Betsi Cadwaladr University Health Board. Quality and Safety Committee Item QS12/60.4. Subject:

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1 Betsi Cadwaladr University Health Board Quality and Safety Committee Item QS12/60.4 Subject: Summary or Issues of Significance Wales Ombudsman s Report Section 16 aggregated review: Serious Concerns about the similarity of complaints relating to Glan Clwyd Hospital: Update and conclusion of actions to May 2012 The response to the Ombudsman for Wales serious concerns about care in Glan Clwyd Hospital was presented to the Health Board in July and October This report presents a final report to the Quality and Safety Committee as assurance that the issues raised in the original report have been taken seriously and have been addressed by the Health Board and by the Ward Sisters and their teams on the wards in the report. There are some outstanding issues that will be subsumed into other agendas. There is progress to report in all of the themes in the aggregated review although an audit of consent remains outstanding. The Health Board has assurance about improvement in the Fundamentals of Care in previous reports, and specific attention has been drawn to this: comfort & warmth; dignity in care and compassion; mouth care and communication with patients and their carers. The Healthcare Inspectorate Wales (HIW) Dignity in Care spot-check that took place in Wards 1 and 11 in December 2011 was published on May 24 th 2012 and this reflects very good progress, albeit with some areas for improvement that are being worked on. The progress that the YGC Acute Medical Unit (AMU) Sister and team have made in terms of recognition of the deteriorating patient and the responses and interventions required is impressive; The AMUs in YM and YG should share and replicate the improvement work, adopt the YGC AMU action plan and continue to audit to monitor compliance to allow peer review and continuous improvement for patient safety in these busy areas. The compliments that the Health Board continues to receive about care from the staff in the identified wards are reassuring; there are occasional complaints therefore we are still not consistent in getting it right for all patients, all of the time. Complaints about nursing care are being audited retrospectively as part of the Quality & Safety Lead Officers Group work on complaints, the cause and key themes that will be undertaken in July The Acute Care Teams require implementation on each site to support clinical teams; The NEWS score provides recognition of deterioration; this action will be complete and BCUHB will have full assurance when there is systematic response to NEWS scores with a concern. The proposal for improvement is developed and in progress for approval and there is mitigation in that Ward Staff will escalate to the Medical Team until the Acute Care Teams are in

2 place. The Ward Round project was successfully piloted on 3 renal speciality wards across the Health Board. The final project report with recommendations was presented to the Board of Directors in December 2011; there should be an audit of progress in all Wards during the summer of 2012 to determine progress that includes review of patients by a Consultant post acute-take. Preparation for dissemination and adoption of the All Wales mouth care bundle is underway in BCUHB and will commence following the All-Wales 1000 Lives + event in July The autumn Fundamentals of Care audits will demonstrate if there has been an improvement in this important area of patient care. Further work is required on improving complaints processes, response times and closing the loop on actions and learning across BCUHB and is a focus for attention of the Quality & Safety Lead Officers Group in June The development, consultation and awaited publication of the BCUHB Discharge Policy is underway and scheduled for date. Finally, the Quality & Safety Committee should note that 3 areas of external assurance were sought to determine the status of patient care in YGC: 1. The Nurse Engagement Survey data from the Nursing Advisory board was received in May 2012; an analysis is underway; 2. HIW Dignity in Care & Hygiene and Infection Control spotchecks undertaken in December 2011 (published May 2012); 3. HIW week-long visit to YGC in February/March 2012 completed; initial feedback received and is being acted upon; final report awaited. National / Local Objectives Addressed: Legislation or Healthcare Standard: Achieving Excellence: The Quality Delivery Plan for the NHS in Wales (WG ); BCUHB: A Strategic Direction ; Free to Lead; Free to Care (2009); Fundamentals of Care (2005); Transforming Care and 1000 Lives + initiatives; Dignity in Care programme BCUHB; The National Dementia Action Plan for Wales (2009); Annual Quality Framework for Wales (2011); NSF for Older People (2006); Carer s Measure for Wales (2011); NHS Wales Delivery Framework for 2011 / 2012; Raising Concerns (2011). Equality Act (2010) and specific duties for Wales (2011); Nursing & Midwifery Council Code (2009); NHS Act (2006); Mental Capacity Act (2005);

