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

Transcription

1 Report on actions you plan to take to meet CQC essential standards Account number Our reference RQM <Inspection ID> Trust name Chelsea and Westminster Hospital (For regulations requiring compliance actions: Require one page per regulation, which includes all Regulated Activities for that level of compliance.) Regulated activity(ies) Treatment of disease, disorder and injury Surgical procedures Regulation Regulation 9 Health and Social Care Act 2008 (Regulated Activities) Regulations Care and Welfare of people using the service How the regulation was not being met: The registered person had not taken proper steps to ensure that each service user was protected against the risks of receiving care or treatment that was inappropriate or unsafe. Regulation 9-1 (a) (b) Health and Social Care Act 2008 (Regulated Activities) Regulations Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve 1) The assessments of the needs of service users were not always undertaken in a timely fashion either when arriving by ambulance or attending on foot in the A&E: Standard: For all patients attending the Emergency Department to have an assessment completed within agreed timescales a) LAS within 15mins ( national target) b) front desk /walk in patients within 20 mins- gold standard but not official target. Capacity issues will remain an issue until end of rebuild in 2016 as there are currently only 2 triage rooms therefore, the focus for action has been the resources required to enable effective triage. An RGN with Manchester Triage Scoring training is required to complete any triage. 4.5wte registered nurse posts have been approved and now recruited into which should enable more stream;lined navigation and traife of patients. The Emergency Nurse Practitioner s will also be asked to assist at peak times ( when triage has more than a minute wait although this may have implications on their role in assessing and treateing patients with monor injuries and therefore will be monitored). The Nurse Consultant for minor injuries will undertake a regular audit of individual streamers to ensure effective/swift streaming is being done. 2) Pain scores needed to be appropriately reassessed in the A&E: Standard: For all patients in the ED to have their pain score assessed within 20 minutes of arrival. For pain scores to be reassessed every hour in majors and for patients who have had pain relief, 30 minutes after this.

2 All adastra patients get pain assessed on arrival mandatory on adastra system. All ED/majors patients get MTS on arrival assessing pain scores. Currently a pain score audit is being undertaken within the emergency department in order to ascertain any areas for specific action this will then be implemented and moniotered through the EED sub committee. Training on re-assessing and recording pain is essential for major patients. This automatically happens on adastra when analgesia is given. There is a link nurse for Pain who will support implementation of the pain audit findings. 3) Patients receiving end of life care did not have appropriate DNACPR orders or mental capacity assessments: Standard: To ensure all patients including those recieving end of life care have DNACPR forms completed appropriately, reviewed and legible as per Trust policy To ensure all patients recieving end of life care have appropriate mental capacity assessments undertaken The annual audit of DNACPR has been completed in October This is being reviewed at the Trust Safety and effectiveness group in November 2014 for intial discussion and engagement in addressing any gaps. The end of life care steering group will review and update the DNACPR action plan (in light of the audit findings implementing and monitoring actions and their impact The governance team will repeat an audit following implementation of action plan to provide assurance and address and gaps. The Trust Lead Nurse for Mental Health supports Mental Capacity training and is currently reviewing how this can be implemented robustly to all Trust staff in order to support effective mental capcity assessments being undertaken. The Lead Nurse for Mental Health and the Clinical Lead for End of Life Care will work collaboratively to ensure that appropriate mental capacity assessments are undertaken for patients recieving end of life care through case reviews and oversight at the End of life care steering group. 4) Compliance with the five steps to safer surgery checklist needed to improve to ensure safety in the planning and delivery of care: Standard: To ensure the surgical safety checklist is used at each stage of the surgical pathway The Matron for theatres is leading weekly spot checks of the process involving the WHO checklist throughout the patients surgical pathway in order to challenge practice and identify and gaps in pracytcie that need addressing. Formal monthly audits of practice will also be undertaken and fed back to the Theatre Improvement and Divisional board. The Surgical team are also working with the learning and development team in order to review the use of a training video to outline best practice. 5) The incidence of pressure sores was high in surgery and there was not a local action plan: Standard: To reduce the incidence of hospital acquired pressure ulcers within surgery by 25% ensuring there is a local action plan to support and monitor improvements The surgical matron will be working with staff to ensure that safety thermometer data (including pressure ulcer prevalence) is visually displayed for the public and staff and supports a process of engagamenet and challenge. The surgical matron will attend the Trust Preventing Harm group to ensure surgical actions

