Report on actions you plan to take to meet CQC essential standards

Transcription

1 R2.1 Report on actions you plan to take to meet CQC essential standards Please see the covering letter for the date by which you must send your report to us and where to send it. Failure to send a report may lead to enforcement action. Account number Our reference Trust name RX2 SPL Sussex Partnership NHS Foundation Trust Regulated activity(ies) Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury Regulation This was in breach of regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 18(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations How the regulation was not being met: The covering of shortfalls of qualified nursing staff with healthcare assistants over long periods of time did not promote the health, safety and welfare of people who use the service, and put young people at risk of inadequate care. Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve Collate the data shared with inspectors and work with Lead Nurse for Safe Staffing (2/6/15) to review and ensure it can accurately identify gaps in provision. There is in place a rotation of B5 nurses Qualified staff who are responsible for reviewing rotas ensure there are no less than 2.00wte qualified nurses per night shift Conclude recruitment of all vacancies. 22 nd June two vacancies remain. Review and enhance skills mix by changing some unqualified posts to qualified Who is responsible for the action? Kate Stammers (Matron) How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? Recruitment progress will be monitored through Locality Leadership Team Skill mix review will be completed by Local Leadership Team and discussed at Service Leadership Team Regular review and monitoring of improvements will be carried out by ChYPS Divisional Leadership Board on a 3 monthly basis.

2 R2.1 Who is responsible? Kate Stammers (Matron) What resources (if any) are needed to implement the change(s) and are these resources available? None at present Date actions will be completed: 30 TH June 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? So that young people are not affected we will ensure risk management plans are in place. When required, additional staff will be rota d. Review of staffing skill mix and patient group will be carried out on a shift by shift, week by week basis. The Lead Nurse for Safe Staffing will provide intensive support. Completed by: Ruth Hillman Position(s): Acting Director - CHYPS Date: 22/06/2015

3 R.2.2 Report on actions you plan to take to meet CQC essential standards Please see the covering letter for the date by which you must send your report to us and where to send it. Failure to send a report may lead to enforcement action. Account number Our reference Trust name RX2 SPL Sussex Partnership NHS Foundation Trust Regulated activity(ies) Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury Regulation This was in breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 12(d) of the Health and Social Care Act 2008 (Regulated Activities) Regulations How the regulation was not being met: We identified a number of ligature risks within the environment at Chalkhill. The ligature risk assessment showed the provider was aware of these, though had not taken appropriate action to mitigate the risk to young people. Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve Ligature risks had been highlighted and acknowledged by organisation. There is a work plan to address those risks identified in the bathroom areas which has been agreed by all corporate and operational services. Date for completion to be confirmed Identified risks are managed in line with the service positive risk management plan. This includes using individual safety management plans to identify frequency/method of observations in line with the Trust Observation and Therapeutic Engagement Policy. Following inspection the ligature risks were re-assessed by Director of Governance and Facilities department and were discussed with the Facilities/Finance Board on 14/5/15. The plan for addressing bathroom ligature risks has been agreed and is underway. All windows in patient access areas, including bedrooms, are due to be replaced with anti-ligature windows. This work was completed in June 2015 Taps in bedrooms The Ward Manager and Matrons have raised the tap ligature issue with the senior leadership team. This has now been taken forward with the ligature reduction panel by the Director of Nursing Standards and Safety for Sussex Partnership. Following this, a senior member of the Project Design and Management team visited Chalkhill on 21 st April 2015 in order to make a full assessment of both 54 and 81 anchor points, with a view to addressing these as a priority. As detailed above this plan has been agreed

4 R.2.2 and is underway. Timescale for completion to be confirmed for all identified bathrooms risks Until all ligature issues are fully resolved, individual clinical risk assessments will continue to address self-harm and suicide risks where clinically appropriate. The de-escalation area has been refitted and has anti-ligature bathroom fittings in place. Ligature Cutters The location of the ward s ligature cutters is part of the local induction process for all staff and is discussed regularly in staff meetings and individual staff supervision. To ensure immediate visibility, the office ligature scissors are attached to the notice board. Labels have been placed on the resuscitation bag, alerting staff to the presence of ligature cutters within the bag. Additional ligature scissors are located in the night nurses bay in a labelled cupboard. Expert advice has been sought from the Director of Nursing Standards and Safety on appropriate ligature cutters and these were ordered on 14 th April These have arrived and are in situ in agreed places.. Who is responsible for the action? Jaqcqui Batchelor (Deputy Service Director) How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? Monitoring of progress against estates plan at monthly local leadership team Continuation of regular site visits and ligature audits Who is responsible? Jacqui Batchelor, Deputy Service Director What resources (if any) are needed to implement the change(s) and are these resources available? Ligature cutters (obtained) Taps to reduce ligature risks (estates agreed to work through plan as priority and are doing so now) Date actions will be completed: June 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Young people will continue to be supported and kept safe by using the mitigated plan previously agreed. This ensures young people are supported with appropriate observation when in areas which require new taps. This plan minimises risk to young people.

5 R.2.2 Completed by: Ruth Hillman Position(s): Acting Director CHYPS Date: 22/06/2015

6 R2.3 Report on actions you plan to take to meet CQC essential standards Please see the covering letter for the date by which you must send your report to us and where to send it. Failure to send a report may lead to enforcement action. Account number Our reference Trust name RX2 SPL Sussex Partnership NHS Foundation Trust Regulated activity(ies) Regulation Assessment or medical treatment for persons detained under the Mental Health Act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury This was in breach of regulation 23(1)(a) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 18(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations How the regulation was not being met: Staff did not receive regular mandatory training updates and lacked training in physical health issues to meet the needs of the high number young people with eating disorders nursed on the ward. Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve The new learning management system My Learning is now live and will enable staff to access appropriate training safely and effectively and allow for managers to monitor it. Work will be undertaken to ensure that statutory and mandatory training will be provided locally where on-line training is not appropriate. New starters to be trained on MEWS at induction to identify physical health risks Training session specific to young people with eating disorders focusing on tubefeeding, re-feeding to be re-run in Who is responsible for the action? Kate Stammers (Matron) How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? Audit of physical health monitoring has been completed Working with the Deputy Director of Nursing where the parameters for physical health monitoring for young people are being reviewed. To be completed by end of July 15. Staff requiring MEWS training have been identified and the programme for training is underway. To be completed 31/7/15 Action plan to complete remaining mandatory training is in place with expected completion date 30/9/15 In future managers to use MyLearning to identify who has and hasn t completed all

7 R2.3 mandatory training and to ensure timely completion Discuss in team meetings and supervision Who is responsible? Kate Stammers(Matron) What resources (if any) are needed to implement the change(s) and are these resources available? Access for all to MyLearning (available) Physical health nursing lead (available) Date actions will be completed: September 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Not all staff will have undertaken the physical health training so will need to utilise trained staff as appropriate. Ward Managers/Charge Nurse will support untrained staff in the physical monitoring and wellbeing of young people on the unit during the training phase and then offer regular updates through existing team processes. Completed by: Ruth Hillman Position(s): Acting Director CHYPS Date: 22/06/2015