3 Human Rights Act (1998); Healthcare Standards for Wales (2005, revised 2009): 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 18, 20, 21, 23, 24, 25 & 26; Raising Concerns (2011). Evidence base or other relevant information to inform decision(s) Consultation with others: Consideration of legal issues Impact on Other Services: Consequences & Risks: Recommendations: RCN Guidelines on Ward Staffing (2010); BCUHB Picker In-Patient Satisfaction Survey (2011); Concerns and Compliments from patients and carers; Patient Stories; Local observation of patient care; Healthcare Inspectorate Wales Spot Check on Dignity in Care (YGC, December 2011; published May 2012). Recommendation 5 has been shared with Local Authority Leads for Older People; Support and Guidance provided by the Equality leads for BCUHB; Updates regularly discussed and shared with the Ward Sisters involved and their Nurse Manager. Legal issues including professional regulation have been considered. This work has a direct impact on Equality therefore this is a key feature of the work as it progresses. The Acute Care Teams require implementation on each site to support clinical teams; The NEWS score provides recognition of deterioration; this action will be complete and BCUHB will have full assurance when there is systematic response to NEWS scores with a concern. The proposal for improvement is developed and in progress for approval and there is mitigation in that Ward Staff will escalate to the Medical Team until the Acute Care Teams are in place. The Health Board needs assurance that consent processes are being audited and are meeting the standard expected within BCUHB Policy. Failure to comply or work towards compliance with the Ombudsman and Healthcare Inspectorate Wales findings will have a significant impact on the reputation of BCUHB and the trust placed upon the Board to provide safe, competent care with compassion and dignity. Sanctions may include special measures and/or increased surveillance and inspection of care. It is recommended that the Quality and Safety Committee: 1. Discusses this update report; 2. Accepts that the actions within the report are now absorbed into one Diginity in Care action plan that will form the basis of the BCUHB Quality in Care Strategy 2012.

4 Author(s) Presented by Jill Galvani, Patient Services with support from Ward Sisters, the Associate Chief of Staff (Nursing) Primary, Community & Specialist Medicine and thematic leads for Falls; Care of the Acutely Ill Adult; Transforming Care and Fundamentals of Care. Jill Galvani, Patient Services Date of report 25 th May 2012 Date of meeting 14 th June 2012 BCUHB Coversheet v3.0

5 Section 16 Aggregated Review: Report to the Quality & Safety Committee May 2012 The Ombudsman expects BCUHB, to instigate its own investigation into Mr R s care from October 2008 until his death, and similarly into the cases noted by the Ombudsman (in particular references , and 2408/ The learning and actions arising from this aggregated review have now been integrated with the Health Board s response to the Older People s Commissioner Report This work is led by the Executive Midwifery and Patient Services and is formally reported to the Health Board via the Quality and Safety Committee. 1. Failure to recognise patients that are deteriorating. Patient Services; The NHS Early Warning Score (NEWS) has been implemented into BCUHB, following the evaluation of a number of pilot sites. As part of the patient care plan, NEWS scoring will be undertaken for every set of patient observations. The frequency of observations and prompt escalation of concerns about a patient will be guided by professional clinical judgement and supported by the scoring system. This work has been lead by senior doctors and nurses through the Managing the Acutely Ill Patient Steering Board. A detailed root cause analysis is undertaken for any septic patients escalated to Critical Care and audit of compliance with the NEWS is embedded in the organisation s assurance arrangements. Work has commenced on the development of the Acute Care Teams to support implementation and leadership of the NEWS system, and as a key part of the recognition and response to the acutely deteriorating patient. A high level of assurance has been received by AMU in YGC with supporting evidence of audit to drive continuous improvement. In April 2012 a new track and trigger score was introduced to AMU in YGC. A key trainer has been identified and all staff have received training. There are visual reminders around the ward, The Acute Care Teams require implementation on each site; The NEWS score provides recognition of deterioration; this action will be complete when there is systematic response to NEWS scores with a concern. All AMUs in BCUHB should share the improvement work, adopt the Patient Services and Medical Director 26th May 2012 Jill Galvani Midwifery and Patient Services 5 of 12