3 are integrated into the Trust wide action plan for pressure ulcer prevention supporting consistent practice and shared learning. The Tissue Viability Nurse will support the Push off the pressure campaign (POP) implemented in one surgical ward to engage all staff in challenging and changing the culture of pressure ulcer prevention and sharing best practice. The aim would be to roll out the programme to a third ward area in the next 6 months. Who is responsible for the action? Lead Nurses and Clinical Leads 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? Each of the services (Emergency department, Surgery and End of Life Care) have enagegd with staff and developed service specific action plans with designated leads and time frames. These will monitored at divisional boards (or the End of Life care steering group) to ensure progress is made or any support required is discussed. The Trust Quality committee chaired by a non-executive director will have the overarching responsibility for seeking assurance that actions are beign completed. For each of the 5 key areas outlined, there is a plan for audit to be undertaken in order to monitor improvements made by specific actions that have been completed and note any changes that need to be made to support sustainability. The Trust are also planning to organise a peer review in April 2015 assessing each of the areas identified by the CQC as needing improvement in order to provide further assurance of change. Who is responsible? Divisional Boards/ End of Life Steering Group/ Preventing Harm Group Trust Quality Committee What resources (if any) are needed to implement the change(s) and are these resources available? The funding for 4.5wte registered nurse posts has already been approved and now recruited into to support effective triage and navigation within the Emergency department. In order to support robust mental capacity training for all staff, the Trust are invesitagting an external company who may be able to facilitate this in a timely manner. Date actions will be completed: End March 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Regulated activity(ies) Regulation

4 Treatment of disease, disorder and injury Surgical procedures Regulation 10 Health and Social Care Act 2008 (Regulated Activities) Regulations Assessing and monitoring the quality of service provision How the regulation was not being met: The provider did not have effective systems to regularly assess and monitor the quality of services provided Regulation 10 (a)(c)(i)(ii) Health and Social Care Act 2008(Regulated Activities) Regulations Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve 1) Reporting and learning from incidents was not consistent and only 36% of serious untoward incidents were investigated within 45 days: Standard: For all staff to be aware of and follow the Trust Incident policy. For all staff to receive feedback from incidents in a consistent manner. For 100% of serious untoward incidents to be investigated within 45 days. The Trust is implementing the electronic datix system which will enable timlier reporting, monitoring and completion of incident reviews. It also supports electronic prompts to appropriate indivduals to remind them of actions and support timely action. Each service will establish a 6 weekly quality, safety and patient experience forum with a trust wide structure developed by the Trust Governance lead which will support consistency across services for reporting, feedback and shared learning. Whilst there is a trust wide policy in place outlining the process for feedback following incidents, a visual flowchart of the feedback process as per the policy will be developed to support staff understanding. There is a Trust wide pack detailing the processand timelines for serious incident investigations. This needs updating in January and so will be disseminated to all new investigators for their review. The Trust will review the process of buddying new lead investigators with those who have been trained and will also develop a system for recording staff who have received training. 2) Quality information, including risk registers, were out of date and not embedded in practice: Standard: For all risks on the risk register to be monitored through directorate/ divisional forums actions being undertaken to be reflected on the risk register and evidence sought regarding the mitigation/ closure of risks. The review and update of the risk register will be added as a standing agenda item at the service clinical effectiveness/ governance forums (and reflected in the terms of reference). The divisional boards will be responsible for noting the timeliness and completion of risks being completed supported by the governance team. 3) Changes to treatment provided following analysis of incidents and conclusions of local service reviews and clinical audits was not made consistently: Standard: To ensure a consistent process is used when changes to treatment are made following analysis and learning from incidents, audit or service reviews.

