Special Measures Quality Improvement Plan Update. Sherwood Forest Hospitals NHS Founda=on Trust. 10 March 2016 KEY. Delivered. On Track to deliver

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1 Special Measures Quality Improvement Plan Update Sherwood Forest Hospitals NHS Founda=on Trust March 6 KEY Delivered On Track to deliver Some issues narra<ve disclosure Not on track to deliver

2 Background & Summary Sherwood Forest Hospitals NHSFT - Our improvement plan & our progress CQC Inspection April 4 The Chief Inspector of Hospitals visited our trust in April 4 and published the findings on the CQC website in June 4. The trust was rated overall as requires improvement and a number of specific recommendations were made in relation to services provided by the trust. The trust published its improvement plan to address these issues at the end of September 4. Some of the planned actions had not been completed when the CQC re-inspected in June 5. Section 9A (Health & Social Care Act) Warning Notice On 6 August 5 the CQC issued a section 9a Warning Notice. The Trust responded to parts and 3 of the Section 9a on the 8 September 5. The trust structured the response around four action plans relating to: risk; suicide risk and call bells in the Emergency Department; the organisation of outpatient services and the fit and proper persons requirement. Part of the Section 9a was responded to on the 6 November 5, the response was structured around three action plans relating to board assurance & clinical governance, support to junior doctors and enhanced reporting. The Trust responded with their plans to the CQC within the required timescales. All elements of this Warning Notice are incorporated within the latest Quality Improvement Plan. Section 3 (Health & Social Care Act) Warning Notice On 7 August 5 the CQC issued a Section 3 Warning Notice, the trust responded on the 4 August 5 and we continue to provide weekly updates. The Trust responded to the CQC within the required timescales with their plans to address the issues raised within the notice. All elements of this Warning Notice are incorporated within the latest Quality Improvement Plan. CQC inspection June 5 & Quality Summit 3 October 5 The Chief Inspector re-visited our trust in June 5. A Quality Summit was held on 3 October to share his findings with the Trust s regulators, local commissioners and partners. The inspection reported that the position of the trust had deteriorated and urgent action was required to address the recommendations contained within the report. The Trust has consolidated the required actions into works streams. Related actions from the 4 inspection and the section 9a and 3 Warning Notices have also been incorporated into those work streams to create one Quality Improvement Plan. Overall ra=ng Are services safe? Are services effec=ve? Are services caring? Are services responsive? Inadequate Inadequate Requires Improvement Are services well led? Inadequate Section (Health & Social Care Act) Warning Notice On 9 January 6 the CQC issued a Section Warning Notice, the trust responded to the registration issue identified within the required timescale of February 6. The requirements of this Warning Notice has been included in the latest Quality Improvement Plan. Good Requires Improvement

3 Background & Summary Sherwood Forest Hospitals NHSFT - Our improvement plan & our progress The Trust entered special measures as a result of the findings of the Keogh Review (3). We have remained in special measures following the CQC Chief Inspector of Hospitals review in May 4. The Trust agreed an action plan following the 4 inspection but a number of actions had not been completed by the time of the 5 inspection. The report following the inspection of June 5 has set out a range of recommendations which the trust must address. The CQC report published on October 5 can be found on the CQC website We recognised all of the recommendations and are addressing them to improve the quality of services. The Trust has developed a Quality Improvement Plan to deal with the CQC recommendations, maintain progress and ensure actions lead to measurable improvements in the quality and safety of care for patients. The Quality Improvement Plan will be updated monthly and will be accessible on the trust internet site. While we take forward our plans to address the CQC s recommendations, the Trust will remain in special measures. Oversight and improvement arrangements have been put in place to support changes required by way of the Trust s Clinical Quality Committee and the Quality Improvement Plan is being managed by a dedicated director to ensure progress is being made. Who is responsible? Our actions to address the recommendations was presented and agreed by the Trust Board on 6 November 5. Our Chief Executive is ultimately responsible for implementing actions in this document. Other key staff, Andy Haynes (medical director) and Suzanne Banks (chief nurse), provide the executive leadership for quality, patient safety and patient experience. The Improvement Director assigned to Sherwood Forest Hospitals NHS Foundation Trust is Eric Morton, who will be acting on behalf of Monitor and in concert with the relevant Regional Team of Monitor to ensure delivery of the improvements and oversee the implementation of the action plan overleaf. Should you require any further information on this role please contact specialmeasures@monitor.gov.uk Ultimately our success in implementing the recommendations of the Quality Improvement Plan will be assessed by the Chief Inspector of Hospitals upon re-inspection of our Trust. If you have any questions about how we are doing, contact Karen Fisher (QIP programme director), karen.fisher@sfh-tr.nhs.uk How we will communicate our progress to you We will update this progress report every month while we are in special measures and the Quality Improvement Plan will be available for access following approval by the monthly meeting of the trust board. Chair / Chief Execu=ve Approval (on behalf of the Board): Chair Name: Sean Lyons Signature: Date: March 6 Chief Executive Name: Peter Herring Signature: Date: March 6 3