6 and observation charts are updated. This system is designed to more accurately capture at risk patients. Registered Nurses complete a RRAILS form on all patients daily. This asks a set of questions which helps staff monitor the bundle of care the patient has received during their admission period. RRAILS template asks the following questions: Admission Bundle a full set of observations are completed done on admission and have a plan for the frequency of observations which is communicated to all staff. Compliance on audit in April 2012 was 98%. Recognition bundle patients are regularly risk assessed using a Track and trigger system and are routinely screened for severe sepsis if found to be at risk. Compliance on audit in April 2012 was 94%. Response bundle All patients are treated appropriately and in a timely manor if their condition deteriorates. In the Acute Medicine Unit a Purple Marker on the patient status white board is an indicator to all clinical staff that a patient s condition has deteriorated. A Red Marker is used to prioritise care for those patients who are at risk of sepsis / raised MEWS score and need priority medical intervention. The Acute Care Team are informed of all patients who have a MEWS score of 4 and above. Medical staff are informed immediately. Sepsis 6 bundle patients are given all 6 elements of the bundle (oxygen, fluids, antibiotics, serum lactate, urinary monitoring, blood cultures) within 1 hour of being diagnosed as severe sepsis. In the Acute Medicine Unit a proforma document is used to document interventions and aid audit. Aid memos are available throughout the unit to assist staff. Compliance between Jan April 2012 was audited at 96%. This programme of care is augmented by a new am briefing where staff discuss any concerns they have about patients at a ward handover; this enhances senior nurse awareness of sick patients. YGC AMU action plan and continue to audit to monitor compliance and allow peer review and continuous improvement for patient safety in these busy areas. 2. Warmth and comfort of patients: The room temperature issues identified in the aggregated review have been resolved. A blanket warmer cupboard was trialled in August 2011 with positive feedback from patients; this was purchased in September 2011 and is in use for patient comfort. 26th May 2012 Jill Galvani Midwifery and Patient Services 6 of 12

7 The Unit Sister meets regularly with Estates to identify and correct any areas of concern in the unit, and to ensure the temperature control is comfortable for patients. Temperature control in AMU has now improved. Window vents sealed by Estates March In April 2012 a spot check of the blanket warmer was undertaken by the Clinical Governance Lead and Unit Manager. The blanket warmer was found to be fully stocked and ready for patient use. There have been no further complaints from patients regarding drafts or low/cold temperatures in the department. Portable radiators are also available to be put in patient rooms for added comfort. Patient Services 3. Poor Communication Communication is Standard 1 in the Fundamentals of Care audit scores and has seen an improvement of 1% for the combined score compared to the score in 2010 (an improvement on 2010 score of 1% for the user experience and an improvement of 3.3% for the operational questions (these are questions regarding patient documentation, to the staff and regarding the environment). The report for 2011 has been submitted to Chief Nursing Officer. Fundamentals of Care audits continue to be repeated in June and October each year by all wards in BCUHB. All Matron posts have been appointed to within the Primary, Community and Specialist Medicine CPG. The main role of the Matron is to support the ward mangers in ensuring the delivery of high quality patient care, driving workforce changes and service design. The Nursing meets with the Matrons every quarter or more often if required to go through the improvements required across the Health Board in terms of expectations of high standards and sustaining our performance against the aggregated report and the Older People s Commissioner Report. The Picker In-patient Survey will be repeated in September 2012 to check progress and identify stubborn areas that may require further attention. Staff have been reminded of the need to ensure that relatives and carers are routinely informed of any changes in patients condition in a timely manner. In YGC AMU ALERT / prompt cards are given to all staff encouraging them to contact relatives with any conditional changes. There have been no untoward incidents in this aspect of care in recent months and all staff are aware that The improvement work from YGC AMU should be replicated across BCUHB. The Ward Round project was been successfully piloted on 3 renal speciality wards across the Health Board. The final project report with recommendations was presented to the Board of Directors in December 2011; there should be an audit of progress in all Wards during the summer of 2012 to determine progress. Patient Services and the Associate Chiefs of Staff (Nursing) and their Matrons 26th May 2012 Jill Galvani Midwifery and Patient Services 7 of 12