5 Each service will ensure that there is representation at both the Trust risk management committee but also the Trust safety and effectiveness group. Learning from incidents, audits or service reveiwes will be shared at these forums to support sharing best practice and consistent approacheds being made to changes in treatment. 4) Clinical guidelines were not consistently reviewed or updated in national guidance: Standard: To ensure that the process for guideline review is fit for purpose and that all staff are aware of it. To ensure that there is a process for monitoring the timescales of timely completion of guideline reviews and that individuals are aware of and carry out their responsibilities. The Governance lead is resending the guideline/ process for guideline reviews to all staff to increase their awareness of the process and responsibilities involvedin guideline review. The Governance lead is sending an up to date list of all out of date guidelines per service to each of the services for review and action. The Divisional Boards will ensure that guideline review in incorporated into the agenda supporting timely update. 5) Clinical audit programmes were not being done according to identified plans: Standard: To ensure that the process for audit review/ update is fit for purpose and that all staff are aware of it. To ensure that there is a process for monitoring the timescales of timely completion of guideline reviews and that individuals are aware of and carry out their responsibilities. The audit process and completion has now been incorporated into the revalidation process for medical staff to enable ownership. The Governance Lead will resend the guidance for audit and closing the loop in terms of sending completed results report to all service leads. The Divisional Boards will review the list of incomplete audits and action any gaps. 6) There was no system for recording that the termination of pregnancy (TOP) forms (HSA4) were sent to the Department of Health. This was a statutory requirement: Standard: To ensure there is a system in place for recording that HSA4 forms have been sent to the Department of Health. All HS A4 forms are forwarded to the Chief Medical Officer. A spreadsheet has been developed and implemented to note the form being sent, patient s hospital number and date of dispatch. 7) End of life care standards need to be appropriately monitored against national standards and the Tracey Court of Appeal in England Judgement (17 June 2014): Standard: For all end of life care standards to be appropriately monitored against national standards The Trust resuscitation Officer will ensure the Trust DNACPR policy is reviewed and updated in line with Tracy judgement The End of life care steering group have developed an action plan to address gaps outlined following the National Care of the Dying Audit with nominated leads and time scales for implementation.

6 The End of Life care Lead is aiming to introduce and implement the Gold Standard Framework (GSF) for end of life care. 8) Patients who need end of life care support were not always identified and referred to the specialist palliative care team. Standard: To ensure that all patients requiring end of life care support are identified and referred to the palliative care team. The palliative care nursing team establishment has been funded to support the ability to cover seven day working. Recruitment is taking place and a six day service has staretd in November with them to recruit further to support the seven days. The palliative care team will Increase specialist care team (SPCT) presence at key MDT meetings and ward rounds The palliative care team will ensure end of life care training (including SPCT services and the end of life aide memoire) is added to all appropriate induction and mandatory training and accurate record of training kept. They will also increase support to ward based staff through ward based teaching and presence. 9) Compliance with standards identified for the care of patients with a learning disability are appropriately assessed and action is taken to address areas for action. Standard: To ensure that standards identified for the care of patients with a learning disability are appropriately assessed, any areas for improvement identified and actions taken to address gaps in practice. The Trust is currently appointing a Lead Nurse for Learning Disability patients. The Lead Nurse for Leraning Disability will undertake a gap analysis assessing current trust practice/ standards against national standards for patients with learning disabilities. Having completed this, an action plan will be developed with the members of the learning disability forum in order to address any gaps. This will enable compliance with Monitor six standards in the Risk Assessment Framework and compliance will be reported quarterly to the Quality board. 10) There was not an operational policy or guidance for the management of deceased patient s belongings. Standard: Ensure belongings of deceased patients are effectively managed and returned to their family Develop and agree a policy to ensure the safe return of patient s property in a sensitive and timely manner. 11) Staff were not always of aware of or used the trust s learning disability passport, and operational standards for people with a learning disability were not appropriately assessed and implemented. Standard: To ensure all staff are aware of the Trust Learning Disability Passport and ensure that it is in place and used appropriately for all patients with a learning disability. To ensure that operational standards are appropriately assessed and implemented for all people with a learning disability. The Lead Nurse for Learning Disability will lead a relaunch of the learning disability passport ensuring that all staff are aware of it and implement its use within their areas. This will be audited and any gaps in practice will be addressed through the Trust learning disability