4 Leadership Total ac<ons - 5 Refresh & redeploy our vision in an understandable form 3 ac<ons Create execu=ve & senior staff capacity 5 ac<ons Revise our performance management arrangements ac<ons 3 May 6 We have announced our Long Term Partner as NoFngham University Hospitals and staff briefed. Our Chief Execu<ve Officer agreed the immediate strategic priori<es for 6/7, within the context of the long term partnership, with the Trust Board in February. We have communicated these to leaders and managers at Team Brief. 3 March 6 We have established the five Clinical Divisions and the senior management teams to lead these. Appointed Divisional Clinical Governance leads within three of the divisions; con<nuing to source for Emergency and Urgent Care, and Medicine Divisions. 3 March 6 Performance Management Agreements have been signed by the Divisions. We have revised and agreed the Performance Management Framework. HR performance management policies reviewed; all fit for purpose to address poor performance and support sefng SMART objec<ves. Blue - Red - Amber - Green

5 Leadership Total ac<ons - 5 Invest in leadership development programmes from board to ward ac<ons 3 September 6 Masterclasses on Governance delivered from February and Performance Management Toolbox Talks commenced in March. Staff Engagement for Managers Toolbox Talk pilo<ng in March 6. Leadership coaching sessions and strategic development days con<nue for Divisional Senior Leadership Triumvirates; Surgery to commence. We have completed a further Leadership TNA and are currently analysing the data to iden<fy training gaps. We have dra^ed a Talent Management Process; to be tested in the Trust. Ensure the Board has the appropriate skills and abili=es 5 ac<ons 3 April 6 The Trust Board con<nue to have development sessions. All Trust Board members have an up to date appraisal with agreed objec<ves. 5 5

6 Governance Total ac<ons - 5 Changing the Governance framework, architecture and define leadership roles and responsibili=es to deliver the governance plan 8 ac<ons 3 March 6 We have reviewed the objec<ves for key individuals within the Governance Unit to establish the roles and responsibili<es within the unit; We have developed a database and a plan for the upda<ng of the Paediatric Clinical Guidelines. 7 completed subject to CQC confirma<on 8 9 Integrated governance and risk assurance processes to ensure that risks are systema=cally iden=fied and responded to appropriately 4 ac<ons 3 December 5 Our Risk Management Commibee approved the suite of formats for repor<ng our risk management; Our Director of Governance has delivered Good Governance Master classes to our senior managers. 3 Improved informa=on to be provided to the board to ensure visibility of risks 5 ac<ons 3 April 6 All ac<ons are on plan and we are working towards embedding these ac<ons into our daily business. completed subject to CQC confirma<on 4 Develop an open and transparent culture that supports good governance to enable the trust to be a learning organisa=on ac<on 3 March 6 We are monitoring our performance on a Duty of Candour tracker; From January 6 we will be compliant with the Duty of Candour. 6

7 Governance Total ac<ons - 5 Corporate oversight and response to external agencies/ regulators reports to ensure a coordinated clinical governance approach 6 ac<ons 3 August 6 We meet regularly with Health Educa<on East Midlands to discuss our ac<on plans and discuss issues that arise; AQuA Pa<ent Safety interven<ons are planned for our Emergency Department; Our Junior Doctors Forums are established and well abended. 7 completed subject to CQC confirma<on 7 8 Ensure proper processes to enable the trust to make the robust assessment as required by the Fit and Proper Person Requirement. 4 ac<ons 3 October 5 We have completed these ac<ons and are embedding into our prac<ce. 3 completed subject to CQC confirma<on 3 Ensure CQC Registra=on is fit for purpose Sec=on Ac<ons February 6 CQC Registra<on has been reviewed; Applica<on for addi<onal regulated ac<vity has been submibed. 7