8 they should check with cares/relatives on admission whether they wish to be contacted should their be a change in the patient s clinical condition. The Health Board continues with the Compassion in Care workstream with a plan including appointment of a psychiatrist to work alongside the Nursing and the team. Specific actions to date include: Developing, launching and embedding a dignity charter, based on care and compassion, so all staff know what is expected of them. Ward / team Care and Compassion champions are identified with the task of leading by example, by pointing out poor delivery of care and implementing the action plan at ward / team level. Regular Intentional Rounding by all nurses and Ward Sisters; Matron s rounds and improved visibility of all senior managers by continuing safety walkarounds with a specific focus on care and compassion. Continuing to build on the Health Board s Big Conversation work to determine the values of staff and a professional staff engagement survey is planned for mid-2012 and will be undertaken by Welsh Audit Office. Zero tolerance of poor attitude. 98.8% of our users who were part of the Fundamentals of Care audit in 2011 felt they were given the opportunity to ask questions about their care. User s comments included staff would always come back after the ward round to make sure I understood what had been said and always given opportunity to ask questions. Of those who answered no areas for improvement suggested has been accessing the family more and to ensure information is readily available in a written format that is easily understood. The score is an improvement on 2010 audit for the same time period. The Ward Round project has been successfully tested on Cunliffe ward combined with the alteration to visiting times this has been particularly successful in engaging relatives further with communication with nursing and medical staff. Recommendations from the activity follow of the medical ward round at consultant, registrar and junior doctor include: To refine the ward round observational tool and test in other clinical areas Patient dignity improvements highlighted Doctor preparation before ward round Suggested the development of an always checklist forward rounds. Patient Services, Medical Director & Therapies & Healthcare Sciences 26th May 2012 Jill Galvani Midwifery and Patient Services 8 of 12

9 4. Falls in hospital Safety Calendars for falls prevention: Safety calendars capture the incidents of falls in all adult wards as part of the Transforming Care programme. This engages frontline teams in data collection and using data for improvement. As the safety calendars have been so successful, they have been adopted by non-transforming Care wards. The wards display the calendars in prominent areas for staff to observe and monitor and then are encouraged to display the days between incidents as a means of motivating the team. The wards in the aggregated review are all demonstrating sustained improvement. In May 2012 safety calendars are in use in 62 clinical areas as a means of displaying knowing how we are doing with regard to falls in adult inpatient clinical areas. Falls symbols: The agreed falls symbol is used as a visual cue, posters, Intentional rounding is been spread across clinical areas as a falls bundle as part of Transforming Care and as apart of the Falls improvement work which the Transforming Care team of facilitators are supporting and are instrumental in the spread and further development. The falls bundle work is a development of the previous improvement work tested on ward 1 and 2 which incorporates the falls pathway. Therapies & Healthcare Sciences, Chief of Staff and Associate Chief of Staff (Nursing) - Therapies and Clinical Support CPG Falls posters in toilets and patient areas: Call don t Fall posters continue to be displayed in toilets in wards 1 and 2 in YGC. The falls pathway and documentation was launched and implemented into all medical and surgical wards on 1 st November The pathway and documentation provide an audit and assurance framework to demonstrate that the Health Board are achieving and maintaining the required standards. Falls champions have been identified across each of the 3 main hospital sites for medical and surgical wards in the first instance. Risk managers are compiling a Health Board-wide register of inpatient falls to identify areas of highest risk, trends and actions required. BCUHB continues to participate in a national WebEx to identify areas of good practice. Falls are one of the first 4 Nursing Metrics to be recorded. 26th May 2012 Jill Galvani Midwifery and Patient Services 9 of 12

10 5. Oral care and Hydration The wards in the aggregated review submitted their Fundamentals of Care audits for Standard 10 oral health and hygiene in November 2011 and these demonstrate improvement on the 2010 scores. These have been discussed with the ward sisters involved in the review. The Nursing led the All-Wales standards for oral health assessment on behalf of the Chief Nursing Officer as this area of care was a concern across Wales. The Mouth care Bundle was launched by The Minister for Health & Social Care on the 17 th May and is being implemented into BCUHB through the Transforming Care Programme. Oral care and hygiene for patients was the BCUHB Patient Safety Issue for November Care of Patients Property Staff awareness has been raised via the use of the corporate patient safety notice. Although previous local policies and procedures are in place, a new BCUHB Losses and Compensations Procedure has been developed and implemented. Staff are required to document fully the property retained by patients whilst within care or treatment areas. The policy will allow audit and assurance to demonstrate that the Health Board is achieving and maintaining the required standards. In addition, new Nursing Admission and Assessment documentation will include a record of patient property. Preparation for dissemination and adoption of the mouth care bundle is underway in BCUHB and will commence following the All-Wales 1000 Lives + event in July The autumn Fundamentals of Care audits will demonstrate if there has been an improvement in this important area of patient care. Patient Services Governance and Communication 7. Transfer of Patients with Infections (such as Clostridium Difficile) Palliative care and adult hospices procedure for transfer completed and there have been no further reported problems in this area. 8. Complaints processes The NHS Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011 are in place across the Health Board. Scrutiny of concerns, incidents and litigation takes place monthly by the clinical executives, and they provide assurance to the Quality and Safety committee of the Board. The wards involved in the aggregated review are scrutinised each month by the Clinical Executives in terms of complaints, incidents and litigation. Since April 2011 there have been complaints associated with the wards in the aggregated review and these are addressed Further work required on improving complaints processes, response times and closing the loop on actions and learning across BCUHB. Medical Director and BCUHB Clinical Director in Palliative Care Governance and Communication. 26th May 2012 Jill Galvani Midwifery and Patient Services 10 of 12