7 forum. Clear expectations of all operational standards and best practive for people with a learning disability will be outlined through the learning disability forum and actions developed for any gaps in practice that need addressing. 12) Discharge summaries are sent to GPs in a timely manner and include all relevant information in line with DH (2009) guidelines. Standard: For 80% of discharge summaries to be sent to GP s before patient discharge and within 7 days (CQUIN target) Our current trust wide position is 63.5% of discharge summaries are being sent within 7 days. This is monitored weekly through the senior operational group chaired by the Chief Operating Officer. There are divisional action plans in place to address this moniotored through SOG and also the executive board. 13) There were only two resuscitation trolleys covering the outpatient area over two floors. There had not been a risk assessment to check if this was sufficient the of patients seen in clinics, the diverse amount of conditions patients had and the floor area that needed to be covered across two floors. Standard: To ensure a risk assessment is in place outlining decisions made regarding the resuscitation trolleys in the outpatient department and that any identified risks are addressed/ mitigated. Whilst a risk assessment had been made through discussions with outpatient and resuscitation staff, this was not clearly evidenced. The team will review the risk assessment and ensure that the evidence of decision making is clearly documented. Who is responsible for the action? Divisional Leads/ Learning Disability Lead/ End of Life care Lead/ Governance team/ Senior Operational Group 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? Each of the services have engaged with staff and developed service specific action plans with designated leads and time frames. These will monitored at divisional boards (or relevant Trust wide committees) to ensure progress is made or any support required is discussed. The Trust Quality committee chaired by a non-executive director will have the overarching responsibility for seeking assurance that actions are being completed. For each of the key areas outlined, there is a plan for audit to be undertaken in order to monitor improvements made by specific actions that have been completed and note any changes that need to be made to support sustainability. The Trust are also planning to organise a peer review in April 2015 assessing each of the areas identified by the CQC as needing improvement in order to provide further assurance of change. Who is responsible? Divisional Boards/ Senior Operational group/ Learning Disability Steering Group/ End of Life Care committee Trust Quality Committee What resources (if any) are needed to implement the change(s) and are these

8 resources available? The Trust has funded the purchase and implementation of an electronic datix system. The project management support to facilitate a timely rollout is currently being finalised. The palliative care nursing team establishment has been funded to support the ability to cover seven day working. A senior nursing and midwifery restructure has taken place enabling the development of a full time Lead Nurse for Leranign Disabilities the post holder starts in January Date actions will be completed: End March 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Regulated activity(ies) Diagnostics and screening Treatment of disease, disorder or injury Regulation Regulation 15 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: Safety and suitability of premises The registered person had not ensured that service users using the premises were protected from the risks associated with unsuitable premises. How the regulation was not being met: The registered person had not ensured that service users using the premises were protected from the risks associated with unsuitable premises. Regulation 15 (a)(c)(i)(ii) Health and Social Care Act 2008(Regulated Activities) Regulations Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve 1) The resuscitation trolley on Annie Zunz Ward had not been checked in two days. Standard: To ensure that the resuscitation trolleys in all areas are checked daily in line with Trust policy. The ward manager has already spoken to staff and monitors the daily checks to ensure that they are completed. 2) The lack of space in the A&E department compared to the number of patients admitted meant that patients often received care and treatment in environments that were not suitable and where it was difficult to appropriately monitor their condition. Standard: Patients are cared for in appropriate areas in the accident & emergency (A&E) department so that there is safe monitoring of their condition. This is on the ED risk register as an identified risk with associated actions and will be monitored through the ED clinical governance meeting. There is a rebuild programme for the emergency department and aims to increase Adult

9 Majors cubicles (opens July 2015) and resus and Paeds (complete 2016). The lead doctor and nurse in charge will undertake supervision throguhout their clinical shifts ensuring that each clinical area is being used optimally and that any bottlenecks to patient flow are escalated in a timely manner in order to support effective patient flow. 3) Facilities in the outpatient department restricted access for patients with a physical disability (eg wide wheelchairs could not access the pre-operative assessment clinic rooms) Standard: For areas to be accessible to all wheelchair users and clearly designated areas for larger wheelchairs that require additional space for manouvering ( the issue is bariatric wheelchair users). 4) The height of the reception desk for pre-operative assessment was not accessible for people in wheelchairs (this was a recent refurbishment) Standard: For all areas to be accessible to wheelchair users. The pre-operative assessment team and estates team have reviewed the space and developed a plan for rebuilding the reception area to ensure that it is suitable for wheelchair users. A plan has been agreed and we are now waiting for a start date for the work to commence. 5) Many of the outpatient clinic areas were so small that patients had to wait standing up, and there was not enough space for wheelchairs to mobilise. Standard: For all areas to be accessible to wheelchair users. For patients waiting within outpatient clinic areas to have access to seating. Who is responsible for the action? Divisional Leads/ Estates team 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? Each of the services have engaged with staff and developed service specific action plans with designated leads and time frames. These will monitored at divisional boards (or relevant Trust wide committees) to ensure progress is made or any support required is discussed. The Trust Quality committee chaired by a non-executive director will have the overarching responsibility for seeking assurance that actions are being completed. For each of the key areas outlined, there is a plan for audit to be undertaken in order to monitor improvements made by specific actions that have been completed and note any changes that need to be made to support sustainability. The Trust are also planning to organise a peer review in April 2015 assessing each of the areas identified by the CQC as needing improvement in order to provide further assurance of change. Who is responsible? Divisional Boards Trust Quality Committee What resources (if any) are needed to implement the change(s) and are these resources available?