8 Recruitment & Reten=on Total ac<ons - 5 Recruitment & reten=on to be priori=sed by a dedicated nursing & medical taskforce 5 ac<ons 3 April 6 All medical vacancies have a Named Head of Service responsible for medical recruitment. Nursing Taskforce group established includes recruitment and reten<on workstream. Weekly recruitment summary presented to Execu<ve and senior management teams. New job plans reviewed early March. Project due to deliver by 3.3.6; risk may not achieve target date. Gap analysis by Specialty and / or Division and trajectory to close gap to be undertaken. 4 Review recruitment processes to shorten the =me to comple=on 3 ac<ons 3 March 6 Recruitment processes reviewed and improvements iden<fied. Electronic recruitment system procured and went live..6. Managers training sessions delivered across all sites during March. Revised Vacancy Authorisa<on process issued; streamlined with electronic signatures. Divisional reten<on targets agreed. Interven<ons to support new starters developed. 3 Targeted medical & nursing recruitment campaigns in UK, Europe & interna=onally commissioned ac<on 3 September 6 Recruitment open day 6..6 appointed 3 candidates; 4 nurses, 8 ODP's. Con<nuing to work with sourcing agency as several chosen Filipino nursing candidates failed IELT re- sit. 8

9 Recruitment & Reten=on Total ac<ons - 5 Targeted campaign for nursing staff to return to prac=ce ac<on 3 June 6 Three return to prac<ce nurses employed at open day Improved alignment of future service provision & workforce planning 4 ac<ons 3 September 6 Emergency Department rota management policy agreed at department level; to be submibed to nego<a<ng bodies for sign off March 6. We have facilitated addi<onal places on Emergency Paediatric Life Support (EPLS) course to train / update staff; risk if staff do not pass assessment. From the 9 March 6 we will roster to ensure x EPLS nurse on each shi^. 3 Enhanced learning from exit interviews to inform reten=on planning ac<on 3 January 6 Exit ques<onnaire process and ques<onnaire revised; following ESR exit ques<onnaire format, to be accessed via survey monkey and paper version. Leaver flow chart revised to show improved process. 9

10 Personalised care Total ac<ons - 3 Adopt a pa=ent centred approach that involves pa=ents in planning, delivery & evalua=on of healthcare 6 ac<ons 3 April 7 We are con<nuing to roll out the Proud to Care programme, with 4 staff abending in February and a further 6 booked in March 6; We have constructed and tested our Ward Accredita<on programme, and we are pilo<ng it. 6 Mental health - Staff will recognise pa=ents with mental health status on admission Staff will recognise an acute deteriora=on in a pa=ent s mental health & understand the escala=on process ac<ons 3 January 6 We are undertaking audits to ensure our environment and procedures are safe to reduce the risk, minimise of self harm. completed subject to CQC confirma<on Safeguarding - All staff will recognise children & vulnerable adults presen=ng to their service & have appropriate training & level of competency for their specialist areas to care for this group of pa=ents or escalate if specialists are required 4 ac<ons 3 September 6 We are working with Alder Hey NHS Trust to undertake a Peer Review of our services and provide advice to the Chief Nurse; We are con<nuing to improve our training programmes for our staff. 4 End of life care - Provide evidenced based end of life care to dying pa=ents & support to their families based on na=onal guidelines and best prac=ce 8 ac<ons 3 April 6 Contact has been made with Hampshire Hospital to provide support in reviewing our service provision; We are securing addi<onal capacity to support the training of our staff. 6

11 Safety Culture Total ac<ons - 75 A systema=c approach to create an open culture where all staff understand the connec=on in what they do & how that impacts on pa=ent safety, in which staff feel empowered to learn & ini=ate improvements from incidents & near misses 4 ac<ons 3 March 6 We have iden<fied key individuals for our Pa<ent Safety Culture team and we are looking towards NoFngham University Hospitals for further support; AQuA plan is in place and is funded for the first months. Mortality & morbidity Bringing HSMR & other measures down to expected NHS levels ac<ons 3 December 6 We have established the five Clinical Divisions and the senior management teams to lead these. Appointed Divisional Clinical Governance leads within three of the divisions; con<nuing to source for Emergency and Urgent Care, and Medicine Divisions. 9 Sepsis Reducing & maintaining death rates from sepsis to with the na=onally expected range 6 ac<on 3 March 6 We are con<nuing to monitor our compliance on the Sepsis Screening and an<bio<c administra<on in severe sepsis as part of the na<onal CQUIN; We are audi<ng our compliance on the Sepsis Screening and Bundle compliance on our inpa<ent wards; We have completed all other ac<ons in this sec<on and are working towards embedding this into our daily business; 9 completed subject to CQC confirma<on 9 7

