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

Transcription

1 R10.2 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 23(1) 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: The trust must have suitable arrangements in place to ensure that persons employed receive appropriate training, professional development, supervision and appraisal to enable them to deliver care and treatment to service users safely and to an appropriate standard. 1. Staff had not received mandatory training within the timescales set by the trust. 2. Staff had not received supervision, appraisals or undertaken reflective practice in line with the trust s policy. 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 provides self-service and manager access to training compliance records, E-Learning and booking courses. This provides the tools required for teams to increase compliance with mandatory training. Locally, individuals training records will be looked at in supervision and appraisal as a matter of routine, this means that every member of staff will have a review of their mandatory compliance on a monthly basis. Staff will be required to take action to address training compliance gaps immediately and failure to address gaps within three months will result in disciplinary action. Local action will include Staff to be informed of the need to book training through "My Learning" Ward managers to monitor monthly compliance with training and supervision. Ward manager to report to matron Who is responsible for the action? Adrian Whittington (Trust Wide) How are you going to ensure that the improvements have been made and are

2 R10.2 sustainable? What measures are going to put in place to check this? Managers to use MyLearning to identify training compliance at a team level Trust wide compliance to be monitored through o Exec Team (monthly report) o People Committee E+T report (monthly) Chaired by Non-exec and attended by 4-5 members of Exec Team o E+T Governance Group (Quarterly) - assurance meeting chaired by Kay Macdonald o Performance contract meeting (monthly) Services to review and discuss at team meetings and supervision Who is responsible? What resources (if any) are needed to implement the change(s) and are these resources available? Access for all to MyLearning (available) 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? Staff will not have the competencies to complete their role, impacting on patient safety Completed by: Adrian Whittington Position(s): Director of Education & Training Date: 22/06/2015

3 R10.3 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) 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 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations How the regulation was not being met: The trust must have suitable arrangements in place for obtaining consent and acting in accordance with the consent of service users in relation to the care and treatment provided for them. 1. On Oakland s ward we found patients who were not detained were prevented from leaving the ward for 24 hours or longer. There was no information available to support patients had consented to this arrangement Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve A full welcome pack is given to both the patient and to their carers upon admission to Oaklands. There is also a separate leaflet which sets out the rights of Informal Patients (MHA Leaflet). In view of the feedback received from the CQC, work is underway to develop this leaflet. It will now also include all of the points raised by the CQC, information relating to agreeing to an informal admission, guidance on contraband items whilst on the ward and details of any routine searches and/or checks which are undertaken to maintain a safe environment. The leaflet will be made available to anyone who agrees to an informal admission at point of referral to ensure that they are able to make a fully informed decision. A draft of the new leaflet is to be prepared by 30 th April 2015 following consultation with the local community team. June Leaflet developed and currently out for comments. Aim to sign off the leaflet by the end of June 2015, adapt and introduce trust wide by Sept The Crisis Resolution Home Treatment Team will record on the screening tool following taking a referral for an admission that this information has been given to the patient and that they agree to an informal admission.

4 R10.3 The Social Care Professional Lead and AMHP Lead in West Sussex ed all West Sussex AMHPs on 2 nd April 2015 to remind them of the nine points which should be considered when deciding if a service user is truly able to consent to informal admission. This document will also be shared widely in Brighton and Hove and East Sussex. Who is responsible for the action? Sue-Davies-Ebsworth 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? When leaflet is given to Informal patients during the process of admission. Screening tool amended and in place. MHA Leaflet for patients admitted informally readily available on the ward and given to relevant patients on admission. Admission leaflet to implemented Oaklands and at Meadowfield. Who is responsible? Sue-Davies-Ebsworth Matron What resources (if any) are needed to implement the change(s) and are these resources available? Not applicable Date actions will be completed: End of June 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Patients not detained will be prevented from leaving services for 24hours or longer Completed by: Jo Scott Position(s): Service Director Coastal West Sussex Date: 22/06/2015