10 Date actions will be completed: End March 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Regulated activity(ies) Treatment of disease, disorder or injury Regulation Regulation 16 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Safety, availability and suitability of equipment. How the regulation was not being met: The provider did not have suitable arrangements to protect patients against the risk of unsafe equipment. Regulation 16 (1) (a) Health and Social Care Act 2008(Regulated Activities) Regulations Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve 1) The cardiac arrest call bell system in the AAU did not link to the nurses' station and the alarm was inaudible on the other side of the ward. Standard: To ensure that the call bell system within AAU is fit for purpose This action has been completed and the call bell system has been updated to ensure that it is fit for purpose. 2) 5 out of 20 items of equipment in outpatients did not have appropriate PAT testing Standard: For all equipment to be in a good state of repair, PAT tested and fit for use. All re-usable medical devices, that are registered on Aims (Management Database system ) are checked, at least annually during the clinical engineering Ward Care Visits or by service providers. The complete historical record, of medical devices, are recorded onto a clinical engineering management database system. This includes when the device was put into service, repairs, service records, to when they are de-commissioned. Clinical Engineering are responsible for managing 'Medical Devices/Equipment '. Computers are managed by the I.T department who have recently undertaken a trust wide review of devices. All other electrical appliances are safety tested by Norlands. All new clinical staff are instructed on nurse Induction days on how & why they need to report a faulty medical device. This is presently happening twice a month, and will continue. The clinical engineering team will be speaking with ward managers during Ward Care Visits follow ups, to establish if there are any issues are a problem with staff reporting faulty devices. This will happen in the following months and be on-going.

11 3) 15 out of 20 items of equipment in outpatients were not appropriately recorded as cleaned. Standard: For all equipment to be cleaned and labelled (in date for 7 days). The process for cleaning equipment and labelling will be clarified within the infection control policy. Department leads will ensure that roles for staff and responsibilities are clearly outlined with job descriptions, clearly explained and implemented. The cleaning of equipment and labelling is monitoried through the monthly cleaning audits undertaken by a member of the clinical area and ISS team. 4) The emergency equipment in the West London Clinic was not suitable for use in the environment and in particular could not be manoeuvred through doors and into the lift. Standard: For Dean Street and WLSHC to have appropriate resuscitation equipment in place. Following discussion with the resuscitation team, rucksacks holding resuscitation equipment would be appropriate for the clinics rather than dressing trollies/ resuscitation trollies. Three will be ordered (2 for Dean street/ Dean street express). Who is responsible for the action? Divisional Leads/ Clinical engineering/ ISS 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? Each of the services have engaged with staff and developed service specific action plans with designated leads and time frames. These will monitored at divisional boards (or relevant Trust wide committees) to ensure progress is made or any support required is discussed. The Trust Quality committee chaired by a non-executive director will have the overarching responsibility for seeking assurance that actions are being completed. For each of the key areas outlined, there is a plan for audit to be undertaken in order to monitor improvements made by specific actions that have been completed and note any changes that need to be made to support sustainability. The Trust are also planning to organise a peer review in April 2015 assessing each of the areas identified by the CQC as needing improvement in order to provide further assurance of change. Who is responsible? Divisional Boards Trust Quality Committee What resources (if any) are needed to implement the change(s) and are these resources available? The costs for 3 resuscitation rucksacks for sexual health clincis is approximately 1800 and have been ordered. Date actions will be completed: End March 2015 How will people who use the service(s) be affected by you not meeting this regulation