12 Safety Culture Total ac<ons - 75 Infec=on control Meet na=onal targets for infec=on control & becoming a leading performer with East Midlands peer trusts ac<ons 3 March 6 We have recruited a full- <me Microbial Pharmacist on the March 6; We have increased our Infec<on Preven<on & Control nursing team, and await this commencement; We are working with the Lead for Ward Accredita<on to roll out across the Trust. Medicines management Improve compliance with procedures & policies & develop awareness of risks among front line staff 9 ac<ons 3 January6 We have completed our ac<ons within the sec<on and are working towards embedding this into our daily business. 9 Equipment Change behaviours to ensure medical equipment management systems are used & triggered appropriately 3 ac<ons 9 February 6 We have procured the PREM trollies and are establishing the content with the Resuscita<on Team; We will move towards quality assurance on all trollies once these are in place. completed subject to CQC confirma<on 3

13 implementa =on Timely Access Total ac<ons 4 Emergency care Alloca=on of resources to emergency pathway to match pa=ent demand along side right- sizing resource levels 7 ac<ons 3 March 6 We have completed the ac<on about inter- facility transfers and EMAS have confirmed we are performing well. We have set up a pilot in ED to improve handover and turnaround <me of the ambulances that arrive. We have put new signage in ED to help pa<ents be able to navigate their way around the department 7 Emergency care increase numbers going through ambulatory care pathways & improvement of the efficiency of the pathways 3 ac<ons 3 December 5 These ac<ons are all completed and we are embedding into our prac<ce Emergency care Move the loca=on of the Decision Support Tools & Health Needs Assessments to a loca=on outside of the hospital ac<on 3 September 5 We con<nue to work with our health community partners to ensure pa<ents receive any con<nuing health care needs assessment in a <mely manner. 3

14 implementa =on Timely Access Total ac<ons 4 Planned care & cancer care Development of an automated real- =me pa=ent treatment list for outpa=ents & use the list to plan clinics ac<ons 3 July 5 We con<nue to monitor daily a number of key performance indicators in outpa<ents. completed subject to CQC confirma<on Planned care & cancer care introduc=on of a refreshed access policy for planned care. Right- sized administra=ve staff, improved training & introduc=on of regular audits of compliance 4 ac<ons 3 June 6 We are con<nuing to monitor how we manage outpa<ent appointments. We are implemen<ng all the recommenda<ons made by the Intensive Support Team that are designed to improve how we manage 8 week guidelines beber. We are con<nuing to train our clinical staff in how to use the Pa<ent Administra<on System. Staff are being trained on our new Access, Booking and Choice policy. 7 completed subject to CQC confirma<on 9 4 Planned care & cancer care introduc=on of con=nuing capacity & demand planning to inform resource planning decisions 4 ac<ons 3 January 6 We con<nue to review pa<ents pathways each month to ensure they meet the na<onal best prac<ce in terms of administra<ve processes. The outpa<ent improvement board con<nues to meet each fortnight to ensure all the good work in outpa<ents is maintained. 4 completed subject to CQC confirma<on 8 6 4

15 Mandatory Training Total ac<ons - 6 Define accountability for line managers & deputy directors for non- compliance & hold them to account ac<ons 3 September 6 Managers comple<ng and returning compliance templates. Compliance templates are being used at confirm and challenge, Service Line Mee<ngs; to be discussed and monitored at Divisional Performance Review mee<ngs. Align remunera=on increments to mandatory training compliance ac<ons Reframe & publicise the alignment of mandatory & statutory training to pa=ent safety objec=ves & prac=ce ac<on Develop mul=- dimensional analysis repor=ng of mandatory & statutory compliance by person/staff group/division/site ac<on 3 March 6 Revised pay progression policy and appraisal policy being agreed with trade unions in March 6;.3.6 e- communica<on of % mandatory training and appraisal compliance requirement to incrementally pay progress as from.4.6. Communica<on reiterated to managers to cascade to staff March 6 Publicity posters aligning mandatory training to pa<ent safety tested at Mandatory Training group and OD and Workforce Commibee: revisions being made based on feedback. Supported e- learning sessions scheduled and adver<sed on Mandatory Training site. Frequently Asked Ques<ons in development 3 April 6 New mandatory training reports are being tested and used in Confirm and Challenge, Service Line Mee<ngs, repor<ng at Divisional Boards and Divisional Performance Review; posi<ve feedback. 5

