care Quality Commission. Overall the result of the review against Outcome 8: Regulation 12 Cleanliness and Infection

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