12 until this date? Regulated activity(ies) Treatment of disease, disorder or injury Surgical procedures Regulation Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: Respecting and involving service users. How the regulation was not being met: People who use services, did not, so far as practicably possible have suitable arrangements to ensure the privacy and dignity and independence of services users. The provider had not made suitable arrangements to ensure the dignity and privacy of patients. Regulation 20(1)(a)(2)(a) Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Records Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve 1) Patients in A&E were, at times, being treated in the corridors of the A&E and their privacy and dignity was not maintained Standard: Patients are cared for in appropriate areas in the accident & emergency (A&E) department so that there privacy and dignity is maintained. This is on the ED risk register as an identified risk with associated actions and will be monitored through the ED clinical governance meeting. There is a rebuild programme for the emergency department and aims to increase Adult Majors cubicles (opens July 2015) and resus and Paeds (complete 2016). An initial meeting has taken place with the Trust and CNWL to review the mental health patient pathway in order to identify actions that would support this group of patients beign cared for in an alternative environment this would support a better patient experience but also support increased capacity within the department. Discussions are taking place with commissioners to discuss collaborative working supporting better seven day working and also better integrated care pathways. There are existing forums in place attended by all partners within the Tri-borough to take forward actions to improve the whole systems pathway such as the Urgent Care board. The lead doctor and nurse in charge will undertake supervision throguhout their clinical shifts ensuring that each clinical area is being used optimally and that any bottlenecks to patient flow are escalated in a timely manner in order to support effective patient flow. 2) In the paediatric area, parents with potentially infectious children were asked to sit outside the department in the corridor due to a lack of segregated space within the department. As a result, they were with adult patients using the corridor to access the x-ray department. Standard: To ensure patients (and parents) are placed in a suitable environment ED staff to utilise the clinical areas as appropriate to minimise this issue. The blue benches

13 on corridor outside Paeds ED are used for overflow and for patients with gatro/infection issues who have been assessed and deemed clinically safe to wait there. Rebuild of increased Adult Majors cubicles opens July 2015 but Resus and Paeds is Unable to assure privacy and dignity at peak times in Paediatrics due to space issues at present. 3) People using the toilet in the pre-operative assessment unit could be seen from the reception area Standard: To ensure that patients privacy and dignity is maintained at all times Having reviewed the toilet and the pre-operative assessment area with the pre-operative lead, patients using the toilet are not visible and therefore, we feel that this action is not relevant. 4) People could be overheard by patients waiting in the waiting area when talking about their condition to the receptionist in the pre-operative assessment area. Standard: To ensure that conversations between staff and patients regarding their condition take place in an environment where confidentiality can be maintained at all times. The receptionist team have been reminded to ensure that any confidential details are not discussed with the patient at the reception area. For nursing staff completing triage, there are some issues with the availability fo rooms in which to have confidential discussions. Two rooms (room 18 and 19) have been identified within the outpatient clinic that are adjacent to the pre-operative clinic and discussions are taking place to review these rooms being available if needed. Who is responsible for the action? Divisional Leads/ commissioners/ Mental Health partners 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? Each of the services have enagaged with staff and developed service specific action plans with designated leads and time frames. These will monitored at divisional boards (or relevant Trust wide committees) to ensure progress is made or any support required is discussed. The Trust Quality committee chaired by a non-executive director will have the overarching responsibility for seeking assurance that actions are being completed. For each of the key areas outlined, there is a plan for audit to be undertaken in order to monitor improvements made by specific actions that have been completed and note any changes that need to be made to support sustainability. The Trust are also planning to organise a peer review in April 2015 assessing each of the areas identified by the CQC as needing improvement in order to provide further assurance of change. Who is responsible? Divisional Boards Trust Quality Committee What resources (if any) are needed to implement the change(s) and are these resources available? Following discussions with CNWL regarding the improvement to the assessment/ emergency department flow and timely transfer of mental health patients, a decision was made to review

14 a business case and funds required to support the development of a transit lounge this is an environment (currently being piloted at Northwick Park) that supports mental health patients whilst they are waiting for a suitable decision or placement to be made rather than this being done within the acute emergency department. Costs for this are being established currently. Date actions will be completed: End March 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Regulated activity(ies) Treatment of disease, disorder or injury Surgical procedures Regulation Regulation 20 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: Records How the regulation was not being met: People who use services were not protected against the risk of unsafe or inappropriate care or treatment because Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve 1) The electronic record did not support personalised care plans. Standard: To ensure that care plans are personalised for each patients need 2) Patient records were not accurately completed Standard: To ensure that all patient records are completed accurately. 3) Two different pain scoring systems were used in surgery and the information did not correlate Standard: To ensure there is one pain scale and this is disseminated and used by all staff The acute pain team will be reviewing the current pain scales in use with a view to having one only. They will then disseminate this tool across all areas to ensure one tool is being used consistently. An audit of the pain tool use will be completed folliwng this to identify any gaps in practice or understanding. 4) Advice from specialist teams was not always recorded in the notes (this referred to the pain team)