16 Staff Engagement Total ac<ons - Understand what genuine good staff engagement means to our staff ac<ons 3 January 6 Staff Engagement QIP Workstream Group con<nues to progress ac<ons. Baseline assessment findings consistent with na<onal research i.e. Engage for Success. Building in senior leadership and management behaviours, feeling valued and having a voice into Toolbox Talks and engagement work. Blue - Red - Amber - Green - 3 Assess the effec=veness of exis=ng staff engagement approaches ac<ons 3 December 5 Ac<ons completed and being embedded into prac<ce; findings used to inform and develop other ac<ons i.e. high impact interven<ons. U=lise staff feedback to inform revision of our Staff Engagement Strategy that clearly iden=fies responsibili=es & expecta=ons ac<on 3 March 6 Consul<ng with Staff Engagement Group on revised Staff Engagement Strategy; revisions within the context of Long Term Partnership and includes a month ac<on plan. 6

17 Staff Engagement Total ac<ons - Develop high impact staff engagement programmes & ini=a=ves to be rolled out across the trust to ensure consistent approach to staff engagement & allows for evalua=on 6 ac<ons 3 October 6 Remains on plan to deliver. Iden<fied interven<ons:. CEO to hold Senior Leadership workshop, launch engagement process, plan and toolkit;. Develop and clarify SFH engagement story; 3. Staff Engagement for Managers Toolbox Talks developed pilo<ng March; 4. Enhance internal communica<on methods; intranet site and use of social media. Interven<ons structure and model based on na<onal research; to deliver in Toolbox Talks, coaching, team mee<ngs, team briefings and apply in prac<ce. 6 Develop effec=ve communica=on & engagement skills within our leadership teams ac<on 3 December 5 Ac<on completed. Resource links in Staff Engagement Toolkit further enhanced, for use in Toolbox Talks developed and pilo<ng in March. Chief Execu<ve to launch at Senior Leadership Workshop early April. 7

18 Maternity Total ac<ons - 3 Ensure that the model of care follows the best prac=ce and is fit for purpose for the local popula=on 6 ac<ons 3 March 6 Maternity Workshop held on 6 January. Outputs being reviewed by the Maternity Improvement Director to determine priori<sed ac<ons. 6 Ensure that the management structure is appropriately set up to enable mul=disciplinary working & swik ac=ons to be taken to iden=fy & mi=gate risks 8 ac<ons 3 March 6 Outstanding pa<ent informa<on leaflets will be translated into alterna<ve languages; We are on track to deliver the business case for elec<ve caesarean theatre list. 6 Establish clear governance processes which are part of the overall trust systems & escala=ons 7 ac<ons 3 December 5 We have received the McKenzie Report on the 9 February 6, and the division is developing an ac<on plan to address the issues iden<fied. 7 Ensure that high professional standards are maintained against best prac=ce & na=onal guidance ac<ons 3 April 6 We have trained 3 midwives (73%) in Depriva<on of Liberty through their mandatory; We con<nue to roll out the Maternity AIMs course. 8 8

19 Newark Total ac<ons - Clarify & enrich the offer for local communi=es in the Newark area 6 ac<ons 3 June 6 We con<nues to engage with local stakeholders regarding the services provided at Newark Hospital. 5 Given the challenge in ac=vi=es faced in Newark, ensure sufficient leadership to support developments within Newark Hospital ac<on Develop a refreshed strategy, supported & developed by the trust, its commissioners, staff, pa=ents & the local community ac<ons Improve theatre u=lisa=on across SFH estates ac<on 9 February 6 3 July 6 3 January 6 Assistant Chief Opera<ng Officer in post and working with colleagues to provide leadership within Newark Hospital. Work from previous ac<ons will inform this process. Progress is being made in rela<on to the services provided from Newark Hospital. On- going monitoring of theatre u<lisa<on (at Newark) across Sherwood Forest Hospitals sites. Specific concern Sec<on 9A warning no<ce September & November 5 We responded to CQC within the required <mescales and con<nue to provide regular updates. Sec<on 3 warning no<ce Ongoing We responded to CQC within the required <mescale and con<nue to provide regular updates. Sec<on warning no<ce February 6 CQC Registra<on has been reviewed Applica<on for addi<onal regulated ac<vity has been submibed. 9