11 individually by the Assistant Nursing; equally and important to note are the letters of praise and thanks for the high standard of care provided in the areas in the review. Following Healthcare Inspectorate Wales visits, it is apparent that Wales and BCUHB still have work to do to improve complaints processes and make it easier for patients and carers to raise concerns. 9. Patient Consent The Ombudsman recommends that BCUHB should ensure that its procedures for obtaining consent from patients comply with the GMC s publication Consent: patients and doctors making decisions together (2008) The Health Board s Clinical Ethics, Consent and Human Rights group has lead the development of the consent audit, which is to be carried out at Ysbyty Glan Clwyd and the other hospital sites by the end of December Professor Peter Lepping, who leads this work, will ensure that the audit of compliance with the consent policy is properly conducted so that the Health Board can be assured that appropriate standards are being achieved. The outcome of the audit will be reported to the Health Board. 10. Review by a consultant The Ombudsman recommends that BCUHB should review its arrangements for post-take ward rounds, with a view to ensuring that ill patients are seen by a senior doctor. 11. End of Life The Ombudsman recommends that BCUHB should ensure that appropriate End of Life strategies have been introduced including the use of suitable End of Life care plans. End of Life Care audits have been undertaken and demonstrate the use of the Integrated Care Pathway, engagement with the palliative care team and Do Not Resuscitate reviews. These were presented to the Medical Grand Round in June Ongoing audit confirms that 27% of all adults dying in Glan Clwyd Hospital do so on the Welsh End of Life Integrated Care Pathway (the percentage suggested by the Welsh Palliative Care Implementation Board is 25%) and this demonstrates significant improvement. This is augmented It is strongly recommended that this is subject to annual audit to determine and provide evidence of compliance. It is recommended that this is subject to annual audit to determine and provide evidence of compliance. Medical Director; Therapies & Clinical Sciences Medical Director Medical Director; Palliative Care Lead & Director of Patient Services 26th May 2012 Jill Galvani Midwifery and Patient Services 11 of 12

12 by a programme of education across BCUHB to support this approach in all areas. A further piece of work is being undertaken by the Specialist Palliative Care Nurse Managers across BCUHB to demonstrate uptake of the care pathway uptake in all settings (acute and community) to ensure that patients are cared for in a setting of their choice at the end of life. In addition funding has been secured for a Clinical Nurse Specialist in Palliative Care for BCUHB to support Care Homes in North Wales to deliver high quality end of life care and promote advanced care planning for their clients. The aim of this post is to further support individuals to be cared for in a place of their choice and avoid unnecessary hospital admission at end of life where the terminal nature of their condition has been identified. 12. Discharge The Ombudsman recommends that BCUHB should review its discharge planning procedures, and arrange for all relevant staff to be trained in these. The discharge planning procedures of the Health Board have been reviewed and a new protocol has been drafted and consulted on in partnership with the 6 local authorities in North Wales. The consultation has just completed and the Policy will be issued as a working document. Areas of work in progress are the choice protocol which is the next piece of work to be issued for consultation. The discharge checklist has been implemented into the medical wards involved in the aggregated review and the Nursing has directed Ward 6 (Surgery) to implement a modified version suitable for surgical patients. Training programmes are being developed incorporating both classroom based and e learning materials; these are in draft format and require agreement from the discharge protocol group. Competencies for discharge are developed, need to be agreed and then implemented. Implement and audit the Discharge Policy; pace needed on the choice protocol and education and training for competencies. Patient Services 26th May 2012 Jill Galvani Midwifery and Patient Services 12 of 12