15 Standard: To ensure all advice provided by the pain team is recorded in the patient record 5) Records were not promptly accessible for agency staff Standard: To ensure that agency staff are able to access, use and update the electroinc patient record. 6) Decision relating to resuscitation were not being accurately recorded and reviewed to ensure they were kept current. Standard: For all decisions relating to resuscitation to be recorded and reviewed as per the Trust policy The annual audit of DNACPR has been completed in October This is being reviewed at the Trust Safety and effectiveness group in November 2014 for intial discussion and engagement in addressing any gaps. The governance team will repeat an audit following implementation of action plan to provide assurance and address and gaps. Who is responsible for the action? Divisional Leads/ Governance team/ Information Technology team 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? Each of the services have enagegd with staff and developed service specific action plans with designated leads and time frames. These will monitored at divisional boards (or relevant Trust wide committees) to ensure progress is made or any support required is discussed. The Trust Quality committee chaired by a non-executive director will have the overarching responsibility for seeking assurance that actions are being completed. For each of the key areas outlined, there is a plan for audit to be undertaken in order to monitor improvements made by specific actions that have been completed and note any changes that need to be made to support sustainability. The Trust are also planning to organise a peer review in April 2015 assessing each of the areas identified by the CQC as needing improvement in order to provide further assurance of change. Who is responsible? Divisional Boards/ IT Steering Group/ Safety and Effectiveness Group Trust Quality Committee What resources (if any) are needed to implement the change(s) and are these resources available?

16 Date actions will be completed: End March 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Regulated activity(ies) Treatment of disease, disorder or injury Regulation Regulation 22 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: Staffing. How the regulation was not being met: The provider did not have suitable arrangements to ensure that, at all times, sufficient numbers of suitably qualified, skilled and experienced nursing staff were employed. Regulation 22 (1) (a) Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve 1) Nurse staffing levels in AAU level 1 did not meet guideline. There was concern about staffing on medical wards, including escalation ward. There had been up to 30% vacancy rates in some ward areas for over a year. Standard: To ensure safe staffing requirements are identified and implemented for all areas. The alignment of ward budgets has been completed and should be implemented by the end November A business case is also being developed to address staffing levels in 5 key areas in line with safer nursing care guidance. The Level 1 area on AAU is being reviewed currently in terms of use and staffing needs. Business case being developed as part of AAU strategy group to review level ½ case mix and plan next steps. The escalation area (discharge suite) now has a dedicated permanent WTE manager. Staffing is being reviewed to support reduced agency possible case for use of winter planning funds to recruit permanent staff. 2) Paediatric nurse staffing levels was concern: One level 1 patient was being monitored by a healthcare assistant. Standard: To ensure safe staffing requirements are identified and implemented for all areas. There is a rolling advertisement for band 5/6 NICU nurses and there are plans for further overseas recruitment. A new matron for NICU has been appointed who will be reviewing the recruitment strategy in order to ascertain if there are different methods of attracting neonatal staff. Who is responsible for the action? Divisional Nurses, Assistant Chief Nurse (LC) 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?

17 Each of the services have enagegd with staff and developed service specific action plans with designated leads and time frames. These will monitored at divisional boards (or relevant Trust wide committees) to ensure progress is made or any support required is discussed. The Trust Quality committee chaired by a non-executive director will have the overarching responsibility for seeking assurance that actions are being completed. For each of the key areas outlined, there is a plan for audit to be undertaken in order to monitor improvements made by specific actions that have been completed and note any changes that need to be made to support sustainability. The Trust are also planning to organise a peer review in April 2015 assessing each of the areas identified by the CQC as needing improvement in order to provide further assurance of change. Who is responsible? Chief Nurse Cabinet Trust Quality Committee What resources (if any) are needed to implement the change(s) and are these resources available? A gap analysis using the RCN guidelines has been undertaken and will be re-submitted to the executive team for a formal decision regarding funding the 1.2M gap to achieve the staffing levels required within paediatrics. The escalation area (discharge suite) now has a dedicated permanent WTE manager. Staffing is being reviewed to support reduced agency possible case for use of winter planning funds to recruit permanent staff. A business case is also being developed to address staffing levels in 5 key areas in line with safer nursing care guidance. Date actions will be completed: End March 2015 How will people who use the service(s) be affected by you not meeting this regulation until this date? Completed by: (please print name(s) in full) Position(s): Holly Ashforth Acting Deputy Chief Nurse Date: November 2014