5 R10.4 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 10 (1)(a)(2)(b)(i) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations How the regulation was not being met: At Langley Green hospital the service must improve the recording and analysis of incidents and complaints, and how lessons are learnt from this. Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve Langley Green has reviewed reporting of incidents. Matrons and General Managers now have access to reports following completion and check quality of report. Langley Green is benchmarking performance on incidents and complaints against other wards in the Trust. A new system has been implemented to promote Report and Learn within Langley Green Hospital. These relate to four themes: first focussing on SIs, then complaints and the third on audit recommendations and 4th on sharing good practice Who is responsible for the action? Teresa Dorey Nurse Consultant Vijay Kalechurn General Manager 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? The above actions are standing items on the Langley Green Hospital leadership meeting agenda and divisional clinical governance meeting The service is developing a local dashboard to monitor SI s and complaints alongside other indicators to improve monitoring, recording and learning Who is responsible? Vijay Kalechurn General Manager What resources (if any) are needed to implement the change(s) and are these resources available? Resources are required to develop the local dashboard (partly available)

6 R10.4 Need to identify resource to continue implementation of a report and learn report after current post ends. 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? Learning from incidents and complaints are essential to ensure that we are providing a safe service that is responsive to patient needs. We have addressed the urgent concerns immediately and therefore are assured that learning with regards to safety issues is embedded in current processes. Completed by: Position(s): Jonathan Beder Date: 22/06/2015 Service Director North West Sussex

7 R10.5 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 17(1)(a)(2)(h) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 How the regulation was not being met: Wards did not always comply with the Department of Health gender separation requirements. For example at Meadowfield hospital and Oaklands ward, female only lounges were locked. All three wards were mixed gender and although they attempted to separate the genders into different corridors, depending on the gender of the patients admitted, this was not always possible. Not all bedrooms were ensuite and on Oaklands ward female patients had to pass a male area to access toilet and bathroom facilities. On Heathfields ward at the Department of Psychiatry we were concerned that male patients were required to walk through female areas to access bathrooms. In addition, there was one assisted bathroom situated in the male area and this was used by female patients if needed. Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve Trust Wide Actions Developing a policy and protocol to formalise the safeguarding of any patient placed in a bedroom which necessitates them having to walk past toilet/ bathing facilities of the opposite sex and ensures that this is resolved as soon as possible. Process to include recording and reporting of breaches in toilet/ bathroom provision to provide assurance to the Trust board that we are working towards meeting the requirements. Developing a Delivering Same-Sex Accommodation (DSSA) Action Plan to include the operationalising of this policy and our intentions with regard to our ward environments. Redesigning our two dementia units in East Sussex to provide one new Dementia Intensive Care Unit (DICU). A working group consisting of clinicians, managers and commercial leads has

8 R10.5 commenced to review and redesign current dementia acute provision to be presented to commissioners this will provide the opportunity to address gender separation. Below are actions being taken locally; Meadowfield, Oaklands & Heathfield Gender of patient is recorded on the Patient Information at a Glance board (completed). Map of the ward in place which indicates the gender of the person in each bedroom (in progress). Ward Managers to complete Institute for Innovation and Improvement Good Practice Guidance Audit (Mental Health component) Privacy and Dignity. The Elimination of Mixed Sex Accommodation. Results to be shared with staff to enable good practice to become embedded in practice Heathfield wecome pack to be updated to include information about gender separation within the ward environment after completion of refurbishment (in progress) Individualised care plans to support and manage needs in relation to the gender separation challenges of the ward environment. Who is responsible for the action? Oaklands Matron Sue Davies-Ebsworth Meadowfield Matron Lucy Mills Heathfield ward Jenny Pickett: 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? Meadowfield/Oaklands/Heathfield Completion of the Audit to be monitored by the Matron. Maps and gender of person recorded in visible place. Who is responsible? Oaklands Matron Sue Davies-Ebsworth Meadowfield Matron Lucy Mills Heathfield ward Jenny Pickett: Matron What resources (if any) are needed to implement the change(s) and are these resources available? Not applicable Date actions will be completed: Meadowfield,Oaklands & Heathfoeld end of July 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date?

9 R10.5 Impact on patient safety and dignity and respect within inpatient services Completed by: Position(s): Date: 22/06/2015 Jo Scott & Neil Waterhouse Service Director Coastal West Sussex & East Sussex